Infection Prevention in Home Health Care (InHOME-CR)

This study, a continuation of the four-year InHOME study (R01NR016865), will be the first comprehensive examination of infection prevention and control (IPC) changes in home health care (HHC) during the pandemic and their impact on patient outcomes. With the results, we will generate recommendations to strengthen HHC agencies’ IPC capacity and preparedness to more effectively respond to the current and future infectious disease crises, protect the millions of Americans using HHC services every year, and reduce health disparities.

This study is conducted by the Columbia University School of Nursing in partnership with the RAND Corporation, Thomas Jefferson University and University of Rochester Medical Center, and has been approved by an IRB at all four institutions.

It is funded by NIH’s National Institute of Nursing Research (NINR) (2R01NR016865-05A1).


In 2019, approximately 3.3 million Medicare beneficiaries received care from Medicare-certified HHC agencies, which provide essential care to elderly Americans with complex needs.1,2 Before the pandemic, IPC in HHC was suboptimal; 12% of HHC patients had infections3 and approximately 16% of HHC-to-hospital transfers were caused by four types of infections.4 In our mixed methods parent grant, InHOME (R01 NR016865), we investigated HHC agencies’ IPC capacity (measured by assessing: IPC staffing, general IPC procedures, infection specific policies, and employee IPC training policies). Through a 2019 survey of HHC agencies (n = 536), conducted just prior to the pandemic, we found that IPC capacity was not consistent with current guidelines.5-7 Our interviews with HHC clinicians also revealed unique challenges with IPC.8 Furthermore, in a smaller survey (n = 121) conducted in April 2020, we assessed HHC agencies’ IPC preparedness (defined as planning for and responding to an infectious disease crisis).9 Responding agencies reported being inadequately prepared to handle the COVID-19 pandemic, and most struggled with shortages of personal protection equipment (PPE) and other necessary supplies. Our earlier work provides the most comprehensive picture of IPC capacity and preparedness in U.S. HHC agencies prior to and early on in the pandemic.

As of July 22, 2022, over 1 million people in the U.S. have died from COVID-19,10,11 and those 65 and older account for 75% of COVID-19 deaths.11 HHC patients are mostly elderly adults with multiple chronic conditions, and many are members of populations historically vulnerable to health disparities (vulnerable populations). Despite of being at high risk for COVID-19,1,11 neither the number of HHC patients that have acquired COVID-19 nor their outcomes are known at this time. While researchers have identified disparities in COVID-19 hospitalizations and deaths,12-14 no one knows how these disparities manifest among the HHC patient population. COVID-19 has resulted in changes to IPC practices across healthcare settings, creating a unique opportunity to reassess how the evolution of HHC IPC capacity and preparedness affects patient outcomes and influences health disparities.

Study Goals

Informed by our work in the parent grant, InHOME (R01 NR016865), and guided by Donabedian’s Quality Model and the Minority Health and Health Disparities Framework15, we will continue to collect longitudinal data through two more national surveys of HHC agencies (expected sample per survey n = 1,500) in 2022 and 2024. We will link the data with our 2019 national survey to assess the evolution of HHC IPC capacity and preparedness across the nation.

We will complement our survey data by linking with administrative data (e.g., OASIS and Medicare claims) and COVID-19 environment data to estimate the associations between HHC IPC capacity and HHC patient outcomes (i.e., infections, mortality). Additionally, we will conduct qualitative interviews with up to 60 HHC staff across the nation to gather insights, discuss our findings, and gain perspectives from those with firsthand experience implementing IPC policies and caring for patients. Finally, we will conduct a systematic literature review and synthesize our findings to inform a Delphi panel made up of key stakeholders (i.e., experts, leaders, advocates, patients and caregivers). Through this Delphi process, clinical and policy recommendations will be developed, refined and endorsed, resulting in data-driven, evidence-based IPC recommendations specific to HHC.

Study Aims

  1. To describe changes in HHC IPC capacity and preparedness over time and its association with vulnerable populations.
  2. To examine associations between HHC IPC capacity and HHC patient outcomes, overall and in vulnerable populations.
  3. To examine the feasibility and potential barriers to implementing best practices in IPC capacity and preparedness through qualitative interviews with HHC personnel.
  4. To develop evidence-based recommendations for improving HHC IPC capacity and preparedness to reduce the burden of COVID-19 and non-COVID-19 infections in HHC.


  1. U.S. Department of Health & Human Services, Administration on Aging. A profile of older Americans: 2020. Published May 2021. Accessed July 15, 2022.
  2. Medicare Payment Advisory Commission (MedPAC). March 2021 Report to the Congress: Medicare Payment Policy. Published March 15, 2021. Accessed July 15, 2022.
  3. Dwyer LL, Harris-Kojetin LD, Valverde RH, Frazier JM, Simon AE, Stone ND, Thompson ND. Infections in long-term care populations in the United States. J Am Geriatr Soc. 2013;61(3):342-349.
  4. Harrison JM, Dick AW, Stone PW, Chastain AM, Sorbero M, Furuya EY, Shang J. Infection trends in home health care, 2013-2018. Infect Control Hosp Epidemiol. 2021 Nov;42(11):1388-1390. 
  5. Shang J, Chastain AM, Perera UGE, Dick AW, Fu CJ, Madigan EA, Pogorzelska-Maziarz M, Stone PW. The state of infection prevention and control at home health agencies in the United States prior to COVID-19: A cross-sectional study. Int J Nurs Stud. 2021 Mar;115:103841. 
  6. Shang J, Harrison JM, Chastain AM, Stone PW, Perera UGE, Madigan EA, Pogorzelska-Maziarz M, Dick AW. Influenza vaccination of home health care staff and the impact on patient hospitalizations. Am J Infect Control. 2022 Apr;50(4):369-374.
  7. Harrison JM, Dick AW, Madigan EA, Furuya EY, Chastain AM, Shang J. Urinary catheter policies in home healthcare agencies and hospital transfers due to urinary tract infection. Am J Infect Control. 2022 Jul;50(7):743-748.
  8. Pogorzelska-Maziarz M, Chastain AM, Mangal S, Stone PW, Shang J. Home Health Staff Perspectives on Infection Prevention and Control: Implications for Coronavirus Disease 2019. J Am Med Dir Assoc. 2020 Dec;21(12):1782-1790.e4.
  9. Shang J, Chastain, AM, Perera, UGE, Quigley, DD, Fu, CJ, Dick, AW, Pogorzelska-Maziarz, M, Stone, P. COVID-19 Preparedness in U.S. Home Health Agencies. J Am Med Dir Assoc. 2020;21(7):924-927. 
  10. Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. COVID-19 Dashboard. Accessed July 22, 2022.
  11. Centers for Disease Control and Prevention (CDC). Demographic Trends of COVID-19 cases and deaths in the US reported to CDC. Accessed July 22, 2022.
  12. Glance LG, Thirukumaran CP, Dick AW. The Unequal Burden of COVID-19 Deaths in Counties With High Proportions of Black and Hispanic Residents. Med Care. 2021 Jun 1;59(6):470-476.
  13. Wadhera RK, Wadhera P, Gaba P, Figueroa JF, Joynt Maddox KE, Yeh RW, Shen C. Variation in COVID-19 hospitalizations and deaths across New York City boroughs. JAMA. 2020;323(21):2192-2195.
  14. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:458–464.
  15. Donabedian A. Evaluating the quality of medical care. Milbank Q. 1966;44:166-206.
Columbia School of Nursing
University of Rochester Medical Center
Thomas Jefferson University, Home of Sidney Kimmel Medical College
RAND Corporation