Master of Science

thesisThere is a high risk for communication failures at the hospital discharge. Discharge summaries (DCS) can mitigate these risks by describing not only the hospital course but also follow-up plans. Improvement in the DCS may play a crucial role to improve communication at this transition of care. This research identifies gaps between the local standard of practice and best practices reported in the literature. It also identifies specific components of the DCS that could be improved through enhanced use of health information technology. A manual chart review of 188 DCS was performed. The medication reconciliations were analyzed for completeness and for medical reasoning. The pending results reported in the DCS were compared to those identified in the enterprise data warehouse (EDW). Documentation of follow-up arrangements was analyzed. Report of patient preferences, patient goals, lessons learned, and the overall handover tone were also noted. Patients were discharged on an average of 9.8 medications. Only 3% of the medication reconciliations were complete regarding which medications were continued, changed, new, and discontinued; 94% were incomplete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges. 14% of those results were in the DCS while 86% were only found in the EDW. Less than 50% iv of patients had clear documentation of scheduled follow-up. Patient preferences, patient goals, and lessons learned were rarely (6%, 1%, and 3% respectively) included. There was a handover tone in only 17% of the DCS. The quality gaps in the DCS are consistent with the literature. Medication reconciliations were frequently incomplete, pending results were rarely available, and documentation of follow-up care occurred less than half of the time. Evaluating the DCS primarily as a clinical handover is novel. Information necessary for safe handovers and to promote continuity of care is frequently missing. Future improvements should reshape the DCS to improve continuity of care

Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition

<p>Abstract</p> <p>Background</p> <p>The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs).</p> <p>Methods</p> <p>The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002–2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis.</p> <p>Results</p> <p>Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability.</p> <p>Conclusion</p> <p>Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.</p

Development of a Transition Program for Young Adults with Type 1 Diabetes Progressing from Pediatric to Adult Care – A Feasibility Study

ABSTRACT Development of a Transition Program for Young Adults with Type 1 Diabetes Progressing from Pediatric to Adult Care – A Feasibility Study Elizabeth A. Minchau Background: Emerging adulthood requires a delicate balance of the competing social, educational, occupational, and financial demands typical of this developmental stage. This time period presents special challenges for adolescents with type 1 diabetes (T1D), who must also prioritize consistent medical follow-up and ongoing intensive self-care. Emerging adults with T1D struggle with glycemic control that is further exacerbated by an often-times disorganized transfer of care between pediatric and adult endocrinology practices. Substantial gaps in care have been noted during this transition process and can lead to suboptimal health care utilization, worsening glycemic control, increased incidence of serious complications, and mental health challenges. A formal healthcare transition process can help prevent gaps in care, improve independent disease management skills and markers of disease control, decrease disease burden, and reduce acute and chronic diabetes complications. Purpose: There is an increased focus within the pediatric community to formally prepare young adults with T1D for independent disease management as they transition to the adult service line. The purpose of this project was to adapt a federal transition framework to an outpatient pediatric endocrinology clinic in a northern West Virginia tertiary care center. A transition program titled, Preparing Emerging Adults with Knowledge and Skills (PEAKS), was designed to help meet the current standard of care. This project had two aims: Aim 1: Adapt the federal “Got Transition” framework to the specific needs of a local pediatric endocrinology clinic and Aim 2: Examine the feasibility of the PEAKS program design. Methods/Interventions: “Got Transition’s” Six Core Elements of Health Care Transition were adapted to the unique needs of the pediatric endocrinology setting by incorporating diabetes-specific transition guidelines recommended by the ADA Transitions Working Group. The PEAKS program targeted patients between the ages of 16-18 and offered structured transition visits (built into the electronic health record) which focused on enhancing knowledge and skills related to the management of T1D. The Model for Improvement’s Plan-Do-Study-Act (PDSA) framework was used to guide the project. Stakeholder feedback related to the acceptability and practicality of key program elements was collected at two time-points during program implementation to evaluate feasibility. Results: The final program design incorporated all six of “Got Transition’s” Six Core Elements of Health Care Transition and was trialed with patients over a four-month time period. Data from stakeholder interviews found the finished product to be both acceptable and practical. The program’s transition-focused education, documentation, and formal transfer of care processes did increase appointment times, resulting in stakeholders reporting increased time-burden. Conclusions: Utilizing the PEAKS program framework to formalize and organize the transition process for emerging adults with T1D appears to be an acceptable and practical way to begin to bridge the identified gap between current practice and best practice. The PEAKS program exemplified the science behind organized transitional care processes and helped stakeholders actualize team-based approaches, interdisciplinary communication, and patient-centered care

Strategic plan 2011-2015

"The National Center on Birth Defects and Developmental Disabilities (NCBDDD) works to advance the health and well-being of our nation's most vulnerable populations. Our focus on women, children, people with a range of disabilities and complex disabling conditions positions us as a resource within public health that is unique and vital. As we approach our ten year anniversary, a reflection on what we have accomplished and what we plan to achieve over the next five years is necessary. This plan describes our vision for the upcoming years and our commitment to achieve important health outcomes during that period." - p. 1"February 2011.""Established by the Children's Health Act of 2000, CDC's National Center on Birth Defects and Developmental Disabilities (NCBDDD) is currently organized into three divisions: Birth Defects and Developmental Disabilities (DBDDD), Blood Disorders (DBD), and Human Development and Disability (DHDD). Congress mandated the creation of the Center in response to strong advocacy efforts by external organizations whose view was that children's health issues were not being adequately addressed by CDC. Prior to formation of NCBDDD, CDC conducted an extensive internal assessment. This assessment focused on existing maternal-child health programs and it made recommendations about critical functions, programs and structure. The initial structure selected was the least disruptive to the Agency while also fulfilling the congressional mandate. It included the activities of two of the current divisions: Human Development and Disability and Birth Defects and Developmental Disabilities. It was not until 2004 that the Division of Blood Disorders was transferred to the Center from the National Center for Infectious Diseases. The rationale for moving Blood Disorders to NCBDDD was based upon the fact that the Center was already working on a number of chronic disability conditions with a strong genetic component." - p. 2Mode of access: Internet as an Acrobat .pdf file (1.25 MB, 52 p.)

European consensus of criteria for the evaluation of good practices in chronic conditions

Los sistemas sanitarios reconocen las enfermedades crónicas como uno de sus grandes desafíos de salud del siglo XXI para los sistemas sanitarios. A pesar de ser en gran medida prevenibles, las enfermedades crónicas son importante causa de mortalidad y morbilidad en Europa. En 2015, más de 1,2 millones de personas en los países de la UE murieron por enfermedades y lesiones que podrían haberse evitado a través de políticas de salud pública más fuertes o de una atención médica más efectiva y menos fragmentada. La presente tesis doctoral reporta el desarrollo y resultados de una proceso de consenso internacional cuyo objetivo ha sido desarrollar criterios de evaluación para valorar el potencial de las prácticas clínicas e intervenciones y políticas sanitarias a la hora de disminuir la carga atribuible a las enfermedades crónicas en cuatro áreas de interés: Promoción de la salud y prevención primaria de condiciones crónicas; Intervenciones organizativas enfocadas al tratamiento de pacientes crónicos con condiciones clínicas múltiples; Intervenciones sobre el empoderamiento del paciente; e, Intervenciones y políticas orientadas a mejorar la diabetes (la diabetes se utiliza como condición paradigmática). Con objeto de acordar los criterios de evaluación y otorgarles relevancia distinta en función del dominio de interés, se desarrolló un consenso internacional mediante la técnica Delphi-modificada, en la que participaron 113 expertos de diferentes disciplinas procedentes de 23 países europeos. El proceso de consenso produjo 145 categoría de evaluación (28 categorías en el Delphi de Health promotion and primary prevention of chronic conditions, 50 en el de Organizational interventions aimed at dealing with complex chronic patients with multiple conditions, 28 en el de Patient empowerment interventions with chronic conditions y 39 categorías en el Delphi de diabetes as a case-study) orientadas a valorar cada uno de los citados dominios y ponderarlos en función de cada área de interés. El conjunto de criterios y categorías acordados para el caso paradigmático de Diabetes apoya la hipótesis de que los criterios de valoración son transferibles y aplicables a la evaluación de prácticas, intervenciones y políticas desarrolladas sobre otras condiciones crónicas. Consistentemente con lo observado en otras iniciativas europeas, en este consenso, los criterios relacionados con ‘diseño de la práctica’, ‘evaluación’, ‘sostenibilidad’ y ‘escalabilidad’ parecen ser componentes esenciales en el desarrollo e implementación de buenas prácticas en Europa. Por último, como virtualidad destacable de este proceso de consenso, el componente internacional de las decisiones consensuadas, apoya la posibilidad de que las prácticas evaluadas con los criterios y categorías acordados puedan ser transferidas a cualquier contexto europeo.<br /

Care Transitions: A Mixed Methods Study Using a Complexity Science Lens

Research studies on care transitions from hospital to nursing home are few and heterogeneous, offering an inadequate characterization to support practice. The purpose of this study was to characterize multiple care transitions among hospitalized older adults with advanced chronic disease who were discharged to a nursing home. This prospective, mixed methods study used multiple case studies with an embedded quantitative strand and multiple sources of information. Four cases included an index patient (an older hospitalized adult with advanced chronic illness), his or her informal caregiver, if available, and healthcare providers involved in the index patient’s care. Two hospitals and two nursing homes participated. Healthcare providers, expert in care transitions within those facilities, were interviewed for facility context. Care transitions occurred in two contexts: the facilities’ organizational context and the patients’ ongoing life transitions. While care transitions were time-bounded healthcare provider-centered processes, life transitions were ongoing and principal-centered. Defined care transition processes were complicated. However, dynamic interactions between patients, family caregivers, and healthcare providers occurred in multiple complex systems. Dynamic interactions within the complex systems were affected by the alignment of the familial approach to patient support with the patient’s needs and the availability of a stable core. Symptom distress and quality of life trajectories did not illuminate differences in principal experiences. However, patterns of dynamic interactions were different between patients experiencing unplanned utilization and those who did not. Fragmented processes and lack of feedback loops were the norm. This fragmentation limited information flow. Simple outcome measures did not reflect the complexity of care transitions. While quality of life measures and symptom distress did reflect the patients’ situation at a moment in time, they did little to explain the patient’s experience of care transitions. Implications for practice relate to the complexity within care transitions. Limited information flow due to role fragmentation and lack of feedback loops hamper learning and adaptation both within individual cases and across facilities. Care transitions from hospital to skilled nursing facility occurred within complex systems. As such, future research must consider not only the processes, but also the relationships and dynamic interactions within the systems