Transitional Care Interventions as Implemented By Faith Community Nurses

Hospitals are seeking innovative and efficient methods of decreasing avoidable readmissions. Despite the volume of nursing literature exploring the use of advanced practices nurses in providing transitional care, only one study mentions the use of a faith community nurse. The faith community nurse operates in the community and has the skills to provide transitional care. The purpose of this study was to describe transitional care as implemented by faith community nurses using a standardized nursing language: the Nursing Intervention Classification (NIC). A mixed method descriptive design was selected to facilitate a thorough exploration of the interventions implemented by faith community nurses. The findings suggested that the majority of interventions are in the coping assistance, communication enhancement, and patient education Classes of the Behavioral Domain. The most frequently selected nursing interventions in NIC (n=26) were found and validated by the faith community nurse focus group. Results were compared to evidenced-based priority transitional care interventions described in research. In addition, results were compared to previous faith community nursing research describing the practice. Results were also described using the Faith Community Nursing conceptual framework. The results may provide the underpinnings for further testing of transitional care interventions

An APN-led COPD Discharge Education Program to Decrease 30-day Readmission Rates

The purpose of this project was to implement an APN-led COPD discharge education program to decrease 30-day readmission rates. This Doctorate of Nursing (DNP) project combined strategies obtained in the literature search and blended these into a cutting-edge and state-of-the-art discharge education program at a major medical center. The significance of chronic obstructive pulmonary disease (COPD) readmission rates include financial implications, a large number of Medicare patients who return to the hospital within 30 days, poor quality of patient care, and poorly coordinated discharge processes. An APN-led transitional care COPD education discharge plan was implemented on the pulmonary floor at a major medical center in New Jersey. Consented patients admitted to OMC pulmonary floor and who received their pulmonary care from Pulmonary & Allergy Associates (PAA) were asked to participate in this quality initiative. This quality initiative was conducted on 18 patients with COPD from October 2015 to January 2016. Patients included in this quality initiative received 1-hour; face-to-face visits by me, three days a week during the 12-week program and totaled 15 hours per week. The primary project outcomes were decreased 30-day readmission rates during the 12-week program. Secondary project outcomes were the implementation of patient discharge education including the following: 7-day pulmonary follow-up; signs and symptoms which require an emergency pulmonary visit; importance of influenza and pneumococcal vaccination; proper inhaler technique utilizing the 10-second breath hold with “teach back” method; importance of physical activity and pulmonary rehabilitation (PR); home oxygen needs; home nebulizer needs; importance of proper nutrition; assessment of anxiety, depression, and gastrointestinal reflux (GERD); and assessment for the safest discharge location based on the patient’s risk for readmission. The clinical significance of this initiative is a suitable approach to decrease 30-day readmission rates resulting in improved quality of care, a multidisciplinary transition of care approach to the patient with COPD, decreased financial burdens for this medical center, and implementation of pulmonary evidence based guidelines

An APN-led COPD Discharge Education Program to Decrease 30-day Readmission Rates

The purpose of this project was to implement an APN-led COPD discharge education program to decrease 30-day readmission rates. This Doctorate of Nursing (DNP) project combined strategies obtained in the literature search and blended these into a cutting-edge and state-of-the-art discharge education program at a major medical center. The significance of chronic obstructive pulmonary disease (COPD) readmission rates include financial implications, a large number of Medicare patients who return to the hospital within 30 days, poor quality of patient care, and poorly coordinated discharge processes. An APN-led transitional care COPD education discharge plan was implemented on the pulmonary floor at a major medical center in New Jersey. Consented patients admitted to OMC pulmonary floor and who received their pulmonary care from Pulmonary & Allergy Associates (PAA) were asked to participate in this quality initiative. This quality initiative was conducted on 18 patients with COPD from October 2015 to January 2016. Patients included in this quality initiative received 1-hour; face-to-face visits by me, three days a week during the 12-week program and totaled 15 hours per week. The primary project outcomes were decreased 30-day readmission rates during the 12-week program. Secondary project outcomes were the implementation of patient discharge education including the following: 7-day pulmonary follow-up; signs and symptoms which require an emergency pulmonary visit; importance of influenza and pneumococcal vaccination; proper inhaler technique utilizing the 10-second breath hold with “teach back” method; importance of physical activity and pulmonary rehabilitation (PR); home oxygen needs; home nebulizer needs; importance of proper nutrition; assessment of anxiety, depression, and gastrointestinal reflux (GERD); and assessment for the safest discharge location based on the patient’s risk for readmission. The clinical significance of this initiative is a suitable approach to decrease 30-day readmission rates resulting in improved quality of care, a multidisciplinary transition of care approach to the patient with COPD, decreased financial burdens for this medical center, and implementation of pulmonary evidence based guidelines

IMPLEMENTATION OF EVIDENCED-BASED CARE MANAGEMENT PRACTICES AMONG INDEPENDENT PHYSICIAN ASSOCIATIONS SERVING ELDERLY MEDICARE ADVANTAGE AND DUAL ELIGIBLE PROGRAM BENEFICIARIES

ABSTRACT Jennifer N. Dunphy: Implementation of Evidenced-Based Care Management Practices among Independent Physician Associations Serving Elderly Medicare Advantage and Dual Eligible Program Beneficiaries (Under the direction of Pam Silberman) Problem Scholars and policy makers have highlighted the importance of preventing hospital admissions and readmissions for individuals with a chronic condition, who account for a large percentage of the nation’s healthcare spending. Providing effective care management strategies can help reduce emergency department use, inpatient admissions or readmissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for Independent Physician Associations (IPAs) that contract with multiple insurers and managed care organizations. Methodology The research synthesized peer-reviewed literature to identify best practices in chronic-disease management for Medicare beneficiaries. A series of key informant interviews were conducted to explore barriers and facilitators to adapting two of these best practices, home visits and multi-disciplinary care teams, in IPA settings. The key informant interviews were conducted with executives, medical directors, and care managers who had significant experience in implementing best practices in IPA environments. Results Several themes were identified in the key informant interviews and include improved use of electronic medical records, enhanced IPA provider engagement and communication, optimizing outreach to patients in IPAs that cover large geographic rations, use of provider incentives to increase participation in best practices, and understanding the structure of the revenue model for each IPA. Recommendations The research suggests the need to: augment the existing communication strategy between the IPA central administrative office and the provider network, assess the IPA’s revenue model to determine readiness to implement best practices, evaluate the number of high volume providers affiliated with the IPA in order to assess ease of implementation of best practices, employ a robust risk stratification system to determine which patients should receive best practice related interventions, include a social worker and pharmacist on care teams, conduct face-to-face patient visits in the home settings of high-risk patients, incorporate transitional care into best practice interventions, and encourage consistent provider involvement as it relates to best practice interventions. Additional research is needed among IPAs nationally to further explore the effects of best practices on vulnerable populations. A particular area that needs attention is standardizing how results of interventions are collected, evaluated, and reported.Doctor of Public Healt

Reducing attendances and waits in emergency departments : a systematic review of present innovations

Reducing the waits in emergency departments is important for patients and is a government priority. In order to reduce waits the whole system must be considered. The flow of patients before arrival at the emergency department determines the workload of the department. The staffing, resources and systems within the emergency department are key to providing high quality timely care. The flow of patients after leaving the emergency department until their return home will determine whether they can be discharged from the department in a timely manner. Despite the present focus on emergency care in the NHS there have been no reviews of the literature to inform the present changes to reduce waits

Patients\u27 Perceptions of Quality of Life and Resource Availability After Critical Illness

Physical, psychological, and social debilities are common among survivors of critical illness. Survivors of critical illness require rehabilitative services during recovery in order to return to functional independence, but the structure and access of such services remains unclear. The purpose of this qualitative study was to explore the vital issues affecting quality of life from the perspective of critical illness survivors and to understand these patients\u27 experiences with rehabilitative services in the United States. The theoretical framework guiding this study was Weber\u27s rational choice theory, and a phenomenological study design was employed. The research questions focused on the survivors\u27 experiences with rehabilitative services following critical illness and post-intensive care unit quality of life. Participants were recruited using purposeful sampling. A researcher developed instrument was used to conduct 12 semistructured interviews in central North Carolina. Data from the interviews were coded for thematic analysis. The findings identified that aftercare lacked unity, was limited by disparate information, and overuses informal caregivers. In addition, survivors\u27 recovery depended on being prepared for post-intensive care unit life, access to recovery specific support structures, and the survivors\u27 ability to adapt to a new normalcy. Survivors experienced gratitude for being saved, which empowered them to embrace new life priorities. The implications for social change include improved understanding of urgently needed health care policies to provide essential therapies and services required to support intensive care unit survivors on their journey to recovery

Hospital utilization in chronic spinal injury and primary physicians' adherence to clinical guidelines: three approaches to answering health services questions

Thesis (Sc.D.)--Boston UniversityThe first study was a prospective observation of predictors of cardiopulmonary hospitalization in a cohort of spinal cord injury (SCI) patients at Veterans Affairs (VA) centers at least one year post-SCI. Baseline data were linked to longitudinal 1996-2003 VA hospitalization data. Predictors of admission with circulatory or respiratory system illness, the outcome, were assessed by multivariate Cox regression. 143 cardiopulmonary hospitalizations were observed. Independent predictors were greater age (3% increase/year), hypertension, lowest body mass index (BMI) quintile (<22.4kg/m^2), and reduced lung function. SCI severity / neurological level did not significantly predict the outcome independent of covariates. Cardiopulmonary hospitalization risk in chronic SCI is related to greater age and medical factors that could result in strategies for reducing such hospitalizations. The second study investigated factors associated with risk-adjusted length of stay (LOS) for VA and Medicare-reimbursed hospitalizations prospectively observed in the same cohort. We merged 1999-2003 admissions in the Medicare Provider Analysis and Review (MEDPAR) dataset with the 1996-2003 VA hospitalizations. Risk-adjusted LOS was assessed in a multivariable Gaussian identity-linked generalized estimating equation (GEE) adjusting for repeated events. Unadjusted median LOS was 6 days for Medicare versus 8 days for the VA. Adjusting for repeated events and geographical location, LOS was significantly associated with ICU days, SCI severity, comorbidities, and surgical procedures. Risk-adjusted LOS did not differ between the Medicare and VA. Reducing LOS across both healthcare systems requires alleviating illness burden, lessening comorbidity, preventing skin ulcers, increasing mobility, and decreasing inpatient procedures. The third study was a cross-sectional observation of managed care attitudes and adherence to evidence-based clinical guidelines among primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration. Participants were 186 survey respondents with complete adherence data for a panel-representative medical condition targeted by P4P incentives. Guideline adherence, defined as the percent of recommended services actually delivered, was the outcome. Provider attitudes that were significantly associated with top-tertile adherence, independent of specialty and prior behavior, were financial salience, peer cooperation, control, and autonomy. The most adherent PCPs found the P4P incentives salient and felt peer-supported, but high-autonomy providers found early-stage incentives intrinsically demoralizing and they reduced work effort

Determinants of reduction in 30-day readmissions among people with a severe behavioral illness: a case study

BACKGROUND: Individuals with serious mental illness face a significant burden of disease, yet experience lower quality care across a range of services (1). Hospital readmission within 30 days of discharge is an important, if imperfect, proxy for quality of care. Factors contributing to readmission are well documented (2–5), yet successful interventions to decrease readmissions have been slow to take shape (6–9). To effectively develop and incorporate evidence-based interventions to reduce 30-day psychiatric readmissions into large, geographically diverse inpatient systems; there is a need to conduct in-depth implementation analyses to better understand the relationship between patient-, hospital-, health system-, and community-level factors and their net impact on readmissions. This research addresses this need. METHODS: Using a modified Consolidated Framework for Implementation Research (CFIR), two state-based case studies were conducted within a large U.S. hospital system. Two hospitals per state were selected-- one with a high and one with a lower readmission rate. We conducted document reviews and semi-structured interviews (N=52) with corporate, clinical and community stakeholders, using the CFIR to identify key themes within each construct. We scored and compared hospitals with lower vs. higher readmission rates. An analysis of EMR data from the hospital system contextualized case study findings. RESULTS: In one state a complex interplay of factors at all levels contributed to readmission rates in both hospitals. In the second, constructs within the inner hospital setting contribute to differences in hospital readmission rates. Facilities with high readmission rates scored lowest among CFIR constructs “Patient Needs and Resources in the Community” and “External Policies and Incentives.” CONCLUSIONS: Ours is the first known study to explore a broad range of factors that influence readmission rates among patients with serious mental illness and a range of comorbidities. Findings from two state-based case studies indicate that readmission rates are determined by multiple, interrelated factors which vary in importance based on hospital and community context and political environment. To be effective, systemic interventions to reduce readmissions must be tailored to the specific context at targeted hospitals

Use of the interRAI Acute Care Assessment Instrument to Predict Adverse Outcomes Among the Hospitalized Elderly

Abstract Objectives: This research project was undertaken to review two commonly used screening instruments for the elderly who attend at hospital emergency departments in Ontario. These instruments were then contrasted with a new potential screening instrument made up of items drawn from the Minimum Data Set-Acute Care instrument (MDS-AC Version 1_CAN). The hypothesized outcome was better specificity and sensitivity utilizing the newly prepared instrument in predicting at an earlier point if an elderly emergency department patient would become an alternate level of care (ALC) patient. The ability of the screener to predict negative outcomes (delirium, longer length of stay) was also analyzed. Methods: One dataset from a previous International Resident Assessment Instrument (interRAI) organization study in southern Ontario completed in 2000 was utilized to inform this research. Each of the commonly used screening instruments was crosswalked to the MDS-AC items, then both univariate and bivariate analyses were completed. Three research questions were then posed. By testing various logistic regression models, the research looked to establish whether the newly developed instrument would be able to perform comparably to the other two currently-used instruments, and whether it would be more effective in predicting ALC status and particular adverse patient outcomes. Results: The newly-developed instrument was found to perform more accurately. While several variables were tested, a core number were found to be more strongly predictive of future need for ALC status. Conclusions: Future research in this area is recommended