Introduction Of Innovative Medical Practices In Mayo Clinic: Effect Of The Interventions On Patient Outcomes

Purpose: Assessment of health technologies in medical practice is an ongoing process to provide clinicians and policymakers with information on the value of those applications. This dissertation aims to add to the existing body of literature and fill the gaps in prior studies by assessing two health technologies in Mayo Clinic Florida (MCF). The first paper provides an assessment of patient portal adoption and activity during hospitalization among cancer patients, and determines whether a portal application is associated with selected indices of patient safety, utilization and satisfaction. The second paper provides an assessment of a new approach in pain management after total knee arthroplasty (TKA), a periarticular anesthetic injection (PAI), and compares patient outcomes postoperatively among those who had this new pain management approach versus the traditionally used approach of peripheral nerve blocks in a consecutive earlier period. Methods: The first paper retrospectively reviewed all cancer inpatients admitted in MCF between 2012-2014 (N=4,594), compared portal adopters (i.e., who registered for a portal account) versus non-adopters, and compared inpatient portal activity among active versus inactive users. The second paper retrospectively reviewed consecutive patients who underwent primary unilateral TKA between March 1, 2013, and August 31, 2014 (N=511) and received FNB with SNB versus those who underwent TKA between October 1, 2014 and March 31, 2016 (N=479) and received PAI. In addition to descriptive statistics, postoperative outcomes, including pain scores, time to ambulation, distance walked, in-hospital falls, length of stay, discharge disposition, satisfaction with pain control, emergency visits within 14 days, readmissions within 30 days, revisions within 90 days, and total cost of hospitalization and 90-day follow-up period, were compared. SAS Version 9.4 was used for all analyses. Results: We found that 2352 (51.1%) were portal adopters, and of them, 632 (26.8%) were active inpatient users. Adoption was influenced by predisposing and enabling factors, such as age, sex, race, marital status, employment status, income, and type of health insurance. Active inpatient use was similarly influenced by predisposing and enabling factors, such as age, race, and marital status, in addition to factors related to need, such as being sicker, nonlocal and admitted for medical treatment (P Conclusion: Based on early evidence, cancer patients reached modest levels of portal adoption, with increased adoption associated with predisposing and enabling determinants, and increased inpatient use associated with need. In pain management after TKA, PAI was superior in providing early postoperative pain relief, improved functional recovery, better patient satisfaction with pain, and lower hospitalization cost compared to FNB with single-shot SNB following TKA. Findings may provide insight for clinicians and policymakers who are interested in health technology assessment and directing future research efforts on the value of care

Improving Transitions of Care From Hospital to Community Provider for Patients with Type II Diabetes Mellitus

Poorly coordinated care transitions result in nearly half of discharged patients’ experiencing at least 1 medication error and 1 in 5 Medicare beneficiaries readmitted within 30 days. Repercussions of suboptimal transitions of care greatly impact the nation’s economy costing between $12 billion and$44 billion annually. Ineffective handoffs between providers at hospital discharge contribute to suboptimal patient outcomes; therefore, strategies to improve transitions of care are necessary to provide quality care while decreasing health care expenditure. A quality improvement project was conducted on an inpatient surgical unit to decrease hospital readmissions and emergency department visits. Proposed interventions for patients with type II diabetes mellitus discharged home included (1) a follow-up appointment arranged with an outpatient provider prior to discharge and (2) receipt of a follow-up phone call within 48 to 72 hours. A process for providing discharge information to outpatient providers was assessed. A total of 58 patients met inclusion criteria: 91% patients received at least 1 intervention, 48.2% had a follow-up appointment arranged prior to discharge, and 29.3% received a discharge phone call within the proposed timeframe. There was a significant negative correlation with the number of interventions a patient received and decreased hospital readmissions (r = -.131). Health care in the United States has become increasingly fragmented and highly complex. Nurses have a pivotal role for ensuring patients’ experience a seamless transition throughout the continuum of care. In accordance with achieving a safe, timely, effective, efficient, equitable, patient-centered health care system a bundled intervention methodology may in fact serve to improve patient outcomes while decreasing health care expenditure

HealtheLife: Using a Patient Portal App to Reduce Type 2 Diabetes in East Los Angeles

The following proposal explores a potentially cost effective and cost efficient solution to alleviate the burden of type 2 diabetes among White Memorial Medical Center (WMMC) patients and their primary service area within Los Angeles County Service Planning Area 4 (SPA-4). SPA-4 is a medically underserved area with numerous key health indicators that indicate the need for increased self-management efforts among its Hispanic population. In response, WMMC has made a commitment to the SPA-4 community and made diabetes atop its community priority. An organization-wide Glycemic Control Project was created by WMMC administrators to provide more effective services by using Health Information Technology (HIT) within its operations. In support of this project, the WMMC Clinical Informatics Systems (CIS) department has proposed the use of Healthelife mobile application to improve diabetes self-management in WMMC transitional care. A literature review was conducted but, found very limited efficacy studies on mobile patient portal apps and patient portals mhealth interventions among Hispanic diabetics. However, several studies have implied that there are great research opportunities in tailoring the use of a patient portal mobile application for Hispanics, expanding its use within DMSE sessions through Community Health Workers, utilizing the trending mhealth functionality of patient portals, as well as proposing eHealth interventions that reduce health disparities. As a newly available resource to WMMC, the Healthelife mobile application is Cerner’s multilingual patient portal mobile application that is already live and fully integrated with WMMC’s “My Adventist Health” patient portal”. Accordingly, WMMC CIS has proposed a HealtheLife pilot program among its Hispanic patients to determine if its use will improve self-management efficacy and glycemic control among WMMC Type 2 diabetics (18+ years old). Technological Acceptance Model (TAM), Social Support, and Social Cognitive Theory will be applied throughout the pilot to gradually condition Healthelife usage among WMMC patients/caregivers for tailored educational experiences that strengthen WMMC Diabetes Self-Management (DSME) sessions. Essentially, diabetes educators will conduct the pilot program on adult Hispanics (18+) who are inpatient diabetics transitioning to Adventist Health Physician Network (AHPN) Physicians and DSME outpatient services. Primarily, the pilot will aim to improve A1Cs, Self-efficacy, and DSME attendance. Secondary outcomes of the intervention will be asses by qualitative assessment of Healthelife functionality, observed ED use, and ED readmission. All outcomes will be assessed through an internal quasi-experimental study examining an intervention group using Healthelife against a retrospective control groups from 2016. In sum, goal of the pilot program will set forth a care path that improve patients’ continuity of care and diabetes prevention beyond the walls of WMMC operations. By adopting the use of Healthelife as a population health tool, WMMC has the potential to intensify current DSME curriculum, to preventative unnecessary ED use, and to improve type 2 diabetes prevention efforts within SPA-4. More importantly, the suggestion to pilot Healthelife progressively introduces the benefits of HIT to Hispanic populations who are underserved and with limited resources

Patient Engagement in Patient Portals in Appalachia Versus Surrounding US Census Regions: An Analysis of HINTS (Health Information National Trends Survey) Data, 2017 - 2020

OBJECTIVE: Those living in the Appalachian regions face more significant healthcare disparities than those in the US. Patient portals can decrease disparities and increase health outcomes and health literacy. The purpose of this study was to determine if those living in the Appalachian region were offered access to and used their patient portals differently than the surrounding US Census region. Additionally, we aimed to determine if there was a difference in reported reasons for non-use of patient portals. METHODS: This was a descriptive study using data from the National Cancer Institute’s Health Information National Trends Survey (HINTS) data (2017-2020) to determine if there is a difference in the use of patient portals in the Appalachian region compared to the surrounding US Census regions. RESULTS: There was no statistically significant difference between the Appalachian and surrounding US Census regions in being offered access to and the use of patient portals. However, when holding race constant, there was a statistically significant difference between regions in the use of patient portals for non-Hispanic whites (p = 0.0192). Common reasons for non-use of patient portals were preferred to speak directly to the provider and perceived CONCLUSIONS: Providers in the Appalachian region should be aware of the non-use of patient portals by non-Hispanic whites. Moreover, understanding the reported reasons for non-use may help providers tailor educational materials to increase the use of patient portals

Transitions of Care: Improving Discharge Teaching in Stroke Patients

Approximately 13% of individuals who experience a stroke require readmission shortly after discharge due to preventable causes. A patient factor for readmission is the patient’s health literacy level and stroke understanding. Improving patient health literacy through systematic discharge education significantly improves the patient’s knowledge. In this quality improvement project, the author educated nurses on targeted discharge education to increase patients’ understanding and attendance at follow-up appointments. In a major teaching institute in North Carolina, a targeted discharge teaching plan was prepared. Using the patient’s medical history, nurses were educated on explaining to the patient their individual risk factors for a stroke and risk for a repeat stroke. The nurses were further educated on the importance of patients’ attendance at their follow-up appointments and the recognition of the signs and symptoms of a stroke. Prior to the education sessions, many nurses did not believe they had any impact on patients’ understanding, attendance at follow-up appointments, ability to help patients prevent a repeat stroke, or played a vital role. Following the education sessions, almost all nurses believed that they had an impact on patients’ understanding, attendance at follow-up appointments, ability to help patients prevent a repeat stroke, and that nurses play a vital role. Educating nurses on targeted discharge techniques will improve the discharge education provided. Effective discharge education improves stroke literacy and can have an impact on patients’ attendance at follow-up appointments.D.N.P

Patient characteristics associated with objective measures of digital health tool use in the United States: A literature review.

The study sought to determine which patient characteristics are associated with the use of patient-facing digital health tools in the United States.We conducted a literature review of studies of patient-facing digital health tools that objectively evaluated use (eg, system/platform data representing frequency of use) by patient characteristics (eg, age, race or ethnicity, income, digital literacy). We included any type of patient-facing digital health tool except patient portals. We reran results using the subset of studies identified as having robust methodology to detect differences in patient characteristics.We included 29 studies; 13 had robust methodology. Most studies examined smartphone apps and text messaging programs for chronic disease management and evaluated only 1-3 patient characteristics, primarily age and gender. Overall, the majority of studies found no association between patient characteristics and use. Among the subset with robust methodology, white race and poor health status appeared to be associated with higher use.Given the substantial investment in digital health tools, it is surprising how little is known about the types of patients who use them. Strategies that engage diverse populations in digital health tool use appear to be needed.Few studies evaluate objective measures of digital health tool use by patient characteristics, and those that do include a narrow range of characteristics. Evidence suggests that resources and need drive use

Mobile Health Applications: Background Research and Best Practices

This capstone was developed with the Patient Experience Department at Maine Medical Center (MMC) and an interdisciplinary MMC Tools and Technologies group. This research and analysis explores and outlines the foundations and best practices for mobile health (mHealth) applications (apps) across the spectrum of healthcare. mHealth apps used at some of the top rated hospitals in the country were selected and studied as possible templates for a similar initiative at MMC

Improving Patient Discharge Satisfaction Scores by Implementing Teach-Back Instructions in a Community Hospital Emergency Department (ED): A Quality Improvement Project

Background: Health literacy and patient satisfaction play a role in healthcare today and it is the responsibility of all providers to ensure that patients are educated about the care they received in the ED and what they should be doing upon discharge. The teach-back method ensures patients have a complete understanding of their ED stay and discharge instructions. Purpose: The purpose of this quality improvement project was to increase patient satisfaction scores by implementing the evidenced-based, patient-centered, teach-back method for all patient education opportunities. Methods: The DNP student led the ED leadership team and staff nurses in a quality improvement project. The DNP student provided education on the use of teach-back and was a resource for the nurses who were expected to use the method. Using comparative analysis the DNP student compared the frequency distribution of the pre and post-intervention survey results and the de-identified EDCAHPS patient satisfaction scores from the three months before and after implementation. Results/Interpretation: There was a reported 7% to 18% increase in the nurses’ familiarity, use, comfort level and perceived sustainability of teach-back in the ED. There was an increase in the patient discharge satisfaction survey (EDCAHPS) scores of 3.96% for the five (5) questions addressing care and teaching by nurses during the ED stay and 6.525% for the four (4) questions related to the discharge process. Conclusion/Implications: Teach-back improved the quality of instructions provided in the ED leaving patients with the improved tools they need to care for themselves upon discharge. There was an improvement in patient discharge satisfaction scores which could lead to improved comprehension, compliance, better outcomes and decreased ED recidivism with complaints they have already been seen for. Teach-back was implemented as the appropriate method to use when providing patient education and discharge instructions in the ED. It will be reviewed with all new nursing staff members and periodically reinforced by the leadership team. Consideration will be given to providing the physicians, nurse practitioners and physician assistants the same instructions on how and when to use teach-back to improve the patient-centered care provided to all patients and family members in the ED