Nurse-Driven Interprofessional Rounds: Improving Care Coordination and Length of Stay

BACKGROUND

Inpatient oncology units care for patients with some of the most complex medical conditions outside of the intensive care unit. These patients benefit from structured care coordination. Reduced ability to admit patients to oncology beds contributes to delays in specialty care.

OBJECTIVES

This quality improvement initiative established nurse-driven interprofessional rounds (IPRs) to reduce length of stay (LOS), improve discharge time of day, and enhance care coordination, patient flow, and access to care in the community.

METHODS

Care coordination during enhanced IPRs (eIPRs) included estimation of discharge dates, comparison of LOS to a standard geometric mean LOS, and discussion of clinical milestones and barriers to progression and discharge. Data analysis evaluated the effect of eIPRs on key outcomes.

FINDINGS

Although LOS variance was reduced by 15.8% and 44.1% in all-unit and hematology-oncology discharges, respectively, the results were not significant. Discharges by 2 pm improved significantly for all-unit and hematology-oncology populations, respectively. Patient flow measured by accepted patient transfers requesting hematology-oncology services improved significantly.

What is being done to respond to the rise of chronic diseases and multi-morbidity in Czechia, Hungary, Poland, and Slovakia?

Although countries in central and eastern Europe (CEE) have relatively younger populations compared to the West, their populations are often affected by higher prevalence of chronic conditions and multi-morbidity and this burden will likely increase as their populations age. Relatively little is known about how these countries cater to the needs of complex patients. This Perspective piece identifies key initiatives to improve coordination of care in Czechia, Hungary, Poland, and Slovakia, including some pioneering and far-reaching approaches. Unfortunately, some of them have failed to be implemented, but a recent strategic commitment to care coordination in some of these countries and the dedication to rebuilding stronger health systems after the COVID-19 pandemic offer an opportunity to take stock of these past and ongoing experiences and push for more progress in this area.

Precision public-health intervention for care coordination: a real-world study

BACKGROUND

Health emergencies disproportionally affect vulnerable populations. Digital tools can help primary care providers find, and reach, the right patients.

AIM

To evaluate whether digital interventions delivered directly to GPs' clinical software were more effective at promoting primary care appointments during the COVID-19 pandemic than interventions delivered by post.

DESIGN AND SETTING

Real-world, non-randomised, interventional study involving GP practices in all Australian states.

METHOD

Intervention material was developed to promote care coordination for vulnerable older veterans during the COVID-19 pandemic, and sent to GPs either digitally to the clinical practice software system or in the post. The intervention material included patient-specific information sent to GPs to support care coordination, and education material sent via post to veterans identified in the administrative claims database. To evaluate the impact of intervention delivery modalities on outcomes, the time to first appointment with the primary GP was measured; a Cox proportional hazards model was used, adjusting for differences and accounting for pre-intervention appointment numbers.

RESULTS

The intervention took place in April 2020, during the first weeks of COVID-19 social distancing restrictions in Australia. GPs received digital messaging for 51 052 veterans and postal messaging for 26 859 veterans. The digital group was associated with earlier appointments (adjusted hazard ratio 1.38 [1.34 to 1.41]).

CONCLUSION

Data-driven digital solutions can promote care coordination at scale during national emergencies, opening up new perspectives for precision public-health initiatives.

Considering a Need for Dementia-Specific, Family-Centered Patient Navigation in Canada

Patient navigation has been proposed as a novel family-centered, integrated care model to address the care needs of persons living with dementia and their family caregivers by helping them navigate the complex range of dementia services offered in hospital and community settings. A key informant qualitative descriptive study explored the perspectives of 48 healthcare professionals to explore the need for dementia-specific patient navigation. Data were analyzed thematically. We identified one overarching theme: "Variability in the Need for Illness-Specific Patient Navigation" and five themes that highlight considerations when providing navigation to individuals with dementia: (1) Taking Part in Ongoing Training, (2) Addressing Stigma, (3) Focusing on Quality of Life, (4) Defining Home, and (5) A Continuous Process of Support. These themes provide preliminary insights into the conceptual differences about the need for illness-specific patient navigation and the areas within patient navigation where healthcare professionals are encouraged to find consensus.

The Entry-Into School Health History Intake: The Starting Point for Care Coordination

Many students enter school with a previously diagnosed chronic health condition necessitating school nurse management during the school day. Common pediatric chronic health conditions include asthma, diabetes, seizure disorder, and severe allergy to name a few. In addition, students might present with a less common health condition or an injury or short-term illness requiring school nursing services. Identification of student health conditions originate from a variety of sources, chief among them being school and sport physicals. Yet, primary healthcare provider information may not be provided for all students and, when provided, may not contain a complete health history. Thus, school nurses should establish a consistent method of collecting an initial entry-into school health history intake and periodic updates for all students, along with developing a system to distinguish between parent and healthcare provider reporting of health conditions. This is no small task. The purpose of this article is to discuss principles surrounding identifying students with health conditions, along with providing a sample intake form developed in one state that is adaptable for both paper and electronic formatting collection of data.

Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study

Introduction

Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design.

Methods

We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants.

Results

Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs.

Discussion

The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.

Physical Activity Patterns, Satisfaction, and Quality of Life Among Nursing and non-Nursing Staff in an Office-Based Care Coordination Program

Introduction

Sedentary work is associated with poor health outcomes. Many healthcare occupations, including office-based care coordination, are largely sedentary. Many nurses do not achieve the recommended levels of daily physical activity, however, the physical activity levels among nurses working in care coordination are not known.

Objective

To assess the physical activity levels, self-reported health and well-being, overall quality of life, and work-related satisfaction of office-based care coordinators, and compare these among nursing and non-nursing staff.

Methods

This study collected objective physical activity data using accelerometry along with self-reported information on work-related quality of life and satisfaction from 42 healthcare staff working in a hospital-affiliated office-based care coordination program. Results were compared among nursing and non-nursing staff.

Results

Nurses had lower moderate-to-vigorous physical activity levels compared to non-nursing staff (25 min/day vs. 45, p  =  .007). There were no differences in daily sedentary time, light activity, or steps between nursing and non-nursing staff. Nurses reported high quality of life scores compared to non-nursing staff (4.4 vs. 4.1, p  =  .02), but similar levels of work-related quality of life, happiness, self-rated health, and well-being.

Conclusion

Nurses working in an office-based care coordination program had lower levels of physical activity but reported a higher overall quality of life than non-nurse work colleagues working in a similar environment. Given known health risks associated with sedentary occupational work and the growing number of care coordination programs, health policies and initiatives aimed at increasing the physical activity levels of care coordination workers is of prime importance.

Caring Transitions - A Care Coordination Intervention to Reduce Suicide Risk Among Youth Discharged From Inpatient Psychiatric Hospitalization

Background: Suicide risk following youth psychiatric hospitalization is of significant concern. This study evaluated Linking Individuals Needing Care (LINC), a theory-driven, comprehensive care coordination approach for youth discharged from crisis services. Aims: To pilot LINC's potential effectiveness in increasing service utilization and decreasing suicide risk. Method: Participants were 460 youth patients who received LINC for approximately 90 days following discharge from crisis services. Service utilization, depressive symptoms, and suicide-related variables were measured at baseline and 30, 60, and 90 days after baseline. Results: Patients significantly increased the use of various beneficial, least restrictive services (individual therapy, medication management, and non-mental health supports) over the 90-day intervention. Significant decreases were observed in depressive symptoms, suicide ideation, and engagement in suicide-related behaviors. Limitations: Absence of a comparison group and nonparticipating families limit causal conclusions and generalizability. Conclusions: LINC may be a promising new approach following inpatient hospitalization that can engage and retain youth in services, likely resulting in improved treatment outcomes. This approach was designed emphasizing patient engagement, suicide risk assessment and management, safety planning, community networking, referral/linkage monitoring, coping and motivational strategies, and linguistic/culturally responsive practices to meet service and support needs of high-risk suicidal youth.

Continuity of Care and Coordination of Care: Can they Be Differentiated?

Introduction

Both care continuity and coordination are considered essential elements of health care system. However, little is known about the relationship between care continuity and coordination. This study aimed to differentiate the concepts of care continuity and coordination by developing and testing the reliability and validity of the Combined Outpatient Care Continuity and Coordination Assessment (COCCCA) questionnaire under the universal coverage health care system in Taiwan from a patient perspective.

Methods

Face-to-face interviews were conducted nationwide with community-dwelling older adults selected via stratified multistage systematic sampling with probability-proportional-to-size process. A total of 2,144 subjects completed the questionnaire, with a response rate of 44.67%.

Results

The 16 items of the COCCCA questionnaire were identified via item analysis and principal component analysis (PCA). The PCA generated five dimensions: three continuity-oriented (interpersonal, information sharing and longitudinal between patients and physicians) and two coordination-oriented (information exchange and communication/cooperation among multiple physicians). The second-order confirmatory factor analysis supported the factor structure and indicated that distinct constructs of care continuity and coordination can be identified.

Conclusion

The COCCCA instrument can differentiate the concepts of care continuity and care coordination and has been demonstrated to be valid and reliable in outpatient care settings from a patient perspective.

Identifying Children With Medical Complexity for Care Coordination in Primary Care Settings

Characteristics of a cohort of 98 children with medical complexity (CMC) insured by Medicaid were identified within an urban/rural pediatric practice for embedded nurse care coordination. Ninety percent of enrolled children fit the predefined requirements of requiring 3 or more subspecialists for their care. Neurology, orthopedic surgery, endocrinology, and gastroenterology were the most frequent subspecialists engaged in longitudinal care. The expected neurodevelopmental disabilities (cerebral palsy, spina bifida, Down syndrome, and other complex syndromes) were found in 64% of the patients. By applying a secondary definition to include children with complex neurodevelopmental or genetic syndromes, 98% of the patients were considered to be medically complex. The use of reliable and adequate criteria to identify medical complexity is important to determine which patients would most benefit from care coordination services, and our method was deemed successful.

Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers

OBJECTIVE

A shared care model was implemented in 2006 in Queensland to facilitate paediatric oncology, haematology and palliative care patients receiving care as close to home as possible. Following initial diagnosis, care planning and treatment at the tertiary children's hospital, appropriate local care was coordinated by Regional Case Managers (RCMs) established at each of 10 Shared Care Units (SCUs). This enabled safe and quality regional care supported by a statewide network providing clinical governance and education. This paper examines learnings from 15 years of this shared care.

SETTING

Ten hospitals throughout Queensland facilitated a statewide model of shared care for paediatric oncology, haematology and palliative care patients, supported by a tertiary hub in Brisbane.

PARTICIPANTS

Regional Case Managers in Shared Care Units and their supporting staff.

DESIGN

Staff from SCUs were surveyed and focus group interviews conducted.

RESULTS

The paper reviews the attributes, knowledge and experience required for RCMs. Standards of care were supported through education workshops, clinical placements, chemotherapy credentialing, guidelines and standards. RCMs facilitated communication and information sharing with the tertiary centre, advocated for their cohort of patients locally and streamlined and supported the family's experience of care.

CONCLUSION

The RCM role provided invaluable clinical leadership for the care of paediatric oncology, haematology and palliative patients across Queensland. As new treatments evolve, the expertise and coordination provided by the RCMs will be even more critical. Achieving high-quality shared care outcomes is underpinned by the RCMs drive to achieve statewide safety and support for this cohort of children.

Is clinical coordination across care levels different according to the secondary care medical speciality? Results from the Catalan health system

BACKGROUND

Despite the scarce evidence, some studies suggest that cross-level clinical coordination may vary among secondary care (SC) doctors, influenced by their speciality and organisational model, including degree of decentralisation to primary care (PC). The aim was to determine the differences in experience and perception of cross-level clinical coordination and related factors according to the SC doctor's speciality in the Catalan health system.

METHODS

Cross-sectional study, based on an on-line survey using the COORDENA-CAT questionnaire, to SC doctors (n = 1666). Descriptive and multivariate analysis were used to compare five groups of SC specialities (decentralised, hospital-based, internists/geriatricians, gynaecologist, and paediatricians), for experience, perception and factors related to coordination.

RESULTS

When comparing with decentralised specialities, hospital-based specialities and internal medicine/geriatrics reported lower care consistency and follow up across levels, while gynaecology and paediatrics, higher accessibility. General perception of cross-level coordination was lower in hospital-based specialities (PR:0.80, 95% CI 0.72-0.89) and higher in gynaecology (PR:1.36, 95% CI 1.18-1.56). Moreover, hospital-based specialities reported a lower use of some coordination mechanisms and lower knowledge of the primary care doctors (PR:0.42, 95% CI 0.23-0.72), while gynaecology a higher knowledge (PR:2.04, 95% CI 1.22-3.45).

CONCLUSIONS

Results show differences in experience, perception of coordination, organisational and interactional factors across specialities. These differences may be explained by their complexity, coordination needs and organisational model. Further research is needed to clarify and understand the causes of such differences and the particular needs of coordination of each speciality to identify strategies to improve cross-level clinical coordination.

The World Health Organization (WHO) Integrated Care for Older People (ICOPE) Framework: A Narrative Review on Its Adoption Worldwide and Lessons Learnt

The World Health Organization (WHO) recently published guidelines on the implementation of a new Integrated Care for Older People (ICOPE) framework in 2017-2019. It is an integrated care framework for the screening, assessment, and management of intrinsic capacity (IC) declines. We aimed to examine where the early adopters of ICOPE are across the world, how these study teams and sites plan to apply the framework or have applied it, and the lessons learnt for future adopters. We systematically searched electronic medical and social sciences databases and grey literature published between 31 October 2017 and 31 March 2022. Records were systematically selected using precise inclusion criteria. There were 18 ICOPE study teams and sites across the 29 selected records. Of the 18 study teams and sites, seven were in the development stage, seven conducted feasibility studies, and four have commenced implementation of interventions that applied the ICOPE framework. Future ICOPE adopters may need to make certain decisions. These include whether to adopt ICOPE in the community setting or other settings, whether to adopt only Step 1 on IC screening or additional ICOPE Steps, whether the ICOPE IC screening tool requires modifications, and whether to use digital health technology. We propose the key factors needed to make these decisions and future research needed.

Primary Care Clinician Perspectives on Patient Navigation to Improve Postpartum Care for Patients with Low Income

Background

Birthing individuals experience significant physical and psychosocial transitions during the postpartum period. Despite amplified health needs, many individuals do not successfully transition from obstetric to primary care. Patient navigation provides a patient-centered solution that has been applied to other health care specialties resulting in improved care coordination and patient engagement for populations in greatest need. Our objective was to understand primary care clinician perspectives regarding the role of navigators in improving postpartum care for individuals with low income.

Methods

In this qualitative investigation, we conducted focus groups with primary care clinicians from family and internal medicine specialties. Semistructured interview guides addressed clinician perceptions of navigator roles during the postpartum period and recommendations for navigator training. Focus group discussions were digitally recorded, transcribed, and analyzed via a constant comparative method.

Results

Twenty-eight primary care clinicians, including 26 physicians and 2 advanced practice registered nurses, participated in 8 focus groups. Participants reported favorable attitudes toward implementation of a postpartum patient navigation program. Themes regarding useful navigation services included streamlining obstetric to primary care transition, enhancing visit effectiveness, creating personalized postpartum care, and providing patient- and clinician-focused education. Recommendations for navigator training included education on basic medical concerns that are common in the postpartum period, health information privacy and electronic health record use, health care systems, and community resources.

Clinical Trial Registration number: NCT03922334.

Conclusions

Primary care clinicians were highly receptive to the concept of patient navigation as a process to improve health in the postpartum period through enhanced care coordination and improved patient knowledge, engagement, and self-efficacy.

Perspectives on Coordinating Health Services for Individuals with Serious Mental Illness - A Qualitative Study

PURPOSE

Individuals with serious mental illness (SMI) might require coordinated health services to meet their healthcare needs. The overall aim of this study was to describe the perspectives of professionals (registered nurses, medical doctors, social educators, and social workers) on care coordination and measures to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI. More specifically, we investigated which measures are taken by employees in municipal health and care services to prevent the deterioration of health conditions and which measures are taken in cases where deterioration occurs despite preventive efforts.

METHOD

The study comprised individual qualitative interviews with professionals employed in municipal health and care services in two Norwegian municipalities. The interview material was analyzed using systematic text condensation.

RESULTS

Three categories and seven subcategories were created in the data analysis: 1) Maintain a stable and meaningful home life, including ensuring proper housing and access to services and assistance in receiving healthcare; 2) Measures to prevent deterioration of the health condition, including close monitoring of symptoms, emergency psychiatric care plans and emergency room calls and visits; and 3) Inpatient care to stabilize acute and severe symptoms, including municipal inpatient care, returning home after inpatient care and a need for shared responsibility for treatment and care.

CONCLUSION

Professionals employed in municipal health and care services coordinate health services to ensure proper and coordinated follow-up of the healthcare needs of individuals with SMI by ensuring housing services and access to the required healthcare. Measures taken when deterioration occurs include monitoring symptoms, use of emergency psychiatric care plans, emergency room contacts, or inpatient care.

Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study

BACKGROUND

As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction.

METHODS

This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups.

RESULTS

VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation.

CONCLUSIONS

The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

Shortening the Time Interval for the Referral of Patients With Soft Tissue Sarcoma to Expert Centers Using Mobile Health: Retrospective Study

BACKGROUND

According to guidelines, all patients with sarcoma must be managed from initial diagnosis at expert sarcoma centers. However, in everyday practice, the time interval to an expert center visit can be long, which delays presentation to an expert multidisciplinary tumor board and increases the risk of inappropriate management, negatively affecting local tumor control and prognosis. The advent of mobile health offers an easy way to facilitate communication and cooperation between general health care providers (eg, general practitioners and radiologists) and sarcomas experts. We developed a mobile app (Sar'Connect) based on the algorithm designed by radiologists from the French Sarcoma Group. Through a small number of easy-to-answer questions, Sar'Connect provides personalized advice for the management of patients and contact information for the closest expert center.

OBJECTIVE

This retrospective study is the first to assess this mobile app's potential benefits in reducing the time interval for patient referral to an expert center according to the initial clinical characteristics of the soft tissue tumor.

METHODS

From May to December 2021, we extracted tumor mass data for 78 patients discussed by the multidisciplinary tumor boards at 3 centers of the French Sarcoma Group. We applied the Sar'Connect algorithm to these data and estimated the time interval between the first medical description of the soft tissue mass and the referral to expert center. We then compared this estimated time interval with the observed time interval.

RESULTS

We found that the use of Sar'Connect could potentially shorten the time interval to an expert center by approximately 7.5 months (P<.001). Moreover, for half (31/60, 52%) of the patients with a malignant soft tissue tumor, Sar'Connect could have avoided inappropriate management outside of the reference center. We did not identify a significant determinant for shortening the time interval for referral.

CONCLUSIONS

Overall, promoting the use of a simple mobile app is an innovative and straightforward means to potentially accelerate both the referral and management of patients with soft tissue sarcoma at expert centers.

An HIT-Supported Care Coordination Framework for Reducing Structural Racism and Discrimination for Patients With ADRD

Black and Latinx Americans are disproportionately at greater risk for having Alzheimer's disease and related dementias (ADRD) than White Americans. Such differences in risk for ADRD are arguably explained through health disparities, social inequities, and historical policies. Structural racism and discrimination (SRD), defined as "macro-level conditions that limit opportunities, resources, and well-being of less privileged groups," have been linked with common comorbidities of ADRD, including hypertension, obesity, diabetes, depression. Given the historical impact of SRD-including discriminatory housing policies resulting in racial residential segregation that has been shown to limit access to education, employment, and healthcare-Black and Latinx populations with ADRD are directly or indirectly negatively affected by SRD in terms of access, quality and cost for healthcare. Emerging studies have brought to light the value of structural-level hospital and public health collaboration on care coordination for improving healthcare quality and access, and thus could serve as a macro-level mechanism for addressing disparities for minoritized racial and ethnic populations with ADRD. This paper presents a conceptual framework delineating how care coordination can successfully be achieved through health information technology (HIT) systems and ultimately address SRD. To address health inequities, it is therefore critical that policy initiatives invest in HIT capacities and infrastructures to promote care coordination, identify patient needs and preferences, and promote engagement of patients with ADRD and their caregivers.

Prevalence and Characteristics of Providers' Care Coordination Communication With Schools

OBJECTIVES

Care coordination between schools and medical providers promotes child health, particularly for children with physical, emotional, and behavioral challenges. The purpose of this study was to assess caregivers' reports of provider-school communication for their children. Further, the study assessed if communication rates varied by child demographic or health conditions.

METHODS

This study was a cross-sectional analysis of the 2016-2017 National Survey of Children's Health focused on school-aged children (age 6-17 years; n = 18,160). Weighted frequencies overall and stratified by provider-school communication status are reported. Multivariable logistic regression examined associations of provider-school communication.

RESULTS

Only 23.5% of the total sample reported provider-school communication. The highest caregiver-reported communication prevalence was for children with diabetes (68.0%). Behavioral/mental health conditions, chronic physical health conditions or having increased medical complexity and needs were significantly associated with increased communication compared to those without these conditions. Odds Ratio (OR) and 95% Confidence Intervals (CI) for children with a behavioral/mental health condition were OR: 1.28; CI: 1.02 to 1.61, for children with a chronic physical health condition were OR: 1.37; CI: 1.15 to 1.63 and for children with special health care needs or with medical complexity were OR: 2.15; CI: 1.75 to 2.64 and OR: 1.77; CI: 1.09 to 2.87, respectively. Significant communication differences existed for every health condition (P < 0.05) except for children who had a blood disorder (P = 0.365).

CONCLUSIONS

Caregiver perception of provider-school communication is low and differences in reported rates existed between health conditions and complexity status. Further work is needed to support provider-school-family communication for children with physical, mental, behavioral, and complex health conditions.

Hospitals serving nursing home residents disproportionately penalized under hospital readmissions reduction program

BACKGROUND

Risk factors common to nursing home (NH) residents are potentially not fully captured by the Hospital Readmissions Reduction Program (HRRP). The unique challenges faced by hospitals that disproportionately serve NH residents who are at greater risk of readmissions have not been studied.

METHODS

Using 100% Medicare Provider Analysis and Review File and the Minimum Data Set from 2010-2013, we constructed a measure of hospital share of NH-originating hospitalizations (NOHs). We defined hospital share of NOHs as the proportion of inpatient stays by patients aged 65 or older who were directly admitted from NHs. To evaluate the impact of the share of NOHs on readmission penalties, we categorized hospitals into quartiles according to their share of NOHs and estimated the differences in the adjusted penalties across hospital quartiles after accounting for hospital characteristics, market characteristics and state fixed effects. We repeated the analyses for the penalties incurred in each year between 2015 and 2019.

RESULTS

Hospitals varied substantially in the share of NOHs (median [interquartile range], 11.3% [8.2%-15.1%]), with limited variation over time. In 2015, hospitals in the highest quartile of NOH received on average 0.58% Medicare payment reduction compared to 0.44% reduction among those in the lowest quartile (32.9% higher penalties, p < 0.001). The increase in penalties continued to grow in 2017 and 2018 when the HRRP expanded to include additional target conditions (47.3% and 66.7%, respectively, p < 0.001 for both). Although the effect diminished in 2019 following the additional adjustment for hospital's dual-eligible share, hospitals in the highest quartile of NOH still incurred 43.0% (p < 0.001) higher penalties than those in the lowest quartile.

CONCLUSIONS

Hospitals varied considerably in their share of NOHs. Hospitals having a higher share of NOHs were disproportionately penalized for excess readmissions, even under the revised policy that adjusts for the share of dual-eligible admissions.

Reasons for Hospitalization while Receiving Dementia Care Coordination through Maximizing Independence at Home

OBJECTIVES

Persons living with dementia (PLWD), particularly those with higher levels of functional impairment, are at increased risk of hospitalization and higher hospital-associated health care costs. Our objective was to provide a nuanced description of reasons for hospitalizations over a 12-month period among community-living persons with dementia taking part in a dementia care coordination study using caregiver-reported data and to describe how reasons varied by disease stage.

DESIGN

Retrospective descriptive analysis of pooled data from 2 concurrent studies of PLWD receiving the MIND at Home dementia care coordination program.

SETTING AND PARTICIPANTS

Four hundred ninety-four community-dwelling PLWD with a family caregiver in the Greater Baltimore and Central Maryland region, 2015‒2019.

METHODS

PLWD sociodemographic, clinical, functional, cognitive, and behavioral characteristics were assessed during an in-home baseline visit. Caregiver-reported hospitalizations and primary reasons for events were recorded every 4.5 months by research staff and by memory care coordinators during program delivery for a 12-month period. Hospitalization event data were subsequently reviewed, reconciled, and coded by a trained investigator.

RESULTS

One hundred seventy PLWD (34.4%) had at least 1 hospitalization within 12 months of enrollment, with 316 separate events. The most common primary reason for hospitalization according to caregivers was infection (22.4%), falls (16.5%), and cardiovascular/pulmonary (12.4%). Top reasons for hospitalization were falls among persons with mild and moderate functional impairment (17.7% and 21.9% respectively) and infection among PLWD with severe impairment (30.3%).

CONCLUSIONS AND IMPLICATIONS

Infections and falls were the most common caregiver-reported reasons for hospitalization in PLWD receiving dementia care coordination. Reasons for hospitalization varied based on severity of functional impairment. Greater understanding of reasons for hospitalization among PLWD receiving dementia care management interventions, from multiple important perspectives, may help programs more effectively address and prevent hospitalization.

Meeting the care needs of people with intellectual and developmental disabilities and their families through the Model of Nursing Based on Activities of Living

AIM

This study aimed to identify the problems families of people with intellectual and developmental disabilities face in meeting their family members' care needs, using the Model of Nursing Based on Activities of Living, and planned implemented and evaluated the nursing interventions to fulfill these care needs.

METHOD

A cross-sectional screening model was used in the study. One hundred families of people with intellectual and developmental disabilities, who accepted home visits between September 2008 and December 2008, were included in the study.

RESULTS

The study revealed a statistically significant difference (p < 0.05) between the Model of Nursing Based on Activities of Living total mean scores of care needs in the pre- (1.69 ± 0.21) and post-nursing intervention (1.50 ± 0.24) periods. Nurse-led interventions for daily life activities of people with intellectual and developmental disabilities and their families were found to be effective (p < 0.05).

CONCLUSION

In line with the Model of Nursing Based on Activities of Living, nurse-led collaboration with families and relevant institutions positively contributed to meeting the care needs of people with intellectual and developmental disabilities and their families.

Barriers and Facilitators to the Implementation of Family-Centered Technology in Complex Care: Feasibility Study

Background

Care coordination is challenging but crucial for children with medical complexity (CMC). Technology-based solutions are increasingly prevalent but little is known about how to successfully deploy them in the care of CMC.

Objective

The aim of this study was to assess the feasibility and acceptability of GoalKeeper (GK), an internet-based system for eliciting and monitoring family-centered goals for CMC, and to identify barriers and facilitators to implementation.

Methods

We used the Consolidated Framework for Implementation Research (CFIR) to explore the barriers and facilitators to the implementation of GK as part of a clinical trial of GK in ambulatory clinics at a children’s hospital (NCT03620071). The study was conducted in 3 phases: preimplementation, implementation (trial), and postimplementation. For the trial, we recruited providers at participating clinics and English-speaking parents of CMC<12 years of age with home internet access. All participants used GK during an initial clinic visit and for 3 months after. We conducted preimplementation focus groups and postimplementation semistructured exit interviews using the CFIR interview guide. Participant exit surveys assessed GK feasibility and acceptability on a 5-point Likert scale. For each interview, 3 independent coders used content analysis and serial coding reviews based on the CFIR qualitative analytic plan and assigned quantitative ratings to each CFIR construct (–2 strong barrier to +2 strong facilitator).

Results

Preimplementation focus groups included 2 parents (1 male participant and 1 female participant) and 3 providers (1 in complex care, 1 in clinical informatics, and 1 in neurology). From focus groups, we developed 3 implementation strategies: education (parents: 5-minute demo; providers: 30-minute tutorial and 5-minute video on use in a clinic visit; both: instructional manual), tech support (in-person, virtual), and automated email reminders for parents. For implementation (April 1, 2019, to December 21, 2020), we enrolled 11 providers (7 female participants, 5 in complex care) and 35 parents (mean age 38.3, SD 7.8 years; n=28, 80% female; n=17, 49% Caucasian; n=16, 46% Hispanic; and n=30, 86% at least some college). One parent-provider pair did not use GK in the clinic visit, and few used GK after the visit. In 18 parent and 9 provider exit interviews, the key facilitators were shared goal setting, GK’s internet accessibility and email reminders (parents), and GK’s ability to set long-term goals and use at the end of visits (providers). A key barrier was GK’s lack of integration into the electronic health record or patient portal. Most parents (13/19) and providers (6/9) would recommend GK to their peers.

Conclusions

Family-centered technologies like GK are feasible and acceptable for the care of CMC, but sustained use depends on integration into electronic health records.

Trial Registration

ClinicalTrials.gov NCT03620071; https://clinicaltrials.gov/ct2/show/NCT03620071

Adaptations to relational facilitation for two national care coordination programs during COVID-19

Background

Adaptations to implementation strategies are often necessary to support adoption and scale-up of evidence-based practices. Tracking adaptations to implementation strategies is critical for understanding any impacts on outcomes. However, these adaptations are infrequently collected. In this article we present a case study of how we used a new method during COVID-19 to systematically track and report adaptations to relational facilitation, a novel implementation strategy grounded in relational coordination theory. Relational facilitation aims to assess and improve communication and relationships in teams and is being implemented to support adoption of two Quadruple Aim Quality Enhancement Research Initiative (QA QUERI) initiatives: Care Coordination and Integrated Case Management (CC&ICM) and the Transitions Nurse Program for Home Health Care (TNP-HHC) in the Veterans Health Administration (VA).

Methods

During 2021-2022, relational facilitation training, activities and support were designed as in-person and/or virtual sessions. These included a site group coaching session to create a social network map of care coordination roles and assessment of baseline relationships and communication between roles. Following this we administered the Relational Coordination Survey to assess the relational coordination strength within and between roles. COVID-19 caused challenges implementing relational facilitation, warranting adaptations. We tracked relational facilitation adaptations using a logic model, REDCap tracking tool based on the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) with expanded Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) dimensions, and member checking. Adaptations were analyzed descriptively and for themes using matrix content analysis.

Results

COVID-19's impact within the VA caused barriers for implementing relational facilitation, warranting eight unique adaptations to the implementation strategy. Most adaptations pertained to changing the format of relational facilitation activities (n = 6; 75%), were based on external factors (n = 8; 100%), were planned (n = 8; 100%) and initiated by the QA QUERI implementation team (n = 8; 100%). Most adaptations impacted adoption (n = 6; 75%) and some impacted implementation (n = 2; 25%) of the CC&ICM and TNP-HHC interventions.

Discussion

Systematically tracking and discussing adaptations to relational facilitation during the COVID-19 pandemic enhanced engagement and adoption of two VA care coordination interventions. The impact of these rapid, early course adaptations will be followed in subsequent years of CC&ICM and TNP-HHC implementation.

Using Video Telehealth to Deliver Patient-Centered Collaborative Care: The G-IMPACT Pilot

Objectives: This pilot project aimed to explore a new model of healthcare delivery to older adult medically complex Veterans by combining telehealth technology with an interdisciplinary medical team operating in real time.Methods: The Geriatric-Interdisciplinary Mobile Patient Access Team (G-IMPACT) was comprised of a field team including a nurse practitioner and technology assistant who visited enrolled patients in their homes using synchronous video to link to a suite of geriatric specialists in a video-enabled room at a Veterans Affairs hospital. Clinicians interacted with patients, caregivers, and each other to develop mutually agreed upon treatment plans that were then immediately implemented in the field.Results: 11 total visits were conducted with 9 Veteran patients aged 55-91 (mean = 75.3 years). Both patients and clinicians reported a high level of satisfaction across multiple metrics, including visit quality, and positive indirect indicators of effectiveness were apparent from qualitative data.Conclusions: Nurse practitioner facilitated video visits allowed geriatric patients to meet with multiple specialists simultaneously with both high patient satisfaction and increased real-time care coordination.Clinical Implications: This project identified challenges and opportunities afforded by this type of real-time telehealth care delivery and can inform the development of future interdisciplinary mobile medical teams.

Care coordination for children with medical complexity and caregiver empowerment in the process: A literature review

PURPOSE

Advances in health care have led to an increase in infants and children being discharged home with increasingly complex conditions. Children with medical complexity require care from many physicians and specialties to thrive in their home environment. While some care coordination programs are in place, these programs are often dependent upon the child living within the geographic area of a major healthcare system. Additionally, children with medical complexity often need specialized care from providers outside the participating healthcare system, placing the onus of care coordination on the child's family. This literature review aimed to examine care coordination programs for children with medical complexity and what tools have been created to empower the child's family in the process.

METHOD

Qualitative and quantitative research studies published from 2015 to 2021 found in Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, and Medline that included a review of a care coordination program for children with medical complexity were included. Nonresearch articles, articles written about adults, or written in languages other than English were excluded. The Johns Hopkins Nursing Evidence-Based Practice grading scale was used to appraise the evidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was utilized to structure this review to deter the risk of bias. A qualitative synthesis was used to analyze and present the results.

CONCLUSIONS

There are varying strategies used to facilitate care coordination of children with medical complexity. Effects of care coordination on the child are inconsistent; however, the child's caregiver considers high-quality care coordination to improve quality of life. There are limited tools available for caregivers of children with medical complexity to coordinate their child's care across healthcare systems. Generalizability is a concern due to the small sample sizes of studies and underrepresentation of non-English speaking families in the research. Risk of bias is possible due to highly engaged families willing to participate in the selected research studies.

PRACTICE IMPLICATIONS

There is an opportunity to develop further and study care coordination tools to empower the caregivers of children with medical complexity.

Caring for Homebound Veterans during COVID-19 in the U.S. Department of Veterans Affairs Medical Foster Home Program

The onset of the COVID-19 pandemic made older, homebound adults with multiple chronic conditions increasingly vulnerable to contracting the virus. The United States (US) Department of Veterans Affairs (VA) Medical Foster Home (MFH) program cares for such medically complex veterans residing in the private homes of non-VA caregivers rather than institutional care settings like nursing homes. In this qualitative descriptive study, we assessed adaptations to delivering safe and effective health care during the early stages of the pandemic for veterans living in rural MFHs. From December 2020 to February 2021, we interviewed 37 VA MFH care providers by phone at 16 rural MFH programs across the US, including caregivers, program coordinators, and VA health care providers. Using both inductive and deductive approaches to thematic analysis, we identified themes reflecting adaptations to caring for rural MFH veterans, including care providers rapidly increased communication and education to MFH caregivers while prioritizing veteran safety. Telehealth visits also increased, MFH veterans were prioritized for in-home COVID-19 vaccinations, and strategies were applied to mitigate the social isolation of veterans and caregivers. The study findings illustrate the importance of clear, regular communication and intentional care coordination to ensure high-quality care for vulnerable, homebound populations during crises like the COVID-19 pandemic.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review

Background

Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans—which typically are difficult to share across care settings and care team members—poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions.

Objective

To review the landscape of e-care plans and care plan–related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions.

Methods

We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards.

Results

We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards.

Conclusions

A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

Patient, caregiving partner, and clinician recommendations for improving heart failure care in the Veterans Health Administration

OBJECTIVE

Heart Failure (HF) care requires substantial care coordination between patients, patients' informal caregivers, and clinicians, but few studies have examined recommendations from all three perspectives. The objective of this study was to understand and identify shared recommendations to improve HF self-care from the perspective of VA persons with HF, their caregiving partners, and clinicians.

METHODS

Secondary data analysis from a study of semi-structured interviews with 16 couples (persons with HF and their caregiving partners) and 13 clinicians (physicians, nurses, other specialists) from a large Veterans Affairs (VA) hospital. Interviews were double-coded, and analyzed for themes around commonly used or recommended self-care strategies.

RESULTS

Three themes emerged: (1) Couples and clinicians believe that improvements are still needed to existing HF education, especially the need to be tailored to learning style and culture, (2) Couples and clinicians believe that technology can facilitate better HF self-care, and (3) Couples and clinicians believe that caregiving partners are part of the self-care team, and should be involved in care management to support the person with HF.

DISCUSSION

Recommendations from couples and clinicians address barriers to HF self-care and encourage patient-centered care.

The Role of Care Coordinators for Children with Respiratory Technologies and Home Nursing

Background: Children with respiratory technologies, particularly those with mechanical ventilation, represent a growing population that require complex home nursing, medical equipment, outpatient medical and habilitative supports to live and thrive in their community. Care coordination is essential to support these children and their families to navigate and integrate key community-based health and educational services, however, care is often fragmented and care coordination needs unmet. Therefore, to fully support children with respiratory technologies, it is critical to understand the role of care coordinators (CCs) and how to sustain this workforce. The aim of this article is to describe CCs' perspective on (1) their role in supporting families in a home care program for children with respiratory technologies and home nursing, and (2) the core components of recruiting into and sustaining the CC workforce. Methods: Semistructured interviews were conducted with 15 CC from the Division of Specialized Care for Children (DSCC) Home Care program for children with technology dependence and home nursing in Illinois. Two independent coders utilized a modified template approach and discussed to agreement to analyze transcripts. Results: CC averaged 6.6 years of CC experience; the majority had social work or nursing backgrounds. CCs' job satisfaction was derived from their role supporting hospital discharge, seeing children improve over time, and navigating challenges with families. CCs enjoyed working in a collaborative environment where they could draw from their colleagues' experience to solve problems. Job dissatisfaction and job turnover stemmed from difficult family interactions, high caseloads, and redundant and time-intensive administrative tasks, which interfered with family engagement. Conclusions: CCs for children with respiratory technologies require diverse skills, but interdisciplinary teams enable collaborative support of families. Seeing children thrive can sustain the workforce, however, CCs report challenges due to high caseloads and administrative tasks, which impede direct family involvement.

From zero to thrive: A model of cross-system and cross-sector relational health to promote early childhood development across the child-serving ecosystem

Early relational health between caregivers and children is foundational for child health and well-being. Children and caregivers are also embedded within multiple systems and sectors, or a "child-serving ecosystem", that shapes child development. Although the COVID-19 pandemic has made this embeddedness abundantly clear, systems remain siloed and lack coordination. Fostering relational health amongst layers of this ecosystem may be a way to systematically support young children and families who are facing adversity. We integrate theory, examples, and empirical findings to develop a conceptual model informed by infant mental health and public health frameworks that illustrates how relational health across the child-serving ecosystem may promote child health and well-being at a population level. Our model articulates what relational health looks like across levels of this ecosystem from primary caregiver-child relationships, to secondary relationships between caregivers and child-serving systems, to tertiary relationships among systems that shape child outcomes directly and indirectly. We posit that positive relational health across levels is critical for promoting child health and well-being broadly. We provide examples of evidence-based approaches that address primary, secondary, and tertiary relational health, and suggest ways to promote relational health through cross-sector training and psychoeducation in the science of early development. This model conceptualizes relational health across the child-serving ecosystem and can serve as a template for promoting child health and well-being in the context of adversity.

Key Care Provision Aspects That Affect Care Transition in the Long-Term Care Systems: Preliminary Review Findings

The aim of this brief report is to present the protocol and preliminary findings of a systematic review on key aspects of care provision that affect care transition of older adults 60+ within the long-term care systems. This brief report describes and classifies the relevant literature found in the review with the purpose to provide a base for further full systematic reviews, and to outlines a model of organizational and financing aspects that affect care transition. Our search was conducted in MEDLINE, Embase and CINAHL on 2 March 2020, before the COVID-19 pandemic. The protocol was registered at the International Prospective Register of Systematic Reviews (number: CRD42020162566). Ultimately, 229 full-text records were found eligible for further deliberation. We observed an increase in the number of publications on organizational and financial aspects of care transition since 2005. Majority of publications came from the United States, United Kingdom and Australia. In total, 213 (92%) publications discussed organizational aspects and only 16 (8%) publications were related to financial aspects. Records on organizational aspects were grouped into the following themes: communication among involved professional groups, coordination of resources, transfer of information and care responsibility of the patient, training and education of staff, e-health, education and involvement of the patient and family, social care, and opinion of patients. Publications on financial aspects were grouped into provider payment mechanisms, incentives and penalties. Overall, our search pointed out various care provision aspects being studied in the literature, which can be explored in detail in subsequent full systematic reviews focused on given aspects. We also present a model based on our preliminary findings, which enables us to better understand what kind of provision aspects affect care transition. This model can be tested and validated in subsequent research. Understating factors that affect care transition is crucial to improve the quality of transitions and ultimately the outcomes for the patients.

Individual-Level and Neighborhood-Level Factors Associated with Longitudinal Changes in Cardiometabolic Measures in Participants of a Clinic-Based Care Coordination Program: A Secondary Data Analysis

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual’s neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning.

Safe care transitions for patients receiving parenteral nutrition

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality and Satisfaction Improvement Project

OBJECTIVE

To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication.

BACKGROUND

Heart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction.

METHODS

A nurse led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum.

RESULTS

Hospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05).

CONCLUSION

Improved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000.

IMPLICATION FOR NURSES

Nurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.

Communication Disparities between Nursing Home Team Members

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Factors Associated With Contracting Between Area Agencies on Aging and Health Care Entities

Contracting with health care entities offers an avenue for Area Agencies on Aging (AAAs) to be reimbursed for providing services that improve health and avoid the need for expensive health care among older adults. However, we have little systematic evidence about the organizational characteristics and policy environments that facilitate these contractual relationships. Using survey data on AAAs from 2017-18, we found that contracting with health insurers was significantly more likely if AAAs had strong business capabilities and access to a state CBO contracting network. AAA contracting with health care delivery organizations trended with different factors, becoming more likely if states had implemented more integrated health care delivery programs, and becoming less likely if states had managed long-term services and supports. Contracting could be facilitated by supports for AAA business capabilities, as well as state policies that increase demand for their services among health insurers and health care delivery organizations.

A Multi-site Case Study of Care Coordination Between Primary Care and Specialty Care

BACKGROUND

Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care.

OBJECTIVES

We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers.

RESEARCH DESIGN

Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care.

SUBJECTS

Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers.

RESULTS

We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care.

DISCUSSION

We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

Hospital Discharge During COVID-19: The Role of Social Resources

CLINICAL TRIAL REGISTRATION

This study is a part of a parent study: Social Needs and Resources in the Evaluation and Enhancement of Discharge Support. The trial registry is clinicaltrials.gov, number NCT04248738. Initial release was 1/27/2020 and the first participant was enrolled on 2/4/2020. Link to the information on the registry: https://clinicaltrials.gov/ct2/show/NCT04248738.

Improving Outcomes for Families of Children With Medical Needs Known to Child Welfare: A Nurse Care Coordination Program

Children known to child welfare are more likely to have poor health compared to the general population. Most children served by child welfare are served in their own homes. New Jersey implemented the Child and Family Nurse Program (CFNP) to provide nurse care coordination to address the health needs of children who remain in-home. Our study described: 1) families served by CFNP; 2) services provided to these families; and 3) family well-being outcomes. The study focused on the 304 families served by CFNP from 2016 to 2017. We used CFNP data to describe families served and services provided, and family baseline and follow-up surveys to assess change in family well-being over time. Families served by CFNP experienced improvements in family protective factors and health-related quality of life from baseline to follow-up. While more rigorous studies are needed to learn CFNP's impact, it is a promising approach that merits consideration by state child welfare leaders.

Optimizing PrEP Continuance: A Secondary Analysis Examining Perceived Autonomy Support and Care Coordination Quality among Black MSM in HPTN 073

At the end of year 2018, it was estimated that in the United States over 1 million people were living with HIV. Although Black/African American individuals comprise an estimated 13.4% of the US population, as of 2019, they represented an estimated 42% of all new HIV diagnoses in 2018. PrEP use among Black men who have sex with men has not reached levels sufficient to have a population impact on HIV incidence. The purpose of this study was to examine whether high perceived autonomy support and care coordination quality were associated with PrEP continuation. Secondary analyses were conducted on data with 226 Black MSM in three US cities. Participants who were PrEP users and scored higher on autonomy support at week 8 were significantly more likely to continue PrEP (OR 1.48; 95% CI 1.04-2.11). Perception of coordination quality did not differ between PrEP users and non-users at any of the visits. Although coordination quality was not statistically significant, greater than half of PrEP users and non-PrEP users utilized the C4 services. Addressing social, individual, and structural barriers to PrEP may benefit Black MSM irrespective of their PrEP use.

What Injured Workers With Complex Claims Look For in Online Communities: Netnographic Analysis

Background

Improved understanding of social constructs around injury may help insurance case managers to understand how best to support people after injury.

Objective

This study sought to explore what people who sustain work-related injuries may seek from online communities. The study highlights potential opportunities for improved engagement with insurance case management practice.

Methods

An observational netnographic analysis was undertaken on anonymous, publicly available messages posted on Australian message boards. All research data were drawn from anonymous, online communities. A person (author SM) with experience of making a claim through an Australian workers’ compensation system and online engagement was involved in study conception, design, and analysis. Data were analyzed using NVivo12 in an iterative, multistage process including coding, journaling, and member checking. A total of 141 people were engaged in discussion across 47 threads housed on 4 Australian forums.

Results

In this qualitative study, themes emerged from the data, describing how injured workers use online communities to help make decisions, get support, and solve problems. The key motivators for action and engagement were seeking information, connection, or justice. Establishment of relationships was a key mediator of each of these parameters.

Conclusions

Some work-related injuries may involve medical and medicolegal complexity as well as changed lifestyle and routine during convalescence and recovery. The mechanism used by some injured workers to seek information and problem solve suggests a capacity for self-management and self-care after work-related injury. Netnography provides information on a community that may not regularly engage with research because of the complexity of their situation and their vulnerability.

Assessing the experience of person-centred coordinated care of people with chronic conditions in the Netherlands: Validation of the Dutch P3CEQ

BACKGROUND

Countries are adapting their health and social care systems to better meet the needs of growing populations with (multiple) chronic conditions. To guide this process, assessment of the 'patient experience' is becoming increasingly important. For this purpose, the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) was developed in the United Kingdom, and translated into several languages.

AIM

This study aimed to assess the internal and construct validity of the Dutch P3CEQ to capture the experience of person-centred coordinated care of people with chronic conditions in the Netherlands.

PARTICIPANTS AND METHODS

Adults with chronic conditions (N = 1098) completed the Dutch P3CEQ, measures of health literacy and patient activation, and reported the use and perceived quality of care services. Data analysis included Principal Component and reliability analysis (internal validity), analysis of variance and Student's T-tests (construct validity).

RESULTS

The two-component structure found was pretty much the same as in the UK validation study. Sociodemographic correlates also resembled those found in the United Kingdom. Women, persons who were less educated, less health-literate or less activated experienced less person-centred coordinated care. P3CEQ scores correlated positively with general practitioner performance scores and quality ratings of the total care received.

CONCLUSION

The Dutch P3CEQ is a valid instrument to assess the experience of person-centred coordinated care among people with chronic conditions in the Netherlands. Awareness of inequity and more attention to communication skills in professional training are needed to ensure that care professionals better recognize the needs of women, lower educated or less health-literate persons, and improve their experiences of care.

PATIENT CONTRIBUTION

The P3CEQ has been developed in collaboration with a range of stakeholders. Eighteen persons with (multiple) chronic conditions participated as patient representatives and codesign experts in (four) codesign workshops. Other patient representatives participated in cognitive testing of the English-language instrument. The usability of the P3CEQ to capture the experience of person-centred coordinated care of older persons has been examined by interviewing 228 older European service users, including 13 living in the Netherlands, as part of the SUSTAIN project. More than a thousand persons with chronic conditions participated in the validation study of the Dutch P3CEQ.

Still Lost in Transition? Perspectives of Ongoing Cancer Survivorship Care Needs from Comprehensive Cancer Control Programs, Survivors, and Health Care Providers

Public health agencies have played a critical role in addressing the complex health and mental health needs of cancer survivors. We conducted a mixed-methods evaluation via a Web-based survey (n = 51) and focus groups (n = 11) with National Comprehensive Cancer Control Program (NCCCP) recipients and interviews (n = 9) with survivors, health care providers (HCPs), and patient navigators to explore these audiences’ cancer survivorship information needs and strategies to improve resource dissemination. Participants revealed a need for tailored resources and support for survivors on healthy lifestyle, post-treatment survivorship concerns, psychosocial health, and navigating the health system. HCP needs included education on survivorship care plans and care coordination to facilitate the transition between oncology and primary care. HCPs were survivors’ most trusted source for information; however, participants noted difficulties engaging HCPs in survivorship care. These findings can help public health practitioners focus their efforts to better meet the needs of cancer survivors and their HCPs.

Multiple Sclerosis: Systemic Challenges to Cost-Effective Care

BACKGROUND

Multiple sclerosis (MS) is a progressive autoimmune disorder of the central nervous system characterized by symptoms including reduced mobility, pain, fatigue, and spasticity. MS affects nearly 1 million people in the United States, with significant negative impact on a patient's quality of life, and an average lifetime cost of care in excess of $4 million. The cost-effective management of patients with MS faces several challenges.

OBJECTIVE

To review the challenges to the cost-effective management of patients with MS, and to offer healthcare stakeholders a roadmap to address them.

DISCUSSION

The cost-effective management of patients with MS, which is driven largely by how quickly a patient receives effective medication therapy, is challenged by a paucity of between-office-visit clinical data, variability of provider expertise with magnetic resonance imaging (MRI), MRI machine quality, lack of standards for MRI machines and reports, misaligned financial incentives, the limited number of available Current Procedural Terminology (CPT) codes for brain MRI, the complexity of disease-modifying therapy (DMT) selection, poor patient adherence to treatment plans, poor communication among providers, and a lack of objective measures of disease progression.

CONCLUSION

Insurers, neurologists, researchers, and patient advocacy groups must address the needs of patients with MS holistically. These efforts should include establishing standards for MRI machines and reports, matching patients with MS specialists, aligning financial incentives, including creating a new CPT code for complex brain MRI, streamlining prior authorization processes of DMTs, using technology to gather patient data and improve coordination of care, and developing better measurement tools of disease activity.

Post-Identification Approaches to Addressing Health-Related Social Needs in Primary Care: A Qualitative Study

BACKGROUND

Social determinants of health play a fundamental role in a patient's health status. In recent years, health systems across the nation have implemented numerous strategies aimed at identifying and addressing the health-related social needs of the patients they serve. Despite the influx of peer-reviewed research highlighting outcomes of specific health-related social needs interventions, the spectrum of practices utilized by primary care clinics has not been established.

OBJECTIVE

To determine the range of ways primary care clinics address health-related social needs after identification and initial contact with a frontline staff person is completed.

DESIGN

We conducted 12 semi-structured, in-person interviews with staff from purposively sampled clinics. If the interview included more than one staff person, all participants were interviewed together.

PARTICIPANTS

Twenty-one administrative staff and frontline clinic personnel with experience in 24 separate primary care clinics in the Minneapolis-St. Paul, Minnesota metropolitan area.

APPROACH

Interviews focused on the range of health-related social needs processes utilized by clinics, including staff titles, referral procedures, and barriers to addressing needs. Interview recordings were transcribed and coded using thematic analysis.

KEY RESULTS

Thematic analysis identified variation in four key areas involving how clinics address patients' health-related social needs after identification and initial contact by frontline staff: clinic personnel involved in addressing needs, clinic referral processes, "resource" and "success" definitions, and barriers to accessing community-based supports.

CONCLUSIONS

This study describes the large variation in primary care clinic practices to address health-related social needs after they are identified. The results suggest challenges to standardization and real-world application of previously published studies. Our findings also highlight the opportunity for improved relationships between health systems and community-based agencies.

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment

INTRODUCTION

The PROMISE study was launched in 2018 to assess and document the implementation of changes to an existing HIV Care Coordination Programme (CCP) designed to address persistent disparities in care and treatment engagement among persons with HIV in New York City. We evaluated provider endorsement of features of the CCP to understand drivers of engagement with the programme.

METHODS

We used a discrete choice experiment to measure provider endorsement of four CCP attributes, including: (1) how CCP helps with medication adherence, (2) how CCP helps with primary care appointments, (3) how CCP helps with issues other than primary care and (4) where CCP visits take place (visit location). Each attribute had three to four levels. Our primary outcomes were relative importance and part-worth utilities, measures of preference for the levels of the four CCP program attributes, estimated using a hierarchical-Bayesian multinomial logit model. All non-medical providers in the core CCP positions of patient navigator, care coordinator and programme director or other administrator from each of the 25 revised CCP-implementing agencies were eligible to participate.

RESULTS

We received responses from 152 providers, 68% of whom identified as women, 49% identified as Latino/a, 34% identified as Black and 60% were 30-49 years old. Visit location (28.6%, 95% confidence interval [CI] 27.0-30.3%) had the highest relative importance, followed by how staff help with ART adherence (24.3%, 95% CI 22.4-26.1%), how staff help with issues other than primary care (24.2%, 95% CI 22.7-25.7%) and how staff help with primary care appointments (22.9%, 95% CI 21.7-24.1%). Within each of the above attributes, respectively, the levels with the highest part-worth utilities were home visits 60 minutes from the program or agency (utility 19.9, 95% CI 10.7-29.0), directly observed therapy (utility 26.1, 95% CI 19.1-33.1), help with non-HIV specialty medical care (utility 26.5, 95% CI 21.5-31.6) and reminding clients about and accompanying them to primary care appointments (utility 20.8, 95% CI 15.6-26.0).

CONCLUSIONS

Ongoing CCP refinements should account for how best to support and evaluate the intensive CCP components endorsed by providers in this study.

Care Coordination for Children with Special Health Care Needs: A Scoping Review to Inform Strategies for Students with Traumatic Brain Injuries

BACKGROUND

Chronic and complex medical issues, including traumatic brain injuries (TBIs), have significant educational implications. The purpose of this study was to identify and summarize the literature on care coordination strategies among health care professionals, educators, and caregivers for children with special health care needs (CSHCN). Clarifying factors that influence care coordination for CSHCN can inform future studies on care coordination for students with TBI. Improved understanding of these factors may lead to better communication, reduction of unmet needs, more efficient service access, and improved long-term outcomes for children.

METHODS

A scoping review was conducted, guided by PRISMA-ScR methodology. Five databases (CINAHL, PSYCINFO, EMBASE, ERIC, PubMed) were searched to identify relevant studies that focused on care coordination and educational settings.

RESULTS

Twelve articles met inclusion criteria. Care coordination interventions for CSHCN used in educational settings focused on relationship-building strategies, clear procedures and roles, and education of members of the school community.

CONCLUSIONS

Findings highlight strategies to coordinate care for CSHCN and factors that may moderate effects of these interventions. Key stakeholders should now study these strategies specifically in children with TBI.