APN-directed transitional home care model: achieving positive outcomes for patients with COPD

Developing an in-depth understanding of patient and caregiver engagement across care transitions from hospital: protocol for a qualitative study exploring experiences in Canada

INTRODUCTION

Patient and caregiver engagement is critical, and often compromised, at points of transition between care settings, which are more common, and more challenging, for patients with complex medical problems. The consequences of poor care transitions are well-documented, both for patients and caregivers, and for the healthcare system. With an ageing population, there is greater need to focus on care transition experiences of older adults, who are often more medically complex, and more likely to require care from multiple providers across settings. The overall goal of this study is to understand what factors facilitate or hinder patient and caregiver engagement through transitions in care, and how these current engagement practices align with a previously developed engagement framework (CHOICE Framework). This study also aims to co-develop resources needed to support engagement and identify how these resources and materials should be implemented in practice.

METHODS AND ANALYSIS

This study uses ethnographic approaches to explore the dynamics of patient and caregiver engagement, or lack thereof, during care transitions across three regions within Ontario. With the help of a front-line champion, patients (n=18-24), caregivers (n=18-24) and healthcare providers (n=36-54) are recruited from an acute care hospital unit (or similar) and followed through their care journey. Data are collected using in-depth semi-structured interviews. Workshops will be held to co-develop strategies and a plan for future implementation of resources and materials. Analysis of the data will use inductive and deductive coding techniques.

ETHICS AND DISSEMINATION

Ethics clearance was obtained through the Western University Research Ethics Board, University of Windsor Research Ethics Board and the University of Waterloo Office of Research Ethics. The findings from this study are intended to contribute valuable evidence to further bridge the knowledge to practice gap in patient and caregiver engagement through care transitions. Findings will be disseminated through publications, conference presentations and reports.

Implications of Transitional Care Interventions on Hospital Readmissions in Patients With Destination Therapy Left Ventricular Assist Devices

BACKGROUND

The rising number of patients with a left ventricular assist device (LVAD) require care management to successfully transition home after implantation. These patients and their families need to manage their heart failure, and the complexities of an LVAD and the associated lifestyle modifications. Translating knowledge of transitional care interventions in patients with chronic diseases to those with an LVAD may provide valuable insight. To help inform the furthering of care transitions in the LVAD patient population, an integrative review was conducted.

AIM

The aim of this review was to explore the transitions of care interventions of care in patients and its potential for application in the destination therapy LVAD.

METHODS

This integrative review was guided by the Whittemore and Knafl's methodology.

RESULTS

A total of 12 articles from 264 retrieved articles met inclusion criteria and were included in the literature review.

DISCUSSION

This review identified that evidence-based transitional care interventions have been shown to decrease avoidable rehospitalization, the associated costs, and improve quality of life when compared to usual care.

IMPLICATIONS FOR PRACTICE

A common feature of transitional care interventions is the inclusion of nurse leadership. Nurses should be prepared to participate in transitional care interventions to optimally improve outcomes for patients with heart failure and potentially those with an LVAD. Additionally, to make transitional care interventions more effective they should be implemented with moderate intensity or greater.

CONCLUSION

This review provided information supporting the trialing of transitional care interventions in patients with an LVAD and suggests pilot research to optimize interventions for this population.

Geriatric Consultation Reduces High-risk Medication Usage at Discharge in Elderly Trauma Patients

Background

Traumatic injury in a growing geriatric population is associated with higher mortality and complication rates. Geriatric consultation (GC) is vital in reducing risk factors that contribute to adverse outcomes. This study aims to determine if receiving a GC had an impact on high-risk medication usage.

Methods

Patients eligible for a GC, age ≥ 65, and length of stay > two days, were identified via a chart review from July 2013 to July 2014 at a Level II trauma center. This population was divided into those with and without a GC. Data collected included demographics, injury severity, medications, delirium, mortality, and readmissions. High-risk medications were defined using the Beers Criteria. Statistical analysis involved using appropriate standard tests to compare groups, including multivariate logistic regression.

Results

Forty-nine of a total of 104 patients received a GC. Groups were comparable on injury severity score, co-morbidities, and high-risk medication use upon admissions. The GC group was 74% less likely to be discharged on high-risk medications than the non-GC group.

Conclusion

GC in elderly trauma patients reduces high-risk medication use upon discharge. Further studies are needed to explore how GC impacts readmission rates and mortality. A multidisciplinary trauma team, including a geriatrician, must exist to address the unique medical, psychological, functional, and social issues of a growing, aged trauma population.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device

BACKGROUND

The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%.

PROBLEM STATEMENT

Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices.

METHODS

Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team.

OUTCOMES

The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%.

IMPLICATIONS FOR PRACTICE

Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

The costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs: A systematic review of international evidence

BACKGROUND

Patients with palliative care needs do not access specialist palliative care services according to their needs. Clinical Nurse Specialists working across a variety of fields are playing an increasingly important role in the care of such patients, but there is limited knowledge of the extent to which their interventions are cost-effective.

OBJECTIVES

To present results from a systematic review of the international evidence on the costs, resource use and cost-effectiveness of Clinical Nurse Specialist-led interventions for patients with palliative care needs, defined as seriously ill patients and those with advanced disease or frailty who are unlikely to be cured, recover or stabilize.

DESIGN

Systematic review following PRISMA methodology.

DATA SOURCES

Medline, Embase, CINAHL and Cochrane Library up to 2015. Studies focusing on the outcomes of Clinical Nurse Specialist interventions for patients with palliative care needs, and including at least one economic outcome, were considered. The quality of studies was assessed using tools from the Joanna Briggs Institute.

RESULTS

A total of 79 papers were included: 37 randomized controlled trials, 22 quasi-experimental studies, 7 service evaluations and other studies, and 13 economic analyses. The studies included a wide variety of interventions including clinical, support and education, as well as care coordination activities. The quality of the studies varied greatly.

CONCLUSION

Clinical Nurse Specialist interventions may be effective in reducing specific resource use such as hospitalizations/re-hospitalizations/admissions, length of stay and health care costs. There is mixed evidence regarding their cost-effectiveness. Future studies should ensure that Clinical Nurse Specialists' roles and activities are clearly described and evaluated.

Informal caregivers of patients with COPD: Home Sweet Home?

The burden of chronic obstructive pulmonary disease (COPD) on society is increasing. Healthcare systems should support patients with COPD in achieving an optimal quality of life, while limiting the costs of care. As a consequence, a shift from hospital care to home care seems inevitable. Therefore, patients will have to rely to a greater extent on informal caregivers. Patients with COPD as well as their informal caregivers are confronted with multiple limitations in activities of daily living. The presence of an informal caregiver is important to provide practical help and emotional support. However, caregivers can be overprotective, which can make patients more dependent. Informal caregiving may lead to symptoms of anxiety, depression, social isolation and a changed relationship with the patient. The caregivers' subjective burden is a major determinant of the impact of caregiving. Therefore, the caregiver's perception of the patient's health is an important factor. This article reviews the current knowledge about these informal caregivers of patients with COPD, the impact of COPD on their lives and their perception of the patient's health status.

[Differential features of DRG 541 readmitting patients]

OBJECTIVE

Hospital readmission is considered an adverse outcome, and the hospital readmission ratio is an indicator of health care quality. Published studies show a wide variability and heterogeneity, with large groups of patients with different diagnoses and prognoses. The aim of the study was to analyse the differences between patients readmitted and those who were not, in patients grouped into the diagnosis related group (DRG) 541.

MATERIAL AND METHOD

A retrospective observational study was conducted on DRG 541 patients discharged in 2010. Readmission is defined as any admission into any hospital department, and for any reason at ≤30 days from discharge. An analysis was performed that included age, sex, day of discharge, month of discharge, number of diagnoses and drugs at discharge, respiratory depressant drugs, length of stay, requests for consultations/referrals, Charlson comorbidity index, feeding method, hospitalisations in the previous 6 months, albumin and haemoglobin levels and medical examinations within 30 days after discharge.

RESULTS

Of the 985 patients included in the study, 189 were readmitted. On multivariate analysis, significant variables were: Haemoglobin -0.6g/dl (95% confidence interval [95%CI] -0.9 to -0.3), gastrostomy feeding odds ratio (OR) 5.6 (95%CI: 1.5 to 21.6), hospitalisations in previous 6 months OR 1.9 (95%CI: 1.3 to 2.8), visits to emergency department OR 17.4 (95%CI: 11.3 to 26.8), medical checks after discharge OR 0.4 (95%CI: 0.2 to 0.8).

CONCLUSIONS

DRG 541 readmitting patients have some distinctive features that could allow early detection and prevent hospital readmission.

Measurement of activities of daily living in patients with COPD: a systematic review

BACKGROUND

The objectives of this systematic review were to synthesize the literature on measures of activities of daily living (ADLs) that have been used in individuals with COPD and to provide an overview of the psychometric properties of the identified measures and describe the relationship of the disease-specific instruments with other relevant outcome measures for individuals with COPD and health-care use.

METHODS

Studies that included a measure of ADLs in individuals with COPD were identified using electronic and hand searches. Two investigators performed the literature search. One investigator reviewed the study title, abstract, and full text of the articles to determine study eligibility and performed the data extraction and tabulation. In cases of uncertainty, a second reviewer was consulted.

RESULTS

A total of 679 articles were identified. Of those, 116 met the inclusion criteria. Twenty-seven ADLs instruments were identified, of which 11 instruments were respiratory disease-specific, whereas 16 were generic. Most instruments combined instrumental ADLs (IADLs) with basic ADLs (BADLs). The majority of the instruments were self-reported; only three instruments were performance based. Twenty-one studies assessed psychometric properties of 16 ADLs instruments in patients with COPD.

CONCLUSIONS

Although several ADLs instruments were identified, psychometric properties have only been reported in a few. Selection of the most appropriate measure should focus on the target construct (BADLs or IADLs or both), type of test (disease-specific vs generic and self-reported vs performance-based), depth of information obtained, and psychometric properties of the instruments. Given the relevance of ADLs to the lives of patients with COPD, its assessment should be more frequently incorporated as a clinical outcome in their management.

WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

This review is now out of date although it is correct as of the date of publication [Issue 2, 2008]. The authors are developing a new protocol which will replace this review. Publication of the protocol is expected in 2014, and serves to update the existing review and incorporate the latest evidence into a new Cochrane Review. The latest version of this review (available in 'Other versions' tab on The Cochrane Library) may still be useful to readers until the new review is published.

In 2016, the replacement review titled 'Non‐pharmacological interventions for breathlessness in advanced stages of malignant and non‐malignant diseases' was deregistered and split into four separate reviews of individual interventions: Respiratory interventions for breathlessness in adults with advanced diseases; Physical interventions for breathlessness in adults with advanced diseases; Cognitive‐emotional interventions for breathlessness in adults with advanced diseases; Multi‐dimensional interventions for breathlessness in adults with advanced diseases.

At September 2020, these replacement titles were deregistered (Multi‐dimensional interventions) or the protocols withdrawn (Cognitive‐emotional interventions; Multi‐dimensional interventions; Respiratory interventions) as they did not meet Cochrane standards or expectations.

The editorial group responsible for this previously published document have withdrawn it from publication.

Exploring Best Practices in Home Health Care

This article summarizes publicly available research related to outcomes and best practices in skilled home health and other kinds of home-based care. As the population ages and the home health care sector grows, the home health community must address current deficiencies in care and expand the use of evidence-based strategies to improve the quality and efficiency of care. Many promising innovations in service delivery currently exist, a wide variety of which have been tested and evaluated in postacute and long-term care settings. Our review found that home health agencies are well positioned to improve patient outcomes through a variety of approaches, including care coordination, telehealth, and data-driven quality of care monitoring. For the most part, evaluations of these interventions show that they can improve patient outcomes and/or cost-effectiveness.

Chronic care management for patients with COPD: a critical review of available evidence

RATIONALE, AIMS AND OBJECTIVES

Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow-up, and number of intervention components.

METHODS

We performed a review of previously published reviews and meta-analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta-regression analyses were performed to explain the variances among the primary studies.

RESULTS

Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta-regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow-up did not significantly explain heterogeneity.

CONCLUSIONS

This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management.

Home care by outreach nursing for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow obstruction, worsening exercise performance and health deterioration. It is associated with significant morbidity, mortality and health system burden.

OBJECTIVES

To evaluate the effectiveness of outreach respiratory health care worker programmes for COPD patients in terms of improving lung function, exercise tolerance and health related quality of life (HRQL) of patient and carer, and reducing mortality and medical service utilisation.

SEARCH METHODS

The Cochrane Airways Group Specialised Register of Trials was searched (November 2011). Study references were hand-searched for additional studies we contacted study authors to identify other unpublished studies.

SELECTION CRITERIA

We included only randomised controlled trials of COPD patients. We included interventions involving an outreach nurse visiting patients in their homes, providing support, education, monitoring health and liaising with physicians. Studies in which the therapeutic intervention under test was physical training were not included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We pooled mortality data from eight studies and found a non-significant reduction in mortality at 12 months (OR 0.72, 95% CI 0.45 to, 1.15).We pooled four studies that assessed disease-specific heath-related quality of life (HRQL) and found a statistically significant improvement in HRQL (mean difference -2.61, 95% CI -4.82 to -0.40).Hospitalisations were reported in five studies. Although there was no statistically significant difference in the number of hospitalisations (OR 1.01, 95% CI 0.71 to 1.44), there was significant heterogeneity. Although this heterogeneity appeared to be caused by one outlying study with a statistically significant decrease in hospitalisations in patients receiving home care, whereas the other studies showed a non-significant increase in hospitalisations, we could not draw firm conclusions about why this heterogeneity exists. Data on GP visits and emergency department presentations were available, however no consistent effect in these was observed with the intervention. The intervention also incurred higher health care costs than standard care as reported in a single study.Very few studies provided data on lung function or exercise performance, so there was insufficient evidence to assess impact on these outcomes.

AUTHORS' CONCLUSIONS

Outreach nursing programmes for COPD improved disease-specific HRQL. However the effect on hospitalisations was heterogeneous, reducing admissions in one study, but increasing them in others, therefore we could not draw firm conclusions for this outcome.

A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adult patient receiving home care services

BACKGROUND

Continuity of care, a concept that in its broadest terms describes patient and provider coordination across time and settings, has evidenced a positive correlation with patient satisfaction and hospital readmission rates. Home health care, where patients receive care from a variety of healthcare practitioners, is one area where these measures are being investigated to determine the effectiveness of continuity of care.

OBJECTIVE

To examine and synthesize the best available evidence related to the effectiveness of continuity of care interventions and their impact on patient satisfaction and all-cause hospital readmissions rates in the adult patient who is receiving home care services.

INCLUSION CRITERIA

Male and female aged 18 years or older receiving home care services, regardless of diagnosis, stage or severity of disease, co-morbidities, or previous treatment received.All types and models of interventions for continuity of care delivered by nurses to patients receiving home care services were considered for inclusion in the review.Patient satisfaction and hospital readmissions.In this review randomised controlled trials were considered for inclusion. In their absence, other research designs, such as non-randomised controlled trials, quasi-experimental studies, and before and after studies were considered for inclusion.

SEARCH STRATEGY

Published and unpublished literature in the English language was sought from the inception of the databases through November 1, 2011.The databases searched included: Academic Search Premier, CINAHL ERIC, Health Reference Center Academic, MEDLINE via PubMed, ProQuest Nursing and Allied Health Source, ProQuest Health Management, Cochrane Central Register of Controlled Trials, EMBASE, Health Source Nursing Academic, PsycINFO and Bio-Med. A search of the grey literature and virtual hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Two reviewers evaluated the included studies for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute.

DATA COLLECTION

Data were extracted using standardised data extraction instruments from the Joanna Briggs Institute.

DATA SYNTHESIS

Statistical pooling via meta-analysis was not possible. The results are presented in narrative form.

RESULTS

Two randomised controlled trails and two quasi-experimental studies were included in this review. In one randomised controlled trial, 66% of patients rated their overall satisfaction with care as very good or excellent as compared with 63% of those receiving usual care at 24 months (p=0.31). Another randomised controlled trial reported no statistically significant difference between groups (p value not reported). In one quasi-experimental study there was higher satisfaction rate amongst intervention patients with a mean difference of 16.88 (95%CI[16.32, 17.43] compared with 14.65 (95%CI[13.61, 15.68] in the control group (p=0.001).In one randomised controlled trial there was no statistically significant difference between intervention and control groups in hospital admission rates per 1000 at year two (700 vs. 740; p=0.66). Another randomised controlled trial showed no difference in readmissions at 90 days between groups (36% vs. 35%; no p value reported). In one quasi-experimental study, the mean number of hospital readmissions per patient was higher in the intervention group compared to the control group (0.75; 95% CI[ 0.47, 1.03] vs. 0.66; 95% CI[ 0.40, 0.91]; p=0.599), In another quasi-experimental study, a statistically significant higher number of intervention group patients in the intervention group were discharged and remained at home (34 or 82.9%), compared to the control group (20 or 51.3%) (p<0.05).

CONCLUSIONS

Home care interventions that include nurses and advanced practice nurses with specialised training in the care of the population served as the direct provider along with collaboration with an interdisciplinary team in a high-risk patient populations contributed to reduced hospital readmission rates. The outcomes of the included studies suggest that consistently scheduled home care services promote patient satisfaction.This review concluded that the utilisation of an advanced practice nurse with specialised training in a specific disease process in collaboration with a multidisciplinary team can affect readmission rates and patient satisfaction.Further research is needed that captures a diverse patient population in terms of age and illness and the role that an advanced practice nurse can play.

Home care by outreach nursing for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow obstruction, worsening exercise performance and health deterioration. It is associated with significant morbidity, mortality and health system burden.

OBJECTIVES

To evaluate the effectiveness of outreach respiratory health care worker programmes for COPD patients in terms of improving lung function, exercise tolerance and health related quality of life (HRQL) of patient and carer, and reducing mortality and medical service utilisation.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register of Trials was searched (November 2009). Study references were hand-searched for additional studies we contacted study authors to identify other unpublished studies.

SELECTION CRITERIA

We included only randomised controlled trials of COPD patients. We included interventions involving an outreach nurse visiting patients in their homes, providing support, education, monitoring health and liaising with physicians. Studies in which the therapeutic intervention under test was physical training were not included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included five new studies in this update, resulting in a total of nine included studies.We pooled mortality data from eight studies and found a non-significant reduction in mortality at 12 months (OR 0.72, 95% CI 0.45 to, 1.15).We pooled four studies that assessed disease-specific heath-related quality of life (HRQL) and found a statistically significant improvement in HRQL (mean difference -2.61, 95% CI -4.82 to -0.40).Hospitalisations were reported in five studies. Although there was no statistically significant difference in the number of hospitalisations (OR 1.01, 95% CI 0.71 to 1.44), there was significant heterogeneity. Although this heterogeneity appeared to be caused by one outlying study with a statistically significant decrease in hospitalisations in patients receiving home care, whereas the other studies showed a non-significant increase in hospitalisations, we could not draw firm conclusions about why this heterogeneity exists. Data on GP visits and emergency department presentations were available, however no consistent effect in these was observed with the intervention. The intervention also incurred higher health care costs than standard care as reported in a single study.Very few studies provided data on lung function or exercise performance, so there was insufficient evidence to assess impact on these outcomes.

AUTHORS' CONCLUSIONS

Outreach nursing programmes for COPD improved disease-specific HRQL. However the effect on hospitalisations was heterogeneous, reducing admissions in one study, but increasing them in others, therefore we could not draw firm conclusions for this outcome.

Structured review: evaluating the effectiveness of nurse case managers in improving health outcomes in three major chronic diseases

AIM

This paper presents the findings of a review and appraisal of the evidence for the effectiveness of nurse case management in improving health outcomes for patients living either with Diabetes, Chronic Obstructive Pulmonary Disease or Coronary Heart Disease.

BACKGROUND

Long term chronic health conditions provide some of the greatest challenges to western health care systems. In the UK, three of the most significant chronic conditions are Diabetes, Chronic Obstructive Pulmonary Disease and Coronary Heart Disease. Patients with these long term conditions are high users of health services who often receive unplanned, poorly co-ordinated, ad-hoc care in response to an exacerbation or crisis. To counter this, the nurse case manager is identified as a central aspect of improving care for these patients. However, the evidence for the effectiveness of nurse case management in improving health outcomes for the chronically ill is scarce.

DESIGN

A structured review of the literature.

METHOD

The review was undertaken focussing on studies that evaluated nurse case management with one or all of the three major long term chronic conditions. A total of 108 papers were initially reviewed and filtered to leave 75 citations that were appraised. About 18 papers were finally included in the review and subject to thematic analysis based on the health outcomes evaluated in the studies.

RESULTS

Significantly positive results were reported for nurse case management impact on five health outcomes; 'objective clinical measurements', 'quality of life and functionality', 'patient satisfaction', 'adherence to treatment' and 'self care and service use'.

RELEVANCE TO CLINICAL PRACTICE

The evidence generated in this review suggests that nurse case managers have the potential to achieve improved health outcomes for patients with long term conditions. Further research is required to support role development and create a more targeted approach to the intervention.

A systematic review of integrated use of disease-management interventions in asthma and COPD

BACKGROUND

The effectiveness of multiple interventions in asthma and chronic obstructive pulmonary disease (COPD) is unclear.

OBJECTIVE

To examine the effectiveness of multiple interventions as compared to single interventions or usual care on health outcomes and health care utilisation within the context of integrated disease management in asthma and COPD.

METHODS

MEDLINE and the Cochrane Library (1995-May 2008) were searched for controlled trials. Two reviewers independently extracted data and assessed study quality. Meta-analyses were performed on quality of life and health care utilisation data. Furthermore, the effects of multiple interventions versus single interventions and usual care were assessed qualitatively.

RESULTS

Of the 36 studies included, 17 targeted double interventions (patient-related and organisational interventions); 19 studies performed triple interventions (patient-related, professional-directed and organisational interventions). They were heterogeneous in terms of (combinations of) interventions, outcomes measured, study design and setting. Pooled data showed that studied disease management programmes significantly improved quality of life on several domains. Patients within triple intervention programmes had less chance of at least one hospital admission compared with usual care. No significant effects were found in number of emergency department visits. Qualitative analyses revealed positive trends on process improvements and satisfaction. Inconclusive results were reported on symptoms; no effects were found in lung function.

CONCLUSION

In spite of the heterogeneity of disease management studies in asthma and COPD care, this review showed promising improvements in quality of life and reductions in hospitalisations, especially for triple intervention programmes.

Can home visits help reduce hospital readmissions? Randomized controlled trial

AIM

This paper is a report of a study to determine whether home visits can reduce hospital readmissions. Background. The phenomenon of hospital readmission raises concerns about the quality of care and appropriate use of resources. Home visits after hospital discharge have been introduced to help reduce hospital readmission rates, but the results have not been conclusive.

METHOD

A randomized controlled trial was carried out from 2003 to 2005 . The control group (n = 166) received routine care and the study group (n = 166) received home visits from community nurses within 30 days of hospital discharge. Data were collected at baseline before discharge and 30 days after discharge.

FINDINGS

Patients in the study group were statistically significantly more satisfied with their care. There were no statistically significant differences in other outcomes, including readmission rate, ADL score, self-perceived life satisfaction and self-perceived health. Regression analysis revealed that self-perceived life satisfaction, self-perceived health and disease category other than general symptoms were three statistically significant variables predicting hospital readmissions.

CONCLUSION

Preventive home visits were not effective in reducing hospital readmissions, but satisfaction with care was enhanced. Subjective well-being is a key variable that warrants attention in the planning and evaluation of postdischarge home care.

Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

BACKGROUND

Breathlessness is a common and distressing symptom in the advanced stages of malignant and non-malignant diseases. Appropriate management requires both pharmacological and non-pharmacological interventions.

OBJECTIVES

The primary objective was to determine the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease.

SEARCH STRATEGY

We searched the following databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness in June 2007. We also searched various websites and reference lists of relevant articles and textbooks.

SELECTION CRITERIA

We included randomised controlled and controlled clinical trials assessing the effects of non-pharmacological and non-invasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure or motor neurone disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed relevant studies for inclusion. Data extraction and quality assessment was performed by three review authors and checked by two other review authors. Meta-analysis was not attempted due to heterogeneity of studies.

MAIN RESULTS

Forty-seven studies were included (2532 participants) and categorised as follows: single component interventions with subcategories of walking aids (n = 7), distractive auditory stimuli (music) (n = 6), chest wall vibration (CWV, n = 5), acupuncture/acupressure (n = 5), relaxation (n = 4), neuro-electrical muscle stimulation (NMES, n = 3) and fan (n = 2). Multi-component interventions were categorised in to counselling and support (n = 5), breathing training (n = 3), counselling and support with breathing-relaxation training (n = 2), case management (n = 2) and psychotherapy (n = 2). There was a high strength of evidence that NMES and CWV could relieve breathlessness and moderate strength for the use of walking aids and breathing training. There is a low strength of evidence that acupuncture/acupressure is helpful. There is not enough data to judge the evidence for distractive auditory stimuli (music), relaxation, fan, counselling and support, counselling and support with breathing-relaxation training, case management and psychotherapy. Most studies have been conducted in COPD patients, only a few studies included participants with other conditions.

AUTHORS' CONCLUSIONS

Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.

Patients with Complex Chronic Diseases: perspectives on supporting self-management

A Complex Chronic Disease (CCD) is a condition involving multiple morbidities that requires the attention of multiple health care providers or facilities and possibly community (home)-based care. A patient with CCD presents to the health care system with unique needs, disabilities, or functional limitations. The literature on how to best support self-management efforts in those with CCD is lacking. With this paper, the authors present the case of an individual with diabetes and end-stage renal disease who is having difficulty with self-management. The case is discussed in terms of intervention effectiveness in the areas of prevention, addiction, and self-management of single diseases. Implications for research are discussed.

Relationships of rurality, home health care use, and outcomes

Rural elders have a disproportionate prevalence of illness and limited access to health services. The purpose of this study is to determine whether degree of rurality and home health care use influences home health care patient outcomes. An adaptation of the Outcomes Model for Health Care Research provided the framework for the study. A stratified random sample was selected from a database of risk-adjusted publicly reported patient outcomes from Medicare-certified home health care agencies and merged with agency factors from Medicare cost reports and U.S. Census data. Path analysis was performed to evaluate the relationships in the model. Hospitalization is the only outcome variable associated with community and agency characteristics or home health care use. Rurality does not have a direct effect on hospitalization; however, increased visits per patient and low-income community status are associated with increased hospitalization. Rurality may not have a direct effect on outcomes but instead acts through health care services.

Transitional care: a critical dimension of the home healthcare quality agenda

Focusing on the critical transitions of patients and their caregivers across healthcare settings and among providers is a promising approach to enhancing care coordination and improving quality. This article describes the research base for the transitional care of older adults and offers recommendations to advance the science, translate best practices into home healthcare settings, and improve the transitions of high-risk older adults to and from home healthcare. Home healthcare is a component of the healthcare industry uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs.

Home health care nursing research priorities

The purpose of this study was to determine research priorities for home health care nursing. A Delphi study was undertaken to generate and prioritize research topics. The first round consisted of members of the Home Health Nurses Association Research Committee (n = 27); subsequent rounds also included nurse researchers who had conducted research in home health care (n = 17). Consensus emerged after three rounds, with the four most important priorities identified as outcomes, health policy, the use of advanced practice nurses, and models of care/best practice. These areas are consistent with the regulatory events in home health care in the last 10 years.

Hospital Readmission From a Transitional Care Unit

The purpose of this project was to characterize patients readmitted to the hospital during a stay in a transitional care unit (TCUT). Typically, readmitted patients were females, widowed, with 8 medical diagnoses, and taking 12 different medications. Readmission from the TCU occurred within 7 days as a result of a newly developed problem. Most patients did not return home after readmission from the TCU. Understanding high-risk patients' characteristics that lead to costly hospital readmission during a stay in the TCU can assist clinicians and healthcare providers to plan and implement timely and effective interventions, and help facility personnel in fiscal and resource management issues.