Care coordination for chronic and complex health conditions: An experienced based co-design study engaging consumer and clinician groups for service improvement

Background

Evidence shows that engaging consumers and clinicians in development of health services creates a more responsive, integrated service that better meets the needs of consumers and the community of practice it serves. Further, consumer and clinician participation in service development processes can boost confidence and motivation levels in organisational employees and help foster clinical accountability.

Objective

To see where consumers’ care experiences could be improved by better understanding where care coordination organisational systems needed improvement.

Methods

Experienced based co-design informed an investigation of consumer and clinician experiences of a care coordination service and involved the sharing of those experiences across service employees in a series of iterative and feedback loops over eighteen months (July 2012-January 2014). Formal participants included care coordination clinicians (n = 13) and consumers. Data from formal participants were collected during September-December 2012, consisting of consumer video-recorded and clinician audio-recorded interviews. Interview transcriptions were analysed to identify service “touch points”, being emotionally significant events related to key service aspects that connect or disconnect consumers and/or clinicians.

Results

Results revealed that consumers highly valued the transdisciplinary skill base of the care coordination workforce, though service improvements were needed for transition support, quality discharge planning and conveying better understandings of care coordination activity both internally and externally.

Conclusion

Incorporating consumer and clinician view-points about their experiences, including the production of a DVD, facilitated conversations across the entire service about care coordination provision and provided a catalyst for design improvement that may otherwise have been difficult to achieve. Some changes to the service were made such as improved client complaints processes, new roles for the care coordination service, and enlisting clinical staff to undertake motivational interviewing training to promote greater consumer self-management capacity. In this study, the user experience was given a platform within a larger healthcare workforce capability development project.

Activity-based funding for safety and quality: A policy discussion of issues and directions for nursing-focused health services outcomes research

Aims

A discussion of the implications and opportunities arising from the Commonwealth of Australia health care reform agenda; linking pricing with quality, with particular reference to directions for nursing‐focused health services outcomes research directed to improve the safety and quality of health care practices.

Background

National activity‐based funding in Australia is a policy‐focused development. As the relationship between cost and quality becomes apparent, the role of clinicians and their contribution to high quality care has become a pressing issue for leadership, teaching, and research.

Design

Discussion paper

Data Sources

This paper is based on seven years' experience as a member of a Commonwealth of Australia statutory committee—the Clinical Advisory Committee of the Independent Hospital Pricing Authority—and is supported by relevant literature and theory.

Implications for Nursing

To date, unravelling the linkage, especially causal relationships, between direct care nursing and patient safety outcomes has not been well established. New activity‐based funding data elements developed for national implementation in Australia provide accessible and meaningful standardised data for measurement of never events, hospital‐acquired complications, and preventable readmissions.

What is already known about this topic?

The advancement of research directed towards finding causal associations attributing nursing interventions to patient outcomes has been constrained by, amongst other things, methodological challenges

The attribution of nursing care interventions to specific patient‐related outcomes is difficult to isolate

Investigating how nursing care interventions contribute to safety and quality health care outcomes is often referred to as the “black box” of nursing‐focused health services outcomes research

What this paper adds?

Research into the impact of nursing interventions on patient outcomes, such as hospital‐acquired complications, remains immature

Activity‐based funding data provide safety and quality measures relevant to nursing‐focused health services outcomes research

Building clinical‐decision support, based on the Australian Commission for Safety and Quality in Healthcare hospital‐acquired complication outcome measures, may assist nurses engage with quality improvement as nurses are likely to act on data relevant to their practice

The implications of this paper:

The Australian Commission for Safety and Quality in Healthcare hospital‐acquired complication outcome measures have enhanced data specifications, useful to support development of nursing‐focused health services outcomes research

The potential for benchmarking of hospital‐acquired complications is high at least in Australia and in other countries that apply activity‐based funding models linked to ICD‐10‐AM codes

Nursing-sensitive indicators: a concept analysis

AIM

To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting.

BACKGROUND

The concept of 'nursing sensitive indicators' is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice.

DESIGN

Concept analysis.

DATA SOURCES

Using 'clinical indicators' or 'quality of nursing care' as subject headings and incorporating keyword combinations of 'acute care' and 'nurs*', CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000-2012. Only primary research articles were selected.

METHODS

A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research.

RESULTS

The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care.

CONCLUSION

This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

Building workforce capacity for complex care coordination: a function analysis of workflow activity

BACKGROUND

The care coordination workforce includes a range of clinicians who manage care for patients with multiple chronic conditions both within and outside a hospital, in the community, or in a patient's home. These patients require a multi-skilled approach to support complex care and social support needs as they are typically high users of health, community, and social services. In Australia, workforce structures have not kept pace with this new and emerging workforce. The aim of the study was to develop, map, and analyse workforce functions of a care coordination team.

METHODS

Workflow modelling informed the development of an activity log that was used to collect workflow data in 2013 from care coordinators located within the care coordination service offered by a Local Health Network in Australia. The activity log comprised a detailed classification of care coordination functions based on two major categories - direct and indirect care. Direct care functions were grouped into eight domains. A descriptive quantitative investigation design was used for data analysis. The data was analysed using univariate descriptive statistics with results presented in tables and a figure.

RESULTS

Care coordinators spent more time (70.9%) on direct care than indirect care (29.1%). Domains of direct care that occupied the most time relative to the 38 direct care functions were 'Assessment' (14.1%), 'Documentation' (13.9%), 'Travel time' (6.3%), and 'Accepting/discussing referral' (5.7%). 'Administration' formed a large component of indirect care functions (14.8%), followed by 'Travel' (12.4%). Sub-analyses of direct care by domains revealed that a group of designated 'core care coordination functions' contributed to 40.6% of direct care functions.

CONCLUSIONS

The modelling of care coordination functions and the descriptions of workflow activity support local development of care coordination capacity and workforce capability through extensive practice redesigns.

Nurse staff allocation by nurse patient ratio vs. a computerized nurse dependency management system: a comparative cost analysis of Australian and New Zealand hospitals

Coding, costing, and accounting for nursing care requirements in Australian public and private hospitals lacks systematic research. Nurse costing for two nurse staffing allocation methods--nurse patient ratios and a computerized nurse dependency management system--were compared. Retrospective nursing workload management data were obtained from hospital information systems in 21 acute care public and private hospitals in Australia and New Zealand. Descriptive statistics, cost analysis, and cost modeling were conducted for 103,269 shifts of nursing care. The comparison of costs for nursing staff by nurse-patient ratios and by a computerized nurse dependency management system demonstrated differences. The provision of nursing care using the computerized nurse dependency management system was, overall, lower in cost than for nurse-patient ratios.

Foundations for a nursing services reference model

The Nursing Services Reference Model (NSRM) is presented as a theoretical position and discussion paper. The aims are to describe the components of the NSRM concept, to explain why such a model needs to be developed and to explore methodological issues in the development of a NSRM. The concept is important to address as it may illuminate a most pressing problem faced by the Australian health care industry where the content and activity of nursing practice is not embedded as computer processable data in health information system structures. Digital documentation of nursing content and activity is urgently needed to enable reliable electronic processing of nursing services. However, it is necessary, prior to this, to develop a reference model that describes the range of nursing services in an unambiguous manner.

An analysis of high-cost users at an Australian public health service organization

High-cost users generate extremely high costs when compared with average users in the same diagnostic-related group (DRG). They represent a major financial loss for a health service organization. The research was conducted using an area health service patient database for online analytical processing to produce descriptive statistics and graphs of 'high-cost' and 'non-high-cost users'. Trends and patterns were identified across key variables derived from clinical, financial and operational categories. The main results are: 20% of costs are spent by 3% of the population; elective admission is higher in the high-cost group; tracheostomy has the most number of cases and is the most expensive DRG; LOS is mostly longer for complex cases however, high costs can be attributed to other factors. In conclusion, these findings are potentially useful to patients, medical staff, management and health service decision-makers. The limitation of this study is the exclusion of profitability.

Wireless communications in acute health-care

Before a particular form of wireless communication is implemented within a health-care institution, consideration should be given to the system's capacity for transmitting voice, data and video information, as well as its reliability and coverage. An important associated choice concerns the best combination of user devices that will enable secure and rapid transmission of data to clinical staff at the point of care. Several technologies are available. No new technology that is likely to become available over the next five years will address the two main concerns of health service organizations: the need for non-interference with sensitive equipment; and the need for immediate communication of urgent messages. We therefore believe that health industries with a mobile workforce will gain five to eight years of useful life from cordless telephone systems and that paging or other radio-based devices will remain an important mode of communication for at least the next five years, especially where emergency communication is concerned.

The "managed care" idea: implications for health service systems in Australia

The growth of corporatism in health-care in the US, and the consequences arising from US models of health-care delivery systems provide an enormously valuable point of comparison with health systems of other developed economies, such as Australia. If lessons are to be learnt from the US, then an analysis of the structure and performance of the US health-care system provides important background for understanding and assessing contemporary policy changes to administrative and organizational designs and techniques for patient care in Australia.

Identification of factors contributing to increased length of stay in two diagnosis related groups

This paper discusses a study conducted to identify factors that contributed to increased length of stay for two diagnosis related groups (DRGs) and their consequential impact on nursing salaries. The study shows that three separate clusters of cost drivers (DRG-related, nurse-related, and patient-related) contributed to increased length of stay for DRG 177 (chronic obstructive airways disease) and DRG 367 (cholecystectomy without exploration of the common bile duct). It was not possible to establish a link between length of stay and nursing salaries due to lack of relevant data. The results of the study can be used to raise professional awareness to the difficulties encountered by nurse managers in controlling length of stay when there are substantial numbers of different DRGs in acute care wards. The results can also be used as a basis for conducting larger studies into DRGs with higher than expected lengths of stay.

Undergraduate student nurses' expectations and their self-reported preparedness for the graduate year role

AIMS OF THE STUDY

The study identifies third-year nurses' expectations of the graduate nurse role and ascertains how prepared they feel to fulfil this role.

BACKGROUND

The literature substantiates that the university-workplace transition is marked by differences between students' expectations of the graduate year and the realities of practice they encounter in the workforce setting. Nursing professionals and health service employers continue to debate the expectations required of the new nurse graduate. Yet there is little assessment of graduate nurses' expectations of the workplace. This study describes student nurses' expectations of the graduate year and the extent to which they regard themselves as well- or ill-prepared.

DESIGN

Third-year student nurses (n=105) from a 3-year Bachelor of Nursing (BN) course at a large Metropolitan University in Australia were surveyed. A group of nursing academics and their senior colleagues in the clinical setting designed a questionnaire in light of common themes derived from literature on the graduate year role. Responses were examined and analysed using descriptive statistics.

RESULTS

Responses revealed that student nurses tended to favour large public hospitals, and sought a good graduate programme with associated opportunities for guidance and support. Most expected to achieve good working relationships with both professional colleagues and patients. Final year students expressed some apprehension about meeting the performance expectations of the workplace, given their self-perceived lack of clinical experience.

CONCLUSION

When asked about their initial expectations of the workplace, third year student nurses expressed little apprehension and reported high levels on scales of organizational commitment and professionalism. The research literature suggests that divisions exist between students' expectations of the graduate year and the actual work experience. The expectations of the graduate year described in this study offer a student-centred perspective that contributes to future planning and policy directions of undergraduate curricula, graduate year programmes and nurse retention.

Transplanted primary neonatal myoblasts can give rise to functional satellite cells as identified using the Myf5nlacZl+ mouse

Myoblast transplantation is a potential therapeutic approach for the genetic modification of host skeletal muscle tissue. To be considered an effective, long-lived method of delivery, however, it is essential that at least a proportion of the transplanted cells also retain their proliferative potential. We sought to investigate whether transplanted neonatal myoblasts can contribute to the satellite cell compartment of adult skeletal muscle by using the Myf5nlacZ/+ mouse. The Myf5nlacZ/+ mouse has nlacZ targeted to the Myf5 locus resulting in beta-galactosidase activity in quiescent satellite cells. Following transplantation, beta-galactosidase-labelled nuclei were detected in host muscles, showing that donor cells had been incorporated. Significantly, beta-galactosidase-positive, and therefore donor-derived, satellite cells were detected. When placed in culture, beta-galactosidase marked myogenic cells emanated from the parent fibre. These observations demonstrate that cell transplantation not only results in the incorporation of donor nuclei into the host muscle syncytia, but also that the donor cells can become functional satellite cells. The Myf5nlacZ/+ mouse therefore provides a novel and specific marker for determining the contribution of transplanted cells to the satellite cell pool.

Expression of CD34 and Myf5 defines the majority of quiescent adult skeletal muscle satellite cells

Skeletal muscle is one of a several adult post-mitotic tissues that retain the capacity to regenerate. This relies on a population of quiescent precursors, termed satellite cells. Here we describe two novel markers of quiescent satellite cells: CD34, an established marker of hematopoietic stem cells, and Myf5, the earliest marker of myogenic commitment. CD34(+ve) myoblasts can be detected in proliferating C2C12 cultures. In differentiating cultures, CD34(+ve) cells do not fuse into myotubes, nor express MyoD. Using isolated myofibers as a model of synchronous precursor cell activation, we show that quiescent satellite cells express CD34. An early feature of their activation is alternate splicing followed by complete transcriptional shutdown of CD34. This data implicates CD34 in the maintenance of satellite cell quiescence. In heterozygous Myf5(nlacZ/+) mice, all CD34(+ve) satellite cells also express beta-galactosidase, a marker of activation of Myf5, showing that quiescent satellite cells are committed to myogenesis. All such cells are positive for the accepted satellite cell marker, M-cadherin. We also show that satellite cells can be identified on isolated myofibers of the myosin light chain 3F-nlacZ-2E mouse as those that do not express the transgene. The numbers of satellite cells detected in this way are significantly greater than those identified by the other three markers. We conclude that the expression of CD34, Myf5, and M-cadherin defines quiescent, committed precursors and speculate that the CD34(-ve), Myf5(-ve) minority may be involved in maintaining the lineage-committed majority.

Evidence for a myogenic stem cell that is exhausted in dystrophic muscle

Injection of the myotoxin notexin, was found to induce regeneration in muscles that had been subjected to 18 Gy of radiation. This finding was unexpected as irradiation doses of this magnitude are known to block regeneration in dystrophic (mdx) mouse muscle. To investigate this phenomenon further we subjected mdx and normal (C57Bl/10) muscle to irradiation and notexin treatment and analysed them in two ways. First by counting the number of newly regenerated myofibres expressing developmental myosin in cryosections of damaged muscles. Second, by isolating single myofibres from treated muscles and counting the number of muscle precursor cells issuing from these over 2 day and 5 day periods. After irradiation neither normal nor dystrophic muscles regenerate to any significant extent. Moreover, single myofibres cultured from such muscles produce very few muscle precursor cells and these undergo little or no proliferation. However, when irradiated normal and mdx muscles were subsequently treated with notexin, regeneration was observed. In addition, some of the single myofibres produced rapidly proliferative muscle precursor cells when cultured. This occurred more frequently, and the myogenic cells proliferated more extensively, with fibres cultured from normal compared with dystrophic muscles. Even after 25 Gy, notexin induced some regeneration but no proliferative myogenic cells remained associated with the muscle fibres. Thus, skeletal muscles contain a number of functionally distinct populations of myogenic cells. Most are radiation sensitive. However, some survive 18 Gy as proliferative myogenic cells that can be evoked by extreme conditions of muscle damage; this population is markedly diminished in muscles of the mdx mouse. A small third population survives 25 Gy and forms muscle but not proliferative myogenic cells.

Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework

Presented with the concerns of emergency department nurses about providing appropriate and co-ordinated care for patients seeking mental health services, a Monash University School of Nursing, Victoria, Australia, research team chose a participatory action research strategy. Jointly executed with staff from the Peninsula Health Care Network, the research process brought together in a number of fora multiple disciplines involved in the care and management of psychiatric patients. The participatory action research process itself was the first step in remedial action. Through it, participants and management gained a firmer view of the issues facing Frankston Hospital Emergency Department staff in dealing with psychiatric patients, and in securing their access to suitable pathways of care. Other research outcomes included: a compilation of summary statistics showing patterns of use by psychiatric patients of Frankston Hospital's Emergency Department; beginning discussions about pathways of care for these patients; and the development of a screening tool to be used by the triage nurse for at-risk psychiatric patients presenting to the Emergency Department.

Patterns of repair of dystrophic mouse muscle: studies on isolated fibers

Repair of damaged skeletal muscle fibers by muscle precursor cells (MPC) is central to the regeneration that occurs after injury or disease of muscle and is vital to the success of myoblast transplantation to treat inherited myopathies. However, we lack a detailed knowledge of the mechanisms of this muscle repair. Here, we have used a novel combination of techniques to study this process, marking MPC with nuclear-localizing LacZ and tracing their contribution to regeneration of muscle fibers after grafting into preirradiated muscle of the mdx nu/nu mouse. In this model system, there is muscle degeneration, but little or no regeneration from endogenous MPC. Incorporation of donor MPC into injected muscles was analyzed by preparing single viable muscle fibers at various times after cell implantation. Fibers were either stained immediately for beta-gal, or cultured to allow their associated satellite cells to migrate from the fiber and then stained for beta-gal. Marked myonuclei were located in discrete segments of host muscle fibers and were not incorporated preferentially at the ends of the fibers. All branches on host fibers were also found to be composed of myonuclei carrying the beta-gal marker. There was no significant movement of donor myonuclei within myofibers for up to 7 weeks after MPC implantation. Although donor-derived dystrophin was usually located coincidentally with donor myonuclei, in some fibers, the dystrophin protein had spread further along the mosaic myofibers than had the myonuclei of donor origin. In addition to repairing segments of the host fiber, the implanted MPC also gave rise to satellite cells, which may contribute to future muscle repair.

A discursive exploration of nursing work in the hospital emergency setting

Emergency nurses apply specialist knowledge to the practice of emergency care. This paper discusses the ways in which three emergency nurses understand the nature of their care from their own frames of reference and experiences and presents some of the data collected in a larger study. Various discourses, which compete to inform emergency nurses' understandings of practice, are linked with the notion of nurses as subjects; that is, each discourse may inform, shape and constitute the practice of the nurse and, in turn, the ways in which the patient comes to be known and understood. I will examine the ways in which emergency nurses come to experience or position themselves vis-à-vis extant forms of knowledge of emergency care and the extent to which they articulate new or distinctive formulations of emergency care. This paper illuminates the commonalities that constitute the discourses of emergency nursing care, and also analyse nurses' language which demonstrates that within each discourse variations, contradictions and resistances exist. Emergency nursing care occurs in a context of a biomedical discourse that dominates, or tends to dominate, the work of the emergency setting and so to determine acceptable or possible practices. Nevertheless, nurses contest in various ways the 'truths' that they understand to underpin their practice. Challenges to biomedical discourses are revealed, to some extent, by drawing attention to specific situations and particular struggles encountered in emergency nurses' everyday practice.

The elderly adult in the emergency department

Over 65-year olds were nominated by emergency staff at a Melbourne regional hospital as a patient group of particular concern. With nurse academics from Monash University, a collaborative study was undertaken of elderly patients and the circumstances of their attendance. The focus of the study was on those elderly patients who were triaged as non-acute and who may have been disadvantaged by the priority given to acute cases. The triage records obtained over a 5 month period were analyzed, and a survey administered to selected patients. Over 65-year olds were found to constitute 19% of incoming patients. They figured more prominently in urgent triage categories than those under 65 years of age, were more likely to be referred by a health professional, and more likely to be admitted or transferred. There was no evidence to suggest slower progress through the emergency department for the non-acute elderly than for their counterparts under 65 years of age.

The (im)possibilities of poststructuralist and critical social nursing inquiry

Methodologies of poststructuralist theory and critical social theory may be appropriated for nursing research and practice. Researchers using either methodology employ an analysis of power to explore experiences in various fields, and raise issues that are highly relevant to nursing. However, the two methodologies differ and, often, the respective theories are sharply opposed. In this paper, the differences both from within and between each approach are explored, showing their tensions and limits. I contend that a reflexive approach to discourse analysis provides insight into some of the methodological challenges that arise in the context of both theories. It is argued that the differences between poststructuralism and critical social theory seem likely to be mellowed by encounters that treat each other with respect. To some extent, such encounters may tend to converge the two positions.

Collaboration: a critical viewpoint

Post-graduate nursing education in Victoria, until recently, has been conducted as certificate level courses within hospital-based programs. These programs have traditionally drawn on the clinical experience, the supervision and the teaching provided by the resources within the hospital. This article describes the nature of a collaborative venture, involving regional hospitals and the university, and the challenges that emerged during the introduction of a post-graduate critical care course. Issues arising out of the course evaluation, which was conducted after the first year of the program elaborate aspects of the beginning nature of a collaborative venture. These issues include the different emphases and expectations of skills and knowledge, perceived as relevant to critical care practice. Some of the difficulties encountered by the students are raised. We employ the concepts of liberal and vocational/professional education to explore the ways in which present tensions signify what we have discovered to be an old pedagogical debate. The particular meanings we have as a profession when we speak about education are explored in the context of critical care education and collaborative practice.