1
|
Kinard T, Brennan-Cook J, Johnson S, Long A, Yeatts J, Halpern D. Effective Care Transitions: Reducing Readmissions to Improve Patient Care and Outcomes. Prof Case Manag 2024; 29:54-62. [PMID: 38015801 DOI: 10.1097/ncm.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE/OBJECTIVES Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services. PRIMARY PRACTICE SETTING A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization. FINDINGS/CONCLUSIONS An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up.
Collapse
Affiliation(s)
- Tara Kinard
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Jill Brennan-Cook
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Sara Johnson
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Andrea Long
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - John Yeatts
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - David Halpern
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| |
Collapse
|
4
|
Anderson AJ, Noyes K, Hewner S. Expanding the evidence for cross-sector collaboration in implementation science: creating a collaborative, cross-sector, interagency, multidisciplinary team to serve patients experiencing homelessness and medical complexity at hospital discharge. FRONTIERS IN HEALTH SERVICES 2023; 3:1124054. [PMID: 37744643 PMCID: PMC10515621 DOI: 10.3389/frhs.2023.1124054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
Introduction Patients with medical and social complexity require care administered through cross-sector collaboration (CSC). Due to organizational complexity, biomedical emphasis, and exacerbated needs of patient populations, interventions requiring CSC prove challenging to implement and study. This report discusses challenges and provides strategies for implementation of CSC through a collaborative, cross-sector, interagency, multidisciplinary team model. Methods A collaborative, cross-sector, interagency, multidisciplinary team was formed called the Buffalo City Mission Recuperative Care Collaborative (RCU Collaborative), in Buffalo, NY, to provide care transition support for people experiencing homelessness at acute care hospital discharge through a medical respite program. Utilizing the Expert Recommendations for Implementing Change (ERIC) framework and feedback from cross-sector collaborative team, implementation strategies were drawn from three validated ERIC implementation strategy clusters: 1) Develop stakeholder relationships; 2) Use evaluative and iterative strategies; 3) Change infrastructure. Results Stakeholders identified the following factors as the main barriers: organizational culture clash, disparate visions, and workforce challenges related to COVID-19. Identified facilitators were clear group composition, clinical academic partnerships, and strategic linkages to acute care hospitals. Discussion A CSC interagency multidisciplinary team can facilitate complex care delivery for high-risk populations, such as medical respite care. Implementation planning is critically important when crossing agency boundaries for new multidisciplinary program development. Insights from this project can help to identify and minimize barriers and optimize utilization of facilitators, such as academic partners. Future research will address external organizational influences and emphasize CSC as central to interventions, not simply a domain to consider during implementation.
Collapse
Affiliation(s)
- Amanda Joy Anderson
- School of Nursing, State University of New York at Buffalo, Buffalo, NY, United States
| | - Katia Noyes
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, United States
| | - Sharon Hewner
- School of Nursing, State University of New York at Buffalo, Buffalo, NY, United States
| |
Collapse
|
5
|
He X, Li D, Wang W, Liang H, Liang Y. Identifying patterns of clinical conditions among high-cost older adult health care users using claims data: a latent class approach. Int J Equity Health 2022; 21:86. [PMID: 35725607 PMCID: PMC9210624 DOI: 10.1186/s12939-022-01688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/14/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify patterns of clinical conditions among high-cost older adults health care users and explore the associations between characteristics of high-cost older adults and patterns of clinical conditions. Methods We analyzed data from the Shanghai Basic Social Medical Insurance Database, China. A total of 2927 older adults aged 60 years and over were included as the analysis sample. We used latent class analysis to identify patterns of clinical conditions among high-cost older adults health care users. Multinomial logistic regression models were also used to determine the associations between demographic characteristics, insurance types, and patterns of clinical conditions. Results Five clinically distinctive subgroups of high-cost older adults emerged. Classes included “cerebrovascular diseases” (10.6% of high-cost older adults), “malignant tumor” (9.1%), “arthrosis” (8.8%), “ischemic heart disease” (7.4%), and “other sporadic diseases” (64.1%). Age, sex, and type of medical insurance were predictors of high-cost older adult subgroups. Conclusions Profiling patterns of clinical conditions among high-cost older adults is potentially useful as a first step to inform the development of tailored management and intervention strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-022-01688-3.
Collapse
Affiliation(s)
- Xiaolin He
- Department of Social Policy, Shanghai Administration Institute, Shanghai, China
| | - Danjin Li
- School of Nursing, Fudan University, Shanghai, China
| | - Wenyi Wang
- School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Hong Liang
- School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Yan Liang
- School of Nursing, Fudan University, Shanghai, China.
| |
Collapse
|
6
|
Kurnat-Thoma EL, Murray MT, Juneau P. Frailty and Determinants of Health Among Older Adults in the United States 2011-2016. J Aging Health 2021; 34:233-244. [PMID: 34470533 PMCID: PMC9100462 DOI: 10.1177/08982643211040706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To characterize frailty phenotype in a representative cohort of older
Americans and examine determinants of health factors. Methods Retrospective analysis of data from 5,553 adults ≥60 years old in the
2011–2016 cross-sectional National Health and Nutrition Examination Survey
(NHANES). World Health Organization “Determinants of
Health” conceptual model was used to prioritize variables for
multinomial logistic regression for the outcome of modified Fried frailty
phenotype. Results 482 participants (9%) were frail and 2432 (44%) prefrail. Four factors were
highly associated with frailty: difficulty with ≥1 activity of daily living
(77%; OR 24.81 p < 0.01), ≥2 hospitalizations in the
previous year (17%, OR 3.94 p < 0.01), having >2
comorbidities (27%; OR 3.33 p < 0.01), and polypharmacy
(66%; OR 2.38 p < 0.01). Discussion A modified Fried frailty assessment incorporating five self-reported criteria
may be useful as a rapid nursing screen in low-resource settings. These
assessments can streamline nursing care coordination and case management
activities, thereby facilitating targeted frailty interventions to support
healthy aging in vulnerable populations.
Collapse
Affiliation(s)
- Emma L Kurnat-Thoma
- National Institute of Nursing Research, 35047National Institutes of Health, Bethesda, MD, USA.,Georgetown University School of Nursing & Health Studies, Department of Professional Nursing Practice, Washington, DC, USA
| | - Meghan T Murray
- National Institute of Nursing Research, 35047National Institutes of Health, Bethesda, MD, USA.,Columbia University, School of Nursing, New York, NY, USA
| | - Paul Juneau
- Division of Data Services, NIH Library, Office of Research Services, National Institutes of Health, 10952Bethesda, MD, USA
| |
Collapse
|