Evaluation of a Home-Based, Nurse Practitioner-led Advanced Illness Care Program

OBJECTIVES

In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality.

DESIGN

Retrospective nearest-neighbor matching.

SETTING AND PARTICIPANTS

Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system.

METHODS

We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality.

RESULTS

We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P < .001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P < .001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P < .001).

CONCLUSIONS

The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive.

IMPLICATIONS

By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.

Mucormycete infection or colonisation: experience of an Australian tertiary referral centre

Mucormycosis is associated with significant morbidity and mortality. We reviewed patients with mucormycete isolated at Alfred Health, Australia. A retrospective review of 66 patients with mucormycete(s) identified, between 1 April 2008 and 30 June 2014. Baseline demographic, microbiological, radiological, treatment/outcome data were recorded. Site of isolation was sinopulmonary in 77% and skin/soft tissue in 21%. A total of 32% of cases were proven-IFD, 12% probable-IFD and 56% were defined as no-IFD (or colonisation). Rhizopus spp. was identified in 48%. Comparing probable/proven-IFD with no-IFD/colonisation, more patients were postallogeneic stem cell transplantation (28% vs. 0%, P < 0.01) and were receiving immunosuppressive therapy (59% vs. 24%, P < 0.01) including prednisolone >20 mg daily (24% vs. 5%, P = 0.04). A total of 93% of patients with proven/probable IFD received treatment while 30% of no-IFD/colonisation were treated. A total of 72% of patients with proven/probable IFD and 92% of those with colonisation had no further mucormycete isolated. Thirty day mortality was higher in the proven/probable-IFD cohort (24%) compared with no-IFD/colonisation (3%) (P = 0.02). Mucormycosis remains uncommon, with 56% of cases not associated with clinical infection. Immunosuppressive therapy remains strongly associated with mucormycosis. Mortality remains high in those with proven/probable IFD.

Legislative and humanitarian impetus for development of alcohol and other drug policy at an Australian university

The rationale for comprehensive alcohol and other drug policy at a tertiary institution is presented here as a health promotion strategy for educating University policy makers. Particular emphasis is placed on a discussion of humanitarian issues, that is, the right to a healthy environment, and the potential for legal liability in an environment where alcohol is readily available and other drugs are present. There is little attention paid to drug use related legal issues in the University, but at the same time drawing the attention of policy makers to the organisation's vulnerability to lawsuits has been reported to be a motivating force for adoption of drug use policy. Universities do experience problems related to alcohol and other drug use by staff and students. Problem reduction, and better management of problems, are the major goals of policy in this area. Local initiatives, for example at the organisational level, make important contributions to the overall drug prevention efforts of the nation. Well-developed policy and procedures and effective implementation constitute an important structural health promotion strategy. Such policy would comply with the immediate requirements of Occupational Health, Safety and Welfare legislation and provide some protection against wrongful dismissal claims and negligence lawsuits, as well as providing long-term educative effects. Situations for which policies are needed, range widely due to the University's unique environment and complex roles.

The influence of ethnicity, social class, and context on judgments about U.S. women

In 2 studies, the authors investigated impression formation as influenced by category-based stereotypes associated with ethnicity and social class. The participants in Study I made judgments about 1 target woman, described as interested in running for office in the Parent Teacher Organization (PTO) of her children's school. The hypothetical woman was presented to the respondents along with her photograph and information about her ethnic background (Anglo-Saxon, Latina, or Jewish) and occupation (middle class or working class). In Study 2, the authors changed the context and presented a younger target woman (also varied by ethnicity and social class) to the respondents as the new girlfriend of their older brother or cousin. In both studies, judgments were assessed by the participants' responses to 45 bipolar adjectives that, in each case, yielded 8 component factors. In both hypothetical contexts, social class was a powerful trigger for a variety of negative expectations: With respect to ethnicity, the Latina women were judged to be more unsuitable for the job of PTO vice president than were the Anglo-Saxon or Jewish women. The authors discussed potential psychological and social consequences of such category-based judgments.

Neurologic sequelae of Rocky Mountain spotted fever

Forty-two children who had Rocky Mountain spotted fever were seen for neurologic and psychologic examination at follow-up. The presence of sequelae was more common in children with severely impaired states of consciousness. Behavioral disturbances and learning disabilities were the most common problems. Seizures, although a common occurrence during acute disease, did not occur as sequelae to Rocky Mountain spotted fever.

Social skills training with mildly retarded young adults

Described a social skills assessment and training model for use with mildly retarded young adults (N = 20). The assessment procedure examined social behavior in three types of social situations (e.g., conversational situation, cooperative task and assertive situation) with both male and female respondents. Group behavioral social skills training was compared with a no treatment control condition using various dependent measures collected in the in-vivo social situations. Group behavioral social skills training was more effective than the control condition in increasing positive social behavior, attention to the transaction, and degree of empathy. It was also more effective than a control condition in decreasing negative social skill behavior. A situation effect also was observed, which suggests a need for more focus on particular social skills and a need to address issues of generalization. A comprehensive social skills assessment and training model is discussed.

Economic viability of the mental health worker

Lower salary costs and effective provision of services to specific community groups are counted among the advantages of the use of mental health workers in community programs. In a cost-benefit analysis of the value of health manpower, salaries and service provision are only two of several factors, yet the circumstances of funding, training, and role diffusion that surround the use of the mental health worker have precluded true cost-benefit analysis. The authors believe that the mental health worker program of the Orange County, California, community mental health program is developed and stable encough that the initial steps of an economic analysis are possible. The data from the analysis show that, in the outpatient program, mental health workers constitute 37 per cent of the clinical staff and provide 41 per cent of the direct services, yet account for 26 per cent of the direct peronnel costs.

Self-destructive behavior patterns in male and female drug abusers

One hundred and fourteen male and female drug abusers were interviewed regarding their histories of self-destructive behaviors. The data were analyzed to determine if, and identify what, differences existed between males and females with respect to types and extent of self-destructiveness. The analyzed data indicate that male and female drug abusers present very different self-destructive portraits. These portraits and their component parts are presented along with possible explanations for the differences. The paper also presents some of the differences between drug abusers and the general population with respect to self-destructiveness.

Compulsive heroin use and interpersonal orientation

This research attempt to clarify and quantify the ways in which heroin addicts deal with interpersonal relations. A sample of heroin addicts on a methadone maintenance program were given the Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) scale. An accidental sample consisted of 35, approximately one-half, of the clinic's population. A mean interpersonal orientation profile is established and interpreted. An analysis of variance was performed for each of the six FIRO-B scores. Patients needs based on FIRO-B scores are discussed with regard to the descriptions of addicts life-styles as described in the literature. The possible etiological basis for these interpersoanl orientations is also discussed. Several therapeutic approaches, as indicated by FIRO-B scores, are explored.

Drug abuse and suicide

This paper examines the relationship between drug abuse and suicide. It attempts to assess the extent of suicidal thoughts or behaviors among a group of drug abusers. The research examines variables related to self-destructive or self-endangering behaviors, such as accidental overdoses, arrests for driving under the influence, and auto accidents in which the subject was the driver. These data were examined in relation to reports of suicidal thoughts and actual suicide attempts. The results indicate a suicide attempt rate at least 12 times greater than expected for the general population. The results also indicate significant correlations between suicidal thoughts and suicide attempts, suicidal thoughts and nonsuicidal overdoses, and arrests for driving under the influece of drugs or alcohol and nonsuicidal overdoses. The implications of these results along with the role of depression as discussed.