Ashley W. Collinsworth

Reducing diabetes disparities through the implementation of a community health worker-led diabetes self-management education program.

Disparities in prevalence of type 2 diabetes and complications in underserved populations have been linked to poor quality of care including lack of access to diabetes management programs. Interventions utilizing community health workers (CHWs) to assist with diabetes management have demonstrated improvements in patient outcomes. Use of CHWs may be an effective model for providing care coordination and reducing disparities, but there is limited knowledge on how to implement this model on a large scale. This article describes how an integrated health care system implemented a CHW-led diabetes self-management education program targeting Hispanic patients and reports lessons learned from the first 18 months of operation.

Community Health Workers in Primary Care Practice Redesigning Health Care Delivery Systems to Extend and Improve Diabetes Care in Underserved Populations

New, comprehensive, approaches for chronic disease management are needed to ensure that patients, particularly those more likely to experience health disparities, have access to the clinical care, self-management resources, and support necessary for the prevention and control of diabetes. Community health workers (CHWs) have worked in community settings to reduce health care disparities and are currently being deployed in some clinical settings as a means of improving access to and quality of care. Guided by the chronic care model, Baylor Health Care System embedded CHWs within clinical teams in community clinics with the goal of reducing observed disparities in diabetes care and outcomes. This study examines findings from interviews with patients, CHWs, and primary care providers (PCPs) to understand how health care delivery systems can be redesigned to effectively incorporate CHWs and how embedding CHWs in primary care teams can produce informed, activated patients and prepared, proactive practice teams who can work together to achieve improved patient outcomes. Respondents indicated that the PCPs continued to provide clinical exams and manage patient care, but the roles of diabetes education, nutritional counseling, and patient activation were shifted to the CHWs. CHWs also provided patients with social support and connection to community resources. Integration of CHWs into clinical care teams improved patient knowledge and activation levels, the ability of PCPs to identify and proactively address specific patient needs, and patient outcomes.

A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units.

Objective: The objective of this review is to examine the effectiveness, implementation, and costs of multifaceted care approaches, including care bundles, for the prevention and mitigation of delirium in patients hospitalized in intensive care units (ICUs). Data Sources: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted utilizing PubMed, EMBASE, and CINAHL. Searches were limited to studies published in English from January 1, 1988, to March 31, 2014. Randomized controlled trials and comparative studies of multifaceted care approaches with the reduction of delirium in ICU patients as an outcome and evaluations of the implementation or cost-effectiveness of these interventions were included. Data Extraction: Data on study methods including design, cohort size, interventions, and outcomes were abstracted, reviewed, and summarized. Given the variability in study design, populations, and interventions, a qualitative review of findings was conducted. Data Synthesis: In all, 14 studies met our inclusion criteria: 6 examined outcomes, 5 examined implementation, 2 examined outcomes and implementation, and 1 examined cost-effectiveness. The majority of studies indicated that multifaceted care approaches were associated with improved patient outcomes including reduced incidence and duration of delirium. Additionally, improvements in functional status and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates were observed. Implementation strategies included structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams. The cost-effectiveness analysis indicated an average reduction of

Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients - Translating knowledge into practice

1000 in hospital costs for patients treated with a multifaceted care approach. Conclusion: Although multifaceted care approaches may reduce delirium and improve patient outcomes, greater improvements may be achieved by deploying a comprehensive bundle of care practices including awakening and breathing trials, delirium monitoring and treatment, and early mobility. Further research to address this knowledge gap is essential to providing best care for ICU patients.

Modifying the Electronic Health Record to Facilitate the Implementation and Evaluation of a Bundled Care Program for Intensive Care Unit Delirium

I njuries are a leading cause of death, disability, years of productive lives lost, and health care costs in the United States. Approximately 190,000 people die each year from injuries, and the total medical and work loss costs of injuries exceed

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

600 billion per year. The 2 leading causes of death after injury are hemorrhagic shock and traumatic brain injury (TBI), in both military and civilian settings, with mortality rates of 30% to 50%. Injured patients treated at designated trauma centers are more likely to survive than those treated at hospitals that are not trauma centers; however, risk-adjustedmortality rates are nearly 50% higher at some trauma centers than at others. Given that designated trauma centers have similar structures and resources, these variations in risk-adjusted patient outcomes are likely explained by variations in clinical practices. Although clinical practice guidelines for the management of hemorrhagic shock and TBI have been developed and disseminated by multiple organizations, adoption of evidence-based practices at trauma centers remains suboptimal. In a study of 5 Level I trauma centers, compliance with 22 commonly

The impact of patient education and shared decision making on hospital readmissions for COPD

Context: Electronic health records (EHRs) have been promoted as a key driver of improved patient care and outcomes and as an essential component of learning health systems. However, to date, many EHRs are not optimized to support delivery of quality and safety initiatives, particularly in Intensive Care Units (ICUs). Delirium is a common and severe problem for ICU patients that may be prevented or mitigated through the use of evidence-based care processes (daily awakening and breathing trials, formal delirium screening, and early mobility—collectively known as the “ABCDE bundle”). This case study describes how an integrated health care delivery system modified its inpatient EHR to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative. Case Description: In order to facilitate uptake of the ABCDE bundle and measure delivery of the care processes within the bundle, we worked with clinical and technical experts to create structured data fields for documentation of bundle elements and to identify where these fields should be placed within the EHR to streamline staff workflow. We created an “ABCDE” tab in the existing patient viewer that allowed providers to easily identify which components of the bundle the patient had and had not received. We examined the percentage of ABCDE bundle elements captured in these structured data fields over time to track compliance with data entry procedures and to improve documentation of care processes. Major Themes: Modifying the EHR to support ABCDE bundle deployment was a complex and time-consuming process. We found that it was critical to gain buy-in from senior leadership on the importance of the ABCDE bundle to secure information technology (IT) resources, understand the different workflows of members of multidisciplinary care teams, and obtain continuous feedback from staff on the EHR revisions during the development cycle. We also observed that it was essential to provide ongoing training to staff on proper use of the new EHR documentation fields. Lastly, timely reporting on ABCDE bundle performance may be essential to improved practice adoption and documentation of care processes. Conclusion: The creation of learning health systems is contingent on an ability to modify EHRs to meet emerging care delivery and quality improvement needs. Although this study focuses on the prevention and mitigation of delirium in ICUs, our process for identifying key data elements and making modifications to the EHR, as well as the lessons learned from the IT components of this program, are generalizable to other health care settings and conditions.

Implementation of the ABCDE bundle: results from a real-world, pragmatic study design

BackgroundAttempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.MethodsA multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.ResultsDraft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.ConclusionEvidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

Health Services Research as Operational Infrastructure Within an Integrated Care Delivery System

Purpose Education on the self-management of COPD has been shown to improve patients’ quality of life and reduce hospital admissions. This study aimed to assess the feasibility of a pilot, pragmatic COPD Chronic Care (CCC) education program led by registered respiratory therapists and determine the CCC’s impact on hospital readmissions, patient activation, and health status. Patients and methods This was a prospective, randomized, pilot study of inpatients with COPD admitted to a US community hospital between August 2014 and February 2016. In total, 308 patients were randomized 1:1 to receive standard care with or without the CCC program. Outcomes included the number of patients completing the program, frequency and time to first all-cause and COPD-related hospital readmissions, and changes in the Patient Activation Measure (PAM) and COPD Assessment Test (CAT). Results Overall, 37% (n=52) of patients in the CCC group and 29% (n=48) of patients in the control group remained in the study for 6 months and completed all follow-up phone calls. In total, 74% (n=105) of patients in the CCC group and 69% (n=115) of patients in the control group had at least one readmission (P=0.316). The time to first all-cause and COPD-related readmission appeared shorter for patients in the CCC group compared with the control group (mean [standard deviation]: 50.2 [54.5] vs 59.9 [63.1] days and 95.1 [80.2] vs 113.7 [82.4] days, respectively; both P=0.231). Patients experienced significant improvement from baseline in mean PAM (both groups) and CAT (CCC group) scores. Conclusion Utilizing respiratory therapists to lead a chronic care education program for COPD in a community hospital was feasible. Although CCC patients showed improvements in perceived symptom severity, they were readmitted sooner than control group patients. However, the program did not impact the frequency of hospital readmissions. A more comprehensive disease management program may be needed to improve outcomes.

Improving diabetes care and outcomes with community health workers

Care processes in the ABCDE bundle (daily awakening, breathing trials, delirium management, early mobility) have been shown to improve a range of clinical outcomes in intensive care unit (ICU) patients. However, uptake of the ABCDE bundle has been inconsistent to date. We examined the effectiveness of a structured implementation program on ABCDE bundle adoption across ICUs in 6 different Baylor Scott & White Hospitals.