Catherine E. Vanderboom

The Gap in Big Data: Getting to Wellbeing, Strengths, and a Whole-person Perspective.

Background: Electronic health records (EHRs) provide a clinical view of patient health. EHR data are becoming available in large data sets and enabling research that will transform the landscape of healthcare research. Methods are needed to incorporate wellbeing dimensions and strengths in large data sets. The purpose of this study was to examine the potential alignment of the Wellbeing Model with a clinical interface terminology standard, the Omaha System, for documenting wellbeing assessments. Objective: To map the Omaha System and Wellbeing Model for use in a clinical EHR wellbeing assessment and to evaluate the feasibility of describing strengths and needs of seniors generated through this assessment. Methods: The Wellbeing Model and Omaha System were mapped using concept mapping techniques. Based on this mapping, a wellbeing assessment was developed and implemented within a clinical EHR. Strengths indicators and signs/symptoms data for 5 seniors living in a residential community were abstracted from wellbeing assessments and analyzed using standard descriptive statistics and pattern visualization techniques. Results: Initial mapping agreement was 93.5%, with differences resolved by consensus. Wellbeing data analysis showed seniors had an average of 34.8 (range=22–49) strengths indicators for 22.8 concepts. They had an average of 6.4 (range=4–8) signs/symptoms for an average of 3.2 (range=2–5) concepts. The ratio of strengths indicators to signs/symptoms was 6:1 (range 2.8–9.6). Problem concepts with more signs/symptoms had fewer strengths. Conclusion: Together, the Wellbeing Model and the Omaha System have potential to enable a whole-person perspective and enhance the potential for a wellbeing perspective in big data research in healthcare.

Seeing the whole person: feasibility of using the Omaha System to describe strengths of older adults with chronic illness.

A promising strategy for enhancing care and self-management of chronic illness is an integrative, whole-person approach that recognizes and values well-being. Assessment tools are needed that will enable health care professionals to perceive patients as whole persons, with strengths as well as problems. The purpose of this study was to examine the feasibility of using a standardized terminology (the Omaha System) to describe strengths of older adults with chronic illness. The Omaha System assessment currently consists of identifying signs/symptoms for 42 health concepts. Researchers mapped self-reported strengths phrases to Omaha System concepts using existing narratives of 32 older adults with 12–15 comorbid conditions. Results demonstrated the feasibility of describing strengths of patients with chronic illness. Exploratory analysis showed that there were 0–9 strengths per patient, with unique strengths profiles for 30 of 32 patients. Given that older adults with multiple chronic illnesses also have strengths that can be classified and quantified using the Omaha System, there is potential to use the Omaha System as a whole-person assessment tool that enables perception of both problems and strengths. Further research is needed to enhance the Omaha System to formally represent strengths-based as well as a problem-focused perspectives.

Using present-on-admission coding to improve exclusion rules for quality metrics: The case of failure-to-rescue

Background:The Agency for Healthcare Research and Quality (AHRQ) patient safety indicator “death among surgical inpatients with serious treatable complications” (failure-to-rescue) uses rules to exclude complications presumed to be present-on-admission (POA). Like other administrative data-based quality measures, exclusion rules were developed with limited information on whether complications were POA. We examine whether the accuracy of failure-to-rescue exclusion rules can be improved with data with good POA indicators. Methods:POA-coded data from 243,825 discharges from a large academic medical center were used to develop 3 failure-to-rescue exclusion rules. Data from 82,871 discharges from California hospitals screened for good POA coding practices was used as a validation sample. The AHRQ failure-to-rescue measure and 3 new measures based on alternative exclusion rules were compared on sensitivity, specificity, and C-statistics for prediction of POA status. Using data from the AHRQ HCUP National Inpatient Sample, the alternative specifications were tested for sensitivity to nurse staffing. Results:The AHRQ exclusion rules had sensitivity of 18.5%, specificity 92.1%, and a C-statistic of 0.553. All POA-informed specifications of exclusion rules improved the C-statistic of the failure-to-rescue measure and its sensitivity, with modest losses of specificity. For all tested specifications, higher licensed hours and proportions of registered nurse were statistically significant and associated with lower risk of death. Conclusions:Failure-to-rescue is a robust quality measure, sensitive to nursing across alternative exclusion rule specifications. Despite expanded POA coding, exclusion-based rules are needed to analyze datasets not coded for POA, legacy datasets, and datasets with poor POA coding. POA-informed construction of exclusions significantly improves rules identifying POA complications.

Key factors in patient-centered care coordination in ambulatory care: Nurse care coordinators' perspectives

BACKGROUND Care coordination within Health Care Homes (HCHs) is an evolving registered nurse role. The purpose of this study was to identify factors influencing nurse care coordination. AIMS The aims are to 1) describe the characteristics of patients perceived by nurse care coordinators (NCCs) to benefit from care coordination and to 2) describe interventions judged by NCCs to be most effective in caring for patients with complex chronic care needs. METHODS This study was an analysis of existing data using a qualitative descriptive design. Experienced NCCs from various practice settings participated in a focus group. Data were analyzed using content analysis. RESULTS Findings indicate the importance of the cumulative impact of complex health problems, limited social support, culture and language on patients needing care coordination. Effective interventions are focused on providing holistic, relationship-based care. CONCLUSION The identification of contextual factors juxtaposed to complex chronic health conditions holds promise as a powerful indicator of individuals needing targeted, individualized interventions.

Care coordination from a strengths perspective: A Practice-based evidence evaluation of evidence-based practice

Background and Purpose: It is critical to accurately represent strengths interventions to improve data and enable intervention effectiveness research from a strengths perspective. However, it is challenging to understand strengths interventions from the multiple perspectives of computerized knowledge representation, evidence-based practice guidelines, and practice-based evidence narratives. Intervention phrases abstracted from nurse care coordinator practice narratives described strengths interventions with community-dwelling elders. This project aims were to (a) compare nurse care coordinator use of evidence-based interventions as described in the two guidelines (what to do and how to do it), (b) analyze nurse care coordinator intervention tailoring (individualized care), and (c) evaluate the usefulness of the Omaha System for comparison of narrative phrases to evidence-based guidelines. Methods: Phrases from expert nurse care coordinators were mapped to the Omaha System for comparison with the guidelines interventions and were analyzed using descriptive statistics. Venn diagrams were used to visually depict intervention overlap between the guidelines and the phrases. Results: Empirical evaluation of 66 intervention phrases mapped to 14 problems using 3 category terms and 19 target terms showed alignment between guidelines and the phrases, with the most overlap across two guidelines and the phrases in categories, and the most diversity in care descriptions. Conclusion: These findings demonstrate the value in having both standardized guidelines and expert clinicians who see the whole person and can synthesize and apply guidelines in tailored ways. There is potential to create a feedback loop between practice-based evidence and evidence-based practice by expanding this approach to use of practice-generated Omaha System data as practice-based evidence. Further research is needed to refine and advance the use of these methods with additional practices and guidelines.

Describing pediatric hospital discharge planning care processes using the Omaha System

PURPOSE Although discharge planning (DP) is recognized as a critical component of hospital care, national initiatives have focused on older adults, with limited focus on pediatric patients. We aimed to describe patient problems and targeted interventions as documented by social workers or DP nurses providing specialized DP services in a childrens hospital. METHODS Text from 67 clinical notes for 28 patients was mapped to a standardized terminology (Omaha System). Data were deductively analyzed. RESULTS A total of 517 phrases were mapped. Eleven of the 42 Omaha System problems were identified. The most frequent problem was health care supervision (297/517; 57.4%). Three Omaha System intervention categories were used (teaching, guidance, and counseling; case management; and surveillance). Intervention targets are varied by role. CONCLUSION The findings provide a rich description of the nature of DP for complex pediatric patients and increase our understanding of the work of DP staff and the influence of the DP practice model.

The feasibility of using technology to enhance the transition of palliative care for rural patients.

Palliative care services for patients with life-limiting conditions enhance their quality of life. Most palliative care services, however, are located in hospitals with limited transitional care for patients who live in distant locations. The long-term goal of this program of research is to use existing technology for virtual visits to provide transitional care for patients initially hospitalized in an urban setting by a nurse practitioner located closer to patients’ homes in distant, rural settings. The purpose of this proof-of-concept study was to determine the resources needed to use the system (efficiency) and the quality of the audio and visual components (effectiveness) to conduct virtual visits between a clinician at an academic center and community-dwelling adults living in rural locations. Guided by the Technology Acceptance Model, a mixed-methods field design was used. Because of the burden of testing technology with patients with life-limiting conditions, the sample included eight healthy adults. Participant satisfaction and perceptions of the ease of using the technology were also measured. Virtual visits were conducted using a 3G-enabled Apple iPad, cellular phone data service, and a Web-based video conference service. Participants and clinicians perceived the technology as easy to use. Observations revealed the importance of the visual cues provided by the technology to enhance communication, engagement, and satisfaction. Findings from this study will inform a subsequent study of technology-enhanced transitional care with palliative care patients.

Exploring indicators of use of costly health services in community-dwelling adults with multiple chronic conditions

&NA; Although experts recognize that including patient functional and social variables would improve models predicting risk of using costly health services, these self-reported variables are not widely used. Purpose of Study: Explore differences in predisposing characteristics, enabling resources, patient-perceived need for care and professionally evaluated need for care variables between patients receiving primary care within a Health Care Home who did and did not use hospital, emergency department, or skilled nursing facility services in a 3-month period of time. Primary Practice Setting(s): Primary care. Methodology and Sample: Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted on data from a study that included 57 community-dwelling older adults receiving primary care in a Health Care Home. Because of the exploratory nature of the study, group differences in the use of costly care services were compared at the 0.10 level of statistical significance. Results: Seventeen patients (29.8%) experienced costly care services. The greatest number of differences in variables between groups was in the category of patient-perceived need for care (functional impairments, dependencies, difficulties). Implications For Case Management Practice: Targeting case management services using evidence-based decision support tools such as prediction models enhances the opportunity to maximize outcomes and minimize waste of resources. Patient-perceived and clinician-evaluated need for care may need to be combined to fully describe the contextual needs that drive the use of health services. Difficulty with Activities with Daily Living and Instrumental Activities of Daily Living should be considered in future studies as candidate predictor variables for need for case management services in primary care settings.

Enhancing Patient-Centered Care Pilot Study Results of a Community Care Team Intervention

Health care reform focuses on primary care and development of Health Care Homes to improve patient-centered chronic illness care. This pilot study evaluated a community care team intervention that linked chronically ill older patients, support persons, and nurse care coordinators from a Health Care Home with community resources using an adaptation of the Wraparound process. A pragmatic clinical trial design was used. Patient-centered chronic illness care; physical, mental, and social health; service use; and study feasibility were evaluated. Differences between groups were compared using two-sample t, Wilcoxon rank sum, chi-square, or Fisher’s exact tests. At 3 months, the intervention group reported higher patient-centered chronic illness care (mean total Patient Assessment of Chronic Illness Care change scores were 0.39 for the intervention group and −0.11 for the control group, p = .03). Results indicate that the integrated community care team intervention is a promising strategy to support patient-centered chronic illness care.

Developing a Community Care Team: Lessons Learned From the Community Connections Program, a Health Care Home-Community Care Team Partnership

This article describes the development of the Community Connections Program (CCP), a community care team, within a health care home (HCH), as a short-term, intensive, team-based service planning and coordination program for older adults with multiple chronic health conditions. Three proven approaches were combined to support patient’s self-management: nurse care coordination, the Wraparound process, and use of community services. Participants’ responses to the CCP demonstrated the success of the community care team in connecting patients and nurse care coordinators (NCCs) with community service providers, thus supplying primary care providers with important information regarding the development of a community care team to support patient-centered care within a HCH.