Diane E. Holland

A comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management

We compared the effects of evidence-based disease management guidelines delivered to patients with heart failure and diabetes using three different modalities: in-person visits alone (Control), in-person visits and a telephone intervention (Telephone), and in-person visits and telemonitoring (Telemonitoring). Patients were randomized to the three groups. There were 112 patients in the Control group, 93 in the Telephone group and 98 in the Telemonitoring group. During the first 60 days, 10% of the Control group were rehospitalized, 17% of the Telephone group and 16% of the Telemonitoring group. Having heart failure and receiving more in-person visits were significantly related to readmission and time to readmission. However, after adjusting for diagnosis and visits, the differences between the three groups were non-significant. There was a trend for increased risk of readmission for the Telephone group compared to Control alone (P = 0.07, risk ratio 2.2, 95% CI: 0.9 to 5.2) and for readmission sooner (P = 0.02, risk ratio 2.3, 95% CI: 1.2 to 4.6). Patient rehospitalization and emergency department visit rates were lower than the national average, making it difficult to detect a difference between groups. Previous rehospitalization was a consistent predictor of those who were rehospitalized, suggesting that it may be a useful indicator for identifying patients likely to need additional attention.

Discharge Planning, Transitional Care, Coordination of Care, and Continuity of Care: Clarifying Concepts and Terms from the Hospital Perspective

SUMMARY Hospital discharge planning is a key element of continuity of care for persons leaving the hospital. Yet many important questions regarding processes and effects of discharge planning have not been addressed, in part because the multiple terms associated with discharge planning have not been consistently defined or used. Failure to clearly name, define, and consistently use terms creates a barrier that inhibits scientific progress and best practice. This article reviews the use of terms and definitions and compares concepts associated with hospital discharge planning across key documents frequently referenced by hospitals. A conceptual model is proposed to facilitate consistent use of these concepts.

Development and validation of a screen for specialized discharge planning services.

Background: There is no rigorously developed and empirically validated screening tool to identify, early in the hospital stay, those adults who will use specialized hospital discharge planning services. Objectives: To develop and validate a screen using hospital admission clinical data that discriminates between adults who use and do not use specialized discharge planning services. Methods: Subjects consisted of prospectively sampled adult patients admitted to two hospitals located in a Midwestern United States city in 1998 (tool development sample, n = 991) and 2002 (validation sample, n = 303). Variables suggestive of being predictive of use of specialized hospital discharge planning services were identified from the literature and were obtained from direct participant interviews, record review, and administrative databases. The outcome was a documented referral for involvement of specialized discharge planning personnel with the patients plan of care and was identified from review of hospital records. Results: Of 24 variables examined, only age, disability, living alone, and self-rated walking limitation were jointly predictive of use of specialized discharge planning services in the development sample. Standardized coefficients from the joint model were used to estimate a screening score. A cut-point was derived and had a sensitivity of 75% and specificity of 78% in the development sample. The screen performed equally well in the validation sample and the development sample. Conclusion: A screening tool consisting of a limited number of characteristics readily available early in the hospital stay that were shown to be highly predictive of the use of specialized discharge planning services was developed. The application of such a tool will hopefully assist providers to deploy services appropriately and in a timely fashion.

Exploring a culture of caring.

AimThe delivery of patient-centered care is basic to a large midwestern healthcare institutions mission and highly valued by the department of nursing. Even so, nurses on one medical unit questioned whether caring behaviors were devalued in a technology-oriented environment of providing care. The nursing leadership on the unit responded to the inquiry by conducting a research study. This study explored the state of patient-centered nursing care on a medical unit as perceived by the nursing staff and patients, using Watsons Theory of Human Caring as a framework. Subjects and methodsThe study utilized surveys for both nursing staff (n = 31) and patients (n = 62), and included a focus group of nursing staff (n = 8) to explore ideas for innovation. Results and conclusionsBoth nurses and patients perceived a high level of caring on the unit. The overall theme from the focus group was that “caring begets caring,” with 2 subthemes: “relationships of care” and “the context of caring.” Caring for each other was identified as essential to keep staff energized and able to work lovingly with patients. Nursing leadership brought the research findings to all staff on the unit for discussion and implementation of structural support for the unit culture of caring.

Problems and Unmet Needs of Patients Discharged "Home to Self-Care"

Purpose of Study: The purpose of this study was to determine the extent to which patients discharged “home to self care” experienced problems and unmet needs. A secondary aim was to explore potential differences in problems and unmet needs between medical and surgical patients. Primary Practice Setting: The study setting was acute care in 2 hospitals that were part of a large academic medical center in the Midwest. Methodology and Sample: The prospective, cohort survey study was designed with a systematic sampling strategy to identify 130 cognitively intact adults hospitalized for either medical or surgical reasons who planned to return home after discharge without formal community services. The hospital information system was checked daily to verify whether dispositions were coded “home to self care,” and to verify whether the patients were not seen by a discharge planner. The Problems After Discharge Questionnaire–English Version (PADQ-E) was then either mailed or administered via a phone interview approximately 1 week after discharge. Results: Overall, 73.8% wanted more information about one or more topics related to their care. Most frequently mentioned were “when they would be completely recovered” (38.0%) and “where and how they could get nursing care at home if they needed it” (36.9%). A majority (91.8%) reported difficulties related to at least 1 physical complaint. Pain was most frequently mentioned by surgical patients (88.1%). Getting tired quickly was an issue for both surgical (76.2%) and medical patients (62.8%). More than 85% received help at home from family or friends. Surgical patients received significantly more assistance than medical patients with personal care, household activities, and mobility. Approximately 1 in 4 surgical patients reported an unmet need within the Physical Complaints subscale on the PADQ-E. Implications for Case Management Practice: Potential problems that may occur after discharge have little chance of getting addressed if not identified during the discharge planning process. Standardized, early screening to accurately identify patients at risk for unmet needs after discharge is critical to the development and implementation of a quality discharge plan. The lack of time available to hospital clinicians to assemble and interpret extensive and complex information calls for improved methods to support identifying patients at risk for poor outcomes, engaging discharge planners efficiently and accurately, providing a standardized assessment to identify and address continuing care needs, and identifying patients who would benefit from post–acute care. Case managers advance their practice by advocating for and participating in the development of improved methods.

Targeting hospitalised patients for early discharge planning intervention

AIMS AND OBJECTIVES The purpose of the study was to describe the ability of an evidence-based discharge planning (DP) decision support tool to identify and prioritise patients appropriate for early DP intervention. Specifically, we aimed to determine whether patients with a high Early Screen for Discharge Planning (ESDP) score report more problems and continuing care needs in the first few weeks after discharge than patients with low ESDP scores. BACKGROUND Improved methods are needed to efficiently and accurately identify hospitalised patients at risk of complex discharge plans. DESIGN A descriptive cross-sectional study was designed using a quality health outcomes framework. METHODS The ESDP was administered to 260 adults hospitalised in an academic health centre who returned home after discharge. Problems and continuing care needs were self-reported on the Problems After Discharge Questionnaire - English Version, mailed 6-10 days after discharge. RESULTS Patients with high ESDP scores reported significantly more problems [mean, 16·3 (standard deviation ±8·7)] than those with low scores [12·2 (±8·4)]. Within the Problems After Discharge Questionnaire subscales, patients with high ESDP scores reported significantly more problems with personal care, household activities, mobility and physical difficulties than patients with low screen scores. Significantly more of the patients with a high ESDP score received consults to a Discharge Planner and referrals for postacute services than patients with low screen scores. CONCLUSION The ESDP is effective as a decision support tool in identifying patients to prioritise for early DP intervention. RELEVANCE TO CLINICAL PRACTICE Use of an evidence-based DP decision support tool minimises biases inherent in decision-making, promotes efficient use of hospital DP resources, and improves the opportunity for patients to access community resources they need to promote successful recovery after hospitalisation.

Standardized discharge planning assessments: impact on patient outcomes.

The purpose of the study was to determine whether a difference exists in patient-reported problems and unmet needs after discharge when a standardized discharge planning assessment is added to usual care by staff nurses. Two groups of 130 adult patients were enrolled while hospitalized. The intervention group patients reported fewer unmet needs (P = .01) and had fewer problems complying with their discharge instructions (P = .04). Standardizing discharge planning assessments by staff nurses may improve identification of continuing care needs.

Prospective evaluation of a screen for complex discharge planning in hospitalized adults

OBJECTIVES: To test the predictive ability of the Probability of Repeated Admission (PRA) screen for nonroutine discharge planning (requiring new referrals for formal services).

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.