The Dynamic Mix of Art and Science in Interdisciplinary Team Care for Community-Dwelling Older Adults With Dementia.
Hospital to Home (H2H) is a national quality improvement initiative sponsored by the Institute for Healthcare Improvement and the American College of Cardiology, with the goal of reducing readmission for patients hospitalized with heart disease. We sought to determine the impact of H2H within the Veterans Affairs (VA) health care system.
Using a controlled interrupted time series, we determined the association of VA hospital enrollment in H2H with the primary outcome of 30-day all-cause readmission following a heart failure hospitalization. VA heart failure providers were surveyed to determine quality improvement projects initiated in response to H2H. Secondary outcomes included initiation of recommended H2H projects, follow-up within 7 days, and total hospital days at 30 days and 1 year.
Sixty-five of 104 VA hospitals (66%) enrolled in the national H2H initiative. Hospital characteristic associated with H2H enrollment included provision of tertiary care, academic affiliation, and greater use of home monitoring. There was no significant difference in mean 30-day readmission rates (20.0% ± 5.0% for H2H vs 19.3% ± 5.9% for non-H2H hospitals; P = .48) The mean fraction of patients with a cardiology visit within 7 days was slightly higher for H2H hospitals (3.0% ± 2.4% for H2H vs 2.0% ± 1.9% for non-H2H hospitals; P = .05). Patients discharged from H2H hospitals had fewer mean hospitals days during the following year (7.6% ± 2.6% for H2H vs 9.2% ± 3.0 for non-H2H; P = .01) early after launch of H2H, but the effect did not persist.
VA hospitals enrolling in H2H had slightly more early follow-up in cardiology clinic but no difference in 30-day readmission rates compared with hospitals not enrolling in H2H.
Facilitation of a Multihospital Community of Practice to Increase Enrollment in the Hospital to Home National Quality Improvement Initiative.
Hospital to Home (H2H) is a national quality improvement (QI) initiative composed of three recommended hospital interventions to improve the transition of care for hospitalized patients with heart disease. A study was conducted to determine if enrollment of Department of Veterans Affairs (VA) hospitals in H2H and adoption of the recommended interventions would both increase following facilitation of an existing Heart Failure (HF) provider-based community of practice (COP) within the VA health care system. The VA HF COP includes more than 800 VA providers and other VA staff from VA inpatient medical centers.
In 2010, 122 VA hospitals were randomized to facilitation using the VA HF COP (intervention) or no facilitation (control). COP members from intervention hospitals were invited to periodic teleconferences promoting H2H and received multiple e-mails asking members to report interest and then progress in H2H implementation.
Among the 61 hospitals randomized to HF COP facilitation, 33 (54%) enrolled in H2H, compared with 6 (10%) of 61 control hospitals (p<.001 at="" five="" months="" after="" randomization.="" of="" intervention="" hospitals="" responding="" to="" the="" follow-up="" survey="" stated="" they="" had="" initiated="" qi="" projects="" as="" a="" result="" h2h="" campaign.="" another="" planned="" projects.="" control="" that="" responded="" and="" no="" additional="" plans="" do="" so.="">
Facilitation using the VA HF COP was successful in increasing enrollment in the H2H initiative and providing implementation support for recommended QI projects. Multihospital provider groups are a potentially valuable tool for implementation of national QI campaigns.
Key insights from the frontier of health information and EMR technology: An interview with Scott Joslin, CIO of MemorialCare
A closer look at nurse case management of community-dwelling older adults: observations from a longitudinal study of care coordination in the chronically ill.
This descriptive, exploratory study of selected characteristics of RN (registered nurse) case management utilized secondary data from a randomized controlled trial in a 5-year Centers for Medicare & Medicaid Services (CMS)-funded Medicare Coordinated Care Demonstration (MCCD) project.
PRIMARY PRACTICE SETTING
The 1,551 older adult, community-dwelling Medicare beneficiaries in the study treatment group population had at least 1 of 5 qualifying chronic diseases (atrial fibrillation, congestive heart failure [CHF], coronary artery disease, chronic obstructive pulmonary disease, diabetes), a mean age of 75 years and an average of 4.5 comorbid conditions. Case management data documented by 14 RN case managers for 2002-2005 for all treatment group patients were analyzed, including a subgroup of 300 patients with CHF as a primary diagnosis.
Nurse (registered nurse) case managers (NCMs) documented case management activities for all patients using 20 standard nursing intervention categories (NICs). Data reflecting the NCM time (in minutes) and mix of interventions were analyzed for patients in all 5 primary disease categories together. Using descriptive, parametric, and nonparametric statistics, the association of case management NIC, timing, and time provided to CHF patients' inpatient admission risk was analyzed, as were patterns of NIC timing and timing for CHF patients.
All patients received an average of 60 min of case management time per month, slightly less than half of which was devoted to documentation of case management tasks by NCMs who had an RN-to-patient ratio of 1:135. Patients experiencing 2 or more inpatient admissions received slightly less case management time (p
IMPLICATIONS FOR CASE MANAGEMENT PRACTICE
Further study of the impact of time, timing, and breadth of NCM intervention in chronic care case management outcomes is needed to better understand case management dosing effectiveness.
Strong barriers prevent the financing of clinical information systems (CIS) in health care delivery system organizations in market segments serving disadvantaged patients. These segments include community health centers, public hospitals, unaffiliated rural hospitals, and some Medicaid-oriented solo and small-group medical practices. Policy interventions such as loans, grants, pay-for-performance and other reimbursement changes, and support services assistance will help lower these barriers. Without intervention, progress will be slow and worsen health care disparities between the advantaged and disadvantaged populations.