Matching Items (5)

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Transitional Care of Adults with Chronic Diseases Post-Discharge from Acute Settings

Description

Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually,

Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually, transitional care should be time-sensitive, patient-centered services intended to ensure continuity of care and an efficient transition between health care settings or home. A patient centered transitional care program was implemented at an outpatient primary care facility to reduce readmission rates. Institutional Review Board approval was obtained.

Twenty adult patients with chronic diseases discharged from an acute setting were identified. A follow up phone call and/or a home visit within 24-72 hours post discharge was employed. The Care Transitions Measure (CTM®) and Medication Discrepancy Tool (MDT®) were utilized to identify quality of care of transition and medication discrepancies. A chart audit collected data on the age of participant, diagnosis for initial hospitalization, CTM score, home visit, and ED visits or re-hospitalizations after 30 days of discharge. The outcome indicated that transitional care within primary care utilizing evidence-based practices is beneficial in reducing readmission rates. A logistic regression showed model significance, p = .002, suggesting that the CTM score was effective for both telephone support (TS) and home visit (HV).

A correlation analysis showed that as age of participants increased, the CTM score decreased, indicating that older adults required more support. A significance p <.001, of a proportional test indicated that readmission rates after the intervention was lower. It is evident that providing a timely and effective transitional care intervention in a primary care setting can reduce hospital readmissions, improve symptom management and quality of life of adult patients with chronic diseases.

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Created

Date Created
  • 2020-05-05

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Nurses Aiding in Patients with Congenital Heart Disease Transition from the Pediatric to the Adult Healthcare Setting

Description

Advancing medical and surgical care has cause for there to be a rapidly growing population of adults with congenital heart disease (CHD). Now that pediatric patients with CHD are living

Advancing medical and surgical care has cause for there to be a rapidly growing population of adults with congenital heart disease (CHD). Now that pediatric patients with CHD are living into adulthood there is a problem with the lack of transitional care these patients receive. The lack of transitional care has led to many issues that adult congenital heart disease (ACHD) patients face such as a lack of autonomy and knowledge, which contributes to an increased chance for a lapse in their care. Lapses in care lead to greater risks of heart failure, arrhythmias, morbidity, and premature death. Research revealed that there is a gap in the transitional care process for patients with CHD from the pediatric to adult healthcare setting that needs to be addressed. Nurses can aid in this process by establishing habits of independence as well as teaching CHD patients about their condition and its care requirements at a younger age. This creative project aims to educate nurses working in the pediatric cardiovascular acute care setting on ways they can aid in the transition process of patients with CHD as they grow out of the pediatric care setting and into the adult care setting in order to establish continuity of care.

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Created

Date Created
  • 2020-12

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Advanced Practice Registered Nurse Led Transitional Care Program in an Accountable Care Organization

Description

Purpose: Reduce or prevent readmissions among heart failure (HF) patients and increase quality of life (QOL), self-care behavior (SCB) and satisfaction through an advanced practice registered nurse (APRN) led transitional

Purpose: Reduce or prevent readmissions among heart failure (HF) patients and increase quality of life (QOL), self-care behavior (SCB) and satisfaction through an advanced practice registered nurse (APRN) led transitional care program (TCP) in collaboration with an Accountable Care Organization (ACO).

Background: Hospital readmissions place a heavy financial burden on patients, families, and health care systems. Readmissions can be reduced or prevented by providing a safe transition through care coordination and enhanced communication. Research demonstrates implementation of APRN led home visits (HV) along with telephonic follow-up are cost effective and can be utilized for reducing readmissions among HF patients.

Methods: A program was designed with an ACO and carried out in a family practice clinic with a group of seven HF patients older than 50 years who were at risk of readmission. Interventions included weekly HV with supplemental telephonic calls by the APRN student along with a physician assistant for 12 weeks. Readmission data was collected. QOL and SCB were measured using “Minnesota Living with Heart Failure Questionnaire” (MLHFQ) and “European Heart Failure Self-Care Behavior Scale” respectively. Data was analyzed using descriptive statistics and the Friedman Test.

Outcomes: There were no hospital readmissions at 30 days and the interventions demonstrated a positive effect on QOL, self-care management and satisfaction (χ2 = 30.35, p=.000). The intervention had a large effect on the outcome variables resulting in an increase in QOL and SCB scores post-intervention (ES= -1.4 and -2 respectively).

Conclusions: TCP designed with an ACO, carried out in a primary care setting has a positive effect on reducing hospital readmissions and improving QOL, SCBs, and patient satisfaction among HF patients. TCPs are not revenue generating at outset due to reimbursement issues, however future considerations of a multidisciplinary team approach with convenient workflow may be explored for long-term feasibility and sustainability.

Funding Source: American Association of Colleges of Nursing and the Centers for Disease Control and Prevention with support of the Academic Partners to Improve Health.

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Agent

Created

Date Created
  • 2017-05-02

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Transitional Care Workflow Redesign

Description

Background and Purpose: Readmission rates for those with chronic conditions are exceeding benchmarks and driving up healthcare spending; there is a need to improve care coordination and outcomes. This project

Background and Purpose: Readmission rates for those with chronic conditions are exceeding benchmarks and driving up healthcare spending; there is a need to improve care coordination and outcomes. This project was done to evaluate and offer evidence-based suggestions for improvement to a multidisciplinary care coordination team in an Accountable Care Organization (ACO). Internal data suggests the team is underutilized within the ACO and that the ACO is underperforming. Conscious workflow design has been shown to improve the efficiency of existing work processes.

Methods: The care coordination team (N=6), licensed practical nurses and social workers, were the project participants. Following Institutional Review Board approval, a presentation was given on current ACO performance data and project goals. Team members were invited to participate by filling out a survey. The 31-item Team Development Measure (Cronbach’s α) assessed team functioning to identify where gaps exist in the team’s processes. Further knowledge about workflow was gained via quality improvement methods of direct observation and informal conversational interviews with team members, the ACO team manager, and various providers within the ACO and their staff. Field notes were analyzed and confirmed with the ACO team manager. Rasch analysis was performed on survey data to convert ordinal numeric results from the Likert scale into an interval score from 0 to 100, which correlates with elements of team development.

Results: Rasch analysis revealed a mean score of 54.17 (SD=8.06). Based on this score, the team has cohesiveness and communication in place but has not yet established role and goal clarity. Analysis of notes and impressions revealed a lack of adherence to date deadlines, inconsistent processes among team members, and use of non-evidence based patient care interventions such as minimal to no home visits and a lack of standardized patient education. Team analysis results, workflow observations, and current evidence on transitional care were integrated into an executive report containing realistic prioritized changes that maximize team member’s skill sets and clarify roles and goals of the team which was provided to the ACO administration along with recommendations for evidence-based process improvements.

Conclusion: This project can serve as a model for analyzing team functioning and workflow to inform agencies where gaps in their processes are affecting performance. The analysis can then be used to recommend evidence based practice changes. Implementation of the suggested workflow should improve existing efforts in trying to meet benchmark quality measures for the ACO as well as improve team functioning.

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Agent

Created

Date Created
  • 2018-04-27

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Improving Transitional Care for Individuals with Severe Mental Illness: The Role of Narrative Repair

Description

Traditional healthcare narratives have set the stage for the care of the population with Severe Mental Illness (P-SMI). Thus far, two prevailing health strategies anchor services for mental illnesses, acute

Traditional healthcare narratives have set the stage for the care of the population with Severe Mental Illness (P-SMI). Thus far, two prevailing health strategies anchor services for mental illnesses, acute psychiatric care, and mental health, psychosocial rehabilitation. Between these, care transitions mediate PSMI’s needs and their movements from the hospital to the community and home. However, as individuals with Severe Mental Illness (i-SMI’s) leave the hospital, time is short with little opportunity to make known authentic narratives born out of self-evidence. After transitional care, maintenance treatment re-centers these individuals back into a playbook with operatives of pathology and disability and inconsistencies with the narratives on recovery and rehabilitation.

This project sought to hear i-SMI’s stories and propose how their experience can be used to create a new “counter” story of transition that empowers these individuals through a better understanding of their “space”: conceptualized here, as all that surrounds them and is dynamic and responsive to their interactions and needs. Underpinning this inquiry is a post-modernist conversation that converges on the critical perspectives in the theory of architecture, philosophy of mind, cognitive science, and the aesthetic practice of psychiatric nursing in the context of transitional care. A qualitative paradigm of narrative repair guides an ethical appraisal, “deprivation of opportunity,” and “infiltrated consciousness,” regarding relational power dynamics that are at work in healthcare master narratives.

Narrative findings of this study reveal that identity and agency come together in a personal space of safety born out of a core sense of self, belonging, and control. Space emerges within the self-narrative as physical sensibilities in the constructs of agency and safety, and as with emotional responses, metaphor and meaning can repair personal transitions.

The counterstory derived from the narrative findings reveals: Equitable relational dynamics attune social space, the physical environment, and meaning, as a response to the dismissiveness and overcontrolling health professional power. Thus, the journey toward narrative repair from the perspective of i-SMI’s uncovers a deeper counternarrative, Ecosystem of Space: the manifestation of a personal architecture for healing, making a systematic organic-space-experience for the core sense of self to transition and flourish.

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Agent

Created

Date Created
  • 2020