“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

Jones, Christine; Jones, Jacqueline; Richard, Angela A.; Bowles, Kathryn H.; Lahoff, Dana; Boxer, Rebecca S.; Masoudi, Frederick A.; Coleman, Eric A.; Wald, Heidi L.

doi:10.1007/s11606-017-4104-0

Cited by 45 publications

(51 citation statements)

References 16 publications

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“…Sepsis type, index LOS, and history of previous hospital admissions (also found to be risk factors for 30-day Sepsis readmissions 3,30e33 ) were all risk factors for 7-day readmission in this study, but are largely information unknown by HHC. For other types of patients, lack of information transferred during transitions is associated with increased readmission risk, 6,34 and could present a serious problem in sepsis. The gaps we have described represent a lost opportunity to intervene early.…”

Section: Discussionmentioning

confidence: 99%

“…We focus on readmissions within 7 days because little is known about the large proportion readmitted by that timeframe and the outcome is potentially most affected by clinical factors that may be amenable to care transitions and HHC interventions. 5,6 Early post-acute care attention shown to significantly reduce readmission hazard among selected populations, 7 including 8 to 7 percentage point rehospitalization reductions among HHC heart failure and sepsis patients, 8,9 provides the opportunity for prompt medication reconciliation, early nursing surveillance, vital sign monitoring, antibiotic stewardship, wound care, patient education, care coordination, and early outpatient assessment.…”

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confidence: 99%

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Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors

Bowles

Murtaugh

Jordan

et al. 2020

Journal of the American Medical Directors Association

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Keywords:Sepsis transitional care hospital discharge home healthcare readmission a b s t r a c t Objective: To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. Design: Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. Setting and Participants: National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N ¼ 165,228). Methods: We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. Results: The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. Conclusions and Implications: Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.Hospitals in the United States discharge over 1 million sepsis survivors annually. 1 Sepsis survivors are a population that experience substantial morbidity and mortality, with readmission rates rivaling or exceeding those for heart failure, pneumonia, and myocardial infarction. 2 Sepsis survivors are twice as likely to be readmitted by 30 days as nonsepsis patients, 3 with 32% of readmissions occurring within 7 days.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors

Bowles

Murtaugh

Jordan

et al. 2020

Journal of the American Medical Directors Association

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“…Next, the evidence for each DISCHARGE element was reviewed (17,(20)(21)(22)(23)25,26). Interventions for each domain were described to demonstrate potential patient impact.…”

Section: Interventionmentioning

confidence: 99%

“…To equip teams with a cognitive approach to discharging patients, we created an evidence-based framework based on prior literature, (13,(17)(18)(19)(20)(21)(22)(23)(24)(25) summarized as the acronym, "DISCHARGE:" Drugs, Identifying barriers, Self-management of diseases, Communication with primary care physicians (PCP) and caregivers, Home services, Appointments, Red ags signs, Go (Activity), and Educate (Teach) back.…”

Section: Introductionmentioning

confidence: 99%

Teaching a DISCHARGE Framework to Hospital Teams to Improve Transitions of Care

Trivedi

Lipkin

Schwartz

2020

Preprint

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Background: Residents typically learn about managing transitions of care as part of the informal curriculum in an ad-hoc, reactive manner. Learning may be enhanced by using a framework to proactively practice addressing key domains for a patient soon-to-be-discharged from the hospital. We developed such an evidence-based framework, DISCHARGE , as a cognitive aid. Using this framework, we implemented and evaluated a workshop designed for hospital teams to learn addressing key components of discharging a patient.Methods: All members of 8 Internal Medicine teams across 4 rotations were invited to attend an hour-long workshop ranging from September 2017 - February 2018. Participants completed a retrospective, pre-post survey on their perceived change in discharge-related behaviors. We evaluated the perceived effectiveness of the workshop with a retrospective pre-post questionnaire. We used Wilcoxon signed-rank tests for pairwise comparisons to access perceived changes in discharge behaviors.Results: A total of 90 of 140 team members (64%) attended the workshop and 79 of the 90 (87%) completed the questionnaire. The session was effective in increasing the likelihood of addressing patient-centered behaviors at discharge (mean 1.4 improvement on a 5-point scale, P<0.001, R>0.5). In addition, senior residents and attendings projected they were more likely to discuss the importance of discharge planning with the team early in a rotation. Interns noted they were more comfortable asking the team for help in carrying out a discharge plan (p<0.001, R>0.5).Conclusions: Teaching teams a cognitive aid to practice managing hospital discharges may increase the likelihood of addressing important domains for their patients. Incorporating the team allows for explicit alignment for priorities and communication. Further study is needed to document how such learning is translated into discharge practice.

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T his qualitative study by Jones et al 1 investigates the challenges and potential solutions for the poor communication between hospitals and home health care (HHC) services. The investigators used select domains from an existing care coordination framework to conduct focus groups with over 50 HHC services nurses and administrators from 6 agencies.

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confidence: 99%

Capsule commentary on Jones et al., “Connecting the Dots”: a Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently-Discharged Patients

Eng

2017

J GEN INTERN MED

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T his qualitative study by Jones et al. 1 investigates the challenges and potential solutions for the poor communication between hospitals and home health care (HHC) services. The investigators used select domains from an existing care coordination framework to conduct focus groups with over 50 HHC services nurses and administrators from 6 agencies. The challenges and potential solutions were mapped to four previously identified domains (Accountability, Communication, Assessing Needs and Goals, and Medication Management) and one additional domain identified during thematic analysis (Safety). The authors found that efforts to improve care coordination with HHC services should focus on defining accountability for orders during transitions, improved communication, alignment of expectations for HHC services, a focus on reducing medication discrepancies, and increased awareness of safety issues for both patients and HHC nurses.With increasing shared accountability for outcomes and costs, care is increasingly shifting from inpatient wards to outpatient clinics to patients' homes, and research and quality improvement efforts must follow and study these shifts in the care location. In particular, the need for greater research on transitions of care involving HHC services is clear given the high percentage of patients experiencing adverse events posthospitalization 2 and the rising number of HHC referrals. 3 The existing literature on HHC services has focused on the frequency and type of adverse events 4 but has not deeply explored how and why those errors occur.For clinicians and administrators, this study points to the need to engage with HHC services directly in this new era of shared accountability. Future directions to improve transition of care involving HHC services should focus on making hospital electronic health record access and direct phone lines to accountable clinicians available to HHC agencies. With improved communication access, HHC agencies can be true partners in the care of patients during the tenuous post-discharge period.

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“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

Cited by 45 publications

References 16 publications

Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors

Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors

Teaching a DISCHARGE Framework to Hospital Teams to Improve Transitions of Care

Capsule commentary on Jones et al., “Connecting the Dots”: a Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently-Discharged Patients

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