Optimize and Thrive: An Electronic Health Record Optimization Program Case Study.

Although electronic health record optimization programs are common in healthcare organizations, a dearth of published evaluations of these programs exists. Little is known about the ability of optimization programs to handle flooding requests for change and achieve their objectives of cost savings, value, quality of care, and efficiency. This program evaluation reviewed one organization's electronic health record clinical optimization program. The evaluation examines the implementation of the insulin dosing calculator project at five hospitals within a large nonprofit healthcare organization using interviews, project documents, reported insulin dosing errors, and workflow observation to determine if the program provides sufficient structure and processes to successfully implement large optimization projects and achieve the project's desired outcomes. This evaluation finds that the optimization program processes support the implementation of large projects. The program can improve the planning of human resources to increase productivity and reduce waste. A clearer definition of meaningful project outcomes at the onset would allow the program to measure and communicate its accomplishments across the organization.

Preparing nursing students for diverse populations.

AIM: To improve undergraduate nursing students and educator intercultural knowledge and competencies by implementing an academic systems change. BACKGROUND: Many organizations have diversity and inclusion guidelines and initiatives for healthcare providers to consider in determining culturally competent care, which has a direct impact on the care given, received, and overall outcomes. DESIGN: 1. Assess student's mindset at the beginning and the end of an undergraduate nursing course. 2. Ensure diversity and inclusion content was provided to faculty through a continuing education program. 3. Review all undergraduate courses for diversity and inclusion content. METHODS: The Intercultural Development Inventory®, a 50-item cross-cultural, theory-based assessment tool was used in a pre- and post-test design (n = 61 intervention; n = 56 control) to determine undergraduate nursing student's mindset and assists the student's in developing a personalized Intercultural Development Plan. The effectiveness of faculty diversity and inclusion education was evaluated using a post program evaluation. Curricular blueprinting of all undergraduate nursing courses for diversity and inclusion content was completed. RESULTS: The results demonstrated a statistically significant difference in the post-test between the intervention and control groups. CONCLUSION: While evidence is lacking in specificity of how to best implement diversity and inclusion content in curriculum, these results provided some excellent baseline data that can be tracked while continued changes occur.

Improving Suicidal Ideation Screening and Suicide Prevention Strategies on Adult Nonbehavioral Health Units.

BACKGROUND: Suicide is a risk in hospitalized patients within and outside of behavioral health units. Williams et al. (2018). Incidence and method of suicide in hospitals in the United States. Williams et al. (2018), suicides occur annually in hospitals, 14%-26% of occurrences outside of a behavioral health unit. OBJECTIVES: The purpose of this project was to improve compliance with universal patient suicide ideation screening and targeted actions for patients screening positive admitted to nonbehavioral health units. METHODS: Electronic medical record (EMR) changes to support screening and targeted patient safety measure documentation were implemented. Nursing education was provided to support these changes. Pre- and postassessments were used to measure knowledge gained from the education. A compliance report was generated from the EMR to measure compliance with universal screening and patient safety measures. RESULTS: In a 4-month period, screening compliance improved by 20.6%, bedside safety companion use was 100%, suicide precautions, documentation 82.5%, and a behavioral health social work note documented 76% of the time. CONCLUSIONS: Universal screening improvement is feasible and has the potential to improve patient safety. Implementation should be considered across health care organizations. IMPLICATIONS FOR NURSING: Providing nursing education and easier EMR workflows for nursing documentation of suicide screening and prevention strategies improves patient safety.

Post-Heart Transplant Care Pathway's Impact on Reducing Length of Stay.

BACKGROUND: Prolonged length of stay (LOS) has undesirable consequences including increased cost, resource consumption, morbidity, and disruptions in hospital flow. LOCAL PROBLEM: A high-volume heart transplant center in the Pacific Northwest had a mean index hospital LOS of 23 days, with a goal of 10 days according to the institutional heart transplant care pathway. METHODS: A retrospective, regression analysis was used to identify the factors contributing to LOS of 41 post-heart transplant patients. INTERVENTIONS: The post-heart transplant care pathway and order set were modified accordingly and reintroduced to the health care team. RESULTS: Factors contributing to LOS included number of days (1) until the first therapeutic calcineurin inhibitor level, (2) until intravenous diuretics were no longer required, and (3) outside of a therapeutic calcineurin inhibitor range. The interventions reduced the mean LOS by 8 days. CONCLUSIONS: Increased awareness of LOS, education, and consistent use of care pathways can significantly reduce length of stay.

The Roundabout Model for Adjunct Clinical Nurse Faculty Retention.

ABSTRACT: The Roundabout Model was created to address the need for developing and retaining adjunct clinical faculty. Three interrelated evidence-based practices form the Roundabout Model: education, mentoring, and ongoing evaluation. Implementation of the model at one private not-for-profit school of nursing in the Midwest resulted in improved adjunct clinical faculty retention, from 50 percent to 100 percent, as well as improved student and clinical agency satisfaction. Students rated 88 percent of adjunct clinical faculty 3.5 or above on a 4.0 scale. Clinical agency complaints were reduced from three to four annually to zero.

Supporting Primary Care Access and Use among Homeless Persons.

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

Identifying an association between socio-demographic factors and breast cancer screening adherence in a federally qualified health centre sample in the United States. A retrospective, cross-sectional study.

Federally Qualified Health Centres (FQHC) are community-based centres in the United States, intended to fill a gap in care for underserved populations, including Medicaid patients and the homeless. Because of the Affordable Care Act, passed into law in 2010, there was a 29% increase in Medicaid enrolees nationally. One service offered at FQHCs is breast cancer screening. Breast cancer screening has been shown to have the lowest adherence levels among low-income women and homeless women. As they serve patients with socio-economic barriers, FQHCs are a vital resource in ensuring access to such screening. This study aimed to identity an association between socio-demographic factors and breast cancer screening adherence in FQHC patients that included the homeless. This exploratory, cross-sectional, retrospective study looked at encounter level data from a FQHC in a major metropolitan (Chicago, IL) area from January 1st, 2017 through December 31st, 2018. Data were collected in January of 2019. This was a convenience sample. Association was tested through bivariate chi-square tests and multivariate logistic regression analysis, investigating the association between socio-demographic characteristics and compliance (Yes/No) for breast cancer screening. Results showed age (55-59; 65-69) and homeless status (doubling-up, transitional) showed a positive association with breast cancer screening, while insurance status (self-pay) had a negative association. Age, homeless status and insurance type were significantly associated with adherence. Demographic characteristics in the homeless population can be used to identify nonadherence.

The Effect of Place of Service on Diabetic Screening Adherence in the Homeless Population.

This study examined the association between place of service and adherence to select diabetes screening measures in a homeless population. At a Midwestern metropolitan federally qualified health center (FQHC), 508 participants with diabetes and also experiencing homelessness were studied throughout calendar year 2018. Diabetes measures included controlled blood pressure, diabetic foot exam and hemoglobin A1C screening. Patients were seen at one of three locations: FQHC only, shelter only and both shelter and FQHC. After controlling for primary insurance, insurance status, homeless status, age group, ethnicity, primary language, race, sex and poverty level, a stepwise binary logistic regression demonstrated significant model improvement in A1c screening (p ≤ 0.001) and controlled blood pressure (p = 0.009) when place of service was added as a predictor. Specifically, results showed significant negative associations in screening adherence for shelter as compared to FQHC for both controlled blood pressure (OR = 0.40; 95% CI = 0.20-0.79; p = 0.009) and A1c screening (OR = 0.06; 95% CI = 0.03-0.16; p ≤ 0.001). Our results support the hypothesis that FQHC care results in higher rates of adherence than shelter only or FQHC and shelter combined care. The study addresses the gap in literature surrounding place of service and patient adherence. Recommendations for future research are included.

"Now that you've got that coverage": Promoting use of a regular source of primary care among homeless persons.

BACKGROUND: The growing number of homeless persons in the United States demonstrates greater morbidity and mortality than the population as a whole. Homeless persons are often without a regular source of primary care. Homeless persons use emergency departments and are hospitalized at higher rates than nonhomeless persons. In 2010, the enactment of the Affordable Care Act expanded access to primary care services. Nurse practitioners were at the forefront of its subsequent implementation. PURPOSE: The purpose of this qualitative study was to explore the factors that influence establishing and maintaining a regular source of primary care among homeless persons. METHODOLOGICAL ORIENTATION: In 2017, semistructured interviews were conducted in a federally qualified health center that serves predominately homeless persons. SAMPLE: A purposive convenience sample included adult health center users (N = 20). The majority of participants were insured (90%), African American (70%), and male (65%). CONCLUSIONS: Thematic analysis revealed five facilitators: sense of community, mutual patient-provider respect, financial assurance, integrated health services, and patient care teams. To establish and maintain use of a regular primary care source, homeless persons desire to experience a sense of community, feel respected by their provider/staff, and have certainty that costs will not exceed their capacity to pay. Integrated care models that leverage a multidisciplinary team approach support the use of a regular primary care source. IMPLICATIONS FOR PRACTICE: Actualizing achievable strategies that promote the consistent use of a regular primary care source can reduce use of avoidable emergency and hospital-based services, thereby improving health outcomes among homeless persons.