Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality and Satisfaction Improvement Project.

OBJECTIVE: To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication. BACKGROUND: Heart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction. METHODS: A nurse led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum. RESULTS: Hospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05). CONCLUSION: Improved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000. IMPLICATION FOR NURSES: Nurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.

Social Determinants of Health and Emergency and Hospital Use by Children With Chronic Disease.

OBJECTIVES: To evaluate the association between caregiver-reported social determinants of health (SDOH) and emergency department (ED) visits and hospitalizations by children with chronic disease. METHODS: This was a nested retrospective cohort study (December 2015 to May 2017) of children (0-18 years) receiving Supplemental Security Income and Medicaid enrolled in a case management program. Caregiver assessments were coded for 4 SDOH: food insecurity, housing insecurity, caregiver health concerns, and safety concerns. Multivariable hurdle Poisson regression was used to assess the association between SDOH with ED and hospital use for 1 year, adjusting for age, sex, and race and ethnicity. ED use was also adjusted for medical complexity. RESULTS: A total of 226 children were included. Patients were 9.1 years old (SD: 4.9), 60% male, and 30% Hispanic. At least 1 SDOH was reported by 59% of caregivers, including food insecurity (37%), housing insecurity (23%), caregiver health concerns (18%), and safety concerns (11%). Half of patients had an ED visit (55%) (mean: 1.5 per year [SD: 2.4]), and 20% were hospitalized (mean: 0.4 per year [SD: 1.1]). Previously unaddressed food insecurity was associated with increased ED use in the subsequent year (odds ratio: 3.43 [1.17-10.05]). Among those who had ≥1 ED visit, the annualized ED rate was higher in patients with a previously unaddressed housing insecurity (rate ratio: 1.55 [1.14-2.09]) or a safety concern (rate ratio: 2.04 [1.41-2.96]). CONCLUSIONS: Over half of caregivers of children with chronic disease enrolled in a case management program reported an SDOH insecurity or concern. Patients with previously unaddressed food insecurity had higher ED rates but not hospitalization rates.

Constructing Doctoral Leadership Scholarly Role Boundaries Through Intraprofessional Nursing Education.

We conducted an intraprofessional education pilot in which students created DNP/PhD leadership parameters through naturalistic classroom experience. Agile, participatory, action research methodology framed a project spanning 3 semesters. Students' multiple ways of knowing influenced a dynamic cycle of noticing, interpreting, acting, and reflecting. Faculty revised course content "in the moment" to meet unique student needs. Researchers analyzed data using qualitative, interpretive descriptive approach. Four key themes interpreted from intraprofessional education included (1) persistent evolutionary progression toward doctoral collaboration, (2) accelerating uptake of research- into-practice continuum, (3) intentional convergent/divergent curriculum, and (4) mutuality of leadership parameters.