ABSTRACT
PURPOSE/OBJECTIVE: The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment. PRIMARY PRACTICE SETTINGS: The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population. FINDINGS/CONCLUSIONS: The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The collaboration of health care providers, social workers, nurse practitioners, physicians, community pharmacists, and the visiting nurses is integral to a successful transition from hospital to home. Home visits by the transition facilitators allowed for the coordination of a multitude of services in the community, including those previously available to patients in the past that have rarely been accessed. Including a pharmacist on the team provided teaching regarding medication adherence, medication management, and pharmacy services, which added to interventions to decrease future hospitalizations.
Subject(s)
Community Networks/organization & administration , Intersectoral Collaboration , Patient Transfer/organization & administration , Population Health , Quality of Health Care/organization & administration , Adult , Aged , Aged, 80 and over , Centers for Medicare and Medicaid Services, U.S. , Cohort Studies , Female , Humans , Male , Middle Aged , Models, Organizational , United StatesABSTRACT
The aim of this project was to evaluate the effectiveness and outcomes of a redesigned newly licensed nurse orientation program. A unique aspect of this program was an end-of-orientation simulated four-patient assignment that was designed to assess five categories of critical thinking: prioritization and delegation, problem recognition, clinical decision making, clinical implementation, and reflection. Newly licensed nurses' critical thinking was measured by the Advisory Board's Critical Thinking Diagnostic tool at 10 weeks, 6 months, and 12 months. Findings showed that in all five categories of critical thinking, a significant increase was found between the 10-week and 6-month evaluation. Two of the categories-prioritization and delegation, and problem recognition-were found to have a significant increase from the 6-month evaluation to the 12-month evaluation. In addition, newly licensed nurses reported improvement in their confidence and in their preparation to work independently. J Contin Educ Nurs. 2017;48(1):22-28.
Subject(s)
Clinical Competence , Inservice Training/organization & administration , Nursing Staff, Hospital/education , Nursing Staff, Hospital/psychology , Patient Simulation , Program Evaluation , Decision Making , Humans , ThinkingABSTRACT
This quality improvement project utilized the Tanner model to identify strategies to enhance the clinical judgment among staff nurses through the development and adoption of an early warning system for patient deterioration outside the ICU. Outcomes included improved communication, decreased variability in the assessment and interpretation of patient status, and a significant decrease in codes.
Subject(s)
Critical Illness/nursing , Hospital Rapid Response Team , Nursing Assessment , Safety Management , Hospital Units , Humans , Intensive Care Units , Massachusetts , Organizational Innovation , Vital Signs , WorkplaceABSTRACT
OBJECTIVE: Measure RNs' and nursing assistants' reports of frequency and reasons for missed nursing care and identify factors related to successful delegation. BACKGROUND: Routine nursing tasks were identified as the most commonly occurring omissions. Reasons for omissions included poor utilization of staff resources, time required for the nursing interventions, poor teamwork, ineffective delegation, habit, and denial. METHODS: Quantitative, descriptive design. RESULTS: Widespread reports of missed care included turning, ambulating, feeding, mouth care, and toileting. Frequently reported reasons were unexpected increase in volume or acuity, heavy admission or discharge activity, and inadequate support staff. Factors affecting successful delegation were communication and relationship, nursing assistant competence and knowledge, and attitude and workload. CONCLUSION: Nurse leaders must focus on implementing strategies to mitigate factors and the consequences of care omissions, including poor patient outcomes. An analysis of point-of-care delivery system failures and ineffective processes is essential.
