Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project.

PURPOSE OF STUDY: Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission. PRIMARY PRACTICE SETTING: The setting was a vertically integrated health care system located in Northern California. METHODOLOGY AND SAMPLE: This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings. RESULTS: Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).

Improving Dementia-Specific Referrals From the Acute Care Setting: A Quality Improvement Project.

PURPOSE OF STUDY: The purpose of this quality improvement project was to design and implement an education and referral protocol for care coordination staff to use when working with hospitalized patients with dementia and their families. The goal was to increase delivery of dementia resource education and dementia-specific referrals during the discharge planning process. PRIMARY PRACTICE SETTING: The practice setting for this project was an acute care hospital in Northern California. The care coordination department collaborated with the Northern California Chapter of the Alzheimer's Association to improve the delivery of referrals and follow-up with patients and families who were interested in additional information and support related to dementia. METHODOLOGY AND SAMPLE: Twenty-one members of the care coordination department received education on the dementia disease process as well as community resources available to the patient population. The registered nurse care coordinators (RNCCs) and social workers (SWs) within the department then implemented a referral protocol to connect patients with dementia and their families to the Alzheimer's Association. Referral volume was captured over a 60-day preimplementation period, a 60-day implementation period, and a 60-day postimplementation period. The Northern California Chapter of the Alzheimer's Association tracked referral volume. A paired-sample t test was used to examine pre/postimplementation Dementia Knowledge Assessment Scale (DKAS) scores to evaluate the impact of the education intervention. Care coordination staff completed a pre/postimplementation survey on knowledge of community resources for dementia and confidence in connecting patients to these resources. They also completed a postimplementation survey about the benefit of the project to their care coordination practice. RESULTS: There was a modest, yet positive increase in referral volume over the 60-day implementation period ( n = 6) compared with the preimplementation period ( n = 1). An increase was sustained during the 60-day postimplementation period ( n = 4). Pre/posttimplementation DKAS scores significantly improved for care coordination staff postimplementation ( p < .001) by an average of 7 points. Fifty-three percent of RNCC and SW staff responded to the postimplementation survey, and results indicated they thought the project was beneficial ( n = 8) or somewhat beneficial ( n = 1) to practice. In addition, RNCC and SW staff reported an increase in awareness of available community resources and confidence in connecting patients and families to these resources. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case management professionals have an important role in providing education and support to patients and families across the continuum of care. The complexity and trajectory of illness, shortage of qualified providers, and gaps in provider knowledge about resources place patients with dementia and their families in an increasingly vulnerable position within the health care system. This quality improvement project demonstrates that care coordination staff can improve referrals to resources when in contact with patients and families in the acute care setting. Case managers can ensure patients with dementia and their families have access to the resources in the community that may prevent return to the emergency department or rehospitalization.

Effect of Increasing Physical Activity on Cognitive Function in Individuals With Mild Cognitive Impairment: A Knowledge Translation to Practice Pilot Project.

The purpose of the current pilot study was to determine if 12 weeks of increased physical activity improved cognitive function in individuals with mild cognitive impairment (MCI). Participants used commercial wearable technology to objectively measure daily steps. Participants wore an activity tracker for approximately 12 hours per day and received telephone support every 2 weeks. The Montreal Cognitive Assessment (MoCA) was used to measure pre/posttest cognitive function. Increased step count was positively correlated with improvement in cognitive function with a moderate effect size (Pearson's r = 0.55; p = 0.04); 5,396 steps per day was the decision boundary for MoCA score improvement. Increased physical activity over 12 weeks improved cognitive function in individuals with MCI. It is feasible for individuals with MCI to wear an activity tracker on a daily basis. [Journal of Gerontological Nursing, 47(5), 14-18.].

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department.

PURPOSE OF STUDY: The purpose of this study was to evaluate the impact of a quality improvement multidisciplinary care coordination program designed to reduce frequent emergency department (ED) utilization and hospital admissions. PRIMARY PRACTICE SETTING: The single hospital ED is part of a large, integrated, managed care delivery system in Northern California serving the city of Oakland, California. METHODOLOGY AND SAMPLE: A retrospective cohort study design was used to analyze a multidisciplinary care coordination program on 58 patients during January 2015 and August 2018. Patients were identified from a high-utilization report when they had 10 or more ED visits in a 6-month period, were 18 years of age or older, and members of the integrated delivery system's health plan. Data were collected at initiation and 6 months postintervention. The pre-/postanalysis consisted of descriptive statistics, Wilcoxon signed ranks test, and binary logistic regression. RESULTS: There was a statistically significant pre-/postdifference of 7.7 ED visits (95% confidence interval [CI] = 4.44-10.97, p < .001). The program did not result in statistically significant reduced hospital admissions (95% CI =-1.24 to 1.45, p = .875). Prior frequent use, number of pre-ED visits, age, sex, complex medical history, and mental health disorder had a significant effect on frequent ED use (χ[6] =17.62, p = .007, McFadden R = .32]. Sex (odds ratio [OR] = 5.13, p = .070), prior frequent use (OR = 2.87, p = .252), and complex medical history (OR = 2.52, p = .412) had the greatest odds of ongoing frequent ED use. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: We demonstrated reductions in ED use among frequent users with a low-cost care management intervention. Our multidisciplinary care coordination program confirms the positive impact case management has on utilization and health outcomes. We established that a care coordination program can optimize the overall quality of care and control hospital costs incurred by this vulnerable population. The effectiveness of this program contributes to the advancement of case management efforts in undertaking the challenging health care issue of reducing repeated visits by frequent users, a practice that strains emergency medical services.

Experiences of transgender individuals when accessing health care: a qualitative systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective is to synthesize existing qualitative literature examining the experiences of transgender individuals when accessing health care.

A Bone Health Intervention for Chinese Immigrants in Santa Clara County.

BACKGROUND: Among Chinese immigrants, osteoporosis is undertreated, misdiagnosed, and a leading cause of fragility fractures. In orthopaedic surgery departments, prevention education and health behavior change programs are necessary to improve their bone health. PURPOSE: The purpose of this study was to examine the effectiveness of an osteoporosis prevention education program on participants' self-efficacy with regard to exercise and nutrition when provided by an orthopaedic surgery team during an annual Chinese Health Fair in Santa Clara County, CA. METHODS: This pilot study used a single-group pretest and posttest design. Chinese immigrants at risk of osteoporosis were recruited during a 1-day health fair. The Bone Health Intervention (BHI) included orthopaedic surgeon consultation, visual aids including osteoporosis images and bone models, a video that included a discussion on calcium and vitamin D in the Chinese diet and culturally-acceptable exercise, and osteoporosis educational handouts. The Osteoporosis Self-Efficacy Scale (OSES) was utilized to measure participants' confidence in the ability to participate in self-care behaviors related to physical activity and calcium intake before and after the intervention. Paired t tests were used to compare participants' OSES scores pre- and postintervention. RESULTS: There was a significant increase in mean OSES scores postintervention, indicating that the intervention could be an effective method of increasing participants' self-efficacy regarding calcium intake and time spent in exercising. CONCLUSION: These results indicate that a culturally meaningful education program can potentially reduce fragility fracture risk. Orthopaedic health providers are ideal candidates to deliver preventive care education to improve outcomes for Chinese immigrants.

Adolescent fathers in the justice system: hoping for a boy and making him a man.

Using a constructivist grounded theory approach, we explored the development of father identity among boys involved in the juvenile justice system. Youth were recruited from a juvenile detention center and school district in a northern California county with a high teen birth rate. The participants were expecting a child or parenting an infant and had been arrested, incarcerated, or had committed a crime. We collected data through observations and individual interviews. Using constant comparative and dimensional analysis, we found that expectant adolescent fathers hoped for a boy and envisioned their central role as father to be making their son a man. This article contributes to greater understanding of father identity development for youth involved in the justice system. We suggest that teen parenting policies and programs include interventions sensitized by gender, accounting for the influence masculine ideals of manhood have on the development of father identity and the father-child relationship.

Choosing fatherhood: how teens in the justice system embrace or reject a father identity.

The purpose of this qualitative study was to further the understanding of father identity and role development among adolescents involved in the justice system. Youth who were expecting a child or parenting an infant and who were incarcerated, arrested, or had admitted to criminal behavior participated in interviews and observations in a juvenile detention center and in the community. Data analysis revealed 4 patterns of fathering intentions: (a) embracing fatherhood, (b) being barred from fatherhood, (c) being ambivalent about fatherhood, or (d) rejecting fatherhood. Community health nurses can use this information to assess father identity status and address factors that interfere with father engagement.

A conceptual model of incarcerated adolescent fatherhood: adolescent identity development and the concept of intersectionality.

TOPIC: Little is known about teen fathers though they are found to be disproportionately represented among incarcerated youth. SOURCE USED: This article is developed from a qualitative pilot study of adolescent fathers in the justice system. PURPOSE: The authors theorize about teen fathers and the process by which they accept, reject, or are "barriered" from a father identity and role. CONCLUSIONS: Adolescence as a developmental period during which an identity is forming is viewed in concert with the concept of hegemonic masculinity and the concept of intersectionality. Risk factors in childhood and adolescence complete the conceptual model through which incarcerated adolescent fathers can be examined.