Evaluation of prediction strategy and care coordination for COPD readmissions.

OBJECTIVES: Factors that influence the likelihood of readmission for chronic obstructive pulmonary disease (COPD) patients and the impact of posthospital care coordination remain uncertain. LACE index (L = length of stay, A = Acuity of admission; C = Charlson comorbidity index; E = No. of emergency department (ED) visits in last 6 months) is a validated tool for predicting 30-days readmissions for general medicine patients. We aimed to identify variables predictive of COPD readmissions including LACE index and determine the impact of a novel care management process on 30-day all-cause readmission rate. METHODS: In a case-control design, potential readmission predictors including LACE index were analyzed using multivariable logistic regression for 461 COPD patients between January-October 2013. Patients with a high LACE index at discharge began receiving care coordination in July 2013. We tested for association between readmission and receipt of care coordination between July-October 2013. Care coordination consists of a telephone call from the care manager who: 1) reviews discharge instructions and medication reconciliation; 2) emphasizes importance of medication adherence; 3) makes a follow-up appointment with primary care physician within 1-2 weeks and; 4) makes an emergency back-up plan. RESULTS: COPD readmission rate was 16.5%. An adjusted LACE index of ≥ 13 was not associated with readmission (p = 0.186). Significant predictors included female gender (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.29-0.91, p = 0.021); discharge to skilled nursing facility (OR 3.03, 95% CI 1.36-6.75, p = 0.007); 4-6 comorbid illnesses (OR 9.21, 95% CI 1.17-76.62, p = 0.035) and ≥ 4 ED visits in previous 6 months (OR 6.40, 95% CI 1.25-32.87, p = 0.026). Out of 119 patients discharged between July-October 2013, 41% received the care coordination. The readmission rate in the intervention group was 14.3% compared to 18.6% in controls (p = 0.62). CONCLUSIONS: Factors influencing COPD readmissions are complex and poorly understood. LACE index did not predict 30-days all-cause COPD readmissions. Posthospital care coordination for transition of care from hospital to the community showed a 4.3% reduction in the 30-days all-cause readmission rate which did not reach statistical significance (p = 0.62).

Opportunities in interdisciplinary care team adoption of electronic point-of-care documentation systems.

We conducted three evaluation studies in community and hospital settings to examine point-of-care documentation system adoption among interdisciplinary care team clinicians. In the community settings, quantitative methods included documentation time-to-completion and a clinician satisfaction survey. Qualitative methods included observations and follow-up interviews. Qualitative data and quantitative data were merged comparing findings along themes. In the hospitals, qualitative scenario testing results indicated clinician system adoption was universal, though not always timely. At all sites, mismatch between system functionality and workflow was a barrier to clinician system access during patient care and reduced clinician efficiency. Clinicians at all settings were satisfied with their ability to access other clinicians' notes, without increased interdisciplinary team communication. Clinicians did not identify any systems impact on patient outcomes. To facilitate adoption, clinicians should see the value of using the system as intended by receiving system data feedback that shows improvement of patient care and patient safety.

Challenges and facilitators to adoption of a point-of-care electronic health record in home care.

Electronic health records (EHRs), intended to improve the clinical process, are understudied in home care. The researchers assessed clinician satisfaction, informed by workflow and patient outcomes, to identify EHR adoption challenges. The mixed methods study setting was a Philadelphia agency with 137 clinicians. Adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow resulting in decreased efficiency. Adoption facilitators were support for team communication and improved clinical data timeliness. Opportunities for improved adoption included sharing with front-line clinicians EHR data related to patient care and health outcomes.

Interdisciplinary care team adoption of electronic point-of-care documentation systems: an unrealized opportunity.

We conducted three health care evaluation studies in community and hospital settings to examine adoption of point-of-care documentation systems among interdisciplinary care team clinicians. Both community studies used a mixed methods design to assess actual system usage and clinician satisfaction. In the hospitals, scenario testing was used. Results indicated clinician adoption of the systems was universal, although not always timely with: (1) a mismatch between system functionality and workflow which was a barrier to clinician system access during patient care and reduced clinician efficiency; (2) no increase in interdisciplinary team communication; and (3) no impact on patient outcomes identified by clinicians. To facilitate adoption, clinicians should see the value of using the system as intended by receiving patient care and patient safety feedback that uses system data.