August 7, 2019

Case Management and the Chronic Care Model: A Multidisciplinary Role

The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward […]
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The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward condition neutral case management, focused on care that is more wholly patient centric, is also examined.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2004/03000/Case_Management_and_the_Chronic_Care_Model__A.7.aspx

August 7, 2019

A Closer Look at Nurse Case Management of Community-Dwelling Older Adults: Observations From a Longitudinal Study of Care Coordination in the Chronically Ill

Purpose/objectives: This descriptive, exploratory study of selected characteristics of RN (registered nurse) case management utilized secondary data from a randomized controlled trial in a 5-year Centers for Medicare & Medicaid Services (CMS)—funded Medicare Coordinated Care Demonstration (MCCD) project. Primary practice setting: The 1,551 older adult, community-dwelling Medicare beneficiaries in the […]
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Purpose/objectives: This descriptive, exploratory study of selected characteristics of RN (registered nurse) case management utilized secondary data from a randomized controlled trial in a 5-year Centers for Medicare & Medicaid Services (CMS)—funded Medicare Coordinated Care Demonstration (MCCD) project. Primary practice setting: The 1,551 older adult, community-dwelling Medicare beneficiaries in the study treatment group population had at least 1 of 5 qualifying chronic diseases (atrial fibrillation, congestive heart failure [CHF], coronary artery disease, chronic obstructive pulmonary disease, diabetes), a mean age of 75 years and an average of 4.5 comorbid conditions. Case management data documented by 14 RN case managers for 2002—2005 for all treatment group patients were analyzed, including a subgroup of 300 patients with CHF as a primary diagnosis. Design/methods: Nurse (registered nurse) case managers (NCMs) documented case management activities for all patients using 20 standard nursing intervention categories (NICs). Data reflecting the NCM time (in minutes) and mix of interventions were analyzed for patients in all 5 primary disease categories together. Using descriptive, parametric, and nonparametric statistics, the association of case management NIC, timing, and time provided to CHF patients' inpatient admission risk was analyzed, as were patterns of NIC timing and timing for CHF patients. Findings/conclusions: All patients received an average of 60 min of case management time per month, slightly less than half of which was devoted to documentation of case management tasks by NCMs who had an RN-to-patient ratio of 1:135. Patients experiencing 2 or more inpatient admissions received slightly less case management time (p < .05) than patients with either 1 or no admissions during the study period. There was no specific rate (in minutes delivered per month) that was found to be associated with individual case managers and their CHF patients' associated readmission risk. Over time, NCM time allocated to routine monitoring exceeded that of self-care, disease, and medication education or counseling. Implications for case management practice: Further study of the impact of time, timing, and breadth of NCM intervention in chronic care case management outcomes is needed to better understand case management dosing effectiveness.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2010/03000/A_Closer_Look_at_Nurse_Case_Management_of.8.aspx

August 7, 2019

A New Era for Case Management: Field Research Makes the Case for Case Managers in Care Coordination

A New Era for Case Management: Field Research Makes the Case for Case Managers in Care Coordination
A New Era for Case Management: Field Research Makes the Case for Case Managers in Care Coordination
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http://journals.lww.com/professionalcasemanagementjournal/Citation/2010/09000/A_New_Era_for_Case_Management__Field_Research.2.aspx

August 7, 2019

The Providers’ Coordination of Care: A Model for Collaboration Across the Continuum of Care

ABSTRACT Objective: With guidance from Health Services Advisory Group, the Arizona Medicare Quality Improvement Organization, a Prescott, Arizona, workgroup consisting of a hospital, nursing home, and 2 home health agencies have come together to improve continuity of care as related to pressure ulcer prevention and treatment. Methods: Weekly, then monthly, […]
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ABSTRACT Objective: With guidance from Health Services Advisory Group, the Arizona Medicare Quality Improvement Organization, a Prescott, Arizona, workgroup consisting of a hospital, nursing home, and 2 home health agencies have come together to improve continuity of care as related to pressure ulcer prevention and treatment. Methods: Weekly, then monthly, meetings were held to develop recommendations for practice standardization, a treatment grid for easy reference, an educational module with posttests, and standardized physicians' orders, which were developed and disseminated to the local provider community. Results: More than 200 staff members were educated at Yavapai Regional Medical Center (YRMC), local skilled nursing facilities, and home health agencies. In addition, new employees and nursing students are now educated on the Providers' Coordination of Care Educational Module at YRMC. The Module has been placed on the hospital's Web site and offered free to all interested parties. Implications for case management: With pressure being mounted by Centers for Medicare & Medicaid Services, the Office of the Inspector General (OIG), and the general public, the role of the case manager (in all practice settings) will increasingly become more crucial. Through development of a network of local venues of care, the case manager can facilitate care transitions throughout the healthcare system with the goal of improved outcomes for the patient regardless of setting. Providing the right care, in the right setting to improve patient care, can only benefit our aging and declining populations. Conclusions: Cross-setting work will become more essential as the Centers for Medicare & Medicaid Services goal of pay-for-performance is realized across all care settings. As a national priority, pressure ulcer prevention and treatment needs to be embraced by all settings. It serves the patient, as well as the healthcare providers, to improve care regardless of setting or competition. Positive results can be accomplished if the best interests of the patient are kept at the forefront. To this end, obstacles of competition and individual facility possessiveness must be overcome to achieve the desired results. Having the right mix of professionals will enhance the results. The lessons learned here can be used in any across-the-settings initiative.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2008/07000/The_Providers__Coordination_of_Care__A_Model_for.7.aspx

August 7, 2019

Patients’ understanding of their treatment plans and diagnosis at discharge

OBJECTIVE: To ascertain whether patients at discharge from a municipal teaching hospital knew their discharge diagnoses, treatment plan (names and purpose of their medications), and common side effects of prescribed medications. PATIENTS AND METHODS: From July to October 1999, we surveyed 47 consecutive patients at discharge from the medical service […]
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OBJECTIVE: To ascertain whether patients at discharge from a municipal teaching hospital knew their discharge diagnoses, treatment plan (names and purpose of their medications), and common side effects of prescribed medications. PATIENTS AND METHODS: From July to October 1999, we surveyed 47 consecutive patients at discharge from the medical service of a municipal teaching hospital in New York City (Brooklyn, NY). Patients were asked to state either the trade or the generic name(s) of their medication(s), their purpose, and the major side effect(s), as well as their discharge diagnoses. Patients were excluded if they were not oriented to person, place, and time, were unaware of the circumstances surrounding their admission to the hospital, and/or did not speak or understand English. RESULTS: Of the 47 patients surveyed, 4 were excluded. Of the remaining 43 patients, 12 (27.9%) were able to list all their medications, 16 (37.2%) were able to recount the purpose of all their medications, 6 (14.0%) were able to state the common side effect(s) of all their medications, and 18 (41.9%) were able to state their diagnosis or diagnoses. The mean number of medications prescribed at discharge was 3.89. CONCLUSIONS: Less than half of our study patients were able to list their diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s). Lacking awareness of these factors affects a patient’s ability to comply fully with discharge treatment plans. Whether lack of communication between physician and patient is actually the cause of patient unawareness of discharge instructions or if this even affects patient outcome requires further study.
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http://download.journals.elsevierhealth.com/pdfs/journals/0025-6196/PIIS0025619611615796.pdf

August 7, 2019

Functional health literacy and understanding of medications at discharge.

The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 […]
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The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.
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http://download.journals.elsevierhealth.com/pdfs/journals/0025-6196/PIIS0025619611607283.pdf

August 7, 2019

Discharge education improves clinical outcomes in patients with chronic heart failure.

Background: Although interventions combining patient education and postdischarge management have demonstrated benefits in patients with chronic heart failure, the benefit attributable to patient education alone is not known. We hypothesized that a patient discharge education program would improve clinical outcomes in patients with chronic heart failure. Methods and Results: We […]
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Background: Although interventions combining patient education and postdischarge management have demonstrated benefits in patients with chronic heart failure, the benefit attributable to patient education alone is not known. We hypothesized that a patient discharge education program would improve clinical outcomes in patients with chronic heart failure. Methods and Results: We conducted a randomized, controlled trial of 223 systolic heart failure patients and compared the effects of a 1-hour, one-on-one teaching session with a nurse educator to the standard discharge process. Subjects were contacted by telephone at 30, 90, and 180 days to collect information about clinical events, symptoms, and self-care practices. The primary end point of the study was the total number of days hospitalized or dead in the 180-day follow-up period. Subjects randomized to receive the teaching session (n_107) had fewer days hospitalized or dead in the follow-up period (0 and 10 days, median and 75th percentiles) than did controls (n_116, 4 and 19 days; P_0.009). Patients receiving the education intervention had a lower risk of rehospitalization or death (relative risk, 0.65; 95% confidence interval, 0.45 to 0.93; P_0.018). Costs of care, including the cost of the intervention, were lower in patients receiving the education intervention than in control subjects by $2823 per patient (P_0.035). Conclusions: The addition of a 1-hour, nurse educator– delivered teaching session at the time of hospital discharge resulted in improved clinical outcomes, increased self-care measure adherence, and reduced cost of care in patients with systolic heart failure. (Circulation. 2005;111:179-185.)
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http://circ.ahajournals.org/cgi/reprint/111/2/179

August 7, 2019

Coordinating care: a perilous journey through the health care system

Thomas Bodenheimer, M.D. N Engl J Med 2008; 358:1064-1071. March 6, 2008. Accessed December 11, 2014. In the United States, 125 million people are living with chronic illness, disability, or functional limitation. The nature of modern medicine requires that these patients receive assistance from a number of different care providers. […]
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Thomas Bodenheimer, M.D. N Engl J Med 2008; 358:1064-1071. March 6, 2008. Accessed December 11, 2014. In the United States, 125 million people are living with chronic illness, disability, or functional limitation. The nature of modern medicine requires that these patients receive assistance from a number of different care providers. Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year. Care among multiple providers must be coordinated to avoid wasteful duplication of diagnostic testing, perilous polypharmacy, and confusion about conflicting care plans.
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http://amcp.org/WorkArea/DownloadAsset.aspx?id=12358

August 7, 2019

Report to Congress on the Evaluation of Medicare Disease Management Programs

This congressionally mandated report summarizes the final evaluation findings for the Demonstration Project for Disease Management for Severely Chronically Ill Medicare Beneficiaries (referred to hereafter as the Medicare Disease Management Demonstration), authorized in Section 121 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (P.L. […]
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This congressionally mandated report summarizes the final evaluation findings for the Demonstration Project for Disease Management for Severely Chronically Ill Medicare Beneficiaries (referred to hereafter as the Medicare Disease Management Demonstration), authorized in Section 121 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (P.L. 106-554). Congress authorized the demonstration to evaluate whether disease management programs—in conjunction with a comprehensive prescription drug benefit—for Medicare beneficiaries in the fee-for-service program with advanced-stage congestive heart failure (CHF), diabetes, or coronary artery disease (CAD), could improve health outcomes and reduce Medicare expenditures. In late 2002, the Centers for Medicare & and Medicaid Services (CMS) selected three organizations, CorSolutions, (later purchased by Matria Healthcare, Inc.), HeartPartners (UnitedHealth, Inc. later purchased PacifiCare, one of HeartPartners’ main members), and XLHealth, to operate demonstration programs in Louisiana, Arizona, California, and Texas.
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http://www.policyarchive.org/handle/10207/bitstreams/8795.pdf

August 7, 2019

Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial

Context: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. Objective: To examine the effectiveness of an advanced practice nurse–centered discharge planning […]
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Context: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. Objective: To examine the effectiveness of an advanced practice nurse–centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. Design: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. Setting Two urban, academically affiliated hospitals in Philadelphia, Pa. Participants: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. Intervention: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. Main Outcome Measures: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. Results A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1% vs 20.3%; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%;P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in postdischarge acute care visits, functional status, depression, or patient satisfaction. Conclusions: An advanced practice nurse–centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus
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http://jama.ama-assn.org/content/281/7/613.abstract

August 7, 2019

Posthospital medication discrepancies: Prevalence and contributing factors

Background: Despite the national attention being given to the problem of medication safety, little attention has been paid to the medication problems that are encountered by older patients who are receiving care across settings. The objective of this study was to determine the prevalence and contributing factors associated with posthospital […]
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Background: Despite the national attention being given to the problem of medication safety, little attention has been paid to the medication problems that are encountered by older patients who are receiving care across settings. The objective of this study was to determine the prevalence and contributing factors associated with posthospital medication discrepancies. Methods: The study population consisted of community-dwelling adults aged 65 years and older admitted to the hospital with 1 of 9 selected conditions (n = 375). A geriatric nurse practitioner performed a comprehensive medication assessment in the patient’s home within 24 to 72 hours after institutional discharge. The assessment focused on what older patients reported taking in comparison with the prehospital medication regimen and the posthospital medication regimen. Prevalence and types of medication discrepancies were categorized using the Medication Discrepancy Tool. Results: A total of 14.1% of patients experienced 1 or more medication discrepancies. Using the Medication Discrepancy Tool, 50.8% of identified contributing factors for discrepancies were categorized as patient-associated, and 49.2% were categorized as system-associated. Five medication classes accounted for half of all medication discrepancies. Medication discrepancies were associated with the total number of medications taken and the presence of congestive heart failure. A total of 14.3% of the patients who experienced medication discrepancies were rehospitalized at 30 days compared with 6.1% of the patients who did not experience a discrepancy (P = .04). Conclusions: A significant percentage of older patients experienced medication discrepancies after making the transition from hospital to home. Both patient-associated and system-associated solutions may be needed to ensure medication safety during this vulnerable period.
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http://archinte.ama-assn.org/cgi/content/full/165/16/1842

August 7, 2019

For-Profit Hospital Status and Rehospitalizations at Different Hospitals: An Analysis of Medicare Data

Background: About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown. Objective: To describe and examine predictors of and payments for rehospitalization at a different […]
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Background: About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown. Objective: To describe and examine predictors of and payments for rehospitalization at a different hospital among Medicare patients rehospitalized within 30 days at for-profit and nonprofit or public hospitals. Design: Cohort study of patients discharged and rehospitalized from January 2005 to November 2006. Setting: Medicare fee-for-service hospitals throughout the United States. Participants: A 5% random national sample of Medicare patients with acute care rehospitalizations within 30 days of discharge (n = 74 564). Measurements: 30-day rehospitalizations at different hospitals and total payments or mortality over the subsequent 30 days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural–urban commuting area, and teaching status; patient sociodemographic characteristics, disability status, and comorbid conditions; and a measure of risk adjustment. Results: 16 622 patients (22%) in the sample were rehospitalized at a different hospital. Factors associated with increased risk for rehospitalization at a different hospital included index hospitalization at a for-profit, major medical school–affiliated, or low-volume hospital and having a Medicare-defined disability. Compared with patients rehospitalized at the same hospital, patients rehospitalized at different hospitals had higher adjusted 30-day total payments (median additional cost, $1308 per patient; P < 0.001) but no statistically significant differences in 30-day mortality, regardless of index hospital for-profit status. Limitation: The database lacked detailed clinical information about patients and did not include information about specific provider practice motivations or the role of patient choice in hospitalization venues. Conclusion: Rehospitalizations at different hospitals are common among Medicare patients, are more likely among those initially hospitalized at a for-profit hospital, and are related to increased overall payments without improved mortality.
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http://www.annals.org/content/153/11/718.abstract

August 7, 2019

Best Practices in Coordinated Care

This report describes lessons learned from current best practices in coordinated care as the first step in designing the mandated demonstration programs. A separate report will propose key demonstration design features, including the method of paying for the intervention, financial incentives for programs to generate savings to Medicare, target sample […]
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This report describes lessons learned from current best practices in coordinated care as the first step in designing the mandated demonstration programs. A separate report will propose key demonstration design features, including the method of paying for the intervention, financial incentives for programs to generate savings to Medicare, target sample sizes for the demonstration programs, and methods for evaluating them. Current health care often fails to meet the needs of chronically ill people. Treatment regimens for chronic illness often do not conform to evidence-based guidelines (Large State Peer Review Organization 1997). Care is frequently rushed and overly dependent on patient-initiated follow-up. Providers typically devote little time to assessing function, providing instruction in behavior change or self-care, or addressing emotional or social distress (Calkins et al. 1991; Clark and Gong, 2000; and Holman and Lorig 1998). Care is fragmented, with little communication across settings and providers (Manian 1999). A small proportion of chronically ill persons also incurs the large majority of health care costs (Eggert 1988). Furthermore, many unplanned hospitalizations of chronically ill persons appear to be preventable. Thus, preventive interventions targeted to this group might yield sizable overall savings in health care.
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http://www.mathematica-mpr.com/PDFs/bestpractices.pdf

August 7, 2019

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 7—Care Coordination

Context: Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements. Objectives: The objectives of this […]
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Context: Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements. Objectives: The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs. Data Sources and Review Methods: We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006 of MEDLINE®, and November 15, 2006 for CINAHL®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider. Results: We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic
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http://www.ahrq.gov/downloads/pub/evidence/pdf/caregap/caregap.pdf

August 7, 2019

Better transitions: improving comprehension of discharge instructions

Discharge out of the hospital is a time of heightened vulnerability for our patients. The combination of shorter lengths of stay and increased clinical acuity results in increased complexity of discharge instructions and higher expectations for patients to perform challenging self-care activities. Yet, the amount of time and resources available […]
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Discharge out of the hospital is a time of heightened vulnerability for our patients. The combination of shorter lengths of stay and increased clinical acuity results in increased complexity of discharge instructions and higher expectations for patients to perform challenging self-care activities. Yet, the amount of time and resources available for patient and family caregiver preparation prior to discharge has not significantly changed commensurate with these new demands. Inadequate health literacy and unrecognized cognitive impairment are two important contributing factors. In this article we discuss the effects of health literacy and cognitive impairment on patient comprehension of discharge instructions, how this may impact the frequency of adverse events after they leave the hospital, and likelihood of readmission, and offer an evidence-based prototype for how to address the problem.
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http://www.caretransitions.org/mwg-internal/de5fs23hu73ds/progress?id=+kXo5Wlvs/

August 7, 2019

ABA: Commission on Law and Aging

American Bar Association. Commission on Law and Aging. [Web site]. http://www.americanbar.org/groups/law_aging.html . Updated 2014. Accessed July 31, 2014. The ABA Commission on Law and Aging examines a wide range of legal issues affecting older persons. This work results in: •Policy and practice research and development •Coordination and collaboration •Education (professional […]
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American Bar Association. Commission on Law and Aging. [Web site]. http://www.americanbar.org/groups/law_aging.html . Updated 2014. Accessed July 31, 2014. The ABA Commission on Law and Aging examines a wide range of legal issues affecting older persons. This work results in: •Policy and practice research and development •Coordination and collaboration •Education (professional and public) •Technical assistance Read more about the Commission’s current work in: Capacity Assessment, Elder Abuse, Guardianship Law and Practice, Health Care Decision Making, International Rights of Older Persons, Medicare, and Voting and Cognitive Impairment.
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http://www.americanbar.org/groups/law_aging.html

August 7, 2019

Lost in transition: the ethics of the palliative care handoff

In the palliative care setting, patients and families may experience transitions of care between home and different care facilities. These handoffs between care teams and settings are opportunities for miscommunication about many aspects of care. Specifically, clear, concise, and accurate information about patients’ preferences and goals may not be a […]
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In the palliative care setting, patients and families may experience transitions of care between home and different care facilities. These handoffs between care teams and settings are opportunities for miscommunication about many aspects of care. Specifically, clear, concise, and accurate information about patients' preferences and goals may not be a part of these transitions. This article presents a case where preferences were unclear and unclearly communicated and the patient received care that was likely contrary to his goals. Suggestions are made for mechanisms that may increase the likelihood that information about goals of care and preferences is clearly communicated during these transitions.
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http://www.sciencedirect.com/science/article/pii/S0885392409004230

August 7, 2019

Institute of Medicine: Priority Areas for National Action: Transforming Health Care Quality—Chapter: Care Coordination

Aim To establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow-up. Clinical integration is further defined as “the extent to which patient care services are coordinated across people, functions, activities, and sites over time so […]
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Aim To establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow-up. Clinical integration is further defined as “the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients” (Shortell et al., 2000:129).
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http://www.nap.edu/openbook.php?record_id=10593&page=49#p200071039970049001

August 7, 2019

End of Life Issues

U.S. National Library of Medicine, U.S. Department of Health and Human Services, National Institutes of Health. End of Life Issues. Medline Plus. http://www.nlm.nih.gov/medlineplus/endoflifeissues.html. Updated July 8, 2014. Accessed July 25, 2014. Planning for the end of life can be difficult. But by deciding what end-of-life care best suits your needs […]
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U.S. National Library of Medicine, U.S. Department of Health and Human Services, National Institutes of Health. End of Life Issues. Medline Plus. http://www.nlm.nih.gov/medlineplus/endoflifeissues.html. Updated July 8, 2014. Accessed July 25, 2014. Planning for the end of life can be difficult. But by deciding what end-of-life care best suits your needs when you are healthy, you can help those close to you make the right choices when the time comes. This comprehensive resource page contains links to many useful materials for both patients or caregivers faced with planning end-of-life of care.
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http://www.nlm.nih.gov/medlineplus/endoflifeissues.html

August 7, 2019

Home Health STAR Site

Welcome to the Home Health Setting Targets-Achieving Results (STAR) site! This site allows home health agencies to set targets for the following publicly reported quality measures: • Acute Care Hospitalization • Improvement in Management of Oral Medications Home health agencies registered to use this website can view their publicly reported […]
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Welcome to the Home Health Setting Targets-Achieving Results (STAR) site! This site allows home health agencies to set targets for the following publicly reported quality measures: • Acute Care Hospitalization • Improvement in Management of Oral Medications Home health agencies registered to use this website can view their publicly reported quality measure scores, select appropriate targets, and track their progress over time. Using the Home Health STAR site, your home health agency can become a 'star' performer. Registration on this site is free and available to all Medicare and/or Medicaid certified home health agencies.
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http://www.hhqi-star.org/