Quantifying care coordination using natural language processing and domain-specific ontology.

OBJECTIVE: This research identifies specific care coordination activities used by Aging in Place (AIP) nurse care coordinators and home healthcare (HHC) nurses when coordinating care for older community-dwelling adults and suggests a method to quantify care coordination. METHODS: A care coordination ontology was built based on activities extracted from 11,038 notes labeled with the Omaha Case management category. From the parsed narrative notes of every patient, we mapped the extracted activities to the ontology, from which we computed problem profiles and quantified care coordination for all patients. RESULTS: We compared two groups of patients: AIP who received enhanced care coordination (n=217) and HHC who received traditional care (n=691) using 128,135 narratives notes. Patients were tracked from the time they were admitted to AIP or HHC until they were discharged. We found that patients in AIP received a higher dose of care coordination than HHC in most Omaha problems, with larger doses being given in AIP than in HHC in all four Omaha categories. CONCLUSIONS: 'Communicate' and 'manage' activities are widely used in care coordination. This confirmed the expert hypothesis that nurse care coordinators spent most of their time communicating about their patients and managing problems. Overall, nurses performed care coordination in both AIP and HHC, but the aggregated dose across Omaha problems and categories is larger in AIP.

Comparing Aging in Place to Home Health Care: Impact of Nurse Care Coordination On Utilization and Costs.

The goal of this study was to compare utilization and cost outcomes of patients who received long-term care coordination in an Aging in Place program to patients who received care coordination as a routine service in home health care. This research offered the unique opportunity to compare two groups of patients who received services from a single home health care agency, using the same electronic health record, to identify the impact of long-term and routine care coordination on utilization and costs to Medicare and Medicaid programs. This study supports that long-term care coordination supplied by nurses outside of a primary medical home can positively influence functional, cognitive, and health care utilization for frail older people. The care coordinators in this study practiced nursing by routinely assessing and educating patients and families, assuring adequate service delivery, and communicating with the multidisciplinary health care team. Care coordination managed by registered nurses can influence utilization and cost outcomes, and impact health and functional abilities.

Cost analysis of a home-based nurse care coordination program.

OBJECTIVES: To determine whether a home-based care coordination program focused on medication self-management would affect the cost of care to the Medicare program and whether the addition of technology, a medication-dispensing machine, would further reduce cost. DESIGN: Randomized, controlled, three-arm longitudinal study. SETTING: Participant homes in a large Midwestern urban area. PARTICIPANTS: Older adults identified as having difficulty managing their medications at discharge from Medicare Home Health Care (N = 414). INTERVENTION: A team consisting of advanced practice nurses (APNs) and registered nurses (RNs) coordinated care for two groups: home-based nurse care coordination (NCC) plus a pill organizer group and NCC plus a medication-dispensing machine group. MEASUREMENTS: To measure cost, participant claims data from 2005 to 2011 were retrieved from Medicare Part A and B Standard Analytical Files. RESULTS: Ordinary least squares regression with covariate adjustment was used to estimate monthly dollar savings. Total Medicare costs were $447 per month lower in the NCC plus pill organizer group (P = .11) than in a control group that received usual care. For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC plus pill organizer group (P = .06) than in the control group. The cost of the NCC plus pill organizer intervention was $151 per month, yielding a net savings of $296 per month or $3,552 per year. The cost of the NCC plus medication-dispensing machine intervention was $251 per month, and total Medicare costs were $409 higher per month than in the NCC plus pill organizer group. CONCLUSION: Nurse care coordination plus a pill organizer is a cost-effective intervention for frail elderly Medicare beneficiaries. The addition of the medication machine did not enhance the cost effectiveness of the intervention.

Medication regimens of frail older adults after discharge from home healthcare.

The purpose of this study was to examine the number and types of discrepancy errors present after discharge from home healthcare in older adults at risk for medication management problems following an episode of home healthcare. More than half of the 414 participants had at least one medication discrepancy error (53.2%, n = 219) with the participant's omission of a prescribed medication (n = 118, 30.17%) occurring most frequently. The results of this study support the need for home healthcare clinicians to perform frequent assessments of medication regimens to ensure that the older adults are aware of the regimen they are prescribed, and have systems in place to support them in managing their medications.

Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy.

BACKGROUND: Self-management of complex medication regimens for chronic illness is challenging for many older adults. OBJECTIVES: The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology. DESIGN: This study used a randomized controlled trial with three arms and longitudinal outcome measurement. SETTING: Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area. METHODS: All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months. RESULTS: After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons. DISCUSSION: Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

Length of stay and charges associated with health care-acquired bloodstream infections.

BACKGROUND: Although many studies have examined outcomes of health care-associated bloodstream infections (HCABSIs), population-based estimates of length of stay (LOS) and costs have seldom been reported. OBJECTIVES: Our objective was to generate US national estimates of LOS and costs associated with HCABSIs using the 2003 National Inpatient Sample (NIS). METHODS: This study utilized a matched case-control design to estimate LOS and costs associated with HCABSIs based on the 2003 (NIS). A special set of ICD-9-CM codes was used to identify cases. A 1:1 matching procedure was used in which HCABSIs in patients were matched with uninfected patients based on age, sex, and admission diagnosis. We performed weighted analysis to construct population estimates and their standard deviations for LOS and total charges. RESULTS: After applying the case finding criteria, 113,436 HCABSI cases were identified. The weighted mean LOS for HCABSIs cases was 16.0 days compared with 5.4 days for the control group (P < .001). The weighted mean total charges for patients with HCABSIs were $85,813 ($110,183 US in 2010) compared with $22,821 ($29,302 US in 2010) for uninfected patients (P < .001). We estimated that, in 2003, HCABSIs potentially cost the US economy nearly $29 billion ($37.24 billion US in 2010). CONCLUSION: This study estimated the economic burden of HCABSIs on the US national economy. With some modifications, the annually published NIS data could be useful as a national surveillance tool for health care adverse events including HCABSIs.

Predictors of nonpharmacological and pharmacological treatments stopped and started among nursing home residents with dementia.

The purpose of this study was to describe the nonpharmacological and pharmacological treatments stopped and started over 6 weeks among a sample of nursing home residents with moderate to severe dementia and to identify nurse and resident factors associated with starting new and stopping ineffective/unnecessary nonpharmacological and pharmacological treatments. One hundred thirty-four nursing home residents with dementia and 39 nurses from 12 nursing homes in the Midwest participated in this study. Resident and nursing process data were collected on daily tracking forms completed by the primary nurse over a 6-week period. Both assessment-driven intervention and evaluation-driven follow through significantly predicted treatments stopped and new treatments started. The findings demonstrate that nurses serve an essential role in maintaining resident physiological and psychological homeostasis by vigilantly responding to residents' physical problems and behaviors with assessment-driven intervention and evaluation-driven follow through.

Aging in place versus nursing home care: comparison of costs to Medicare and Medicaid.

The objective of this study was to compare the community-based, long-term care program called Aging in Place (AIP) and nursing home care, in terms of cost to the Medicare and Medicaid programs. A retrospective cohort design was used in this study of 39 nursing home residents in the Midwest who were matched with 39 AIP participants. The AIP program consisted of a combination of Medicare home health, Medicaid home and community-based services (HCBS), and intensive nurse care coordination. Controlling for high inpatient Medicare cost in the 6 months prior and the 10 most frequently occurring chronic conditions, multiple regression was used to estimate the relationship of the AIP program on Medicare and Medicaid costs. Total Medicare and Medicaid costs were $1,591.61 lower per month in the AIP group (p < 0.01) when compared with the nursing home group over a 12-month period. The findings suggest that the provision of nurse-coordinated HCBS and Medicare home health services has potential to provide savings in the total cost of health care to the Medicaid program while not increasing the cost of the Medicare program.

The impact of Prenatal Care Coordination on birth outcomes.

OBJECTIVE: To measure the impact of a Medicaid benefit called Prenatal Care Coordination (PNCC) on healthy birth outcomes. DESIGN: A cross-sectional design was used to compare the birth outcomes of infants born to women who received Medicaid and PNCC services to the birth outcomes of infants born to women who received Medicaid but did not receive PNCC services. SETTING: Services were provided in community based settings in Wisconsin. PARTICIPANTS: Of the 45,406 Medicaid births in 2001 to 2002, 10,715 (23.6%) mothers received PNCC services and were considered the treatment group. METHODS: Secondary analyses of birth certificate and Medicaid billing data were conducted using binary logistic regression analyses to evaluate the impact of PNCC and the hours of PNCC service on birth outcomes. RESULTS: Controlling for nine covariates, women who received PNCC services were found to have significantly better birth outcomes, including fewer low-birth-weight infants (odds ratio [OR]=0.84; 95% CI [.777, .912]), fewer very-low-birth-weight infants (OR=0.70; 95% CI [.587, .855]), fewer preterm infants (OR=0.83; 95% CI [.776, .890]), and fewer infants transferred to the neonatal intensive care units (OR=.83; 95% CI [.759, .906]). Women who received 6 or more hours of service were less likely to deliver infants with poor birth outcomes. CONCLUSIONS: The use of PNCC is an effective strategy for preventing adverse birth outcomes. Strategies to further enhance PNCC's positive benefits include increased outreach and engagement with at risk pregnant women.

The relationship of community-based nurse care coordination to costs in the Medicare and Medicaid programs.

The purpose of this evaluation was to study the relationship of nurse care coordination (NCC) to the costs of Medicare and Medicaid in a community-based care program called Missouri Care Options (MCO). A retrospective cohort design was used comparing 57 MCO clients with NCC to 80 MCO clients without NCC. Total cost was measured using Medicare and Medicaid claims databases. Fixed effects analysis was used to estimate the relationship of the NCC intervention to costs. Controlling for high resource use on admission, monthly Medicare costs were lower ($686) in the 12 months of NCC intervention (p = .04) while Medicaid costs were higher ($203; p = .03) for the NCC group when compared to the costs of MCO group.

Incidence of and risk factors for nosocomial bloodstream infections in adults in the United States, 2003.

BACKGROUND: Although many studies have examined nosocomial bloodstream infection (BSI), US national estimates of incidence and case-fatality rates have seldom been reported. OBJECTIVE: The purposes of this study were to generate US national estimates of the incidence and severity of nosocomial BSI and to identify risk factors for nosocomial BSI among adults hospitalized in the United States on the basis of a national probability sample. METHODS: This cross-sectional study used the US Nationwide Inpatient Sample for the year 2003 to estimate the incidence and case-fatality rate associated with nosocomial BSI in the total US population. Cases of nosocomial BSI were defined by using 1 or more International Classification of Diseases, 9th Revision, Clinical Modification codes in the secondary field(s) that corresponded to BSIs that occurred at least 48 hours after admission. The comparison group consisted of all patients without BSI codes in their NIS records. Weighted data were used to generate US national estimates of nosocomial BSIs. Logistic regression was used to identify independent risk factors for nosocomial BSI. RESULTS: The US national estimated incidence of nosocomial BSI was 21.6 cases per 1,000 admissions, while the estimated case-fatality rate was 20.6%. Seven of the 10 leading causes of hospital admissions associated with nosocomial BSI were infection related. We estimate that 541,081 patients would have acquired a nosocomial BSI in 2003, and of these, 111,427 would have died. The final multivariate model consisted of the following risk factors: central venous catheter use (odds ratio [OR], 4.76), other infections (OR, 4.61), receipt of mechanical ventilation (OR, 4.97), trauma (OR, 1.98), hemodialysis (OR, 4.83), and malnutrition (OR, 2.50). The total maximum rescaled R(2) was 0.22. CONCLUSIONS: The Nationwide Inpatient Sample was useful for estimating national incidence and case-fatality rates, as well as examining independent predictors of nosocomial BSI.

Severe fatigue and depressive symptoms in lower-income urban postpartum women.

The purpose of this study was to identify whether severe postpartum fatigue at 1 and 3 months postpartum was associated with depressive symptomatology at 6 months in lower-income urban women. A convenience sample of 43 lower-income postpartum women completed the Modified Fatigue Symptoms Checklist and Edinburgh Postpartum Depression scale at 1, 3, and 6 months postpartum. Participants who were severely fatigued at both 1 and 3 months postpartum were significantly more likely to exhibit depressive symptomatology at 6 months. Fatigue and depressive symptoms were moderately to strongly correlated at 1 (r = .68), 3 (r = .74), and 6 (r = .70) months postpartum (p = .001). Severe fatigue and depressive symptomatology often co-exist for months after childbirth. Future research should examine whether interventions to targeting severe postpartum fatigue in lower-income urban women may also effectively reduce depressive symptoms.