Interactions Between Physicians and Skilled Home Health Care Agencies in the Certification of Medicare Beneficiaries' Plans of Care: Results of a Nationally Representative Survey.

Background: Physicians are required to certify a plan of care for patients who receive Medicare skilled home health care (SHHC) services. The Centers for Medicare & Medicaid Services form 485 (CMS-485) is typically used for certification of SHHC plans of care and for interactions between SHHC agencies and physicians. Little is known about how physicians use the CMS-485 or their perceptions of its usefulness with respect to coordinating care with SHHC agencies. Objective: To determine how physicians interact with SHHC agencies and use the CMS-485 in care coordination for patients receiving SHHC services. Design: Mailed survey. Setting: Nationally representative random sample. Participants: Physicians from the American Medical Association Physician Masterfile specializing in family or general medicine (excluding adolescent and sports medicine), geriatrics, geriatric psychiatry, internal medicine, or hospice and palliative medicine. Measurements: Time spent reviewing the plan of care and experiences with making changes and communicating with SHHC clinicians. Results: The response rate after 3 mailings was 53% (1044 of 1968). Of 1005 respondents who provided patient care, 72% had certified at least 1 plan of care in the past year. Nearly half (47%) reported spending less than 1 minute reviewing the CMS-485 before certification, whereas 21% reported spending at least 2 minutes. Physicians typically interacted with multiple SHHC agencies by fax or mail. Approximately 80% rarely or never changed an order on the CMS-485, and 78.3% rarely or never contacted SHHC clinicians with questions about information. The mean reported ease of contacting the SHHC agency was 4.7 (SD, 2.3) on a scale of 1 (easy) to 10 (difficult). Limitation: Self-reported data and 53% response rate. Conclusion: The CMS-485 does not meaningfully engage physicians. Physicians spend little time reviewing or acting on the SHHC plan of care. Strategies to enhance meaningful communication between SHHC agencies and physicians are needed. Primary Funding Source: National Institute on Aging and National Institute of Mental Health.

Communication between office-based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE.

AIMS AND OBJECTIVES: To examine themes of communication between office-based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses' concerns. BACKGROUND: Lack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community-based nurses and primary care providers. DESIGN: Secondary analysis of process data from 'Community Aging in Place: Advancing Better Living for Elders (CAPABLE)'. METHODS: Independent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses. RESULTS: Primary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client-raised concerns. Nurses' letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation. CONCLUSIONS: Effective communication between home-based nurses and primary care providers enhances care coordination and improves outcomes for home-dwelling elders. Various methods of contact show promise for addressing specific communication needs. RELEVANCE TO CLINICAL PRACTICE: Nurses practicing within patients' homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.

Implementation of a telehealth videoconference to improve hospital-to-skilled nursing care transitions: Preliminary data.

BACKGROUND: Transition-related patient safety errors are high among patients discharged from hospitals to skilled nursing facilities (SNFs), and interventions are needed to improve communication between hospitals and SNF providers. Our objective was to describe the implementation of a pilot telehealth videoconference program modeled after Extension for Community Health Outcomes-Care Transitions and examine patient safety errors and readmissions. METHODS: A multidisciplinary telehealth videoconference program was implemented at two academic hospitals for patients discharged to participating SNFs. Process measures, patient safety errors, and hospital readmissions were evaluated retrospectively for patients discussed at weekly conferences between July 2019-January 2020. Results were mapped to the constructs of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) model. Descriptive statistics were reported for the conference process measures, patient and index hospitalization characteristics, and patient safety errors. The primary clinical outcome was all-cause 30-day readmissions. An intention-to-treat (ITT) analysis was conducted using logistic regression models fit to compare the probability of 30-day hospital readmission in patients discharged to participating SNFs across 7 months prior to after telehealth project implementation. RESULTS: There were 263 patients (67% of eligible patients) discussed during 26 telehealth videoconferences. Mean discussion time per patient was 7.7 min and median prep time per patient was 24.2 min for the hospital pharmacist and 10.3 min for the hospital clinician. A total of 327 patient safety errors were uncovered, mostly related to communication (54%) and medications (43%). Differences in slopes (program period vs. pre-implementation) of the probability of readmission across the two time periods were not statistically significant (OR 0.95, [95% CI 0.75, 1.19]). CONCLUSIONS: A pilot care innovations telehealth videoconference between hospital-based and SNF provider teams was successfully implemented within a large health system and enhanced care transitions by optimizing error-prone transitions. Future work is needed to understand process flow within nursing homes and its impact on clinical outcomes.

Training in the Era of EHR: Examining the Experience of Medical Student Documentation in the Ambulatory Care Setting.

This article was migrated. The article was marked as recommended. Purpose: Documenting clinical encounters in the electronic health record has become an important component of medical student training. Reflecting this trend, recent rule changes by the Centers for Medicare and Medicaid services now permit billing for medical student notes. We sought to investigate the educational value of student note-writing following implementation of these changes. Methods: We surveyed medical students at a private research university who participated in longitudinal ambulatory care experiences. Survey questions assessed the incorporation of student note-writing into clinic workflow, as well as the benefits and disadvantages of note-writing. Results: Thirty-six students completed the survey. A majority of students perceived benefits in regards to residency preparedness, engagement with the clinical team, and clinical reasoning ability as a result of writing notes in clinic. While some students reported seeing fewer patients as a result of note-writing, most felt that use of the electronic health record did not negatively impact patient interaction. Barriers cited included a lack of knowledge regarding billing requirements and preceptor apprehension toward student note-writing. Conclusion: The results of this study indicate that student note-writing continues to be a valuable part of medical training following recent billing changes. Our results also identify areas for improvement, including clarifying billing requirements and assuaging preceptor concerns.