The role of the assessment nurse: one hospital's vision for meeting Joint Commission standards.

In evaluating the progress made during one year, it is clear that the position of assessment nurse has been an extremely valuable, effective role. The staff nurses' perception is that they not only understand the importance of the nursing process more thoroughly, but they also view the role of nursing administration as that of trying to help the registered professional nurse at the bedside. It is key in today's health care climate that the nursing administrator be visible. One method to assure visibility is for staff to actually see a role model serving as an extension of the nurse administrator. If nurse administrators truly value the importance of the nursing process, then they need to ensure that this message is being communicated throughout the entire nursing service organization. Such an innovative position can function as a liaison between nursing management and the staff. There is no better method of communicating this than having someone who visibly echoes the values of the nurse administrator. It also should be noted here that Shore Memorial Hospital's Nursing Division received a perfect Joint Commission survey evaluation in April 1990. The Nursing Division attributes this to the efforts made regarding implementation of the nursing process, and the forward thinking of a systems change with implementation of a computerized nursing information system that incorporates the nursing process with everyday documentation. Nurse administrators must effect change and demonstrate leadership within their respective organizations. Organizational change can be slow and difficult at times; however, the end result is worth the effort. It is important that the values of the nurse administrator be disseminated throughout the organization.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical pathways in home healthcare.

Administrators and directors of home health agencies are increasingly accountable for the productive use of resources and quality patient outcomes. However, few reliable ways exist to measure and influence these components. The author proposes the use of the critical pathway typically used in acute care case management as an efficient tool to guide home health nursing practice. The author presents the process for developing a critical pathway for congestive heart failure patients in a home health agency, as well as results of a study determining when nursing interventions were implemented.

Making information accessible and useful to practicing clinicians. Problem-knowledge coupling.

Assessments of health care technology will lead to improvements in patient services only if this information is actually used by clinicians. Traditional methods of planning treatment that rely solely on memory limit the clinician's access to and use of the full available body of knowledge in the field. An alternative approach using a computer-assisted methodology is presented as a way to overcome traditional limitations and promote the development and diffusion of knowledge.

Diagnosis and disability in Geriatric Assessment Team clients: a pilot study.

This study presents the results of a pilot study examining the diagnosis and disability levels of a sample of clients seen by four Victorian Regional Geriatric Assessment Teams (GATs). It identifies a clear relationship between the client disability profile and the resultant recommended care plan. As expected, clients recommended for nursing home care are the most disabled, although clients recommended for inpatient treatment/rehabilitation also have very high levels of physical disability. Recipients of hostel or Special Accommodation Home (SAH) recommendations, however, exhibit levels of physical disability comparable to those of clients with community care recommendations. The distinguishing factor here is the presence of cognitive disability, which substantially reduces the likelihood of retention in the community.

Assessment and utilization of patient strengths in acute care treatment planning.

Strength-focused assessment and treatment planning are presented as a partner to diagnostic evaluation of symptoms, syndromes, and clinical history. It is not advocated as a replacement, but as an extension of what we now do. However, we must not underestimate the new attitude inherent in the search for barely visible coping moments and coping momentum. It's a new attitude more than a new technique for both the patient and the practitioner.

Innovations in managing difficult behaviors.

Caring for people with difficult behaviors is among the greatest challenges for nursing facility providers. This month, Provider looks at successful techniques in caring for people with dementias and other difficult-to-manage behaviors.

Assessing assessment in social work.

This article reviews trends in social work assessment that are likely to shape the future of clinical practice. In contrast to the rich contextual information provided by traditional psychosocial approaches to assessment, classification systems like DSM-III-R can lead to oversimplification and loss of information that is important to intervention planning. The movement toward the use of continuous, dimensional alternatives to categorical classifications will have a significant effect on clinical assessment and treatment monitoring. Technical advances and efforts to conceptualize and operationalize the contextual complexities of clients' lives will be increasingly important in the future.

A case mix procedure for matching the clinical characteristics of patients with dual disorders to planned treatment and treatment costs.

A procedure for matching the clinical characteristics of patients with a dual substance abuse psychiatric disorder to planned treatment resource consumption is described. The procedure uses current standards and practices within the mental health literature on dual diagnosed patients, providing an empirical basis for quality assurance, utilization review, and program evaluation. These procedures permit an empirical linking of clinical service performance to the costs of clinical resources, thereby providing a means of: (a) evaluating program costs in terms of the specific clinical characteristics of patients and (b) planning budgets based on the patients' clinical needs. The methods are sufficiently flexible so that as new clinical research recommend changes in assessment and treatment, the case mix definitions and evaluation procedures can be easily modified.

Patient assessment and treatment planning in child and adolescent partial hospital programs.

Thirty-six patient records were examined during site visits to 18 child and adolescent (PH) programs. The documentation of patient assessment and treatment planning was examined. The history of present illness, past psychiatric history, and medical history were at least adequate in about 60-70% of evaluations. Treatment plans were generally complete, but at least one-half of mandated treatment plan reviews lacked revisions. Psychiatric justification of admission and diagnosis was poor in 41% and 44% of charts, respectively, and there was no documentation of ongoing psychiatrist-patient contact in 44% of charts. Possible explanations for these findings include inadequate funding of PH programs, lack of psychiatric time, and uniform approaches to treatment.

Individual versus team case management in optimizing community care for chronically ill patients with dementia.

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.

[A modified technic of preoperative acute normovolemic hemodilution--the advantages and economic effect of its use in planned colorectal surgery]. / Modifitsirana tekhnika na predoperativna ostra normovolemichna khemodilutsiia--predimstva i ikonomicheski efekt ot prilozhenieto i v planovata kolo-rektalna khirurgiia.

In a prospective and comparative study were included 129 patients undergone planned operation for colorectal cancer. They were divided in two randomized groups: Group A consisted of 65 patients operated under conditions of preoperative acute normovolemic hemodilution (PANHD) by an own modified technique with Ringer-lactate and hemodex. Group B (control) included 64 patients operated with the use of homologous blood substitution. The results in the two groups were compared as to: intra- and postoperative blood transfusions; time (in days) of postoperative treatment; number of postoperative complications. Statistically significant differences (p less than 0.001) referrable to all three compared values were found. The modified PANHD technique in planned colorectal surgery is safer for the patients than the so far suggested techniques and may readily gain acceptance with the use of solutions of domestic produce. It leads to significant decrease in homologous blood transfusion, shortening the postoperative stay in hospital of patients subjected to hemodilution. The number of patients in whom postoperative complications developed was reduced.

Models to promote medical health care delivery for indigent families: computerized tracking to case management.

Poor patient/parental medical compliance is one of the most important health care issues of today. Multiple interrelated factors contribute to this problem. Of prime importance is patient/parental maturity and knowledge. Reversal of this process is undoubtably harder than prevention. The cost effectiveness of various methods of intervention is discussed in relation to a large mid-south indigent population. Computerized patient tracking is cost efficient and effectively promotes compliance in a percentage of patients. Its additional utility is the identification and triage of patients, most in need of intervention, to existing social service personnel for family-centered case management. Family-centered case management holds the best hope of reversing the many factors adversely affecting patient compliance. However, this method is costly and requires a low ratio of clients to caseworkers in order to be effective. Community-centered patient management is less costly to implement and is very useful in tightly woven communities resistant to outside intervention. However, this method often has a high client to caseworker ratio and has less utility in dealing with complex medical problems.

Monitoring patient outcome following discharge: a computerized geriatric case-management system.

Many political, economic, and social factors are influencing health care providers to consider case-management programs. The authors describe a computer-supported, hospital-based case management program for elderly patients and report on the benefits and drawbacks of the program. Primary benefits include access to better client data, improved discharge planning capabilities, and greater program efficiency. Drawbacks chiefly are related to the difficulties inherent in introducing computerization into a human service setting. Overall, the program is a beneficial addition to patient care efforts and is a valuable tool for tracking high-risk patients in acute-care settings.

Outcomes of five years of continuous intensive case management.

Five years of intensive case management and specialized alternatives to hospitalization were provided to 72 young recidivistic, treatment-resistant, chronically thought-disordered patients. Compared with a two-year prestudy baseline, patients' days in the hospital during the five years were reduced by 75 percent, but this reduction was offset by a 193 percent increase in structured residential care days in the community. Patients' level of functioning as rated by the Global Assessment Scale and other measures remained essentially the same over the five years. However, use of emergency services and after-hours on-call services decreased steadily throughout the study. Comprehensive cost-analysis revealed that savings in hospital costs were offset by increased costs of community care. The authors conclude that this treatment approach effectively stabilized the treatment-resistant patients in the community but did not reduce net costs in constant dollars.

Matching models to environments. A planning guide to the selection of pediatric home care models.

Many children receiving sophisticated life-support technology in hospitals can be returned to their families if all parts of a home care program are in place: the appropriate trained personnel, available high-tech equipment, and necessary financial resources.

Description and analysis of preadmission screening.

The practice of screening applicants for nursing home admission to determine whether less restrictive residential settings are possible is growing as states attempt to limit costs of Medicaid expenditures for long-term care. Preadmission screening (PAS) is a repetitive task conducted under conditions of complexity and uncertainty. Extensive knowledge and skills are required to make recommendations concerning appropriate residences for elderly persons that match their needs with available services while assuring their autonomy, as well as that of their families. We used task analysis to explicate the specific task characteristics and the knowledge and skill requirements for successful PAS.

The need for special interventions for multiple hospital admission patients.

Although a high proportion of Medicare hospital admissions and expenditures are accounted for by a small proportion of the elderly who experience chronic patterns of acute hospital use, little emphasis has been placed on reducing hospitalization among these high users. Five interventions that have succeeded in substantially reducing the number of hospital days among high users living at home are discussed in this article, as are several interventions that have reduced hospital use by nursing home residents. With the passage of the Medicare Catastrophic Coverage Act of 1988, research and demonstration activities for high users of hospital care will, for the first time, have a Federal focus.