Essential Elements of Communication.

Relationship-centered communication (RCC) is an effective approach to patient-provider communication. This article describes RCC components known as the essential elements of communication. The article also describes current standard conceptual models for applying RCC to the patient encounter, including a structure for relationship building. The authors also explore the challenges to using RCC.

Platelet response to direct thrombin inhibitor or fondaparinux treatment in patients with suspected heparin-induced thrombocytopenia.

Making a definitive diagnosis of heparin-induced thrombocytopenia (HIT) can be problematic. A prompt platelet rise following treatment has been proposed as a "post-test" criterion for diagnosis. However, the platelet response following discontinuation of heparin and initiation of a recommended alternative anticoagulant remains largely undefined and unstudied. This study aimed to characterize platelet response to initial treatment in patients with a low, intermediate, or high likelihood of having HIT. This was a multicenter retrospective cohort study. Patients were over 18 years in age, underwent serologic testing for HIT, and received alternative anticoagulation treatment for HIT. Classification of each patient's likelihood of having HIT was based on an empiric, pre-hoc combination of the 4T score and serology results. The primary outcome for this study was a platelet count response after initiation of direct thrombin inhibitor (DTI) or fondaparinux therapy within 48 h. 124 patients were analyzed. The sensitivity and specificity of having an immediate platelet rise of at least 10,000/µL by day 2 after starting treatment among high-likelihood for HIT patients were 0.71 (95% CI 0.55-0.84) and 0.64 (95% CI 0.5-0.76), respectively. The negative predictive value of no platelet rise was 75.5% (95% CI 0.61-0.86). A prompt platelet count rise may be appropriate to consider along with other known criteria for the clinical diagnosis of HIT. The rise should be immediate following discontinuation of heparin and initiation of recommended treatment, with an upward rise within 48 h.

Reduce readmissions with service-based care management.

PURPOSE OF STUDY: In response to the U.S. Affordable Care Act, the Centers for Medicare & Medicaid Services proposed a change in reimbursement penalties for hospitals beginning October 1, 2012. Reducing the occurrence of unplanned readmissions has become a more urgently focused topic. As part of the health care system, care management aligns with physicians to significantly improve service, financial, and clinical care outcomes. To address the changing health care climate in 2008, care management services were restructured at an academic university medical center located in 1 of the 3 largest counties in California. Changing from a unit-based to a service-based care management model partnered care managers and social workers with physician services. We sought to assess the effect of this change on surrogates for patient experience and clinical quality of care. PRIMARY PRACTICE SETTING: Tertiary academic medical center in southern California. METHODOLOGY AND SAMPLE: Retrospective data were collected from 2 databases for all hospital patient care services from November 2008 to January 2010 to determine whether clinical quality of care and experiential service improvements were realized. Primary outcomes included all-cause and related readmission rates. Secondary outcomes were Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) scores. An interrupted time series analysis compared data from the single institution for the diffusion and postintervention periods. RESULTS: Comparing data from the diffusion and postintervention periods, the rate of disease-related readmissions decreased significantly (mean 5.43-4.58, p < .05), and all-cause readmissions also decreased, although the difference failed to achieve statistical significance (11.42-10.49, p = .056). H-CAHPS scores with the patient response of "recommend this hospital" was unchanged over the 2 time points (mean 78.9%-77.8%, p = .26731). Data also showed stable care management staffing rates whereas average daily census (ADC) increased over time (ADC 274-297). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: With health reform driving value-driven care transformation, partnering care managers and social workers with physician services has the potential to impact the patient's experience as well as financial and clinical care outcomes. Care managers serve a significant role in improving the clinical quality of care by reinforcing a consistent and clear message by the health care team to the patient during the entire hospitalization, not just at the time of discharge. At one institution, partnering physicians with care managers through the acute care continuum (service-based care management) appeared to reduce readmissions without compromising patient satisfaction. Both readmission reduction and effective patient satisfaction scores impact the Centers for Medicare & Medicaid Services value-based purchasing reimbursement calculations.