Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days. We examined admissions nurses' visit pattern decision-making and whether it is influenced by documentation available before and during the first home visit, agency standards, other disciplines being scheduled, and electronic health record (EHR) use. This observational mixed-methods study included admission document analysis, structured interviews, and a think-aloud protocol with 18 nurses from 3 diverse HHC agencies (6 at each) admitting 2 patients each (36 patients). Findings show that prior to entering the home, nurses had an information deficit; they either did not predict the patient's visit frequency and episode duration or stated them based on experience with similar patients. Following patient interaction in the home, nurses were able to make this decision. Completion of documentation using the EHR did not appear to influence visit pattern decisions. Patient condition and insurance restrictions were influential on both frequency and duration. Given the information deficit at admission, and the delay in visit pattern decision making, we offer health information technology recommendations on electronic communication of structured information, and EHR documentation and decision support.

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

OBJECTIVES: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. DESIGN: Observational field study. SETTINGS AND PARTICIPANTS: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total). METHODS: Researchers observed the admission process in the patient home and at the HHC agency. The nurses' tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored. RESULTS: Polypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider. CONCLUSIONS AND IMPLICATIONS: Changes to the referrer medication list and calls to providers highlighted the nurses' effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

OBJECTIVES: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. DESIGN: Observational field study. SETTING AND PARTICIPANTS: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). METHODS: Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). RESULTS: Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. CONCLUSIONS AND IMPLICATIONS: Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

Availability and Quality of Information Used by Nurses While Admitting Patients to a Rural Home Health Care Agency.

Home health care admission nurses need high quality patient information but that information is not uniformly available. Despite this challenge, these nurses must make four critical decisions at patient admission to construct the plan of care: (1) patient problems to address in the home health care episode; (2) patient medication management; (3) services in addition to skilled nursing; and (4) skilled nursing visit pattern. We observed 12 in-home admissions at a rural home health care agency and interviewed nurses before and after about these decisions. We analyzed content and quality of documents. To evaluate quality, for each decision we assessed concordance between documents. Interview responses provided context in the analysis. Across all admissions, documents and their contents were not uniformly present. Nurses rarely received visit pattern or medication management information. There was discordance in the number of patient problems among and between available documents and the plan of care. Electronic health record design recommendations include interoperability and structured, consistent, actionable information.

Incongruence of Patient Problem Information Across Three Phases of Home Care Admission: There's a Problem with the Problem List.

In home health care, the patient problem list is an important component of the admission and care planning processes and determines the subsequent care received. We examined the information received from the referring facilities and its relationship with the final patient problem list generated at home health care admission. Researchers observed 12 admissions and collected available documents related to the admission and care planning process. Problems identified in documents provided to admission nurses (input documents) and in documents subsequently created by those nurses (output documents) were coded to form a standardized set of problem terms across the documents. Documents available, distribution of problems within the documents, and concordance between input and output documents were assessed. A varying number of the 17 unique problems found across the documents were distributed by document type. Patients were referred to home health care with more clinical problems than were documented in the output documents.

Using a Decision Support Algorithm for Referrals to Post-Acute Care.

OBJECTIVES: Although hospital clinicians strive to effectively refer patients who require post-acute care (PAC), their discharge planning processes often vary greatly, and typically are not evidence-based. DESIGN: Quasi-experimental study employing pre-/postdesign. Aimed at improving patient-centered discharge processes, we examined the effects of the Discharge Referral Expert System for Care Transitions (DIRECT) algorithm that provides clinical decision support (CDS) regarding which patients to refer to PAC and to what level of care (home care or facility). SETTING AND PARTICIPANTS: Conducted in 2 hospitals, DIRECT data elements were collected in the pre-period (control) but discharging clinicians were blinded to the advice and provided usual discharge care. During the postperiod (intervention), referral advice was provided within 24 hours of admission to clinicians, and updated twice daily. Propensity modeling was used to account for differences between the pre-/post patient cohorts. MEASURES: Outcomes compared between the control and the intervention periods included PAC referral rates, patient characteristics, and same-, 7-, 14-, and 30-day readmissions or emergency department visits. RESULTS: Although 24%-25% more patients were recommended for PAC referral by DIRECT algorithm advice, the proportion of patients receiving referrals for PAC did not significantly differ between the control (3302) and intervention (5006) periods. However, the characteristics of patients referred for PAC services differed significantly and inpatient readmission rates decreased significantly across all time intervals when clinicians had DIRECT CDS compared with without. There were no differences observed in return emergency department visits. Largest effects were observed when clinicians agreed with the algorithm to refer (yes/yes). CONCLUSIONS/IMPLICATIONS: Our findings suggest the value of timely, automated, discharge CDS for clinicians to optimize PAC referral for those most likely to benefit. Although overall referral rates did not change with CDS, the algorithm may have identified those patients most in need, resulting in significantly lower inpatient readmission rates.

Home Care Admission Information: What Nurses Need and What Nurses Have. A Mixed Methods Study.

Effective communication between clinicians across care settings is fundamental for continuity of care and decreased risk of errors. The home care admission often starts without important information needed for formulation of the plan of care. We conducted a mixed methods analysis to investigate home care admission information from two perspectives: qualitative information regarding information nurses reported they needed during an admission, and quantitative information regarding information actually available. We mapped both data sets to an international specification for transitions in care information, the Continuity of Care Document (CCD). The information that homecare nurses said they needed mapped sufficiently (90%) to the CCD. Regarding available information: no observation had all the CCD information present; CCD information was missing in varying amounts across the admission documents. Nurses searching among pages of documentation for information which may not be present is inefficient and introduces patient safety concerns of increased risk for errors.

Why older adults may decline offers of post-acute care services: A qualitative descriptive study.

The most common post-acute care (PAC) services available to patients after hospital discharge include home care, skilled nursing facilities, nursing homes, inpatient rehabilitation, and hospice. Patients who need PAC and receive services have better outcomes, however almost one-third of those offered services decline. Little research exists on PAC decision-making and why patients may decline services. This qualitative descriptive study explored the responses of thirty older adults to the question: "Can you, from the patient point of view, tell me why someone would not want post hospital care?" Three themes emerged. Participants may decline due to 1) previous negative experiences with PAC, or 2) a preference to be home. Some participants stated, "I'd be there" and would not decline services. Participants also discussed 3) why other patients might decline PAC which included patients' past experiences, lack of understanding/preconceived ideas, and preferences. Clinical implications include assessing patients' knowledge and experience before providing recommendations.

Using Electronic Case Summaries to Elicit Multi-Disciplinary Expert Knowledge about Referrals to Post-Acute Care.

BACKGROUND: Eliciting knowledge from geographically dispersed experts given their time and scheduling constraints, while maintaining anonymity among them, presents multiple challenges. OBJECTIVES: Describe an innovative, Internet based method to acquire knowledge from experts regarding patients who need post-acute referrals. Compare, 1) the percentage of patients referred by experts to percentage of patients actually referred by hospital clinicians, 2) experts' referral decisions by disciplines and geographic regions, and 3) most common factors deemed important by discipline. METHODS: De-identified case studies, developed from electronic health records (EHR), contained a comprehensive description of 1,496 acute care inpatients. In teams of three, physicians, nurses, social workers, and physical therapists reviewed case studies and assessed the need for post-acute care referrals; Delphi rounds followed when team members did not agree. Generalized estimating equations (GEEs) compared experts' decisions by discipline, region of the country and to the decisions made by study hospital clinicians, adjusting for the repeated observations from each expert and case. Frequencies determined the most common case characteristics chosen as important by the experts. RESULTS: The experts recommended referral for 80% of the cases; the actual discharge disposition of the patients showed referrals for 67%. Experts from the Northeast and Midwest referred 5% more cases than experts from the West. Physicians and nurses referred patients at similar rates while both referred more often than social workers. Differences by discipline were seen in the factors identified as important to the decision. CONCLUSION: The method for eliciting expert knowledge enabled national dispersed expert clinicians to anonymously review case summaries and make decisions about post-acute care referrals. Having time and a comprehensive case summary may have assisted experts to identify more patients in need of post-acute care than the hospital clinicians. The methodology produced the data needed to develop an expert decision support system for discharge planning.

Patient Preferences for Information on Post-Acute Care Services.

The purpose of the current study was to explore what hospitalized patients would like to know about post-acute care (PAC) services to ultimately help them make an informed decision when offered PAC options. Thirty hospitalized adults 55 and older in a Northeastern U.S. academic medical center participated in a qualitative descriptive study with conventional content analysis as the analytical technique. Three themes emerged: (a) receiving practical information about the services, (b) understanding "how it relates to me," and (c) having opportunities to understand PAC options. Study findings inform clinicians what information should be included when discussing PAC options with older adults. Improving the quality of discharge planning discussions may better inform patient decision making and, as a result, increase the numbers of patients who accept a plan of care that supports recovery, meets their needs, and results in improved quality of life and fewer readmissions. [Res Gerontol Nurs. 2016; 9(4):175-182.].

Impact of discharge planning decision support on time to readmission among older adult medical patients.

PURPOSE OF THE STUDY: Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission. PRIMARY PRACTICE SETTING: Four medical units at one urban, university medical center. METHODOLOGY AND SAMPLE: A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental). RESULTS: After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.

Conducting research using the electronic health record across multi-hospital systems: semantic harmonization implications for administrators.

Administrators play a major role in choosing and managing the use of the electronic health record (EHR). The documentation policies and EHR changes enacted or approved by administrators affect the ability to use clinical data for research. This article illustrates the challenges that can be avoided through awareness of the consequences of customization, variations in documentation policies and quality, and user interface features. Solutions are posed that assist administrators in avoiding these challenges and promoting data harmonization for research and quality improvement.

Predictors of objectively measured medication nonadherence in adults with heart failure.

BACKGROUND: Medication nonadherence rates are high. The factors predicting nonadherence in heart failure remain unclear. METHODS AND RESULTS: A sample of 202 adults with heart failure was enrolled from the northeastern United States and followed for 6 months. Specific aims were to describe the types of objectively measured medication adherence (eg, taking, timing, dosing, drug holidays) and to identify contributors to nonadherence 6 months after enrollment. Latent growth mixture modeling was used to identify distinct trajectories of adherence. Indicators of the 5 World Health Organization dimensions of adherence (socioeconomic, condition, therapy, patient, and healthcare system) were tested to identify contributors to nonadherence. Two distinct trajectories were identified and labeled persistent adherence (77.8%) and steep decline (22.3%). Three contributors to the steep decline in adherence were identified. Participants with lapses in attention (adjusted OR, 2.65; P=0.023), those with excessive daytime sleepiness (OR, 2.51; P=0.037), and those with ≥2 medication dosings per day (OR, 2.59; P=0.016) were more likely to have a steep decline in adherence over time than to have persistent adherence. CONCLUSIONS: Two distinct patterns of adherence were identified. Three potentially modifiable contributors to nonadherence have been identified.

Double jeopardy: the influence of excessive daytime sleepiness and impaired cognition on health-related quality of life in adults with heart failure.

AIMS: To determine how excessive daytime sleepiness (EDS) and impaired cognition contribute to health-related quality of life (HRQL) in heart failure (HF). METHODS AND RESULTS: Adults with chronic HF were enrolled into a prospective cohort study. Data were obtained from 280 subjects enrolled from three sites in the northeastern USA; 242 completed the 6-month study. At baseline, cohorts with and without EDS were identified using the Epworth Sleepiness Scale. Each EDS group was further subdivided into those with and without impaired cognition using a battery of five neuropsychological tests. Two disease-specific measures, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Functional Outcomes of Sleep Questionnaire (FOSQ), were used to measure HRQL. General linear modelling of square-transformed variables was used to test the hypothesis that cohort membership was a significant predictor of HRQL. At 6 months the remaining sample was 62.5 [standard deviation (SD) 12] years old, mostly male (63%), white (65%), and functionally compromised [72% New York Heart Association (NYHA) class III/IV]. The cohort with both EDS and impaired cognition had the lowest KCCQ overall summary score (60.5 ± 22.5) compared with the cohort without EDS or impaired cognition (74.6 ± 17.4, P ≤ 0.001). A similar effect was seen on the FOSQ (16.0 ± 2.8 vs. 18.5 ± 2.2, P < 0.001). CONCLUSION: Impaired cognition alone did not explain poor HRQL, but the addition of EDS poses a significant risk for poor HRQL. Interventions designed to influence EDS may improve HRQL in this population.

Determinants of excessive daytime sleepiness and fatigue in adults with heart failure.

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p = .048), worse functional class (p = .004), not taking a diuretic (p = .005), and lack of physical activity (p = .04). Only sleep quality was associated with fatigue (p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention.

Implementation and testing of interdisciplinary decision support tools to standardize discharge planning.

Improving transitions in care is an international priority. In acute care, this complex process starts upon admission and requires multiple interventions to appropriately transition patients from one setting to the next. Within this multi-step process are two important decision points that warrant standardization and support. Our research teams have developed decision support tools that meet this critical need. The Early Screen for Discharge Planning (ESDP) and the Discharge Decision Support System (D(2)S(2)) bring evidence based, interdisciplinary decision support to two common and important decisions. The purpose of this paper is to share information about "real life" experiences in implementing decision support covering the development and use of the tools, advising about implementation considerations, making suggestions for automating the process, and sharing findings from our recent implementation study.

Excessive daytime sleepiness is associated with poor medication adherence in adults with heart failure.

BACKGROUND: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect. METHODS AND RESULTS: A sample of 280 adults with chronic HF were enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence were obtained at baseline and 3 and 6 months by using the Basel Assessment of Adherence Scale. Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over 6 months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (P = .035). The odds of nonadherence increased by 11% for each unit increase in EDS (adjusted odds ratio 1.11; 95% confidence interval 1.05-1.19; P = .001). In longitudinal models, there was a 10% increase in the odds of nonadherence for each unit increase in EDS (P = .008). The only cognition measure significantly associated with medication adherence was attention (P = .047). CONCLUSIONS: Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.

Risk factors for lymphedema after breast cancer treatment.

BACKGROUND: As cancer treatments evolve, it is important to reevaluate their effect on lymphedema risk in breast cancer survivors. METHODS: A population-based random sample of 631 women from metropolitan Philadelphia, Pennsylvania, diagnosed with incident breast cancer in 1999 to 2001, was followed for 5 years. Risk factor information was obtained by questionnaire and medical record review. Lymphedema was assessed with a validated questionnaire. Using Cox proportional hazards models, we estimated the relative incidence rates [hazard ratios (HR)] of lymphedema with standard adjusted multivariable analyses ignoring interactions, followed by models including clinically plausible treatment interactions. RESULTS: Compared with no lymph node surgery, adjusted HRs for lymphedema were increased following axillary lymph node dissection [ALND; HR, 2.61; 95% confidence interval (95% CI), 1.77-3.84] but not sentinel lymph node biopsy (SLNB; HR, 1.04; 95% CI, 0.58-1.88). Risk was not increased following irradiation [breast/chest wall only: HR, 1.18 (95% CI, 0.80-1.73); breast/chest wall plus supraclavicular field (+/- full axilla): HR, 0.86 (95% CI, 0.48-1.54)]. Eighty-one percent of chemotherapy was anthracycline based. The HR for anthracycline chemotherapy versus no chemotherapy was 1.46 (95% CI, 1.04-2.04), persisting after stratifying on stage at diagnosis or number of positive nodes. Treatment combinations involving ALND or chemotherapy resulted in approximately 4- to 5-fold increases in HRs for lymphedema [e.g., HR of 4.16 (95% CI, 1.32-12.45) for SLNB/chemotherapy/no radiation] compared with no treatment. CONCLUSION: With standard multivariable analyses, ALND and chemotherapy increased lymphedema risk whereas radiation therapy and SLNB did not. However, risk varied by combinations of exposures. IMPACT: Treatment patterns should be considered when counseling and monitoring patients for lymphedema.

Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms.

PURPOSE: To examine the incidence, degree, time course, treatment, and symptoms of lymphedema in breast cancer survivors. METHODS: We conducted a 5-year, population-based prospective study of 631 randomly selected Philadelphia and Delaware County, Pennsylvania female residents with incident breast cancer who were diagnosed from 1999 to 2001. Using a questionnaire previously validated against physical therapists' measurement-based clinical criteria, we assigned a score indicating the degree of lymphedema (none, mild, or moderate/severe) to each month of follow-up based on the respondent's perceived differences in hand/arm size. Standard survival analysis methods permitted maximum use of follow-up. RESULTS: Five-year cumulative incidence of lymphedema was 42 (42%) per 100 women. Among the 238 affected women, lymphedema first occurred within 2 years of diagnosis in 80% and within 3 years in 89%. Among 433 women observed for 3 years, 23% reported no more than mild lymphedema, 12% reported moderate/severe lymphedema, and 2% reported chronically moderate/severe lymphedema. Women with mild lymphedema were more than three times more likely to develop moderate/severe lymphedema than women with no lymphedema. Thirty-seven percent of women with mild lymphedema and 68% with moderate/severe lymphedema received treatment. Increasing proportions of women with increasing degree of lymphedema reported symptoms (eg, jewelry too tight, tired/thick/heavy arm). Symptoms present before the first occurrence of lymphedema were associated with a higher probability of later lymphedema (eg, hazard ratio for jewelry too tight = 7.37; 95% CI, 4.26 to 12.76). CONCLUSION: Lymphedema after breast cancer is common but mostly mild. Subtle differences in self-reported hand/arm size and symptoms can be early signs of progressing lymphedema.

Modifiable risk factors for breast cancer recurrence: what can we tell survivors?

The potential for recurrence causes considerable distress for breast cancer survivors. Major information sources for survivors and providers offer few clear recommendations for postdiagnosis lifestyle change related to recurrence. To design interventions to improve long-term survivors' care and quality of life, we must know what survivors are doing to prevent recurrence in the absence of solid evidence, whether survivors' perceptions and behaviors correspond to hypothesized modifiable risk factors for recurrence, and whether survivors are adopting behaviors that could otherwise be harmful to their health. Our review first addresses the general lack of consensus on the impact of specific lifestyle factors on breast cancer recurrence and the resulting equivocal lifestyle recommendations for survivors. Second, we describe inadequacies of the studies of survivors' lifestyle changes related to recurrence. Because much of the existing knowledge about modifiable risk factors for recurrence comes from studies of survivors whose participation and behavior change were potentially influenced by their concern about recurrence, we need large, population-based observational studies of randomly selected breast cancer survivors, adequately representing the target population. Critical are data on lifestyle change from prediagnosis to postdiagnosis and changes over time after diagnosis, extensive data on conventional and nonconventional treatments, and the temporal relationship between behaviors and treatments, and inclusion of the full complement of potential lifestyle risk factors for recurrence. Understanding in detail the current status of survivors' perceptions and behaviors related to modifiable risk factors for recurrence can provide considerable practical information to inform future interventions and communication strategies for breast cancer survivors.