Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis.

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.

Case Management Consultant to Attorneys in Litigated Cases.

ABSTRACT: Rehabilitation nurses possess knowledge and skills that are ideally suited to a variety of roles. This article informs rehabilitation nurses about opportunities to work in private case management for medical-legal cases. A brief overview of the process of litigation gives nurses the context in which case management interventions are needed. Case examples illustrate the services that nurses provide to attorneys and their clients that help obtain needed care and aid in progressing litigation to resolution.

Bringing Delirium to Light: Impact of CAM-ICU Tool to Improve Care Coordination.

BACKGROUND: Delirium is a serious complication in patients in the critical care unit (CCU) that may lead to prolonged hospitalization if left undetected. The CCU at our hospital does not have a framework for determining delirium that could affect patient outcomes and discharge planning. PRIMARY PRACTICE SETTING: CCU in a community hospital. METHOD: A posttest-only design was used for this study. We established a framework for the early assessment of delirium, educated and trained nurses to detect delirium, collaborated with the informatics department, intensivist, nursing, respiratory therapy and worked with case management to deploy the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We used a one-tailed independent t test to determine the impact of CAM-ICU on length of stay (LOS). Cross-tabulation and chi-square tests were used to examine the impact of CAM-ICU tool on home care utilization between the intervention and comparison groups. RESULTS: There was a 3.12% reduction in LOS after implementing the CAM-ICU tool. Also, a reduction in home care service utilization demonstrated statistical significance ( p = .001) between the intervention group (62.5%; n = 177) and the comparison group (37.5%; n = 106). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case managers are essential in improving care transitions. Case managers need to become competent in understanding the implications of the CAM-ICU tool because of their relevant role in the multidisciplinary rounds as advocates to improve care transitions across the continuum of care. Case managers need to have an understanding on how to escalate when changes in the Richmond Agitation-Sedation Scale scores occur during the multidisciplinary rounds because it can affect care coordination throughout the hospital. CONCLUSIONS: Implementing the CAM-ICU decreased LOS, and reduced health care utilization. The early identification of patients with delirium can affect the outcomes of critically ill patients and entails multidisciplinary collaboration.

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations.

INTRODUCTION: The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement. METHODS: Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach. RESULTS AND DISCUSSION: Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders' engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders' engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers. CONCLUSION: Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Improved kala-azar case management through implementation of health facility-based sentinel sites surveillance system in Bihar, India.

BACKGROUND: Visceral leishmaniasis (VL), also known as kala-azar (KA), is a neglected vector-borne disease, targeted for elimination, but several affected blocks of Bihar are posing challenges with the high incidence of cases, and moreover, the disease is spreading in newer areas. High-quality kala-azar surveillance in India, always pose great concern. The complete and accurate patient level data is critical for the current kala-azar management information system (KMIS). On the other side, no accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections are available under the current surveillance system, which might emerge as a serious concern. Additionally, in low case scenario, sentinel surveillance may be useful in addressing post-elimination activities and sustaining kala-azar (KA) elimination. Health facility-based sentinel site surveillance system has been proposed, first time to do a proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions. METHODOLOGY/PRINCIPAL FINDINGS: Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar, India, using stratified sampling technique during 2011 to 2014. Data were collected through specially designed performa from all patients attending the outpatient departments of sentinel sites. Among 20968 symptomatic cases attended sentinel sites, 2996 cases of KA and 53 cases of PKDL were registered from 889 endemic villages. Symptomatic cases meant a person with fever of more than 15 days, weight loss, fatigue, anemia, and substantial swelling of the liver and spleen (enlargement of spleen and liver).The proportion of new and old cases was 86.1% and 13.9% respectively. A statistically significant difference was observed for reduction in KA incidence from 4.13/10000 in 2011 to 1.75/10000 in 2014 (p<0.001). There were significant increase (0.08, 0.10 per 10 000 population) in the incidences of PKDL and co-infection respectively in the year 2014 as compared to that of 2011 (0.03, 0.06 per 10 000 population). The proportion of HIV-VL co-infection was significantly higher (1.6%; p<0.05) as compared to other co-infections. Proportions of male in all age groups were higher and found statistically significant (Chi-square test = 7.6; P = 0.026). Utilization of laboratory services was greatly improved. Friedman test showed statistically significant difference between response of different anti kala-azar drugs (F = 25.0, P = 0.004).The initial and final cure rate of AmBisome was found excellent (100%). The results of the signed rank sum test showed significant symmetry of unresponsiveness rate (P = 0.03). Similarly, relapse rate of sodium antimony gluconate (SAG) was also found significantly higher as compared to other drugs (95%CI 0.2165 to 19.7035; P = 0.03). A statistically significant difference was found (p<0.001) between villages having 1-2 cases (74%) and villages with 3-5 cases (15%). Significantly higher proportion (95%) of cases were captured by existing Govt. surveillance system (KMIS) (p<0.001), as compared to private providers (5%). CONCLUSIONS/SIGNIFICANCE: Establishment of a sentinel site based kala-azar surveillance system in Bihar, India effectively detected the rising trend of PKDL and co-infections and captured complete and accurate patient level data. Further, this system may provide a model for improving laboratory services, KA, PKDL and co-infection case management in other health facilities of Bihar without further referral. Program managers may use these results for evaluating program's effectiveness. It may provide an example for changing the practices of health care workers in Bihar and set a benchmark of high quality surveillance data in a resource limited setting. However, the generalizability of this sentinel surveillance finding to other context remains a major limitation of this study. The justifications for this; the sentinel sites were made in the traditionally high endemic PHC's. The other conditions were Program commitment for diagnostic (rk-39) and the first line anti kala-azar drug i.e. miltefosine throughout the study period in the sentinel sites. In addition, there were clause of fulfillment of readiness criteria at each sentinel site (already described in the line no 171 to 180 at page no-8, 181-189 at page no-9 and 192-212 at page no-10). Rigorous efforts were taken to improve all the sentinel sites to meet the readiness criteria and research activities started only after meeting readiness criteria at the site. Therefore sentinel site surveillance described under the present study cannot be integrated into other set up (medium and low endemic areas). However, it can be integrated into highly endemic areas with program commitment and fulfillment of readiness criteria.

Text or Not to Text? A Narrative Review of Texting as a Case Management Intervention.

PURPOSE: To review current literature on texting as a sustainable intervention of case management in the outpatient setting. FINDINGS: Texting, as a case management intervention, provides the medically complex client with a pathway to achieve care plan goals. Texting increases adherence, communication, and self-management. It can increase client enrollment in disease management programs, while providing support, flexibility, convenience, cost savings, and increased participation. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: In current practice, such as management of the coronavirus (COVID-19), other pandemics, or natural/environmental disasters, texting is a solution-focused intervention that can deliver and retrieve real-time information to a medically complex population. It can link patients to resources and increase outreach, efficiency, quality, and coordination of care. Texting can promote adherence to appointments, increase medication compliance and disease management interventions, and provide motivational change messages. However, there are legal and regulatory concerns that carry potential consequences and implications that should be approached judiciously (Mellette, 2015). Texting is not one size fits all; it can cause HIPAA breeches, hinder communication with certain populations, confuse health messaging, and replace human communication, thereby reducing staffing in practice.

Impact of COVID-19-Related Social Distancing on Delivery of Intensive Case Management.

ABSTRACT: Social distancing due to COVID-19 may adversely impact treatment of adults with serious mental illness, especially those receiving intensive forms of community-based care, in part through weakening of the therapeutic alliance. Veterans and staff at a Veterans Affair (VA) medical center were surveyed 3 months after social distancing disrupted usual service delivery in intensive community-based treatment programs. Veterans (n = 105) and staff (n = 112) gave similar multi-item ratings of service delivery after social distancing, which involved far less face-to-face contact and more telephone contact than usual and rated their therapeutic alliances and clinical status similarly as "not as good" on average than before social distancing. Self-reported decline in therapeutic alliance was associated with parallel decline in clinical status indicators. Both veterans and staff indicated clear preference for return to face-to-face service delivery after the pandemic with some telehealth included.

Case Management on the Front Lines of COVID-19: The Importance of the Individualized Care Plan Across Care Settings.

PURPOSE: Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the disease known as COVID-19, case management has emerged as a critical intervention in the treatment of cases, particularly for patients with severe symptoms and medical complications. In addition, case managers have been on the front lines of the response across the health care spectrum to reduce risks of contagion, including among health care workers. The purpose of this article is to discuss the case management response, highlighting the importance of individual care plans to provide access to the right care and treatment at the right time to address both the consequences of the disease and patient comorbidities. PRIMARY PRACTICE SETTINGS: The COVID-19 response spans the full continuum of health and human services, including acute care, subacute care, workers' compensation (especially catastrophic case management), home health, primary care, and community-based care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: From the earliest days of the pandemic, case managers have assumed an important role on the front lines of the medical response to COVID-19, ensuring that procedures are in place for managing a range of patients: those who were symptomatic but able to self-isolate and care for themselves at home; those who had serious symptoms and needed to be hospitalized; and those who were asymptomatic and needed to be educated about the importance of self-isolating. Across the care spectrum, individualized responses to the clinical and psychosocial needs of patients with COVID-19 in acute care, subacute care, home health, and other outpatient settings have been guided by the well-established case management process of screening, assessing, planning, implementing, following up, transitioning, and evaluating. In addition, professional case managers are guided by values such as advocacy, ensuring access to the right care and treatment at the right time; autonomy, respecting the right to self-determination; and justice, promoting fairness and equity in access to resources and treatment. The value of justice also addresses the sobering reality that people from racial and ethnic minority groups are at an increased risk of getting sick and dying from COVID-19. Going forward, case management will continue to play a major role in supporting patients with COVID-19, in both inpatient and outpatient settings, with telephonic follow-up and greater use of telehealth.

Highly targeted spatiotemporal interventions against cholera epidemics, 2000-19: a scoping review.

Globally, cholera epidemics continue to challenge disease control. Although mass campaigns covering large populations are commonly used to control cholera, spatial targeting of case households and their radius is emerging as a potentially efficient strategy. We did a Scoping Review to investigate the effectiveness of interventions delivered through case-area targeted intervention, its optimal spatiotemporal scale, and its effectiveness in reducing transmission. 53 articles were retrieved. We found that antibiotic chemoprophylaxis, point-of-use water treatment, and hygiene promotion can rapidly reduce household transmission, and single-dose vaccination can extend the duration of protection within the radius of households. Evidence supports a high-risk spatiotemporal zone of 100 m around case households, for 7 days. Two evaluations separately showed reductions in household transmission when targeting case households, and in size and duration of case clusters when targeting radii. Although case-area targeted intervention shows promise for outbreak control, it is critically dependent on early detection capacity and requires prospective evaluation of intervention packages.

Community and Case Management Interventions to Address Social Determinants of Health in Infectious Disease.

PURPOSE/OBJECTIVES: Professional case managers are responsible to conduct education, counseling, and other interventions that address the unique needs and gaps of the patients and families they serve. Social determinants of health (SDH) can impact barriers to patient care and outcomes that may go undetected among underserved populations without reliable data. This article describes an implementation science study using patient and provider-informed data and designed interventions to mitigate barriers in SDH related to hepatitis B virus (HBV). PRIMARY PRACTICE SETTINGS: Case managers and other health care team members in community health clinics examined discordances in their own patients' and providers' beliefs about patients' barriers to HBV care. Data were then used to help identify and engage unique strategies in education, counseling, and clinic outreach to improve outcomes in HBV and lessen barriers to care among at-risk minority populations. FINDINGS/CONCLUSIONS: Findings from data and information conducted among the clinic patients and health care team members revealed many important barriers in key aspects of SDH occurring in each clinic. As a result, case managers and other health care team members were able to examine distinct differences in what they predicted their patients would say versus what patients actually answered about SDH aspects of their care experiences, including barriers in access to care, health monitoring, and treatment of HBV. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The study and data results have implications for case management practice that may also be applied to other infectious diseases. Implications include patient and community outreach strategies to improve access to care; resource management techniques to improve referrals and disease monitoring; and ongoing and improved education and counseling to change behaviors associated with infectious disease prevention, screening, and linkage to care.

Roles, Training, and Qualifications of a Case Manager in the Canadian Health Care Industry: A Narrative Review.

PURPOSE: The purpose of this article is to explore primary roles, training, competencies, and qualifications of a case manager in the Canadian health care industry and how to improve case management practice in Canada. PRIMARY PRACTICE SETTING: Case managers' primary practice setting investigated in this article is the Canadian health care industry, which includes clinics, hospitals, continuing care, short-term and long-term care facilities, as well as palliative and end-of-life care settings. CONCLUSION: The main role of case managers is to help clients meet their goals. Assessment, monitoring, interpersonal communication, and collaboration are essential roles and competencies of case managers. Many case managers come from regulated health care professions and have prior years of professional experience, and many of them come from a nursing profession. This article is a narrative review based on the current literature about case managers' roles, training, and competencies in the Canadian health care industry and how to improve Canadian case management practice. Certification and standardization of case managers in Canada are needed to better understand the roles, training, and qualifications of case managers in the Canadian health care industry. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case managers require skills in assessment, monitoring, cultural competency, interpersonal communication, collaboration, coordinating, and advocating for resources and services to meet clients' goals in the health care industry. Case managers must also consider how to combat and address other social determinants of health such as a client's social economic status, literacy, income, employment, and working conditions that influence client's health. Ongoing professional development for case managers is fundamental in achieving effective case management practice. Finally, it is important to have case management certification in Canada in order to better understand case manager's roles and qualifications in the Canadian health care industry.

Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists.

We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.

Implementing a Nurse Discharge Navigator: Reducing 30-Day Readmissions for Heart Failure and Sepsis Populations.

PURPOSE/OBJECTIVES: The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations. PRIMARY PRACTICE SETTING: The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities. METHODOLOGY AND SAMPLE: The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance. RESULTS: Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.