Reducing Recurrence and Complications Related to Clostridioides difficile Infection: A Panel Discussion Summary.

BACKGROUND: The Centers for Disease Control and Prevention identifies Clostridioides difficile infection (CDI) as an urgent threat to people and health care systems. CDI leads to high health care utilizations and results in significantly reduced quality of life for patients. The high burden of disease is seen across all health care settings, outside of the hospital, in the community, and in younger people. Individuals with CDI transition from hospitals to long-term care facilities to the community, and management of these transitions can reduce the incidence of recurrence and rehospitalization. PURPOSE: The most common cause of diarrhea occurring in a health care setting is Clostridioides difficile and is also the cause of antibiotic-associated colitis (L. C. McDonald, 2021). The infection results from a disruption in the microbial flora of the gastrointestinal tract, mostly after antibiotic use or other medications such as proton pump inhibitors (PPIs). As a result, infected individuals are colonized and shed the spores into the environment, exposing others-goals of treatment focus on reducing the exposure and individual susceptibility. Although the incidence of C. diff is stable, recurrence is increasing significantly, with severe complications also a concern. The increased incidence and potential for life-threatening conditions require reducing initial exposure, supporting prescribed treatment, and preventing recurrence. PRIMARY PRACTICE SETTINGS: C. diff infection can be contracted in health care facilities and in the community. Case managers from nearly all practice settings may encounter patients with the infection. FINDINGS/CONCLUSIONS: To avert the devastating complications of Clostridioides difficile infection, case managers play an essential role in the prevention of recurrence with education, advocacy of best practices, effective care coordination, and thorough transitions of care. Each recurrence of C. diff infection leaves the patient vulnerable to the potential for surgical intervention, sepsis, and death. IMPLICATIONS FOR CASE MANAGEMENT: Mitigating the risk for readmission and recurrence will enhance C. diff infection care, safety, and outcomes to improve a patient's health care journey and quality of life. Case managers need to take a primary role in the transition and care coordination processes, including patient and support system education, coordination of any postdischarge services, connection to providers, adherence support activities, and follow-up for improvement or changes in condition. Supportive adherence activities and prevention education can result in the avoidance of recurrence. Case managers are well-equipped to locate resources to assist those patients challenged with the cost of medications, inability to attend appointments, or access basic needs. Although not directly related to C. diff, these challenges contribute to recurrence and readmission. Mitigating risk for readmission and recurrence results in an improved quality of life.

Transitions of care in Clostridioides difficile infection: a need of the hour.

Clostridioides difficile infection (CDI) is a complex disease that by virtue of both its initial virulence and proclivity toward recurrent episodes causes a high morbidity, mortality, and financial burden. This burden is felt by patients and their families as well as the U.S. healthcare system. Recurrent CDI episodes can occur in 25-65% of patients, with a cycle of multiple recurrences in a single patient contributing to the complexity of care. Patients with or suspected of having CDI will receive treatment and their care will be managed across multiple healthcare settings and will include many different levels of healthcare workers. The understanding of this infection is essential for all who are involved in the care of these patients. A well-structured and implemented Transition of Care process can ease the burden on the healthcare system, patients, and their families; reduce the cost of care; and improve patient outcomes. We review the development of Transitions of Care processes, resource guides, and their relevance to improving the management of CDI.

Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.

PURPOSE/OBJECTIVES: Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). PRIMARY PRACTICE SETTING(S): The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. FINDINGS/CONCLUSIONS: Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise, coordinating care and TOC for patients with comorbidities, providing patient and caregiver education, promoting engagement between patients and the team, advancing the care plan, and improving ongoing adherence to treatment in order to maximize the patient's pulmonary function. Details regarding these interprofessional roles and responsibilities are provided in the full interdisciplinary TOC pathways for PAH and IPF.

Two useful tools: to improve patient engagement and transition from the hospital.

We use an Internet-based health assessment and feedback system to examine the range of needs and diverse experiences of 520 hospitalized adults in transition and the factors most strongly associated with their self-reported health confidence. Our results strongly suggest that patient engagement prior to admission and the quality of care coordination and communication during hospitalization can greatly enhance successful transition from the hospital back to the community. Hospitals are complex institutions. This report illustrates how the Internet or a straightforward graphic can make the complexity less overwhelming to patients and efficiently increase their health confidence for transitions.

Practices to improve transitions of care: a national perspective.

Improving transitions of care has significant importance to our health care system. While care transitions has been studied and researched by many individuals over the past 20 years, more work is needed to further improve the process. Those beginning to focus on transitions need not begin from scratch, but can use information and research from national and regional collaborative models, as well as other tools and resources to enhance the quality of transitions programs.

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators.

OBJECTIVE: This article describes an innovative integrated approach to case management using a standardized complexity assessment grid and communication tool, which is designed to identify barriers to improvement in 4 domains: biological, psychological, social, and health system; to create and implement holistic care plans based on "anchored barriers; and to document ongoing targeted outcomes. PRACTICE SETTINGS: Adult and pediatric case and disease managers working for hospitals or clinics, health care delivery systems, general medical health plans, care management vendors, government agencies, and employers can effectively employ integrated case management procedures. INTEGRATED CASE MANAGEMENT: Integrated case management augments traditional care coordination by allowing trained medical or mental health managers to assist with cross-disciplinary barriers without handoffs; to connect multidomain barriers to mutually agreed-upon care plan goals and activities; and to measure clinical, functional, fiscal, quality of life, and satisfaction outcomes as a part of the management process, especially in high-cost, complex patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrated case management provides a step-by-step interdisciplinary approach for helping complex patients that has the potential to maximize clinical and functional value, while reducing total health-related costs.

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators.

The 5% of patients using 50% of health resources commonly have interacting and persistent multimorbid illnesses; concurrent mental health problems; impaired social networks; and/or difficulties in accessing care through the health system. To improve outcomes in these patients, it is necessary to overcome clinical and nonclinical barriers that lead to poor health, treatment resistance, high health care cost, and disability. This article describes an innovative complexity-based and outcome-oriented approach using integrated case management. It helps treating physicians and health administrators understand how to incorporate value-based case managers to optimize care for complex patients while better utilizing resources.

The impact of CMSA's case management adherence guidelines and guidelines training on case manager-reported behavior change.

PURPOSE/OBJECTIVES: The Case Management Society of America (CMSA) developed evidence-based guidelines (Case Management Adherence Guidelines, CMAG) for case managers to support increased efficacy of case managers in helping patients become more adherent to medication regimens. The effort was in response to documented high levels of nonadherence, and evidence demonstrating that lack of adherence negatively impacts patient health status. The CMSA engaged in a massive training program to support case manager adoption of the CMAG tools and approaches to improve patient knowledge and motivation. This article reports on findings of a follow-up survey that evaluated case manager's use of the tools and strategies discussed in the CMAG. PRIMARY PRACTICE SETTING(S): Seven hundred fifty case managers from all settings were trained in the use of the CMAG. FINDINGS/CONCLUSIONS: In a follow-up survey, 42% of respondents reported that there has been a very, or fairly, significant impact of using their new skills to increase their effectiveness in helping patients reach their outcome improvement goals. In addition, 43% reported that there has been a very, or fairly, big improvement in patient adherence since they took the training, while 39% did not see a major impact. At the time of the survey (up to 1 year after training), 43% of respondents indicated that the training was very valuable; another 39% reported that it was fairly valuable. Participants continue to use the skills and information adopted in the training sessions: 26% report that they currently use at least some of the information and skills very often, while another 49% use them fairly often. Sixty-six percent of respondents indicated that they specifically use motivational interviewing to help address patient knowledge and motivation regarding medication adherence. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Medication adherence is a key issue in case management practice; efforts to positively impact low patient knowledge and motivation can be frustration for case managers. The CMAG offer evidence-based assessment tools to evaluate patient knowledge of medications and their motivation to adhere, and recommend the strategy of motivational interviewing to help case managers address adherence more effectively with patients. A 1-time training on the CMAG and motivational interviewing had some effect on self-reported case manager effectiveness in addressing medication adherence. Case managers appreciated the training; many reported that they continue to use skills and that they have observed changes in patient outcomes. Additional training, skill building, and reinforcement may help case managers apply CMAG and motivational interviewing effectively to support patients' adherence to medication regimens. The CMSA may continue to evaluate the impact of the CMAG and CMAG training to refine the tools and the training approach.