Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US.

BACKGROUND: Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed. OBJECTIVE: To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization. RESEARCH DESIGN: Secondary analysis of a multi-site dataset from a study of discharge readiness assessment and post-discharge return to hospital, comparing matched samples of patients referred and not referred for home health care at the time of hospital discharge. SETTING: Acute care, Magnet-designated hospitals in the United States PARTICIPANTS: The available sample (n = 18,555) included hospitalized patients discharged from medical-surgical units who were referred (n = 3,579) and not referred (n = 14,976) to home health care. The matched sample included 2767 pairs of home health care and non- home health care patients matched on patient and hospitalization characteristics using exact and Mahalanobis distance matching. METHODS: Unadjusted t-tests and adjusted multinomial logit regression analyses to compare the occurrence of readmissions and Emergency Department/Observation visits within 30 and 60-days post-discharge. RESULTS: No statistically significant differences in readmissions or Emergency Department /Observation visits between home health care and non-home health care patients were observed. CONCLUSIONS: Home health care referral was not associated with lower rates of return to hospital within 30 and 60 days in this US sample matched on patient and clinical condition characteristics. This result raises the question of why home health care services did not produce evidence of lower post-discharge return to hospital rates. Focused attention by home health care programs on strategies to reduce readmissions is needed.

Clinical nurses' perspectives on discharge practice changes from participating in a translational research study.

AIM: To describe clinical nurses' experiences with practice change associated with participation in a multi-site nursing translational research study implementing new protocols for hospital discharge readiness assessment. BACKGROUND: Nurses' participation in translational research studies provides an opportunity to evaluate how implementation of new nursing interventions affects care processes within a local context. These insights can provide information that leads to successful adoption and sustainability of the intervention. METHODS: Semi-structured focus groups from 30 of 33 participating study hospitals lead by team nurse researchers. RESULTS: Nurses reported improved and earlier awareness of patients' discharge needs, changes in discharge practices, greater patient/family involvement in discharge, synergy and enhanced discharge processes, and implementation challenges. Participating nurses related the benefits of participation in nursing research. CONCLUSION: Participation in a unit-level translational research project was a successful strategy for engaging nurses in practice change to improve hospital discharge. IMPLICATIONS FOR NURSING MANAGEMENT: Leading unit-based implementation of a structured discharge readiness assessment including nurse assessment and patient self-assessment encourages earlier awareness of patients' discharge needs, improved patient assessment and greater patient/family involvement in discharge preparation. Integrating discharge readiness assessments into existing discharge care promotes communication between health team members that facilitates a timely, coordinated discharge.

Using the consolidated framework for implementation research to evaluate clinical trials: An example from multisite nursing research.

BACKGROUND: The Consolidated Framework for Implementation Research (CFIR) is a comprehensive guide for determining the factors that affect successful implementation of complex interventions embedded in real-time clinical practice. PURPOSE: The study aim was to understand implementation constructs in a multi-site translational research study on readiness for hospital discharge that distinguished study sites with low versus high implementation fidelity. METHODS: In this descriptive study, site Principal Investigator interviews (from 8 highest and 8 lowest fidelity sites) were framed with questions from 20 relevant CFIR constructs. Analysis used CFIR rules and rating scale (+2 to -2 per site) and memos created in NVivo 11. FINDINGS: From a bimodal distribution of differences (1.5 and 5), 7 constructs distinguished high and low fidelity sites with ≥5-point difference. DISCUSSION: CFIR provided a determinant framework for identifying elements of a study site's context that impact implementation fidelity and clinical research outcomes.

Nurse Continuity at Discharge and Return to Hospital.

BACKGROUND: Promoting continuity of nurse assignment during discharge care has the potential to increase patient readiness for discharge-which has been associated with fewer readmissions and emergency department visits. The few studies that examined nurse continuity during acute care hospitalizations did not focus on discharge or postdischarge outcomes. OBJECTIVES: The aim of this research was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and emergency department or observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderating effects of unit environment and unit nurse characteristics. METHODS: In a sample of 18,203 adult, medical-surgical patients from 31 Magnet hospitals, a correlational path analysis design was used in a secondary analysis to evaluate the effect of nurse continuity on readmissions and emergency department or observation visits within 30 days after hospital discharge. The mediating pathway through discharge readiness measured by patient self-report and nurse assessments was also assessed. Moderating effects of unit environment and nursing characteristics were examined across quartiles of unit environment (nurse staffing hours per patient day) and unit nurse characteristics (education and experience). Analyses were adjusted for patient characteristics, unit fixed effects, and clustering at the unit level. RESULTS: Continuous nurse assignment on the last 2 days of hospitalization was observed in 6,441 (35.4%) patient discharges and was associated with a 0.85 absolute percentage point reduction (7.8% relative reduction) in readmissions. There was no significant association with emergency department or observation visits. Sensitivity analysis revealed a stronger effect in patients with higher Elixhauser Comorbidity Indexes. Readiness for discharge was not a mediator of the effect of continuity on return to hospital. Unit characteristics were not associated with nurse continuity. No moderation effect was evident for unit environment and nurse characteristics. DISCUSSION: Continuity of nurse assignment on the last 2 days of hospitalization can reduce readmissions. Staffing for continuity may benefit patients and healthcare systems, with greater benefits for high-comorbidity patients. Nurse continuity prior to hospital discharge should be a priority consideration in assigning acute care nurses to augment readmission reduction efforts.

Clarifying model for continuity of care: A concept analysis.

AIM: The aim is to clarify the use of the term continuity in the specific context of acute care hospitalization and discharge. BACKGROUND: The meaning of "continuity" is often co-mingled with other concepts, specifically coordination and communication. To increase usefulness for contemporary concerns with the hospitalization-postdischarge continuum, continuity of care is examined from the specific context of acute hospitalization and discharge. DESIGN: Concept analysis. DATA SOURCES: Medline via Ovid, Cochrane Library, Cinahl, and Google Scholar. Search years encompassed 2001-2016. REVIEW METHODS: Rodgers evolutionary concept analysis method. RESULTS: A total of 50 papers were included in this concept analysis. Synthesis of findings from these papers resulted in a model of continuity of care that illustrates the hierarchical and interdependent relationship between time and setting, patient-provider relationships, communication, and coordination in the context of discharge transitions. CONCLUSION: The continuity model provides a framework to assist in the design of multicomponent, interdisciplinary, integrated interventions that can then be tested for their effect on patient care practices and outcomes.

Interprofessional Health Team Communication About Hospital Discharge: An Implementation Science Evaluation Study.

The Consolidated Framework for Implementation Research guided formative evaluation of the implementation of a redesigned interprofessional team rounding process. The purpose of the redesigned process was to improve health team communication about hospital discharge. Themes emerging from interviews of patients, nurses, and providers revealed the inherent value and positive characteristics of the new process, but also workflow, team hierarchy, and process challenges to successful implementation. The evaluation identified actionable recommendations for modifying the implementation process.

A Model for Hospital Discharge Preparation: From Case Management to Care Transition.

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Models of Discharge Care in Magnet® Hospitals.

OBJECTIVE: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals. BACKGROUND: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models. METHODS: This was a descriptive, Web-based survey of 32 Magnet hospitals (64 units) participating in the Readiness Evaluation and Discharge Interventions study. RESULTS: Most hospitals have adopted 1 or more national readmission reduction initiatives. Most unit models include several discharge preparation roles; RN case managers, and discharging RNs lead the process. Nearly one-half of units actively screen for readmission risk. More than three-fourths report daily discharge rounds, but less than one-third include the patient and family. More than two-thirds report a follow-up phone call, mostly to assess patient satisfaction. CONCLUSIONS: Magnet hospitals operationalize discharge preparation differently. Recommended practices from national discharge initiatives are inconsistently used. RNs play a central role in discharge planning, coordination, and teaching.

Integrated literature review of postdischarge telephone calls.

This systematic review of the literature assessed the impact of a postdischarge telephone call on patient outcomes. Nineteen articles met inclusion criteria. Data were extracted and an evidence table was developed. The content, timing, and professional placing the call varied across studies. Study strength was low and findings were inconsistent. Measures varied across studies, many sample sizes were small, and studies differed by patient population. Evidence is inconclusive for use of phone calls to decrease readmission, emergency department use, patient satisfaction, scheduled and unscheduled follow-up, and physical and emotional well-being. Among these studies, there was limited support for medication-focused calls by pharmacists but no support for decreasing readmission. Health care providers benefited from feedback but did not need to place the call to realize this benefit. Inpatient nurses were unable to manage the volume of calls. There was no standardized approach to the call, training, or documentation requirements.

Clinical nurse specialist-led evaluation of temporal artery thermometers in acute care.

PURPOSE: A systematic review of literature and intensive evaluation were conducted using a quality process to assess temporal artery thermometer (TAT) accuracy in an acute-care setting. BACKGROUND: Inaccurate temperature measurements were reported following adoption of the TAT. Concern for patient safety and outcomes generated a need to reevaluate use of the TAT. DESCRIPTION OF THE PROJECT: Using components of evidence-based practice and intensive evaluation processes, a clinical nurse specialist (CNS)-led team evaluated existing research, assessed current practice, and obtained additional clinical data. OUTCOMES: Existing research provides inadequate evidence to support use of the TAT for acutely ill hospitalized patients. Findings from an intensive evaluation indicated low interrater reliability in controlled testing, inaccurate technique by staff despite retraining, lack of nurse confidence in the accuracy of the device, and a need for continuous costly retraining. These findings are consistent with findings in a University HealthSystem Consortium report. SUMMARY AND CONCLUSIONS: A multifaceted evaluation process was needed for the team to compile data, identify issues, and make decisions. A recommendation was made to discontinue use of the TAT. IMPLICATIONS: : Clinical nurse specialists have the knowledge and ability to provide clinical leadership at a system level. When usual processes result in safety concerns, the CNS provides leadership to identify patterns, provide direction, creatively integrate evaluation processes, synthesize findings, and uses his/her influence within the system to change practice.