Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

BACKGROUND AND OBJECTIVES: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. METHODS: Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. RESULTS: Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). CONCLUSIONS: This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

Veterans Finding Community and a "Home" Within an Emergency Housing Environment.

In April 2020, the Department of Veterans Affairs responded to the COVID-19 pandemic and escalating unsheltered homelessness in Los Angeles by sanctioning a tent turned tiny shelter encampment at the West Los Angeles Veterans Affairs medical center. Initially, staff offered linkages to on-campus VA healthcare. However, as many Veterans living in the encampment struggled to avail themselves of these services, our "encampment medicine" team was launched to provide on-site care coordination and healthcare at the tiny shelters. This case study showcases the team's engagement with a Veteran experiencing homelessness struggling with opioid use disorder and depicts how this co-located, comprehensive care team allowed for trusting care relationships formed with, and empowerment of the Veterans living in the encampment. The piece highlights a healthcare model that engages with persons experiencing homelessness on their own terms while building trust and solidarity, focuses on the sense of community that formed in the tiny shelter encampment, and gives recommendations for how homeless services might adapt to use the strengths of this unique community.

Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience.

OBJECTIVE: To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits. DATA SOURCES AND STUDY SETTING: Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019. STUDY DESIGN: Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity. DATA COLLECTION/EXTRACTION METHOD: Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data. PRINCIPAL FINDINGS: In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity. CONCLUSIONS: Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

Improving heart failure care and guideline-directed medical therapy through proactive remote patient monitoring-home telehealth and pharmacy integration.

To address ambulatory care sensitive hospitalisations in heart failure (HF), we implemented a quality improvement initiative to reduce admissions and improve guideline-directed medical therapy (GDMT) prescription, through proactive integration of remote patient monitoring-home telehealth (RPM-HT) and pharmacist consultations. Each enrolled patient (n=38) was assigned an RPM-HT registered nurse (RN), cardiology licensed independent provider (provider), and, if referred, a clinical pharmacy specialist (pharmacist). The RN called patients weekly and for changes detected by RPM-HT, while the pharmacist worked to optimise GDMT. The RN and pharmacist communicated clinical status changes to the provider for expedited management. Process measures were the percentage of outbound RN weekly calls missed per enrolled patient; the weekly percentage of provider interventions missed; and the number of initiative-driven diuretic changes. Outcome measures included eligible GDMT medications prescribed, optimisation of those medications, and the pre-post difference in emergency department (ED) visits/hospitalisations. After a 4-week run-in period, RN weekly calls missed per enrolled patient decreased from a mean of 21.4% (weeks 5-15) to 10.2% (weeks 16-23). Weekly missed provider interventions decreased from a mean of 15.1% (weeks 1-15) to 3.4% (weeks 16-23), with special cause variation detected. The initiative resulted in 43 diuretic changes in 21 patients. Among 34 active patients, 65 ED visits (0.16 per person-month) occurred in 12 months pre intervention compared with 8 ED visits (0.04 per person-month) for 6 intervention months (p<0.001). Among 16 patients referred to pharmacist, the per cent of eligible GDMT medications prescribed increased by 17.1% (p<0.001); the number of patients receiving all eligible medications increased from 3 to 11 (p=0.008). Similarly, the per cent optimisation of GDMT doses increased by 25.3% (p<0.001), with the number of patients maximally optimised on GDMT increasing from 1 to 6 (p=0.06). We concluded that a cardiology, RPM-HT RN and pharmacist team improved prescription of GDMT and may have reduced HF admissions.

Isolated primary blast alters neuronal function with minimal cell death in organotypic hippocampal slice cultures.

An increasing number of U.S. soldiers are diagnosed with traumatic brain injury (TBI) subsequent to exposure to blast. In the field, blast injury biomechanics are highly complex and multi-phasic. The pathobiology caused by exposure to some of these phases in isolation, such as penetrating or inertially driven injuries, has been investigated extensively. However, it is unclear whether the primary component of blast, a shock wave, is capable of causing pathology on its own. Previous in vivo studies in the rodent and pig have demonstrated that it is difficult to deliver a primary blast (i.e., shock wave only) without rapid head accelerations and potentially confounding effects of inertially driven TBI. We have previously developed a well-characterized shock tube and custom in vitro receiver for exposing organotypic hippocampal slice cultures to pure primary blast. In this study, isolated primary blast induced minimal hippocampal cell death (on average, below 14% in any region of interest), even for the most severe blasts tested (424 kPa peak pressure, 2.3 ms overpressure duration, and 248 kPa*ms impulse). In contrast, measures of neuronal function were significantly altered at much lower exposures (336 kPa, 0.84 ms, and 86.5 kPa*ms), indicating that functional changes occur at exposures below the threshold for cell death. This is the first study to investigate a tolerance for primary blast-induced brain cell death in response to a range of blast parameters and demonstrate functional deficits at subthreshold exposures for cell death.