Acute Care Reimagined: Home Hospital Care Can Support the Triple Aim and Reduce Health Disparities.

EXECUTIVE SUMMARY: Home hospital care (HHC) is a new and exciting concept that holds the promise of achieving all three components of the Triple Aim and reducing health disparities. As an innovative care delivery model, HHC substitutes traditional inpatient hospital care with hospital care at home for older patients with certain conditions. Studies have shown evidence of reduced cost of care, improved patient satisfaction, and enhanced quality and safety of care for patients treated through this model. The steady growth in Medicare Advantage enrollment and the expansion in 2020 of the Centers for Medicare & Medicaid Services (CMS) Hospitals Without Walls program to include acute hospital care at home creates an opportunity for hospitals to implement such programs and be financially rewarded for reducing costs. Capacity constraints exacerbated by the COVID-19 pandemic suggest that now is the ideal time for healthcare leaders to test and advance the concept of HHC in their communities.

A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients.

PURPOSE: Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community. METHODS: 183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method. RESULTS: From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective. CONCLUSIONS: Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Cost of Quality Pilot: A Systematic Methodology for Examining the Cost of Pressure Injury.

Health care costs in the United States are considerable, and total national cost of preventable adverse events in the United States ranges from billions to trillions of dollars annually. Achieving the highest quality of health services requires delivering care that mitigates the risk of patient adverse events. Pressure injuries are a significant and costly adverse event. Mitigating or eliminating harm from pressure injuries not only improves quality and increases patient safety but also decreases costs of care. The purpose of this article is to pilot a systematic methodology for examining the differences in the cost of care for a subset of patients with and without hospital-acquired pressure injuries in an acute care setting.

Hospital Costs Associated with Sepsis Compared with Other Medical Conditions.

Sepsis is a condition that has become a main focus for health care organizations owing to the alarming cost of caring for patients, as well as the disturbing mortality rates, that accompany this condition. Sepsis is one of the costliest conditions billed to all payer groups: Medicare, Medicaid, private insurance, and uninsured patients. Health care organizations have implemented multiple strategies and best practices to improve the outcomes of patients with a diagnosis of sepsis.

The Relationship Between Nursing Workload, Quality of Care and Nursing Payment in Intensive Care Units.

Nursing workload adversely affects patient safety in intensive care units, the higher nursing care hours were lower incidence rate of bedsores.

[Nursing workload indices TISS-10, TISS-28, and NEMS : Higher workload with agitation and delirium is not reflected]. / Pflegeaufwandsindizes TISS-10, TISS-28 und NEMS : Erhöhter Arbeitsaufwand bei Agitation und Delir wird nicht erfasst.

BACKGROUND: Financial resources for the treatment of ICU patients requiring high nursing workload are allocated within the German diagnostic-related groups (DRG) system in part through the Therapeutic Intervention Scoring System-10 (TISS-10). TISS-10, however, has never been validated. This study evaluated whether delirium and agitation in ICU were reflected by TISS-10, and also by the established workload indices TISS-28 and Nine Equivalents of Nursing Manpower (NEMS). Secondary aims were if indices correlated, and what effects delirium and agitation had on financial balances. MATERIALS AND METHODS: Analyses were performed retrospectively in 521 datasets from 152 patients. Nursing workload was assessed with TISS-28, TISS-10, and NEMS, delirium with the Confusion Assessment Method for Intensive Care Units (CAM-ICU), and vigilance with the Richmond Agitation-Sedation Scale (RASS). Revenues were retrieved from the institution's patient data management system, and costs calculated with the Budget Calculation Tool 2007 provided by the German Society of Anaesthesiologists. RESULTS: Delirium was found in 36.2 % of patients (n = 55). TISS-28, TISS-10, and NEMS were not higher in patients with delirium, if corrected for mechanical ventilation. TISS-28, TISS-10, and NEMS were significantly higher in deeply sedated and comatose patients (RASS ≤ - 3, p < 0.001), but not in agitated (RASS ≥ 1) and lightly sedated patients (RASS - 1/- 2). TISS-10 and TISS-28 had a linear correlation (r (2) = 0.864). Median financial balances were negative, but much more pronounced in patients with delirium that without (- 3174 € with delirium vs. - 1721 € without delirium, p = 0.0147). CONCLUSION: The standard workload-scores (TISS-10, TISS-28, NEMS) do not reflect higher daily workload associated with patients with delirium and agitation.

A comparison of salary-wage and hourly-wage acute care nursing units: a pilot study.

OBJECTIVE: This pilot study examined differences in RN perception of the professional practice environment and financial indicators between salary-wage and hourly-wage compensation models. BACKGROUND: There is a dearth of current information regarding use of salary-wage models for compensation for direct care nurses. METHODS: A descriptive, comparative design was used to examine the Revised Professional Practice Environment Scale (RPPE) and financial indicators of nurses in a nonprofit healthcare system over a 6-month period. RESULTS: Mean scores on the RPPE were significantly lower for hourly-wage RNs, and the hourly-wage model resulted in a 1.2% additional cost for overtime hours compared with the fixed cost of the salary-wage model. CONCLUSIONS: Nurses in an hourly-wage unit reported a significantly lower perception of the clinical practice environment than did their peers in a salary-wage unit, indicating that professional practice perceptions in a salary-wage unit may provide a more effective professional practice environment. Financial analysis resulted in a budget-neutral impact.

Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals: Study protocol.

AIMS: With this study protocol, a research program is introduced. Its overall aim is to prepare the instruments and to conduct the first monitoring of nursing service context factors at three university and two cantonal hospitals in Switzerland prior to the introduction of the reimbursement system based on Diagnosis Related Groups (DRG) and to further develop a theoretical model as well as a methodology for future monitoring following the introduction of DRGs. BACKGROUND: DRG was introduced to all acute care hospitals in Switzerland in 2012. In other countries, DRG introduction led to rationing and subsequently to a reduction in nursing care. As result, nursing-sensitive patient outcomes were seriously jeopardised. Switzerland has the opportunity to learn from the consequences experienced by other countries when they introduced DRGs. Their experiences highlight that DRGs influence nursing service context factors such as complexity of nursing care or leadership, which in turn influence nursing-sensitive patient outcomes. For this reason, the monitoring of nursing service context factors needs to be an integral part of the introduction of DRGs. However, most acute care hospitals in Switzerland do not monitor nursing service context data. Nursing managers and hospital executive boards will be in need of this data in the future, in order to distribute resources effectively. METHODS/DESIGN: A mixed methods design in the form of a sequential explanatory strategy was chosen. During the preparation phase, starting in spring 2011, instruments were selected and prepared, and the access to patient and nursing data in the hospitals was organized. Following this, online collection of quantitative data was conducted in fall 2011. In summer 2012, qualitative data was gathered using focus group interviews, which helped to describe the processes in more detail. During 2013 and 2014, an integration process is being conducted involving complementing, comparing and contrasting quantitative and qualitative findings. CONCLUSION: The research program will produce baseline data on nursing service context factors in Swiss acute care hospitals prior to DRG introduction as well as a theoretical model and a methodology to support nursing managers and hospital executive boards in distributing resources effectively. The study was approved by the ethics committees of Basel, Bern, Solothurn and Zürich.

Quality and financial impact of adding nurse practitioners to inpatient care teams.

OBJECTIVE: The purpose of this project was to examine the financial impact of adding nurse practitioners (NPs) to inpatient care teams at Vanderbilt University Hospital. BACKGROUND: National initiatives targeting quality, safe, and cost-effective healthcare have created the optimal environment for NPs to showcase their abilities and contributions. Identifying outcomes that are directly affected by NPs and quantifying data in terms of dollars can be affirmation for the contribution of the NP practice. Value can be garnered in terms of revenue generation and cost-effectiveness of hiring NP providers; however, a considerable financial impact can be in cost avoidance and cost savings through NP-associated outcomes of care. METHODS: This was a retrospective, secondary analysis of return on investment after adding NPs to 5 teams. Software was used to abstract billing, acuity, and length of stay (LOS) data and NP-associated quality metrics. Billing data, LOS, and risk-adjusted LOS data for designated years before and after adding NPs were compared. RESULTS: Gross collections compared with expenses for 4 NP-led teams for 2 year time periods were 62%, 36%, and 47%, and +32%. Average risk-adjusted LOS for the 5 time periods after adding NPs decreased and charges decreased, thus demonstrating less resource use. Most clinical outcomes improved beyond preproject baselines. CONCLUSION: This project demonstrated the value of adding NPs to inpatient care teams by means of generated revenue, reduction in LOS, and standardization of quality care.

A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective.

The purpose of this study was to understand the cognitive processes underlying nurses' decision to interrupt other nurses. The Institute of Medicine (2000) reported that interruptions are likely contributors to medical errors. Unfortunately, the research to date has been quite homogenous, focusing only on the healthcare provider being interrupted, ignoring the true complexities of interruptions. This study took a socio-technical approach being the first to examine interruptions from the viewpoint of the interrupting nurse. Over 15 h of observations and 10 open-ended interviews with expert nurses in a Neuroscience Surgical Intensive Care Unit were conducted. It was found that nurses conduct a quick cost-benefit assessment to determine the interruptibility of other nurses and whether an interruption is value-added vs. non-value added. To complete the assessment, nurses consider several conditional factors related to the interruptee, the interrupter, and the nature of the interruption content, and different potential consequences of the interruption.

Cost-benefit analysis: patient care at neurological intensive care unit.

Modern quality definition relies on patient centeredness and on patient needs for particular services, continuous control of the service provided, complete service quality management, and setting quality indicators as the health service endpoints. The health service provided to the patient has certain costs. Thus, one can ask the following: "To what extent does the increasing cost of patient care with changes in elimination improve the quality of health care and what costs are justifiable?" As stroke is the third leading cause of morbidity and mortality in Europe and worldwide, attention has been increasingly focused on stroke prevention and providing quality care for stroke patients. One of the most common medical/nursing problems in these patients is change in elimination, which additionally affects their mental health.

A modest proposal: nurse practitioners to improve clinical quality and financial viability in critical access hospitals.

Rural health care has achieved a new focus of attention with the passage of the Affordable Care Act (ACA). This article argues that nurse practitioners may be an important resource to help rural hospitals, especially critical access hospitals (CAH), achieve their mission of community service while protecting their always-delicate financial sustainability. Nurse practitioners' scope of practice is well suited to the needs of rural patients, and their ability to participate in expanding preventive services is especially essential in remote areas. Barriers to nurse practitioner practice include restrictive state laws and federal and state policies.