Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018.

PURPOSE AND OBJECTIVES: Emergency departments see a disproportionate share of low-income and uninsured patients. We developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data. INTERVENTION APPROACH: We leveraged an academic-community partnership to develop a social needs screening tool and referral process. EVALUATION METHODS: In a 25-day feasibility trial incorporating rapid improvement cycles, emergency department staff screened 210 patients for social needs. Observational and interview notes were analyzed, and data were linked from patient screenings, the United Way of Salt Lake 2-1-1 consumer information system, and electronic health records. RESULTS: Domains uncovered during pilot testing included screening based on appearance or insurance; discomfort asking stigmatizing questions; and lack of clarity regarding the screening's purpose. During the trial, 61% (n = 129) of patients reported 1 or more need, 52% (n = 67) of whom wanted follow-up. Of the 65 patients with complete data who wanted referrals, 49% (n = 32) were ultimately reached by 2-1-1, which provided an average of 4 community referrals (eg, pharmacy programs, utility assistance). Service usage 3 months before versus 3 months after emergency department index dates demonstrated that patients with social needs experienced a significant increase in emergency department use compared with those without needs (1.07 vs 1.36, P = .03), while patients with no needs experienced increases in primary care visits compared with those patients with unmet needs (0.24 vs 0.56, P = .03). IMPLICATIONS FOR PUBLIC HEALTH: We demonstrated the ability to systematically screen and refer for emergency department patients' unmet social needs by using existing resources and to link screening results, service referral details, and health service data. However, our experiences demonstrate that widespread implementation efforts should thoughtfully address staff perceptions and patient communication challenges.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups.

Health professions trainees' performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = -0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

A Secondary Data Analysis of Technology Access as a Determinant of Health and Impediment in Social Needs Screening and Referral Processes.

Introduction: Although health systems increasingly integrate social needs screening and referrals into routine care, the effectiveness of these interventions and for whom they work remains unclear. Methods: Patients (N=4,608) seen in the emergency department were screened for social needs (e.g., transportation, housing, food) and offered an opportunity to receive outreach from community service specialists. Results: Among 453 patients with 1 or more social needs who requested assistance, outreach specialists connected with 95 (21.0%). Patients preferred to be contacted through their telephone (n=21, 60.2%), email (n=126, 28.0%), someone else's telephone (n=30, 6.7%), or first by telephone followed by email (n=23, 5.1%). Preferred contact method varied by patient age; endorsement of unmet transportation, housing, and utility needs; receipt of service outreach; and differences in emergency department utilization from the 6 months before the index visit to the 6 months after. Conclusions: Because limited access to a stable telephone or internet connection may prevent patients from connecting with resource referrals, social needs interventions may not benefit the most underserved populations who are at the highest risk of negative health outcomes. Future research should investigate whether communication preferences are an important indicator of needs and how to adapt social needs screening and referral processes so that they are more accessible to populations who may experience more frequent disruptions in methods utilized for digital communication.

Bias and the Psychological Safety in Healthcare Teams.

The levels of biases, stereotypes, and prejudices are present at the same level within our healthcare teams as they are in society in general. The effect of biases on teams, team development, and team functioning is less known, but what to do with bias is known and important for all healthcare clinicians to understand. Exploring bias and psychological safety is vital for optimal team development. Teams need trust, sense of belonging, and a culture of open communication to provide the best care possible for their patients; yet often teams do not address their own biases or stereotypes nor do they feel prepared to open these conversations. In this article, we present a case study, provide definitions of bias and psychological safety, as well as offer strategies to combat biases, provide steps all of the healthcare team can employ to promote belongingness in the interprofessional team, and offer strategies of supporting team members experiencing biases.

The Future of Nursing: Application of Health Equity in Orthopaedics.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report was released in May 2021 by the National Academies of Sciences, Engineering, and Medicine. The goal is attainment of health equity in the United States using nursing capacity and expertise by designing a pathway for the nursing profession to generate a culture of health, reduce health disparities, and improve the nation's health and well-being. The focus of this article is to develop an awareness and understanding of the nine Future of Nursing recommendations for attaining health equity over the next decade with an application to orthopaedic nursing.

Psychometric Evaluation of the Screener for Intensifying Community Referrals for Health.

This study examined the psychometric properties of the Screener for Intensifying Community Referrals for Health (SINCERE), a 10-item, low literacy screening tool developed to elicit social needs (e.g., transportation, housing) impacting patients' ability to engage in health-related activities. Patients seeking care in a tertiary care emergency department (ED) were invited to complete the SINCERE as part of registration processes, and were asked about their desire for follow-up by a partnering service provider offering low- and no-cost community resource referrals. A total of 5,081 patients completed screenings were included in this sample. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) identified and verified one-factor structure, suggesting that the SINCERE's 10-items are homogenous and measure one construct. The reliability of Cronbach's α and McDonald's ω were 0.89. Item Response Theory (IRT) suggested the SINCERE can effectively identify patients wishing referrals, or who have social needs. Moreover, patients who had two or more social needs were those willing to receive referrals after discharge. The SINCERE is a valid and reliable tool for measuring social needs for health, and should be considered as a screening option for practice interventions seeking to address social needs.

Social Determinants of Health: What Are They and How Do We Screen.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report recognizes nurses' impact on the medical and social factors that drive health outcomes (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). The report calls for nursing to take bold steps to address individual and structural level social determinants of health (SDoH)-or social and environmental factors contributing to poor health, poor health outcomes, and health disparities (NASEM, 2021, p. 5). Nurses must recognize the significance of SDoH on patient health outcomes in order to advance health equity and employ nursing interventions to affect positive change for our patients. SDoH are part of our patients' stories, and holistic nursing means we know the whole patient story. Although it is now widely recognized that SDoH affect health outcomes, a key challenge for nurses is that they represent an enormous range of factors-from food and housing insecurity to personal safety and environmental exposures-that may be more or less able to change with interventions in clinical settings. Furthermore, concerns have been raised that screening for SDoH-especially when not done with sensitivity, cultural competence, or ready intervention-may compromise therapeutic relationships and marginalize patients (Wallace et al., 2020). However, despite these concerns, healthcare systems are widely adopting SDoH assessments, generally through electronic health record screening questions, and attempting to implement associated workflows and interventions. Given this landscape, the purpose of this article, within this special issue of Orthopaedic Nursing, is to provide an overview of SDoH factors, identify best practices related to screening and referral, and highlight nurse-directed interventions in clinical settings.

Caregiver Inclusion in IDEAL Discharge Teaching: Implications for Transitions From Hospital to Home.

PURPOSE: Despite recognition that unpaid (e.g., family, friends) caregivers (caregivers) play an important role in successful transitions home after hospitalization, limited information is available about whether and how caregiver experiences of discharge align with current strategies for providing high-quality discharge processes, and how these experiences at discharge impact successful transitions home. The purpose of this study was to explore perceptions of caregivers regarding their discharge preparation, focusing particular attention on whether and how they believed discharge preparation impacted postdischarge patient outcomes. METHODS: We conducted in-depth, case interviews with four English-speaking caregivers (61-75 years of age). Content analysis was framed by the nature of caregiver involvement proposed by the Agency for Healthcare Research and Quality's (AHRQ's) IDEAL (Include, Discuss, Educate, Assess, Listen) discharge planning strategy. RESULTS: Caregivers reported receiving clear discharge instructions, or basic education, and yet felt only passively included in discharge teaching. Once home, the caregivers reported gaps in their knowledge of how to care for the patient, suggesting key gaps related to knowledge of warning signs and problems. Two of the four caregiver participants attributed a hospital readmission to postdischarge knowledge gaps. CONCLUSION: The experiences of these caregivers demonstrate how their limited, passive involvement in discharge education may result in suboptimal patient outcomes after hospitalization. Our findings suggest that structured programs aimed at increasing caregiver involvement in discharge, particularly related to assessment of caregiver problem solving, planning, and postdischarge support, are important in efforts seeking to improve care transitions and postdischarge outcomes. IMPLICATIONS FOR CASE MANAGEMENT: This study assesses caregivers' experience with discharge planning and problems they encounter post-discharge, providing case managers with important information regarding the effectiveness of discharge processes. This study of caregiver experiences suggests that the IDEAL discharge planning strategy remains a useful and important framework for case managers to follow when providing discharge services.

Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges.

BACKGROUND: Despite the importance of social determinants in health outcomes, little is known about the best practices for screening and referral during clinical encounters. This study aimed to implement universal social needs screening and community service referrals in an academic emergency department (ED), evaluating for feasibility, reach, and stakeholder perspectives. METHODS: Between January 2019 and February 2020, ED registration staff screened patients for social needs using a 10-item, low-literacy, English-Spanish screener on touchscreens that generated automatic referrals to community service outreach specialists and data linkages. The RE-AIM framework, specifically the constructs of reach and adoption, guided the evaluation. Reach was estimated through a number of approaches, completed screenings, and receipt of community service referrals. Adoption was addressed qualitatively via content analysis and qualitative coding techniques from (1) meetings, clinical interactions, and semi-structured interviews with ED staff and (2) an iterative "engagement studio" with an advisory group composed of ED patients representing diverse communities. RESULTS: Overall, 4608 participants were approached, and 61% completed the screener. The most common reason for non-completion was patient refusal (43%). Forty-seven percent of patients with completed screeners communicated one or more needs, 34% of whom agreed to follow-up by resource specialists. Of the 482 participants referred, 20% were reached by outreach specialists and referred to community agencies. Only 7% of patients completed the full process from screening to community service referral; older, male, non-White, and Hispanic patients were more likely to complete the referral process. Iterative staff (n = 8) observations and interviews demonstrated that, despite instruction for universal screening, patient presentation (e.g., appearance, insurance status) drove screening decisions. The staff communicated discomfort with, and questioned the usefulness of, screening. Patients (n = 10) communicated a desire for improved understanding of their unmet needs, but had concerns about stigmatization and privacy, and communicated how receptivity of screenings and outreach are influenced by the perceived sincerity of screening staff. CONCLUSIONS: Despite the limited time and technical barriers, few patients with social needs ultimately received service referrals. Perspectives of staff and patients suggest that social needs screening during clinical encounters should incorporate structure for facilitating patient-staff relatedness and competence, and address patient vulnerability by ensuring universal, private screenings with clear intent. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04630041 .

Essential Nursing Care Management and Coordination Roles and Responsibilities: A Content Analysis.

BACKGROUND: Care management roles and responsibilities are frequently called out in leading white papers and exemplars; yet, the actual roles and responsibilities are poorly defined. METHOD: A qualitative content analysis using 6 landmark white papers and exemplars from national organizations to collect emerging care management and coordination roles and responsibilities. RESULTS: Three major themes emerged from the content analysis: (1) care management is about complex systems and complex medical and social needs, (2) nurses are central to the interdisciplinary team, and (3) informatics is vital to support and enhance care management. IMPLICATIONS FOR PRACTICE: Care managers need to be experienced with complex systems of care as well as complex diagnoses and conditions that our clients and their caregiver's experience. A nurse being central to the clients and embedded within the interdisciplinary team aids in diminishing the burden of negotiating the trajectory of a condition/illness as well as improves the interdisciplinary communication and teamwork. This review of literature has defined the complexity of care management and the discreet roles and responsibilities, as well as how informatics is vital for care managers to target and monitor key populations needing care management.

Discharge Processes: What Evidence Tells Us Is Most Effective.

The quality of discharge teaching is statistically linked to decreased readmission rates. Nursing most often bears the major responsibility of patient and caregiver teaching. Currently, discharge teaching is complicated by problems including time constraints, patient and caregiver overload, and coexisting comorbidities that add complexity to the patient's care needs at home. Not only are readmissions a preventable cost, more importantly, but they also are a negative patient experience signifying to our patients that they are unable to optimally care for themselves or that their disease or healing is not something they can care for alone. The following is a review of Agency for Healthcare Research and Quality's IDEAL discharge process, common problems in discharge teaching, and nursing's responsibilities with assessing a patient and his or her caregiver for discharge readiness. IDEAL is a structured discharge process with tools to help healthcare organizations improve their discharge process to decrease readmissions rates.

Looking at childhood obesity through the lens of Baumrind's parenting typologies.

Obesity is becoming the leading negative health outcome for the current generation of children to a greater degree than for any previous generation. Pediatric orthopaedic nurses encounter many patients and families with concerns about obesity and need the ability to promote parenting capacity in order to detect, prevent, or treat childhood obesity. Parenting is a complex process with numerous two-way interactions between the parent and child. Pediatric orthopaedic nurses affect parenting capacity daily as they care for families in all care settings. Many family researchers use Baumrind's parenting typologies (styles) and their correlations to child health outcomes in research. Understanding Baumrind's theories can help pediatric orthopaedic nurses understand the mechanisms parents use to affect the health outcomes related to the obesity of their children. Baumrind's is one parenting theory that can help demonstrate how parental behaviors and practices affect a child's self-concept and self-care development and ultimately a child's health promotion beliefs and practices related to obesity prevention and care that continue into adulthood. Nurses can use reviews of literature and application to practice of parenting styles to expand their repertoire of parent guidance and anticipatory teaching directed to the prevention and care of childhood obesity.

Nursing Care Management: Influence on Bundled Payments.

Fragmented and uncoordinated care is the third highest driver of U.S. healthcare costs. Although less than 10% of patients experience uncoordinated care, these patients represent 36% of total healthcare costs; care management interaction makes a significant impact on the utilization of healthcare dollars. A literature search was conducted to construct a model of care coordination for elective surgical procedures by collecting best practices for acute, transitions, and post-acute care periods. A case study was used to demonstrate the model developed. Care management defines care coordination as a model of care to address improving patient and caregiver engagement, communication across settings of care, and ultimately improved patient outcomes of care. Nurse-led care coordination in the presurgical, inpatient, and post-acute care settings requires systems change and administrative support to effectively meet the goals of the Affordable Care Act of reducing redundancy and costs while improving the patient experience. Nursing is the lynchpin of care management processes in all settings of care; thus, this model of care coordination for elective surgical admissions can provide nursing care management leaders a comprehensive view of coordinating care for these patient across settings of care during the predetermined time period of care. As bundled payment structures increasingly affect hospital systems, nursing leaders need to be ready to create or improve their care management processes; care coordination is one such process requiring immediate attention.

Parent perceptions of health promotion for school-age children with spina bifida.

PURPOSE: To gain insight into how parents develop their beliefs of health promotion for their children with spina bifida (SB) and how they develop and promote health promotion practices for their children. DESIGN: Qualitative, exploratory design with semi-structured interviews of parents of children between 6 and 12 years of age diagnosed with SB was used for this study. RESULTS: Perceptions of health promotion were maintaining healthy bowel function and managing SB care. Good bowel function and SB management is health promotion and adequate bowel function is viewed as a marker of health. Maintaining healthy bowel function was identified by parents as the key marker of health for their children with SB. Further, the term health promotion brought up plans, concerns, and goals more related to their child's physiologic functioning and health care needs rather than promoting health and avoiding preventable disease. PRACTICE IMPLICATIONS: Nurses and healthcare providers are in unique and powerful positions for strategizing with parents on how to integrate health promotion into the lives of children with SB. Team-based, whole-person, holistic assessment and teaching inclusive of promoting healthy lifestyle behaviors in addition to providing excellent care related to their physiologic systems affected by SB can improve how we promote health for these children.

A Statewide Survey Report of Roles and Responsibilities in Current Utah Care Management Processes.

PURPOSE OF THE STUDY: Measure current roles and responsibilities of care managers in the state of Utah. PRIMARY PRACTICE SETTING: All settings of health care including inpatient, outpatient, community, payer, post-acute, and transitional care settings. METHODS AND SAMPLE: A quantitative descriptive survey design was used to assess and describe current care management roles and responsibilities of 191 care managers within the state of Utah. Quantitative variables of roles and responsibilities were collected an electronic database (REDCap). RESULTS: Major results conclude that care managers spend most of their time on direct patient interactions including discharge planning, population care, and utilization review. These care managers are highly experienced in their field, with most being in their professional practice for more than 10 years. Most of the care managers are bachelor's prepared nurses. IMPLICATIONS FOR CARE MANAGEMENT AND CARE COORDINATION PRACTICE: To create or expand care management processes to meet the goals of health care reform, systems first need to know what care managers/coordinators are doing and where their current focus on care presides. Educators, leaders, and, indeed, the care managers themselves are a part of preparing this dynamic workforce. The major responsibility of care management continues to be direct patient interactions, meaning that care managers are performing vital interpersonal patient interaction needed to achieve highly personalized patient care with assurances of quality and safety. No matter the name-care management, case management, or care coordination-these activities are an essential part of health care, with highly specialized skills that promote patient engagement and activation.

Broken bones: common pediatric lower extremity fractures--Part III.

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.

Changing paradigm for the treatment of clubfeet.

Clubfoot is one of the most common pediatric orthopaedic conditions. Until recently, surgical management was the treatment of choice. Nonoperative treatment techniques, including the Ponseti casting and French physical therapy methods, have peeked interest of orthopaedists eager to find a less aggressive treatment method that can assure a lasting, good result. Both methods have proven successful in reducing the number of patients requiring extensive surgical release and, as a result, have become an integral part of pediatric orthopaedic practice. A clear understanding of both treatment methods is important for the orthopaedic nurse to allow quality nursing care and help assure a successful outcome for young patients.

Congenital muscular torticollis.

Congenital muscular torticollis is a painless condition usually presenting during infancy with a tight sternocleidomastoid muscle causing the child's head to be tilted to the tightened side. Limited neck motion and a palpable tumor within the muscle are often present. A regimen of stretching exercises is the most common form of treatment with positive outcomes for over 90% of the identified cases. Rarely children require surgical intervention to release the tightened muscle. Botox injections to relax the tight muscle is a new form of treatment being used by some practitioners. Torticollis also presents as a symptom for a variety of muscular, bony, and neurologic conditions, which are briefly reviewed in this article.

What does the Affordable Care Act mean for nursing?

Nurses are ethically bound to engage in efforts of improving health and healthcare delivery and, even more important, nurses recently have been called out as key leaders in the reform of healthcare delivery, including many components of the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act, its history, and what healthcare will look like during and after implementation are addressed in this article. A discussion of the role and value of nurses in healthcare reform accompanies knowledge-building and action-oriented resources available to nurses and clients.

Differing perceptions regarding quality of life and inpatient treatment goals for children with severe disabilities.

OBJECTIVE: To describe and compare during an acute hospitalization the perceptions of parents, pediatric interns, and pediatric hospitalists regarding the long-term health-related quality of life (HRQoL) of children with severe disabilities when not hospitalized and to identify treatment goals. METHODS: Parents of children with severe disabilities aged 5 to 18 years, as well as the intern and hospitalist caring for the child during acute hospitalizations at a tertiary care center in Salt Lake City, Utah, participated in this study. All participants completed the KIDSCREEN-10 and an investigator-developed survey; a subset was interviewed to qualitatively ascertain perceptions of the child's HRQoL before the current acute illness. Responses were summarized with descriptive statistics and content analysis. RESULTS: We enrolled 115 subjects. Overall, parents rated the HRQoL of their children significantly higher than did either group of physicians on both the KIDSCREEN-10 (37.4 ± 3.9 vs 29.6 ± 5.5, P < .001) and the investigator-developed survey (30.3 ± 5.9 vs 26.3 ± 5.5, P < .001). Parents described the HRQoL of their children more positively and broadly than did physicians. Parents and physicians also expressed different goals for treatment. Parents expressed optimism despite uncertainty regarding their child's future, whereas physicians anticipated increased medical complications and focused on caregiver burden. CONCLUSIONS: Parents of children with severe disabilities rated their children's long-term HRQoL higher than physicians did. Such discrepancies may increase tensions and hinder shared decision-making efforts during acute hospitalizations. Explicit discussions between parents and physicians regarding the HRQoL of children with severe disabilities and treatment goals may facilitate care processes for everyone involved.