Illness is a combination of pathophysiology and associated thoughts, emotions, and behaviors. Given the large number of treatments that are discretionary and preference sensitive, one goal is accurate diagnosis of patient preferences. Reliance on biomedical treatments (e.g., medication and procedures) may overlook important opportunities for improved health such as amelioration of stress and distress and training in more effective coping strategies.
This evaluation was designed to examine the perspectives of 15 frontline staff who implemented a managed care program and 154 high-risk, high-cost disabled Medicaid clients who were participants in the program. Results indicated that positive relationships between staff and clients played a key role in facilitating program implementation. Challenges included finding ways to provide a wide breadth of services including food, shelter, and transportation; handling difficulties following from staff turnover; and creating transitions of care for clients to community health clinics. Staff identified training in motivational interviewing and having both nurse care managers and social workers collaboratively deliver the intervention as among the most powerful components of the program. Staff and clients expressed high levels of satisfaction with the program, and clients believed they were experiencing positive impacts of the program. Lessons learned from this study may inform the design of services as the Affordable Care Act continues to unfold.
Pasifika Support Services (PSS) was a program managed by a nongovernment organization, Mission Australia, and funded by the New South Wales Premiers Office to meet the needs of young offenders from a Pacific background. PSS ran from June 2005 to June 2009 and implemented a cost-effective integrated case management model with the New South Wales Police Force adapted to address social risk factors specific to Pacific youth offenders and family support networks. Sixty young people were reviewed regarding the outcomes achieved through their participation, further supported by an evaluation carried out by an external evaluator who found that 65% of participants did not reoffend after 18 months of completing the program. An importance of developing a shared approach to employing a holistic and intensive model of case management that affects individual, community, and organizational change through culturally relevant processes and practices, paired with a cross institutional commitment underpins the various outcomes discussed.
Few studies have examined predictors of hospital readmission among high-using patients enrolled in a behaviorally oriented intensive care management program. The purpose of this case control study was to describe risk factors and the effectiveness of a complex care management program for hospital readmission among vulnerable patients at a large academic medical center. One hundred sixty-three patients enrolled in the University of Michigan Complex Care Management Program (UM CCMP) were hospitalized between January 2014 and March 2015. Sixty were readmitted within 30 days of discharge. Among all patients, the mean age was 51.1 years, 38.7% were non-White, 81.5% had Medicaid and/or Medicare, 50.3% were without stable housing, and 27.6% had significant psychiatric illnesses. Although mostly not statistically significant, multivariable risk of readmission was increased by having twice the mean number of hospitalizations in the last 6 months (odds ratio [OR] = 1.44, 95% CI [1.00, 2.06]), having chronic pain on a scheduled narcotic (OR = 1.49, 95% CI [0.67, 3.35]), and going to a primary care physician within 30 days of discharge (OR = 1.35, 95% CI [0.63, 2.89]). Risk was decreased by going to a specialist (OR = 0.54, 95% CI [0.23, 1.27]) and receiving moderate-intensity CCMP intervention (OR = 0.48, 95% CI [0.20, 1.19]). Among hospitalized high-using patients enrolled in the UM intensive care management program, readmission is likely significantly influenced by medical, behavioral, and social challenges. Care management appears most effective in preventing readmission among patients with mid- rather than high- or low-level needs. These findings at a single program should be explored in further, larger studies.
Objectives: To systematically assess barriers delaying home respiratory equipment requisition and to evaluate for temporal correlation between delays and emergency room or hospitalization episodes.Background: Initiation of home respiratory treatments is delayed because of delays in delivery of durable medical equipment (DME). This study assesses root causes of such delays from a system perspective. We also describe clinical consequences by measuring emergency room visits and hospitalization days for temporal correlations.Methods: We conducted a retrospective review of DME ordering records from April 2011 to March of 2012.Settings: Outpatient DME records in Pediatric Pulmonary Division.Results: Of 164 available orders studied, deliveries were made as followed: 31 (19%) within 24 hr: 18 (59%) oxygen orders and 10 (32%) nebulizer orders 50 (30%) within 1 week: 25 (50%) nebulizer orders and 10 (20%) oxygen orders Delays: 45 (27%) delivered > 1 month: Bilevel positive airway pressure (BPAP) = 16 (36%) Oxygen = 12 (26%) Cough assist device = 7 (16%) Nebulizer = 5 (11%) Miscellaneous devices = 5 (11%) Analysis of barriers includes (a) type of insurance, (b) human error, (c) communication barrier, (d) deficit in training or knowledge, (e) no clear policy, (f) differences in clinical policy/ standard, (g) no DME benefit, (h) no clinical justification, and (i) error in communication/record keeping. Six patients with 7 emergency department (ED) visits and 4 inpatient admissions, totaling 24 hospital days, were temporally associated with delays in delivery of equipment over 30 days.Conclusion: One half of commonly used DMEs were delivered within the first week. One quarter of more expensive required more steps for approval. Twenty-nine ED/hospital days with respiratory morbidities were temporally associated with delays.
BACKGROUND:Despite compelling evidence showing that social networks and social support are associated with depression, relatively little research is available on this topic for older Koreans at high risk of depression. This article aimed to examine the relationship among different types of social networks (family vs. friends), social support (instrumental vs. emotional), and perceived general health among older Koreans at high risk of depression. We would then test for possible differences in pathways between two age groups (60-74 years vs. 75 years and older).METHODS:Using data from the 2008 Survey of Elderly Life and Welfare Need, age 60-74 years (n = 2,815) and age 75 years and older (n = 1,784) were analyzed separately. Path analyses were used to examine the relationships among social network, support, and health among Korean older adults at high risk of depression.RESULTS:Findings highlighted the complex associations among social networks, social support, and perceived general health within old age. Moreover, this study called attention to the negative association between instrumental support from family networks and perceived general health among older Koreans aged 60-74 years at high risk of depression.CONCLUSIONS:The work discussed in this article would help inform the design of much needed and effective social intervention programs for the growing number of Korean older adults with depression.
Previously, we have used a multidisciplinary team (MDT) approach to individualize rehabilitation of very old stroke patients as a means to establish intervention points for addressing impaired activities of daily living (ADL). However, this previous study was limited because of a lack in describing the communication process over time. This case study characterized the MDT communication process in the rehabilitation of an 84-year-old patient over the course of 15 weeks. The MDT consisted of 3 nurses, 1 doctor, 6 therapists, and the patient/families. Meetings (15 minutes each) were held at 4, 6, 8, and 15 weeks following the patient's admission. To individualize the rehabilitation, the communication process involved gaining knowledge about ADL impairments, sharing assessments, providing treatment options, and reflecting on desired treatment outcomes-a process termed KATR. The knowledge, assessment, treatment, and reflection (KATR) process established intervention points focusing on specific ADL impairments. The team members focused the interventions on the impaired ADL identified in the KATR process, and individualized rehabilitation was generated from the MDT information-sharing knowledge. In the initial meeting (Week 4), intervention points derived from the KATR process focused on rehabilitation of self-care impairments. These impairments improved by Week 15. By the last meeting, the MDT intervention points focused on mobility impairments. Having an organized communication process (i.e., KATR) facilitates individualization of rehabilitation without lengthy and frequent MDT meetings and enhances the quality of rehabilitation after a stroke.
OBJECTIVES:The current cross-cultural study examines the pathways underlying different formations of social networks and social support systems, which affect depression symptoms among older Korean immigrants and non-Hispanic Whites in the United States.METHOD:Data for this study came from a panel survey of 223 older Korean American immigrants and 201 non-Hispanic White older adults 65 years of age and older living in Los Angeles. Structural equation modeling (SEM) is used to test the proposed conceptual model designed to explain the direct and indirect relationships between social networks and social support on depression symptoms.RESULTS:Empirical evidence from this study indicated different effect of one's social networks and social support on depression by race/ethnicity.DISCUSSION:The work discussed in this article pointed to the need to recognize the role of culture in assessing the relationships between social networks, social support, and health among older adults.
Numerous studies have demonstrated the short-term effectiveness of the Cash and Counseling model option of participant-directed home and community-based personal care service programs for Medicaideligible recipients with disabilities requiring long-term care. However, long-term experiences with participant-directed services have yet to be examined for these individuals. We addressed this gap in the literature through participatory action research and qualitative content analysis. Working together as coresearchers with members of the National Participant Network, a peer organization for people interested in or enrolled in participant-directed services, we interviewed 17 adults enrolled in one state's Cash and Counseling-based program. Participants' ages ranged from 40 to 83 years, had been enrolled for at least 5 years, and acted as their own representative within the program. Our major findings show (a) the program's flexibility allowed for adaptation to meet participants' changing needs over time and (b) that program attendants helped connect participants with community in multiple ways. In this article, we provide important policy and practice implications for participant-directed programs for people with disabilities.
A factor contributing to uncontrolled hypertension in older persons is medication nonadherence. Older Black men in a rural cardiology clinic were not taking blood pressure medication as prescribed resulting in uncontrolled hypertension. A nurse protocol to assist with self-administration of hypertensive medication was proposed to address the problem. This qualitative key informant study identified a purposive sample of 10 hypertensive Black men who were 65-70 years of age and nonadherent in taking their medication. The nurse conducted teaching sessions using the protocol to review evidence-based strategies for improving medication adherence. A follow-up phone call was done after 1 week. Participants were interviewed about their perceptions of taking hypertensive medication. The interviews were recorded, transcribed, and coded for themes using constant comparative analysis. Six themes emerged: Medication Bottle Guides Medication Usage, Confusion about Side Effects, Reasons for Not Taking Medications, New Behavior, Unchanged Behavior, and Discovery of Other Problems. The results showed that the nurse-administered protocol resulted in participants' changed attitudes about taking medication.
AIM:To investigate important case management goals and key influences on the achievement of the goals in community aged care practice from the perspectives of case managers in Australia.METHODS:We surveyed 154 case managers, representing 17.1% of the target population in the State of Victoria, Australia. The key information collected was case managers' characteristics and their selections of important case management goals. We also conducted 33 interviews with 47 case managers to explore their perceptions of important case-managed community aged care goals and the key influences on the achievement of these goals. Descriptive analysis, logistic regression, and qualitative thematic analysis were performed.RESULTS:The survey findings showed that important case management goals included improving client outcomes, improving care quality, enhancing care coordination and accessibility, and reducing nursing home admissions. The interview findings indicated that important case management goals were divided into client-centered goals (e.g., maintaining clients safely at home), case managers' personal goals (e.g., gaining professional development), and organizational goals/expectations/values (e.g., expecting case managers to manage budgets wisely). Finally, the mixed research methods determined constraints of organizational resources and policies, clients' risky decisions, and case managers' work experience and employment status as key influences or significant factors associated with the achievement of case management goals.CONCLUSION:Client-centered goals are of particular importance among those important case management goals. Case managers helping clients establish reasonable expectations and organizations developing favorable professional development policies and establishing reasonable job requirements and expectations will facilitate the achievement of case management goals.
This article describes a model for care managers that is based on attachment theory supplemented by knowledge from neuroscience. Together, attachment theory and basic knowledge from neuroscience provide for both an organizing conceptual framework and a scientific, measureable approach to assessment and planning interventions in a care plan.
Communication obstacles in health care settings adversely impact patient–practitioner interactions by impeding service efficiency, reducing mutual trust and satisfaction, or even endangering health outcomes. When interlocutors are separated by language, interpreters are required. The efficacy of interpreting, however, is constrained not just by interpreters’ competence but also by health care providers’ facility working with interpreters. Deaf individuals whose preferred form of communication is a signed language often encounter communicative barriers in health care settings. In those environments, signing Deaf people are entitled to equal communicative access via sign language interpreting services according to the Americans with Disabilities Act and Executive Order 13166, the Limited English Proficiency Initiative. Yet, litigation in states across the United States suggests that individual and institutional providers remain uncertain about their legal obligations to provide equal communicative access. This article discusses the legal and ethical imperatives for using professionally certified (vs. ad hoc) sign language interpreters in health care settings. First outlining the legal terrain governing provision of sign language interpreting services, the article then describes different types of “sign language” (e.g., American Sign Language vs. manually coded English) and different forms of “sign language interpreting” (e.g., interpretation vs. transliteration vs. translation; simultaneous vs. consecutive interpreting; individual vs. team interpreting). This is followed by reviews of the formal credentialing process and of specialized forms of sign language interpreting—that is, certified deaf interpreting, trilingual interpreting, and court interpreting. After discussing practical steps for contracting professional sign language interpreters and addressing ethical issues of confidentiality, this article concludes by offering suggestions for working more effectively with Deaf clients via professional sign language interpreters.
Optimally, transition in health care should be seamless and incorporate a well-thought-out patient-centered discharge plan; yet, many hospitalized patients are unprepared for discharge, thereby compromising patient safety and quality of care. Transition of care should include a broad range of time-limited services designed to ensure health care continuity to avoid poor outcomes among at-risk populations. This case study demonstrates that advanced practice nurses (APNs) are in the perfect position to bridge the existing gap, reduce readmissions, and improve patient health. Transition from hospital to home is stressful under the best of circumstances. Naylor's transition of care model and Meleis's transition theory provides the foundation for APNs to manage patients' wounds across the continuum of care. The patient is educated and guided through the convoluted health care system, resulting in decreased discontinuity and improved outcomes and safety.CONCLUSION:A smooth transition between levels of care requires collaboration and care coordination of medical services and health care providers. The result of this continuity is improved patient outcomes, improved patient satisfaction, and reduced medical errors. APNs as care coordinators have the ability to bridge the existing gap between hospitalization and home while preventing readmission.
OBJECTIVE:This article examined individual characteristics associated with having higher costs in a 5-year period to identify patients that may potentially benefit from case management.METHODS:Florida Medicaid claims data from 2005 to 2010 were used to examine the characteristics, diagnoses, and services (in 2005) associated with individual costs in 5 future years (2006-2010). The data were divided into estimation and prediction samples with regression models estimated using diagnoses and service use in 2005 to predict future costs. Predictive power was assessed by applying the model results to the prediction sample and comparing predicted costs to actual costs.RESULTS:Demographics, service use, and diagnosis in 2005 were associated with costs in the following 5 years. Models were predictive of future costs with a significant relationship between the predicted costs and actual costs.CONCLUSION:Diagnosis-based models in conjunction with prior costs can predict future costs. Individuals predicted to have higher costs may be candidates for case management to potentially avoid reduce costs.
