INTRODUCTION: While transitions of care (TOC) programs are known to decrease readmissions for heart failure (HF), significant policy and resource challenges inhibit the implementation of hospital based TOC programs, thus novel models of TOC are urgently needed. The purpose of this study is to evaluate the need and readiness of a private practice based TOC program led by DNP-prepared nurse practitioners. METHODS: In this descriptive study, cardiology providers from a private practice in the Southwest (N=14) participated in a survey on HF TOC. The practice’s electronic medical records (EMR) database was queried for patient demographic data along with other HF measures (N=3175). RESULTS: There were 1,827 females (57.5%) and 1,348 males (42.5%) with the mean age being 75.1 years +/-11.1. The 70-79 year age bracket represented 41.0% of all HF patients. The most common ICD-10 code for HF was [I50.32] Chronic Diastolic Congestive Heart Failure (N=986), which translates into 31.0% of the total HF population. Almost 30% of the providers (N=4) acknowledge that they never document their HF readmissions in the practice’s EMR. Nearly 65% percent of respondents “strongly agree,” that HF patients discharged from the hospital require a specific plan of care, while 86% of providers (N=12) either “somewhat agree” to “strongly agree” in the need for a TOC program for HF patients within their cardiology practice. Over 71% (N=10) of the providers “strongly agree” with a DNP-led TOC program for HF. CONCLUSION: This study provides encouraging results for the future implementation of a cutting edge private cardiology practice based TOC program for HF in Tucson, AZ. The study results clearly indicate the need and readiness for the Tucson-based private practice TOC program for HF. The DNP prepared nurse practitioner is thoroughly prepared to take the lead in designing, implementing and evaluating such a program and this unique role was supported by the practice. Importantly, the results of this study may provide the foundation for future studies examining the effects of private practice based TOC programs for HF.

The purpose of this DNP project was to determine the feasibility of implementing a nurse practitioner led interprofessional collaborative management model of caring for patients with complex medical conditions who are at high risk for ED and hospital readmission. The target of the feasibility study was an accountable care organization (ACO) in Idaho. The ACO assumes greater financial risk for providing care to a population that includes Medicare Advantage patients - dual insured Medicare/Medicaid patients. The care management teams are currently led by physicians. The members of the population that suffer most from multiple chronic conditions often encounter barriers to accessing high quality primary care, in particular when transitioning between different levels of care. Interprofessional collaborative team based care coordination can address medical and social issues that can affect a patient’s ability to achieve/maintain wellness. The literature suggests that nurse practitioners are ideally suited to lead those teams Approval was given by leadership in the ACO to accomplish a study to determine the feasibility of successfully implementing an innovative NP led interprofessional collaborative care management model: the AEIØOU Bundle of Care Practices. Principles of qualitative descriptive methodology, using content analysis, were applied to explore the responses provided at individual interviews by thirteen key stakeholders. The data collected were not intended to be generalized, but rather to evaluate the potential for implementation of a new model of interprofessional collaborative care within the ACO. Findings suggest that implementation of this model is feasible within the ACO. Common themes uncovered include: (a) change is challenging, (b) coordinated patient care aligns with organizational goals, (c) success requires cost analysis, a comprehensive business plan, buy-in from primary care physicians, and a pilot program, and (d) strong support among all participants for NP and RN home visits was notable.

Class of 2016 Abstract and Report / Objectives: An estimated 5.7 million Americans had heart failure (HF) in 2012 with an economic cost of $30.7 billion. By 2030 the prevalence of the disease is expected to increase by 46%. Centers for Medicare and Medicaid Services penalizes hospitals for 30-day readmissions. This study evaluated the effect of our multidisciplinary HF intervention on readmissions. Methods: This is a retrospective cohort study. Patients were identified from electronic inpatient admission records from January 1 to December 31, 2014. Patients who received any component of intervention were compared to patients who did not receive any intervention. Intervention included student pharmacist medication counselling, HF education, and post-discharge phone calls with Modified Morisky questionnaire. Age, sex, admission/discharge dates, readmission diagnosis, smoking status, ejection fraction, medications, and Charlson Comorbidity Index (CCI) conditions were collected. Results: A total of 221 patients with 249 discrete admissions were identified. No difference in age (p=0.42), sex (p=0.48), smoking status (p=0.10) existed between the groups. No difference in readmissions was found between patients receiving complete intervention and control (p=0.41) or patients receiving 1 or 2 intervention components and control (p=0.41). Patients with CCI score≥ 8 had greater risk of readmission compared to CCI scores 0-2 (OR 7.7, 95% CI 1.6-36.3, p=0.01). Conclusions: This analysis did not identify an intervention impact on 30-day readmissions in patients with HF; high CCI scores were associated with increased readmission risk. The intervention may be best targeted towards patients with high CCI scores as they have the highest readmission rate.

Indiana University-Purdue University Indianapolis (IUPUI) / Hospital readmission is of growing importance in the healthcare industry because of associated patient and system costs, impact to the quality of patient care, and hospital Medicare payment penalties. The increasing interest in sepsis readmission prevention has highlighted the uniqueness of severe sepsis or septic shock survivors. The results of this study provide insight into the relationship between index hospital length of stay (LOS) and 30-day readmissions for older adults (> 65 years) who discharged home from an index hospital with a principle or secondary discharge diagnosis of severe sepsis or septic shock. The purpose of this study was to investigate the relationship between index hospital LOS and 30-day readmissions in older adults (> 65 years) whose expected primary payer was Medicare and who discharged home with a principle or secondary diagnosis of severe sepsis or septic shock. Data used to answer the proposed research questions consisted of older adult discharge records from the 2014 Nationwide Readmissions Database (NRD), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Differences in 30-day readmissions between older adult age groups, gender, and older adult location were examined. The number of days to readmission since discharge was evaluated for the subset of older adults with a readmission. Approximately 15.6% of older adults were readmitted within 30 days of their discharge. Readmissions were statistically different based on the older adult’s age, gender, and LOS. Location did not have a significant effect on readmissions. Mean LOS among readmitted older adults was 10.1 days. Analysis indicates that an older adult’s LOS had a significant effect on readmissions, although models performed poorly. Findings suggest that there are certain factors that can predict older adults who are at risk for being readmitted after being discharged with a principle or secondary discharge diagnosis of severe sepsis or septic shock.

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Background: The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014. Methods: This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses. Results: 189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16–1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases’ aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289). Conclusion: OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.

With medical evidence constantly advancing, the health care system faces pressure to generate, apply and integrate innovations to improve the quality of patient care. This dissertation examines how organizational characteristics influence these processes. The first study, a systematic review, investigates how organizational features influence the translation of basic research findings to clinical applications. Results showed a dearth of peer-reviewed literature on this topic, despite a proliferation of efforts to accelerate translational research by manipulating organizational structures and processes. Few studies effectively linked structures, processes and outcomes and no organizational feature was associated conclusively with translation of research into clinical practice. The second study draws on in-depth qualitative interviews (82 participants at 10 hospitals) to understand how hospitals that reduced readmission rates had applied innovations in clinical practice and organizational context. High performing and low performing hospitals had both implemented similar clinical practice changes in their efforts to reduce readmissions; however, high performing hospitals reported greater investment in creating an organizational context to facilitate readmissions. This included more extensive efforts to improve collaboration within the hospital, greater coordination between the hospital and outside providers, deeper engagement in learning and problem solving related to readmissions, and greater senior leadership support. The third study draws on an expanded set of interviews from the same data collection (90 participants at 10 hospitals) to investigate mechanisms through which innovations become integrated into hospital routines. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs. Results showed that when an innovation was integrated successfully, a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Innovations that proved intrinsically rewarding to staff integrated through shifts in attitudes and norms over time. Innovations that did not provide direct benefits to staff were integrated through changed incentives or automation. Together, these studies illuminate opportunities for hospitals to improve patient care by managing the organizational context in which innovations are deployed. Understanding how organizational context affects translation requires further research. / 2017-10-02T00:00:00Z

Thesis (M.S.)--Boston University

The current fragmented delivery of health care has contributed to unplanned hospital readmissions as a leading problem in the United States. Reducing readmissions to urban teaching hospitals is difficult. Many patients living in urban communities face social, economic, language, and transportation barriers to maintaining their health. Both the patient and the medical center experience the burden of readmission and are challenged with addressing SDoH and social injustices at several levels. Medicare views hospital readmissions as a marker representing lower quality of health care delivery to penalize hospitals providing care to the poor. This thesis addresses multiple social and economic factors associated with hospital readmissions, explores the interrelated components of readmissions at the personal and hospital system level, and delves into the interactions of bioethical principles associated with urban living. Hospital readmissions remain a serious issue nationwide and in order to reduce the rates of re-hospitalization the social and economic inequalities contributing to hospital readmissions are significant and must be addressed. / Urban Bioethics