A mixed methods approach was used for this study. The setting was a low-income, subsidized housing apartment building for community-dwelling older and younger disabled adults identified as a health care hot spot due to high rates of ambulance use. The study purpose was to identify reasons for ED use and problems during transition from ED to home, predictors of zip code 23220 (health care hot spot) in emergent and non-emergent ED visits, and predictors of total ED costs in community-dwelling older adults living in a health care hot spot. Semi-structured interviews with residents who used the ED, an existing database from an interprofessional care coordination and wellness program for residents, and community-dwelling older adults’ electronic medical record and billing data from 2010-2013 ED visits from an academic medical center were used. The Gelberg-Andersen Behavioral Model for Vulnerable Populations was utilized. A total of 14 interviews were conducted. Themes related to ED use included: high use of ambulance services, timely use of the ED or attempt at self-care, and lack of communication with a health care provider prior to ED visit. Themes related to care transitions were: delay in medication receipt after discharge, lack of a current medication list and personal health record, PCP follow-up instruction, and education on warning signs of a worsening condition. The interprofessional program’s care coordination activities were education, disease monitoring, referral for PCP visit, and discrepancy reconciliation. A total of 7,805 ED visits were included, of which 3,871 were non-emergent and 1,179 were emergent. Common primary ED visit diagnoses were chest pain and abdominal pain. White race, a Charlson Comorbidity Index score of 3, and a total disease count of 10 or more were significant predictors of zip code 23220 in non-emergent ED visits. White race was a significant predictor of zip code 23220 in emergent ED visits. Significant predictors of total ED costs were white or other race, arrival by ambulance, emergent visit type, and year of visit. Pain was a common reason for ED use. Care transition problems related to medication management and follow-up care indicate an area for targeted interventions after ED discharge.

Background: Generating evidence to inform care for pediatric medium-chain acyl-CoA dehydrogenase (MCAD) deficiency requires sustainable and integrated measurement of priority outcomes. Methods: From an existing Canadian cohort study, we evaluated the quality of metabolic clinic chart-abstracted data for measuring core outcomes for pediatric MCAD deficiency. We then modelled variation in emergency department (ED) use, in association with disease severity, child age, and distance to care. Results: Children with MCAD deficiency visit the metabolic clinic at least annually on average but we identified data quality challenges related to inconsistent definitions of core outcomes and missing information in patient charts. Rates of ED use were highest among children aged 6 to 12 months, with more severe disease, and living closest to care. Conclusion: While measuring core outcomes through the metabolic clinic for children with MCAD deficiency is feasible, harmonized data collection is needed to evaluate care and further understand ED use.

No description available.

The Affordable Care Act of 2010 proposed a new integrated care model for individuals with chronic mental illness and multiple medical comorbidities by using Behavioral Health Homes (BHH). The purpose of this doctoral project was to evaluate the effectiveness of the BHH in reducing emergency department (ED) use in the community mental health outpatient setting. Guided by the American Association for Critical Care Nurses synergy model for patient care a cross-sectional, post-test only with comparison group quasi-experimental research design was used. A de-identified data set of 68 patient records in the BHH group and 73 patient records in non-BHH as a control group were analyzed using logistic regression. The analysis revealed that participants in the BHH were statistically less likely to visit the ED. Sensitivity was 16.2%, specificity was 95.2%, positive predictive value was 54.5%, and negative predictive value was 76.2%. The Homer-Lemeshow and omnibus test of model coefficients showed the model was a good fit (p=.726, p=.007). Participants in BHH were .225 less likely to visit the ED. For every year of reduction in age, the odds of visiting the ED increased by a factor of 1.0. Females had a 1.8 higher odds of visiting the ED than males. This study provides evidence for the effectiveness of the BHH in reducing visits to the ED. Standard measures to track ED use in BHH are essential to understanding reasons for ED use and reducing nonurgent use. The BHH has the potential to transform health care delivery toward an all-inclusive model of care. Providers can utilize the findings of this project to promote social change by targeting patients with serious mental illness and reducing health disparities by emphasizing preventive care and eliminating barriers to care.

Expansion of Medicaid and private health insurance coverage through passage of the Affordable Care Act of 2010 was expected to increase primary care access and reduce emergency department (ED) use by reducing financial burden and improving affordability of care. The aim of this study was to examine the differences in utilization patterns that exist among the Medicaid population that participated in an optimal level of care (OLC) intervention inclusive of appointments scheduled to primary care providers. Using the integrated behavior model as a theoretical framework, the key research question focused on determining if there was a difference in ED use among Medicaid individuals who scheduled follow-up appointments compared to those that did not schedule follow-up appointments. The sample population consisted of 176 Medicaid enrollees who presented to the ED for treatment of nonurgent conditions and participated in an OLC intervention from June 2016 to July 2017. The results showed that there were no differences in ED utilization between the population that had scheduled appointments compared to the population that did not have scheduled appointments. A bivariate analysis on demographic variables also showed no differences in ED utilization among the variables. The social change implications of this study are that the practice of scheduling appointments with primary care providers does not reduce or affect ED utilization in the Medicaid population. This study contributes to positive social change through the findings that reducing ED utilization requires more than follow-up appointment scheduling with primary care providers. Further studies are warranted to understand the potential barriers and factors that affect ED utilization.

No description available.

Aim. The aim of this study was to examine the relationship of advance care planning protocols with hospitalization, rehospitalization, and emergency department use rates in U. S. home health agencies (HHA). Background. Since 2003, CMS has required HHAs to report on quality outcomes such as hospitalization, rehospitalization, and emergency department use rates, made publicly available online. Advance care planning (ACP) is a conversation about beliefs, goals, values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on ACP have taken place outside of HHAs among populations with serious illnesses such as HIV/AIDS, cancer, dementia, and end stage renal disease. Meanwhile, the U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses. Effective January 1, 2016, the Center for Medicare and Medicaid Innovation implemented the Home Health Value-Based Purchasing (HHVBP) Model among home health agencies (HHAs) in nine states representing each geographic region in the United States. Agencies in these states began competing on value in the HHVBP model, and reimbursement rates began to be tied to quality performance (innovation.cms.gov). As part of HHVBP, CMS implemented an additional process-level mandate requiring them to report on ACP, though this data is not publicly available. It is currently unknown how ACP protocols in HHAs may affect agencies’ overall rates of acute care services use. Methods. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics, diagnoses, hospitalization, rehospitalization, and ED use were accessed online via CMS websites. Descriptive and regression analyses were conducted using the electronic survey results and the existing data. Results. Associations between the variables were observed and compared to the hypotheses. Statistical significance was found in the relationship between ACP protocols and hospitalization, where one increased the other increased. Several trends were found: Agencies with increased total percentage of cardiac and pulmonary diagnoses tended to have increased hospitalization rates; agencies with increased average age of patients tended to have increased ACPP scores; and agencies with increased proportion of Black patients tended to have higher hospitalization rates.

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.

In this study, the utilization of palliative care services, acute care services, and location of death for clients who were palliative and receiving services from Champlain Community Care Access Centre (CCAC) in Ontario during their last month of life were investigated. An adaptation of Andersen?s Behavioral Model of Health Services Utilization provided context and structure to this study. This is an historical, quantitative descriptive study using chart audits for data collection. The data on CCAC clients who were palliative and who died during the month of July 2009 were tracked during their last month of life. Collection of socio-demographic data, services provided through CCAC, emergency department visits, hospital admissions, and location of death provided the data for this study. The clients who died at home used more CCAC services than those who died at other locations and frequently community palliative care physicians provided their medical care. The findings of this study included: 1) The majority of the clients, who expressed a preference, died in their preferred location. 2) The role of community palliative care physicians was an important component of the services that supported the clients to die in their location of choice. 3) Over 25% of the study sample died in a hospital and the clients used a large number of in-patient hospital days with one quarter of the hospital deaths taking place in an emergency department or an intensive care unit. 4) During the last month of life, 25% of the clients received chemotherapy and/or radiation therapy. 5) The clients who died at home used more CCAC services than those who died in other locations and who used institutional resources. The implications for practice, policy, research, and education are discussed.