Class of 2014 Abstract / Specific Aims: It has been demonstrated through numerous studies that pharmacists have the ability to significantly impact patient outcomes. It is especially important to measure the effect that pharmacists have on psychiatric patient care as this is a population that is often underserved and can potentially benefit from pharmacist intervention. To date, there has been little research on pharmacist led patient medication education groups for patients with psychiatric diagnoses. Therefore, the purpose of this study was to assess the effectiveness of a pharmacist led medication education group in reducing adult psychiatric hospital readmission rates due to medication non-adherence. Methods: Patients admitted to an acute adult inpatient psychiatric unit at an academic medical center between September 1, 2011 and July 31, 2012 were included. A random sample of 100 patients that attended the medication education group (intervention group) and 100 patients that did not attend the group were selected (control group). The following data were collected: patient age, gender, ethnicity, insurance benefits, primary diagnosis, substance abuse history, number of medications at first discharge, length of stay on initial admission, time to first readmission, length of stay on first readmission, and reason for readmission (medication non-adherence versus other). A chi square analysis was conducted to determine if admission rates as well as reason for readmission were different between the two groups. An independent t test was conducted to determine if time to first readmission or length of stay on first readmission was different between the two groups. Main Results: There were 28 psychiatric hospital readmissions in the intervention group and 28 readmissions in the control group. Although these numbers were similar, there was a statistically significant difference in the number readmitted due to medication non-adherence, 11 in the intervention group vs. 19 in the control group (p=0.032). There was also a clinically significant difference in the time to readmission between the two groups (an average of 94.43 days in the intervention group vs. 60.70 days in the control group.) Conclusion: The pharmacist-led medication education group did not have an impact on readmission rate. However, the group did reduce the number of readmissions for medication non-adherence. There is a clinically significant increase in the time to readmission in patients that attended the medication education group. The data in this study support the implementation of pharmacist-led medication education groups to improve outcomes in adults admitted to acute inpatient psychiatry units.

Class of 2013 Abstract / Specific Aims: The purpose of this study was to determine what characteristics are most often associated with patients who are readmitted to a hospital for care within a 30-day time period for one of the five applicable conditions listed in the Hospital Readmissions Reduction Program, including heart failure, pneumonia, myocardial infarct, vascular procedures, and chronic obstructive pulmonary disease. Methods: This study was a retrospective chart review of patients who had a 30-day inpatient hospital readmission to a tertiary referral teaching hospital in Tucson, Arizona during the period from January 1, 2012 to June 30, 2012. Patient demographics and other characteristics thought to influence readmission were collected, including sex, age, race, type of insurance, number of applicable diagnoses at first admission, and number of medications prescribed at first discharge. “Applicable diagnoses” included: congestive heart failure (CHF); pneumonia (PN); myocardial infarct (MI); vascular procedures (VP); and chronic obstructive pulmonary disease (COPD). Main Results: Of the 1,102 patients included in this study, only 5% were readmitted for one of the five applicable conditions. The largest proportion of patients who were readmitted for the same diagnosis were in the 21 to 40 year old category, whereas the largest proportion of patients who were readmitted for different diagnoses were in the greater than 40 year-old category. The results of the multiple regression analysis showed that none of the independent variables predicted 30-day readmissions with the exception of Asian race (p=0.008, n=8) and other race (p=0.012, n=57). In addition, the only significant predictor of 30-day readmission was the diagnosis at initial admission (p<0.05). Conclusion: In our sample, only 5% of patients readmitted at 30-days were readmitted for an applicable condition. This means the majority of readmissions include diagnoses that are not currently affected by the changes to Medicare reimbursement, though other diagnoses are likely to be added to the list in the coming years. Our study provides evidence that specific patient demographic characteristics are not closely linked to 30-day readmissions. Therefore, it may be necessary to turn the focus away from targeting specific patient populations and towards improving efforts in the areas of discharge planning and quality of care for all patients.

The Multi-Visit Patient (MVP) Clinic at Temple University Hospital was established as a community health worker-driven effort to reduce patient readmissions. The clinic employs a multidisciplinary approach, with both social and medical needs addressed at each visit. Patients “graduate” from the program when they are connected with adequate healthcare follow-up outside the clinic. This study aimed to explore the impact of social determinants of health on patient success in the program, with the goal of identifying the types of social support that may be most important for the clinic to provide. A retrospective review was conducted using the social determinants of health screen embedded in Temple University Hospital’s medical record platform. Social determinants of health data was compared between “graduated” patients (n=104) and those lost to follow-up (n=35). Successfully-engaged patients also participated in a survey (n=87). Results revealed no significant differences between the two patient samples in terms of legal sex, marital status, race, ethnicity, housing insecurity, food insecurity, or transportation insecurity. There were no statistically significant differences in readmission rates or emergency department use within 30 days of patients’ last MVP Clinic visit. Among surveyed patients, 64.2% had recently visited a primary care provider and 79.3% reported having social support to help manage their medical conditions. Our results suggest that the examined social barriers are unlikely to be the cause of difficulty engaging with the MVP Clinic, implying that community health worker interventions should continue to be individualized to each patient’s needs. Future studies should explore the impact of other non-quantifiable factors such as patient motivation and positive experiences with the healthcare system on success within the program. / Urban Bioethics

Unplanned readmissions to the hospital are a problem faced by most health care organizations in the United States; hospitals are penalized for such readmissions. The project site identified high readmission rates for patients who were discharged after acute myocardial infarction (AMI), making careful transition home a necessity for post-AMI patients. The focus of this quality improvement (QI) project was implementation of an early follow-up appointment of AMI patients following discharge. The purpose of this project was to evaluate the effectiveness of changing follow-up appointments for patients with an AMI from 14-30 days to 7-14 days post discharge to reduce unplanned readmission rates. Bandura’s self- efficacy theory provided the theoretical framework for this project. An evaluation of the QI project was completed by comparing patient readmission rates 6 months before and 6 months after implementation of the early follow-up appointments. Data analysis demonstrated that the readmission rate was not improved in the first 6 months post QI project implementation. Using the plan-do-check-act process, a multifactorial approach was recommended to refine the QI project and address the system-wide readmission rates. The implications of this project for positive social change include providing early analysis of the readmission QI project, which allowed the hospital to restructure the QI approach and improve the plan for preventing readmission.

Class of 2016 Abstract / Objectives: The specific aims of this study were: 1) describe the frequency of off-label medication use in pediatric discharge medication regimens, 2) compare the frequency of FDA-approved and off-label medication use in pediatric discharge medication regimens, and 3) identify potential patient-specific risk factors, including use off-label use of medications, associated with 90-day readmission. Methods: This was a retrospective chart review of pediatric patients admitted to a tertiary academic medical center during a 6-month period. Inclusion criteria included age less than 18 years of age and admission between January 1, 2014 and June 30, 2014. Exclusion criteria included admission for oncology chemotherapy, admitted < 24 hours, admission to NICU only and patient expiration prior to discharge. Data collection included patient demographics, types and number of medications, and FDA approved and off-label indication of medications. Data analyses were completed on STATA 11.0 (College Station, TX) including student t-test/Mann Whitney U and Chi square/Fisher Exact test with a priori of α= 0.05. Results: A total of 706 admissions were included in the study. There were no significant differences in demographic characteristics between groups (readmitted within 90 days of discharge vs. not readmitted within 90 days of discharge) except sex (males vs. females, 56.3% vs. 44.2%, p=0.034). Length of hospital stay was significantly higher in subjects readmitted within 90 days of discharge compared to those who were not (8.55 ± 12.5 vs. 3.79 ± 4.43 days, p<0.001). Number of medications at discharge (7.31 ± 5.92 vs. 2.91 ± 2.93, p<0.001) and total number of non-FDA approved medications (3.16 ± 3.81 vs. 1.12 ± 1.44, p<0.001) were all significantly higher in subjects readmitted within 90 days of discharge compared to those who were not. The percentages of patients taking medications related to cardiovascular (6.1% vs. 2.4%, p=0.002), electrolytes and nutrition (12.2% vs. 8.5%, p=0.007), and gastrointestinal (19.2% vs. 14.3%, p=0.004) disorders were significantly higher in the subjects readmitted within 90 days of discharge compared to those who were not. Additonally, subjects readmitted within 90 days of discharge (versus those not readmitted within 90 days) demonstrated less use of medications related to neurology (17.7% vs. 25.8%, p<0.001) and respiratory (16.4% vs. 21.4%, p=0.008) disorders. A significantly higher percentage of subjects whose third party payor was Medicaid, were readmitted within 90-days of discharge (69.7% vs. 58.3, p=0.045). Conclusions: In comparing several characteristics of pediatric patients readmitted to a tertiary medical center within 90 days of discharge versus those who were not, it was noted that several factors may be associated with readmission, including: sex, length of initial hospital stay, third-party payor, and the number of medications as well as the types of medication a patient takes. Future research may be warranted to further investigate these potential patient-specific factors in helping identify children at increased risk for readmission and develop more effective approaches to patient education, discharge planning, and continuity of care to reduce preventable readmission.

Heart failure (HF) hospital readmission reductions are linked to nursing interventions that include scheduling a hospital follow-up appointment with the patient's health care provider within a week of discharge. Yet, patients often leave the hospital without an appointment scheduled. The focus of this integrative literature review was on analyzing data that associated follow-up within 7 days with reduced 30-day readmissions. A search of articles using CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, and ProQuest databases resulted in 4,813 articles retrieved using the following search terms: heart failure, readmissions, follow-up appointments, and heart failure guidelines. Scholarly articles selected for inclusion were published between January 1, 2007, and June 30, 2017, in the English language, regarding studies completed in the United States, available online in full text, and specific to patients with HF. The Melnyk Critical Appraisal Guide was used for the appraisal, evaluation, and synthesis of the evidence. The transitional care model served as the theoretical framework for the project. A key finding of the review was that follow-up appointment scheduling within 7 days was associated with a modest reduction in readmissions; more research is needed to produce additional evidence on this topic. Project dissemination may result in positive social change by raising awareness of health disparities and empowering patients and staff to work collaboratively. Through improved communication and follow-up between patients and the interdisciplinary team, patients with HF may be able to experience improved disease management and a reduced number of hospitalizations.

No description available.

Chronic obstructive pulmonary disease (COPD) is a collection of chronic conditions that results in irreparable lung damage and stress to patients. COPD also has considerable financial impacts on health care entities due to frequent hospital readmissions of COPD patients. The Centers for Medicare and Medicaid Services penalize care entities for 30-day hospital readmissions. Many rehospitalizations attributed to COPD are due to exacerbations, often preceded by physiologic and emotional changes that can be monitored, allowing action to be taken to prevent readmissions. The practice problem for this quality improvement project explored whether the use of remote home monitoring of COPD patients discharged to home health care, coupled with the use of a medication rescue pack, would reduce rehospitalizations within 30 days after discharge. The purpose of the project was to evaluate the effectiveness of telehealth remote monitoring and initiation of a medication rescue pack in decreasing 30-day readmissions of COPD patients. The self-efficacy model was used to encourage health-promoting actions that are necessary for chronic disease management. Data from the project agency's records of COPD patients were evaluated for readmission rates. Analysis of the data from 8 preintervention patients showed that 3 (38%) were readmitted. Postintervention data showed that of the 9 participants, only 1 was readmitted (11%). Comparison of the data showed a 27% decrease in readmissions because of the intervention. The results of this project have the potential to bring about positive social change by improving care management remotely in real time, thus decreasing rehospitalization in COPD patients.

A deficiency of care coordination and delayed discharge planning has contributed to increased lengths of stay for telemetry patients and has pressed staff to discharge patients expeditiously, potentially leading to increased 30-day readmissions. Rushing the discharge process on the day of discharge has resulted in breakdowns in communication and lack of collaboration amongst the health care team of this study, contributing to extended lengths of stay, increased readmissions, and low Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) scores. This project highlighted a patient-centered care coordination team approach with 2 clinical registered nurses and a social worker who coordinated the discharge plan with the patients on admission. Discharge planning on admission and daily briefings involving care coordination and bedside staff reduced the length of stay, improved HCAPHS scores, and reduced 30-day readmissions by fostering better communication and collaboration. A 1-group pretest and posttest were utilized to compare data before care coordination and after care coordination. These findings yielded a length of stay reduction of 2.04 days, a 50% reduction in 30-day readmissions, and HCAPHS communication composite scores above the 50th percentile. The care coordination team exposed various programs and community resources that assisted with medications and durable medical equipment and suggested that companionship alleviated potential anxiety post discharge for those financially and socially burdened. The implications of a patient-centered team-based approach to discharge planning on admission eliminated barriers to discharge, improved patient knowledge of disease management, and provided a positive hospital experience.

Following implementation of the Patient Protection and Affordable Care Act, hospitals have seen a reduction in Medicare reimbursement for 30-day post-discharge readmissions of acute myocardial infarction patient. The purpose of this project was to develop a plan for a navigator program to improve a patient's health status post discharge and reduce readmission rates. The Johns Hopkins nursing evidence-based practice model and guidelines were used in determining the quality of obtained experimental and non-experimental studies with or without meta-analysis and popular source articles. The literature revealed the most successful programs involved providing best practices for a navigator program allowed better patient education, discharge planning, safety and quality of care, improved communication and post-discharge follow-up, and improved facility finances to achieve positive results for the patient and the hospital. Watson's caring theory was used as the theoretical framework since it incorporated the aspect of caring to create a good working nurse-patient relationship. A navigator program training module, job description, objectives, program forms, mission and goal statements, and a health care team were developed and seen as crucial to the success of the program and its evaluation process. Using navigator practices, based on evidence, formed the infrastructure and management process for the facility and health care providers, thereby increasing the quality of patient care. The resulting social change was positive, benefiting the patient, family, the organization, and the region served. With implementation, this project was anticipated to reduce 30-day readmissions and increased facility reimbursement.