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Thesis advisor: Rosanna DeMarco / Abstract Testing the Efficacy of A Nurse-Led, Patient Self-Management Intervention to Decrease Rehospitalization in Older Adults Merrily Evdokimoff, Ph.D. Rosanna DeMarco, Ph.D., Committee Chair Rehospitalization rates of 20% within 30 days of hospital discharge and 27% within 60 days are one of the highest strains on the federal Medicare budget. The Center for Medicare and Medicaid Services (CMS) has responded by imposing financial disincentives in reimbursement regulations directed to those providers deemed responsible for preventable rehospitalizations. Identifying cost-effective interventions that are appropriate for individuals with chronic illnesses that may be provided within the current home health care system of reimbursement is critical. The purpose of this quasi-scientific intervention study was to test the efficacy of a cost-effective, nurse-led intervention to decrease rehospitalizations of community dwelling older adult Medicare beneficiaries receiving certified home health services following an acute care hospital admission. The intervention was based on Eric Coleman's Care Transition Intervention SM utilizing a personal health record, patient goal setting, and knowledge of "red flags" or changes in condition. Coaching by the home care nurses was added to Coleman's intervention to facilitate support of patient self-management. Three home care agencies, 60 clinicians and 87 patients participated in the study. Findings demonstrated a lower rate of readmission to the hospital in patients receiving the intervention. However, it was not statistically significant. Significant differences were noted between the intervention and the comparison groups including more married or partnered members and higher Case Mix Weight (CMW) or acuity score within the intervention group. Among the rehospitalized participants, provision of a greater number of skilled nursing visits was found. Future replication of the study should include a larger sample and greater time for education of the clinical staff. Inclusion of therapists and productivity adjustments for participating staff during initiation of study is also needed. Further examination of the role of depression in rehospitalization with a larger sample would provide greater understanding of the role depression plays in self-management and rehospitalization. / Thesis (PhD) — Boston College, 2012. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Desde a descrição inicial dos primeiros casos da síndrome da imunodeficiência adquirida, em 1981, a doença se expandiu por todo o mundo tornando-se grave problema de saúde pública mundial. Com o advento da terapia antirretroviral (TARV) altamente potente em meados da década de 1990 houve considerável declínio da mortalidade por causas relacionadas à AIDS. No entanto, as doenças oportunistas ainda respondem por consideráveis taxas de mortalidade em pessoas vivendo com HIV em diferentes regiões do mundo. Associado a isto, neste grupo de pacientes são frequentes fatores que prejudicam a adesão ao tratamento e o adequado controle da doença, como uso de drogas ilícitas, vulnerabilidade social e transtornos psiquiátricos. Tais fatores se refletem em elevadas taxas de internação hospitalar em pacientes infectados pelo HIV. Por outro lado, as elevadas taxas de internação elevam custos às instituições de saúde e potenciais risco à saúde dos pacientes. As taxas de reinternação hospitalar em 30 dias tem sido utilizada como marcador de qualidade da assistência á saúde e auxilia da definição de estratégia de prevenção de reinternacões . Neste contexto o presente trabalho buscou avaliar fatores preditores de reinternação hospitalar em pacientes infectados pelo HIV. O estudo realizado foi do tipo prospectivo sendo realizado em enfermaria especializada no tratamento deste grupo de pacientes. Foram avaliados fatores clínicos, contagem de células CD4 + e da carga viral do HIV, indicadores sociais, uso de drogas ilícitas e adesão à terapia antirretroviral, na tentativa de identificar preditores de reinternação hospitalar precoce. A identificação destes potenciais preditores poderão auxiliar no desenvolvimento de estratégias para prevenir readmissões hospitalares evitáveis. Foram convidados a participar do estudo 71 pacientes que passaram por internação no período de agosto de 2016 a agosto de 2018. O estudo buscou apontar através de entrevistas os fatores que levaram a reinternação precoce. Entre os 71 pacientes incluídos no estudo 16 apresentaram reinternação precoce no período de 30 dias. Vale ressaltar que as internações foram consideradas preveníveis diante dos critérios estabelecidos e através dos resultados foi possível concluir que os pacientes que reinternaram na UETDI precocemente apresentam dificuldades de adesão ao tratamento ocasionadas pelo contexto social em que vivem, onde enfrentam o preconceito, abandono, rompimento e fragilização dos vínculos familiares, além dos vícios, que é um grande fator para a não adesão ao tratamento nos pós alta hospitalar / Since the initial description of the first cases of acquired immunodeficiency syndrome in 1981, the disease has spread worldwide becoming a serious public health problem worldwide. With the advent of highly potent antiretroviral therapy (HAART) in the mid-1990s there was a considerable decline in mortality from AIDS-related causes. However, opportunistic diseases still account for considerable mortality rates in people living with HIV in different regions of the world. Associated to this, in this group of patients, frequent factors that impair adherence to treatment and adequate control of the disease, such as illicit drug use, social vulnerability and psychiatric disorders are frequent. These factors are reflected in high hospital admission rates in HIV-infected patients. On the other hand, high hospitalization rates raise costs for health institutions and potential health risks for patients. Hospital readmission rates in 30 days have been used as a marker of health care quality and help to define a strategy to prevent rehospitalization. In this context, the present study aimed to evaluate predictive factors of hospital readmission in patients infected by HIV. The prospective study was performed in a specialized ward in the treatment of this group of patients. Clinical factors, CD4 + cell count and HIV viral load, social indicators, use of illicit drugs and adherence to antiretroviral therapy were evaluated in an attempt to identify predictors of early hospital readmission. The identification of these potential predictors may assist in the development of strategies to prevent preventable hospital readmissions. We were invited to participate in the study 71 patients who were hospitalized in the period from August 2016 to August 2018. The study sought to indicate through interviews the factors that led to early rehospitalization. Among the 71 patients included in the study 16, they presented early readmission within 30 days. It is worth mentioning that hospitalizations were considered preventable in view of the established criteria and, through the results, it was possible to conclude that the patients who returned to the UETDI at an early stage presented difficulties in adhering to the treatment caused by the social context in which they live, where they face prejudice, abandonment, disruption and weakening of family ties, as well as addictions, which is a great factor for non adherence to treatment after hospital discharge

Background: The rising cost of health care in relation to rehospitalizations continues to be a challenge. Medicare 30-day readmissions have an annual estimated cost of $17.4 billion. Irrespective of these costs and the continued improvement in the quality of care, skilled nursing facilities (SNF) still face high readmission rates. Purpose: The purpose of this quality improvement project was to enhance SNF care processes by improving the utilization of the electronic medical record software program “INTERACT” to increase early identification and treatments of patients to minimize 30-day hospital readmissions. Theoretical Framework: The theory of planned behavior by Icek Azjen was used. Methods: Project design: This project used a pretest and posttest design to assess for improvement in the use of the INTERACT tools and increased nursing proficiency after participating in a 45-minute INTERACT training session. A 60-day retrospective and prospective rehospitalization rates data were also compared. Results: After the training, there was a statistically significant improvement in the number of nurses using the INTERACT tool. The two-tailed paired sample t-test result showed a significant difference in the use of the INTERACT clinical decision support tools: Pretest (M = 2.08, SD = 0.88) and posttest (M = 1.33, SD = 0.63), t(23) = 3.30, p = .003. There was no statistical difference in the proficiency of nurses post the training. This result is associated to probable data loss and/or limited time for data collection. Although a 15% decrease in SNFs rehospitalizations rates was noted, there is no direct causative explanation that increased nurses use of the tool significantly contributed to the reduction in rehospitalization rates among other factors. Conclusion: The INTERACT program has contributed by improving early identification and treatment of patients and facilitated improved patient outcomes and nursing care processes. It is assumed that as nurses begin to build up their use of the INTERACT support tools, this tool will result in an increase in proficiency, which will increase responsiveness to change in condition and a corresponding decrease in avoidable rehospitalizations.

There is compelling evidence for the effectiveness of home-based occupational therapy and physiotherapy rehabilitation for community dwelling elderly who may struggle with basic activities and the functions of daily living and mobility. Nonetheless, an estimated 2% of home care’s elderly clients receive these therapies. Ontario’s home care data indicates that 78% of clients that could benefit from these specific therapies are not receiving them. The study examined a subset of elderly clients receiving home care following a hospital discharge during 2009-2010. The aim of this study was to: understand the difference between those home care clients who received occupational therapy or physiotherapy and those who did not; and determine if receiving these therapies impacted the utilization of hospital emergency departments and inpatient admissions. A retrospective cohort design and multivariate and survival analysis of hospital and home care administrative data structured the study. Results suggest that home-based rehabilitation is offered to a minority of the home care population. Distinct client characteristics and process variables significantly associated with the increased likelihood of receiving home-based occupational and physical therapies included: clients who were older, females, admitted to home care from hospital inpatient units, assessed as non-acute for clinical and service needs and required more home making support and assistance with activities of daily living. Almost one quarter of the total sample returned to hospital. Visits to emergency departments accounted for the greater part of hospital utilization and primarily for sub-acute general symptoms and signs, post-procedural complications, infections or acute episodes from chronic obstructive pulmonary disease and renal failure. Slightly over half of the clients returning to hospital did not receive home-based rehabilitation. Clients who received occupational therapy returned to the hospital sooner following their home care admission whereas clients receiving physiotherapy spent the longest time before rehospitalizing. The majority of the clients receiving occupational therapy were admitted to home care having just resolved sub-acute conditions or symptoms, many of which are known to influence functional and physical decline. Moreover, analysis of process variables indicated that the wait time for a referral to occupational therapy was two times longer compared to physiotherapy. These same clients also waited, on average, over one month before an occupational therapist’s first visit. The need to discriminate who receives home-based rehabilitation is essential to understanding how specific therapies contribute to improving systems outcomes. This study is the first examination that focuses specifically on home-based occupational therapy and physiotherapy rehabilitation and the client characteristics and process variables associated with receiving/not receiving these therapies and the impact these factors have on the time-to-rehospitalization. / Thesis (Ph.D, Rehabilitation Science) -- Queen's University, 2013-06-27 12:24:53.085

Older people admitted to hospital are at high risk of rehospitalization and medication errors. We have demonstrated, in a randomized controlled trial, that a clinical pharmacist intervention reduces the incidence of revisits to hospital for patients aged 80 years or older admitted to an acute internal medicine ward. The aims of this thesis were to further study the effects of the intervention and to investigate possibilities of targeting the intervention by identifying predictors of treatment response or adverse health outcomes. The effect of the pharmacist intervention on the appropriateness of prescribing was assessed, by using three validated tools. This study showed that the quality of prescribing was improved for the patients in the intervention group but not for those in the control group. However, no association between the appropriateness of prescribing at discharge and revisits to hospital was observed. Subgroup analyses explored whether the clinical pharmacist intervention was equally effective in preventing emergency department visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing on admission. The intervention appeared to be most effective in patients taking fewer drugs, but the treatment effect was not altered by appropriateness of prescribing. The most relevant risk factors for rehospitalization and mortality were identified for the same study population, and a score for risk-estimation was constructed and internally validated (the 80+ score). Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid and being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked with a lower risk. These variables made up the components of the 80+ score. Pending external validation, this score has potential to aid identification of high-risk patients. The last study investigated the occurrence of prescription errors when patients with multi-dose dispensed (MDD) drugs were discharged from hospital. Twenty-five percent of the MDD orders contained at least one medication prescription error. Almost half of the errors were of moderate or major severity, with potential to cause increased health-care utilization.

Au Canada, les Commissions d'Examen des Troubles Mentaux de chaque province ont la responsabilité de déterminer les conditions de prise en charge des personnes déclarées Non Criminellement Responsables pour cause de Troubles Mentaux (NCRTM) et de rendre, sur une base annuelle une des trois décisions suivantes: a) détention dans un hôpital, b) libération conditionnelle, ou c) libération absolue. Pour favoriser la réinsertion sociale, la libération conditionnelle peut être ordonnée avec la condition de vivre dans une ressource d’hébergement dans la communauté. Parmi les personnes vivant avec une maladie mentale, l’accès aux ressources d’hébergement a été associé à une plus grande stabilité résidentielle, une réduction de nombre et de la durée de séjours d'hospitalisation ainsi qu’une réduction des contacts avec le système judiciaire. Toutefois, l’accès aux ressources d’hébergement pour les personnes trouvées NCRTM est limité, en partie lié à la stigmatisation qui entoure cette population. Il existe peu d’études qui traitent du placement en ressources d’hébergement en psychiatrie légale. Pour répondre à cette question, cette thèse comporte trois volets qui seront présentés dans le cadre de deux manuscrits: 1) évaluer le rôle du placement en ressources d’hébergement sur la réhospitalisation et la récidive chez les personnes trouvées NCRTM; 2) décrire les trajectoires de disposition et de placement en ressources d’hébergement, et 3) mieux comprendre les facteurs associés à ces trajectoires. Les données de la province du Québec du Projet National de Trajectoires d’individus trouvés NCRTM ont été utilisées. Un total de 934 personnes trouvées NCRTM entre le 1er mai 2000 et le 30 avril 2005 compose cet échantillon. Dans le premier manuscrit, l’analyse de survie démontre que les individus placés dans un logement indépendant suite à une libération conditionnelle de la Commission d’Examen sont plus susceptibles de commettre une nouvelle infraction et d’être ré-hospitalisés que les personnes en ressources d’hébergement. Dans le deuxième article, l'analyse de données séquentielle a généré quatre modèles statistiquement stables de trajectoires de disposition et de placement résidentiel pour les 36 mois suivant un verdict de NCRTM: 1) libération conditionnelle dans une ressource d’hébergement (11%), 2) libération conditionnelle dans un logement autonome (32%), 3) détention (43%), et 4) libération absolue (14%). Une régression logistique multinomiale révèle que la probabilité d'un placement en ressource supervisée comparé au maintien en détention est significativement réduite pour les personnes traitées dans un hôpital spécialisé en psychiatrie légale, ainsi que pour ceux ayant commis un délit sévère. D'autre part, la probabilité d’être soumis à des dispositions moins restrictives (soit le logement indépendant et la libération absolue) est fortement associée à des facteurs cliniques tels qu’un nombre réduit d'hospitalisations psychiatriques antérieures, un diagnostic de trouble de l'humeur et une absence de diagnostic de trouble de la personnalité. Les résultats de ce projet doctoral soulignent la valeur protectrice des ressources en hébergement pour les personnes trouvées NCRTM, en plus d’apporter des arguments solides pour une gestion de risque chez les personnes trouvées NCRTM qui incorpore des éléments contextuels de prévention du risque, tel que l’accès à des ressources d’hébergement. / In Canada, Provincial and Territorial Review Boards are mandated to evaluate the risk and custody decisions about individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) and render one of three dispositions: (a) custody, (b) conditional discharge, or (c) absolute discharge. To promote community reintegration, conditional discharge can be ordered with the condition to live in supportive housing. Among individuals living with a mental illness, supportive housing in the community has been associated with increased housing stability, reduced number and length of hospitalization and reduced involvement with the criminal justice system. However, NCRMD accused face great barriers to housing access as a result of the stigma associated with the forensic label. To date, there is little information regarding the housing placement for the forensic mentally ill individuals, such as those found NCRMD. In order to address the dearth of literature on supportive housing for the forensic population, the goal of the present thesis is threefold and addressed through two manuscripts: 1) to evaluate of the role of housing placement on rehospitalization and recidivism among individuals found NCRMD; 2) to describe the disposition and housing placement trajectories of individuals found NCRMD, and 3) to explore the factors that predict such trajectories. Data from the Québec sample of the National Trajectory Project of individuals found NCRMD were used. A total of 934 individuals found NCRMD between May 1st 2000 and April 30th 2005 comprise this sample. In the first paper, survival analyses showed that individuals placed in independent housing following conditional discharge from the Review Board were more likely to be convicted of a new offense and to be readmitted for psychiatric treatment compared with individuals residing in supportive housing. In the second paper, sequential data analysis resulted in four distinct trajectories: 1) conditional discharge in supportive housing (11%), 2) conditional discharge in independent housing (32%), 3) detention in hospital (43%) and 4) absolute discharge (14%). A multinomial logistic regression revealed that the likelihood of a placement in supportive housing compared to being detained significantly decreased for individuals treated in a forensic hospital, as well as those with an increased index offense severity. On the other hand, less restrictive disposition trajectories (i.e. independent housing and absolute discharge) were significantly influenced by clinical factors such as reduced number of prior psychiatric hospitalizations, a diagnosis of mood disorder and an absence of a comorbid personality disorder diagnosis. The findings from this study point to the protective value that supportive housing can have on the community outcomes of forensic patients, and provides solid arguments for the development of a management strategy that incorporates contextual factors such as supportive housing.