Sharon Hewner1, Suzanne S Sullivan2, Guan Yu3. 1. Associate Professor, University at Buffalo School of Nursing, Buffalo, NY, USA. 2. Adjunct Faculty, Nursing, University at Buffalo School of Nursing, Buffalo, NY, USA. 3. Assistant Professor, University at Buffalo Department of Biostatistics, Buffalo, NY, USA.
Abstract
BACKGROUND: Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings. AIMS: To improve post-discharge utilization value using technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health with the goal of reducing inpatient and emergency department visits. METHODS: The project employed a before and after comparison of the intervention site with similar primary care practice sites using population-level Medicaid claims data. The intervention targeted discharged persons with preexisting chronic disease and delivered a care transition alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social determinants of health and incorporated problems into the EHR to share across settings. The project evaluated health outcomes and the value of nursing care on existing electronic claims data to compare utilization in the years before and during the intervention using negative binomial regression to account for rare events such as inpatient visits. RESULTS: Avoiding readmissions and emergency visits, and increasing timely outpatient visits improved the individual's experience of care and the work life of healthcare providers, while reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits, and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular Medicaid trend was $664 per adult with chronic disease, generating $71,289 in revenue from additional outpatient visits. LINKING EVIDENCE TO ACTION: Using health information exchange to deliver appropriate and timely evidence-based clinical decision support in the form of care transition alerts and assessment of social determinants of health, in conjunction with data science methods, demonstrates the value of nursing care and resulted in achieving the Quadruple Aim.
BACKGROUND: Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings. AIMS: To improve post-discharge utilization value using technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health with the goal of reducing inpatient and emergency department visits. METHODS: The project employed a before and after comparison of the intervention site with similar primary care practice sites using population-level Medicaid claims data. The intervention targeted discharged persons with preexisting chronic disease and delivered a care transition alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social determinants of health and incorporated problems into the EHR to share across settings. The project evaluated health outcomes and the value of nursing care on existing electronic claims data to compare utilization in the years before and during the intervention using negative binomial regression to account for rare events such as inpatient visits. RESULTS: Avoiding readmissions and emergency visits, and increasing timely outpatient visits improved the individual's experience of care and the work life of healthcare providers, while reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits, and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular Medicaid trend was $664 per adult with chronic disease, generating $71,289 in revenue from additional outpatient visits. LINKING EVIDENCE TO ACTION: Using health information exchange to deliver appropriate and timely evidence-based clinical decision support in the form of care transition alerts and assessment of social determinants of health, in conjunction with data science methods, demonstrates the value of nursing care and resulted in achieving the Quadruple Aim.
Authors: Bonnie L Westra; Martha Sylvia; Elizabeth F Weinfurter; Lisiane Pruinelli; Jung In Park; Dianna Dodd; Gail M Keenan; Patricia Senk; Rachel L Richesson; Vicki Baukner; Christopher Cruz; Grace Gao; Luann Whittenburg; Connie W Delaney Journal: Nurs Outlook Date: 2016-12-08 Impact factor: 3.250
Authors: Carla R Jungquist; Chris Pasero; Nicole M Tripoli; Rachel Gorodetsky; Mark Metersky; Rosemary C Polomano Journal: Worldviews Evid Based Nurs Date: 2014-09-23 Impact factor: 2.931
Authors: Mohsen Bazargan; James L Smith; Sharon Cobb; Lisa Barkley; Cheryl Wisseh; Emma Ngula; Ricky J Thomas; Shervin Assari Journal: Int J Environ Res Public Health Date: 2019-04-02 Impact factor: 3.390
Authors: Rowan G M Smeets; Dorijn F L Hertroijs; Mariëlle E A L Kroese; Niels Hameleers; Dirk Ruwaard; Arianne M J Elissen Journal: Int J Environ Res Public Health Date: 2021-11-10 Impact factor: 3.390