Professional Case Management最新文献

Purpose/objectives: Sickle cell disease (SCD) is a complex genetic hemoglobinopathy which is associated with a severely shortened lifespan; the median age of death remains in the low 50's. Individuals living with SCD have complex medical, psychological, and social needs. The complexity results in difficulty navigating the healthcare system, and often being unaware of existing resources that may assist with addressing unmet social needs. Navigating fragmented healthcare and other support systems, as well as ensuring access to care, is challenging for persons with complex chronic diseases such as those living with SCD. Most healthcare institutions do not use SCD-specific nurse navigation models. The purpose is to describe an evidence-based SCD practice model for nurse navigation to improve the quality of whole-person healthcare delivery.

Primary practice settings: Care for individuals with SCD.

Findings/conclusions: This disease-focused, nurse navigation model was adapted from effective models and theories. The authors identify and describe nurse navigator competencies, including care coordination, patient education and support, communication, and expertise in SCD care delivery. Each of these competencies is operationalized into core and adaptable intervention components in this model to improve the quality of life and longevity of individuals living with SCD.

Implications for case management practice: Nurse navigators are required to understand and manage the care of individuals with complex healthcare needs. The authors identified a comprehensive model that clearly delineates the most effective components of nurse navigation for SCD that can be adopted to a variety of healthcare and community settings to achieve the highest likelihood of meeting whole person healthcare delivery needs. Partnering with community-based organizations, healthcare systems, and government resources is critical.

On January 1, 2025, the Advanced Primary Care Management (APCM) services, were inaugurated by the Centers for Medicare & Medicaid Services (CMS). APCM is being launched to address longstanding challenges in primary care delivery, including fragmented care, inadequate compensation for comprehensive services, and the need to better support practices in managing complex patient populations and social determinants of health (SDOH).

Purpose of study: The aim of this quality improvement (QI) project was to determine whether implementing the Agency for Healthcare Research and Quality (AHRQ) Re-Engineered Discharge (RED) Toolkit would impact 30-day readmissions among adult medical-surgical patients in an urban Arizona hospital over 8 weeks. This quality improvement project aims to address the lack of evidence-based practice (EBP) discharge guidelines at the project site and to improve readmissions by translating research evidence into clinical practice.

Primary practice setting: The project site is a single medical center within a hospital system located in an urban area of Arizona.

Methodology and sample: The medical-surgical nurses utilized the AHRQ RED components in the form of a discharge checklist. Education and staff teaching were conducted at the project site, with stakeholders provided with EBP resource materials, including the AHRQ's RED Toolkit and scientific evidence on how this process can impact hospital 30-day readmissions. This checklist incorporates the 11 RED components of the discharge process. The checklist served as a procedural guide for nurses during discharge.

Results: Patient data were collected to measure the impact of the AHRQ RED Toolkit on 30-day readmissions. Data were collected from the electronic health record and EBP tool, the AHRQ RED checklist. Thirty-day readmissions were measured as counts in a sample of 307 patients, with data collected before intervention (n = 199) and again after intervention (n = 108). The frequencies of 30-day readmissions were described using counts and percentage rates, then compared using Pearson's chi-square test. In the comparison patient group, there were 99 readmissions (50%) out of 199 patients. In the intervention patient group, 24 patients (22%) out of 108 were readmitted. Pearson's chi-square test showed a statistically significant difference in the number of patients readmitted within 30 days of discharge [ X 2(1, N = 307) = 22.0; p = .001).

Implications for case management: The AHRQ RED components are evidence-based discharge interventions and strategies that have been proven to be crucial in reducing readmissions and improving patient outcomes. The project results highlight the importance of incorporating EBP guidelines into health care settings and validate the effectiveness of these interventions in bridging gaps in patient care, such as avoidable readmissions. The project outcomes demonstrate the role of the RED components in guiding case managers during a patient's hospital discharge. Applying the RED components was essential in preventing readmissions, thereby influencing health care and case management practices, including ensuring safe discharges, reducing costs, and improving care quality. The project outcomes showed significant improvements in the discharge process, providing opportunitie