Effect of a patient care partnership project on cost and quality of care at an academic teaching hospital

BACKGROUND: In 1998, the Patient Care Partnership Project was conducted by general internal medicine physicians and hospital administration in an academic health care center. The project was designed to optimize cost, quality, and service results to inpatients. METHODS: The project focused on improved communication among physicians, a nurse discharge planner, and hospital administration regarding appropriate resource utilization. The outcomes were average cost per inpatient, length of hospital stay, 30-day readmission rates, mortality rates, and resident and patient satisfaction. Comparisons were made with three control groups. RESULTS: The postintervention generalist-staffed services showed significant reductions in average costs per patient and length of stay. These parameters increased in the specialist group from 1997 to 1998. Readmission rates remained stable, and mortality rates actually decreased. Patient and resident satisfaction remained unchanged. CONCLUSIONS: A collaborative effort between generalists and hospital administration led to a significant improvement in resource utilization compared with the three control groups, with no compromise in quality outcomes.     

Managing the care of patients discharged from home health: a quiet threat to patient safety?

Threats to patient safety can originate from the overuse or underuse of care, in addition to provider-initiated errors. The past decade has seen a dramatic decrease in the duration and volume of home health services provided per patient by Medicare-certified home health agencies (HHAs). Research findings have been mixed with respect to the impact of home health utilization on patient safety and outcomes. This study aimed to explore a related yet fundamental question: How confident are home health nurses that their patients can manage their care when discharged from home health services?     

Identification and referral of hospitalized patients in need of home care

Given current concerns about the cost-effectiveness of home health care, better targeting of home health services for high risk groups is viewed as one way to provide controls on both service delivery and costs. The purpose of this exploratory study was to determine the degree to which patients with identifiable levels of need for services were referred for home health care and if selected clinical and functional status measures are useful in distinguishing need for service. Using a convenience sample of 145 patients ready for hospital discharge, data were collected on physical function, dependency at discharge, perceived helpfulness of others, social support, readiness for self-care, and planned adherence to treatment as well as demographic and medical variables. Using a combination of study variables, 93% of patients not in need of services could be correctly classified. In addition, patients in need of service but not referred by their physicians were found to differ significantly from patients not in need of care on all dimensions. Suggestions are offered for further research to determine if and what systematic factors influence referral decisions for home health care and which specific patient characteristics are associated with the most cost-effective long-term outcomes. ©1995 John Wiley & Sons, Inc.     

Individual correlates of health service utilization and the cost of poor adjustment to chronic illness

It was conjectured that a small group of chronically ill in tertiary ambulatory clinics consume a large amount of health resources and that, from the perspective of the patient, psychosocial rather than disease variables would most explain their health service utilization and subsequent cost. New referrals with a chronic illness (N = 215) to one of three clinics (oncology, rheumatology, and gastroenterology) consented to participate in a subsequent trial of a psychosocial intervention designed to promote their adjustment to illness and, conceivably, to reduce their health service utilization. At baseline an inventory to describe the disease, treatment, functional capacity, prognosis, and socioeconomic situation of consenting subjects was completed. In addition, subjects completed the Psychosocial Adjustment to Illness Inventory (PAIS-SR), the Family Assessment Device (FAD), the Meaning of Illness Questionnaire (MIQ), and a Health Service Utilization Inventory designed to assess direct and indirect costs of health resources. These data were entered into a concurrent analytic survey design. Participating subjects represented a more socioeconomically advantaged and better-adjusted group of chronically ill patients compared with others referred to the tertiary clinics. They were representative of all new referrals in their use of the majority of health services. However, once hospitalized, participating subjects stayed longer and used specialists less. There was no important relationship between disease severity or prognosis and any type of service utilization, including hospitalization. Because the strongest correlate of all types of health services consumed was psychosocial adjustment to illness (r = 0.28 to 0.33), patients were partitioned into one of three categories of adjustment to illness: good, fair, and poor. The total annual cost per patient was $23,883, if poorly adjusted, compared with $9,791 if well adjusted. If cash transfers (benefits paid by different types of insurance) are added, the average 1987 annual cost per poorly adjusted subject was $31,291 per patient, compared with $13,771 for a patient well adjusted to the illness. There was a statistically significant and economically important linear gradient in 1987 treatment costs per category of adjustment. The possible economic implications for psychosocial intervention are highlighted.     

Predicting Opioid Use,Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received.PerspectiveThis article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.     

Nurse-led telephone triage in an Australian rural mental health service

This paper reports on changes in referral patterns of a rural mental health telephone triage service based in Gippsland, Victoria, Australia. A retrospective audit of service data over the period 1999–2005 was undertaken as part of a quality improvement exercise. Data collected included service utilization statistics and critical reflection on the role of the mental health triage clinician within the service.
There was an average of 2771 referrals each year and a trend for increased use by general practitioners and hospital emergency departments. Triage nurses reported concerns about: professional isolation, lack of formal education, difficulties in making decisions based on limited data as well as poor understanding of the role by users (patients and referrers). Further research is needed to evaluate the impact of this form of patient assessment on psychiatric nursing practice and clinical outcomes.     

Day hospital service in rehabilitation medicine: an evaluation

The purpose of this study was to evaluate Day Hospital care in rehabilitation medicine as an alternative to intensive inpatient care. The study design called for two groups of randomly selected patients who met all admission criteria for intensive inpatient rehabilitation, who had Medicare or Medicaid insurance coverage, and who had a responsible other person living in the home. Those in the Day Hospital group were sent home after a short period of family training and then were taken to the hospital for treatment five days a week. The control group remained in the hospital on the rehabilitation service as inpatients and received the routine care provided to all other inpatients on that service. Data on utilization of health services, both during and after rehabilitation, cost of services, medical, functional, psychologic and social outcomes were collected for all study participants and analyzed. Findings showed no essential difference between the two groups in physical or functional outcome; however at full capacity with the research costs removed, the Day Hospital method proved the more cost effective.     

Predictors of nursing home placement and home nursing services utilization by elderly patients after hospital discharge in Taiwan

BACKGROUND: Providing appropriate follow-up health/long-term care services after hospital discharge for elderly persons is important to enhance health and quality of life. Therefore, identifying factors that affect follow-up service utilization has become an important concern. Most studies of predictors of follow-up service utilization for elderly persons after discharge were conducted in the United States of America (USA). Taiwan differs substantially from the USA in health care system, clinical practice, case-mix, culture, and social organization; thus the findings from the USA need to be validated in Taiwan to ensure appropriate discharge referrals. AIM: To investigate pre-discharge predictors of follow-up care including home nursing services and nursing home placement for elderly patients, discharged from hospitals in Taiwan. METHODS: A prospective study with a case-control design was used. FINDINGS: The strongest predictors of institutionalization in a nursing home at 1, 3 and 6 months after discharge were the elderly person's pre-admission institutionalization (0.33 to 0.48) and the caregiver's preference for institutional displacement (0.23 to 0.85). The strongest predictors of use of home nursing services were the elder's self-care ability (0.69 to 0.76), conscious level (0.51 to 0.73), and tubes remaining before discharge (0.58 to 0.79). These predictors were stable at 1, 3 and 6 months after discharge and could correctly classify 60-89% of sample. CONCLUSIONS: When taking nursing home and home nursing utilization into considerations at the same time, the elderly person's pre-admission institutionalization and the caregiver's preference for institutional displacement strongly predicted nursing home utilization after hospital discharge. The elder's self-care ability, conscious level, and tubes remaining before discharge strongly predicted the use of home nursing services after discharge.     

优化健康体检服务流程的实践研究

运用计划—实施—检查—处理(plan-do-check-action,PDCA)循环管理,对健康体检流程不满意环节进行调查分析,找出问题,分析原因,制订简化开单流程,增设专职导诊人员,设备升级改造等整改措施,评价结果,进行持续质量改进。实施PDCA循环管理后,健康体检流程得到优化,平均体检时间由(164.16±6.72)min下降至(105.78±9.34)min,体检者满意度由92.20%上升至98.42%,差异有统计学意义(P<0.01)。PDCA循环管理优化了健康体检服务流程,提高了体检者满意度。     

Home and community occupational therapy for children and youth: a before and after study

BACKGROUND: There has been an increased focus on home care service provision in recent years, yet there are few data available about the provision of home and community occupational therapy for children and youth. PURPOSE: To evaluate key elements of a service provision model for home care occupational therapy in terms of occupational performance outcomes, perception of care and cost. METHODS: Eleven centres in Ontario and Quebec recruited 167 children and youth up to 18 years of age to a before and after study of occupational therapy services in the home and community. Occupational performance, quality of life and costs were measured at baseline and study end. Perception of care was measured at study completion. RESULTS: A statistically and clinically significant improvement in occupational performance was demonstrated (p < 0.001). The clients' families gave high ratings to the process of care provided by the occupational therapists. These data did not demonstrate a clear relationship between amount of service, cost and occupational performance outcome. PRACTICE IMPLICATIONS: Children receiving home and community occupational therapy services change in their occupational performance abilities. These changes are not directly related to the amount or focus of the occupational therapy services.     

Predicting utilization of home health resources. Important data from routinely collected information

This study examined the feasibility of using routinely collected information on patients enrolled in home health care to predict their subsequent use of services. Data were gathered from 1,984 episodes of care randomly sampled from home health care agencies of the Virginia Health Department. Age, sex, Medicare and Medicaid enrollment, referral source, medical diagnosis, and prognosis were used to predict the total number of visits, the duration of enrollment, and the intensity of service. Since the data were originally gathered to study the effects of the implementation of diagnosis-related groups (DRGs) on home health services, half of the patients were enrolled before and half after the implementation of DRGs. Using multiple linear regression analysis, significant amounts of variance in each measure of home health care utilization were explained by the predictor variables (R2 = 0.04 to 0.10). For example, after controlling for other predictor variables, age 75 years or older predicted longer durations of enrollment and lower intensities of service as compared with other age groups (P less than 0.05), and four of 14 diagnosis categories predicted at least one measure of utilization (P less than 0.05). Medicaid enrollment predicted longer durations of enrollment and lower intensities of service in home health care (P less than 0.05) in the post-DRG but not the pre-DRG period. These results demonstrate the value of routinely collected information in predicting the use of home health services. To develop more accurate estimates of needs for home health services for particular groups of patients, additional information on chronic functional impairments, informal caregiving, and the chronicity of needs may be useful.     

Outcomes and effectiveness research: capacity building for nurse researchers at the Agency for Healthcare Research and Quality

Several of AHRQ's priority areas including disease prevention, health promotion, primary care, quality of care, service delivery, and patient safety are particularly relevant to nurse researchers. With much national attention focused on nursing-related issues such as staff shortages, training, mandatory overtime, working conditions, and autonomy, it is mandatory that nursing research be conducted to inform healthcare delivery and policy. Nurses also need to contribute to the health services literature so that an even balance of discipline perspective is represented. AHRQ's mandate is represented by the slogan "quality research for quality health care." Although our understanding has expanded of contributors to and determinants of evidence-based practice and the relationship between clinical care and improved outcomes, we have much to learn. Appreciating how and which components of nursing care influence patient outcomes represents an essential area of research in need of development. While clarifying nursing contributions to improved outcomes is not the sole purview of nurse researchers, it is plausible to assume that a clinical background in nursing combined with strong methodological skills can help policy makers and health system leaders understand how nurses can most effectively contribute to outcomes and quality improvement. AHRQ is clearly interested in capacity building of researchers from all relevant disciplines. Nurses, the largest provider of healthcare, need to build capacity and develop a much stronger presence in the health services research community of scholars.     

中老年住院患者冠心病健康素养与健康服务利用的关系研究

目的探讨中老年住院患者冠心病健康素养与健康服务利用的关系。方法 2014年9月-2015年5月,采用整群抽样法对新疆乌鲁木齐市某三甲医院的冠心病患者进行调查,将其中符合纳入标准的414例患者作为研究对象,发放冠心病健康素养量表和一般状况量表。采用单因素分析冠心病健康素养与健康服务利用的关系,采用多重线性回归模型分析冠心病健康素养的影响因素。结果 (1)冠心病患者平均年龄为(61.65±10.60)岁,冠心病健康素养平均得分(76.10±30.41)分,处于较低水平。单因素分析显示:不同年龄、性别、族别、教育水平、曾经从事职业、婚姻状况、家庭人口数、子女数、家庭平均月收入的冠心病健康素养评分比较,差异有统计学意义(P0.05);健康教育和距离上次体检时间在冠心病健康素养得分上差异有统计学意义(P0.01)。(2)多重线性回归分析显示:民族、文化程度、曾经或现在的职业、健康教育、距离上次体检时间是冠心病健康素养的独立影响因素。结论冠心病健康素养对健康服务利用有一定影响,应通过健康教育提高冠心病患者的健康素养水平。采取相应措施使冠心病患者更易获得和利用健康服务,从而促进健康,改善生活质量。     

Partnership for better patient outcomes: home health and HMO collaboration

This article describes the evolution of a collaborative model of quality improvement between an HMO and six contracted home health agencies using OASIS items to measure patient outcomes. The results showed that when agencies completed quality improvement activities independently, HMO patients' outcomes did not improve substantially. In contrast, when the HMO and agencies collaborated, patient outcomes improved as much as 19% in 1 year. This collaborative model can help purchasers and providers to share responsibility for improvement in patient outcomes.     

晚期肿瘤患者社区卫生服务利用现状的调查分析

目的了解社区晚期肿瘤患者对卫生服务的利用现状。方法采用问卷调查法,对上海市94名社区晚期肿瘤患者进行调查。结果患者对多项肿瘤随访服务内容的需求率大于接受率;患者常见的外出就医地点为二、三级医院门诊,接受的医疗服务主要是中医和对症治疗;虽然70．21％的患者对家庭病床存在需求,但只有37．23％的患者知晓家庭病床,且仅6．38％的患者使用过家庭病床;“就医连续性”和”交通方便”程度是患者就医地点的主要影响因素。结论社区晚期肿瘤患者对卫生服务的利用程度较高,但对社区层面的卫生服务利用程度却极低。应从社区肿瘤随访、肿瘤门诊、家庭病床以及与对口医院建立双向转诊入手,优化社区晚期肿瘤患者卫生服务模式。     

A comparison of the cost-effectiveness of hospital-based home care with that of a conventional outpatient follow-up for patients with mental illness

The purpose of this study was to compare the outcomes of a hospital-based home-care model with those of a conventional outpatient follow-up for mentally ill patients in Taiwan by means of cost-effectiveness analysis. The study design was a two group posthoc design. We interviewed 40 mentally ill patients who were followed up in the psychiatric outpatient department. Another 40 mentally ill patients who participated in a hospital based home care program were also interviewed. The outcome measures we used for interviews were disease maintenance behavior, psychotic symptoms, social function, service satisfaction, and cost. The cost for each patient was the sum of costs for all direct mental health services. The cost-effectiveness ratio showed that the costs of the hospital-based home care model (4.3) were lower than those of conventional outpatient follow-up (13.5) and that over a one-year period, the hospital-based home care model was associated with improvements in mental conditions, social functional outcomes, and service satisfaction. The improved outcomes and the lower costs in the hospital-based home care program support the view that it is the most cost-effective of the two. Policy makers may consider this analysis as they allocate resources and develop policy for the care of mentally ill patients.