Reducing Emergency Room Visits and In‐Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data

Hewner, Sharon; Sullivan, Suzanne S.; Yu, Guan

doi:10.1111/wvn.12286

Cited by 31 publications

(41 citation statements)

References 17 publications

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“…Thus, WIA is a useful model to consider in tandem with the grounded theory of relationship‐based care when developing technology‐aided approaches to personalize care and support clinical decision‐making in the homecare setting. The use of information technology would enhance communication and support the homecare RNs ability to be informed of changes (Hewner et al., 2018) as they engage all stakeholders and manoeuvre through various barriers when transitioning their patients to supportive care services. Moreover, establishing interoperability standards and shared care planning (Sullivan et al., 2017), supported by nursing informatics, is an effective approach for enriching cross‐sector communication of social needs from within the home, promotes health equity (Matheny et al., 2020), and may help promote a trusting relationship with primary care providers (Lanham et al., 2016).…”

Section: Discussionmentioning

confidence: 99%

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship‐based care

Sullivan

Mann

Mullen

et al. 2021

Journal of Advanced Nursing

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Aims To identify the process that homecare nurses use when recognizing serious illness, engaging patients and families in goals‐for‐care discussions and guiding transitions to comfort‐focused care. Design Constructivist grounded theory. Methods Semi‐structured focus group interviews of 31 homecare Registered Nurses were recorded and transcribed (June–August 2019). Line‐by‐line coding using the constant comparative method until saturation was achieved and a grounded theory was identified. Credibility, transferability, and confirmability establish study rigor. Results A grounded theory of relationship‐based care. Nurses cogitate and act when recognizing serious illness. They have difficult conversations and support care transitions with wisdom and knowing, by identifying changes in illness trajectories and being informed and alert to diminishing quality of life. Nurses are skilled at engaging patients, families, and the team and accommodate care in the home for as long as possible, while manoeuvring through complex systems of care; ultimately relinquishing and guiding care to other providers and settings. However, nurses feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team. Conclusion This study identifies a grounded theory to support clinical decision‐making and position homecare nurses as leaders in guiding goal care discussions and transitions to comfort‐focused care. These findings reinforce the importance of developing health policy that ensures care continuity in serious illness. Further research is needed to improve relationships across care settings and enhance training for the delivery of comfort‐focused care in the home as changing needs emerge during serious illness management.

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Section: Discussionmentioning

confidence: 99%

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship‐based care

Sullivan

Mann

Mullen

et al. 2021

Journal of Advanced Nursing

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“…Delivery of health care in an interrupted, fragmented, or uncoordinated manner contributes to increased healthcare costs and inappropriate healthcare use [66]. Improving continuity of care in this context requires careful coordination across the healthcare continuum [67]. Successful communication between EDs and primary care providers in acute and community settings is an essential component of such interventions and programs [67].…”

Section: Discussionmentioning

confidence: 99%

“…Improving continuity of care in this context requires careful coordination across the healthcare continuum [67]. Successful communication between EDs and primary care providers in acute and community settings is an essential component of such interventions and programs [67]. A recent systematic review that evaluated the effectiveness of several types of interventions and programs (such as care plans, case management, printout case notes, diversion strategies, and social work practitioners) targeting adult frequent ED users, showed that some interventions are effective in reducing visit frequency and improving patient outcomes [68].…”

Section: Discussionmentioning

confidence: 99%

Emergency Department Utilization among Underserved African American Older Adults in South Los Angeles

Bazargan

Smith

Cobb

et al. 2019

IJERPH

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Objectives: Using the Andersen’s Behavioral Model of Health Services Use, we explored social, behavioral, and health factors that are associated with emergency department (ED) utilization among underserved African American (AA) older adults in one of the most economically disadvantaged urban areas in South Los Angeles, California. Methods: This cross-sectional study recruited a convenience sample of 609 non-institutionalized AA older adults (age ≥ 65 years) from South Los Angeles, California. Participants were interviewed for demographic factors, self-rated health, chronic medication conditions (CMCs), pain, depressive symptoms, access to care, and continuity of care. Outcomes included 1 or 2+ ED visits in the last 12 months. Polynomial regression was used for data analysis. Results: Almost 41% of participants were treated at an ED during the last 12 months. In all, 27% of participants attended an ED once and 14% two or more times. Half of those with 6+ chronic conditions reported being treated at an ED once; one quarter at least twice. Factors that predicted no ED visit were male gender (OR = 0.50, 95% CI = 0.29–0.85), higher continuity of medical care (OR = 1.55, 95% CI = 1.04–2.31), individuals with two CMCs or less (OR = 2.61 (1.03–6.59), second tertile of pain severity (OR = 2.80, 95% CI = 1.36–5.73). Factors that predicted only one ED visit were male gender (OR = 0.45, 95% CI = 0.25–0.82), higher continuity of medical care (OR = 1.39, 95% CI = 1.01–2.15) and second tertile of pain severity (OR = 2.42, 95% CI = 1.13–5.19). Conclusions: This study documented that a lack of continuity of care for individuals with multiple chronic conditions leads to a higher rate of ED presentations. The results are significant given that ED visits may contribute to health disparities among AA older adults. Future research should examine whether case management decreases ED utilization among underserved AA older adults with multiple chronic conditions and/or severe pain. To explore the generalizability of these findings, the study should be repeated in other settings.

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“…Integration with the existing system facilitates health information exchange, which involves reducing unnecessary hospitalizations and emergency visits (Hewner et al. ). Hence, this integration should be addressed promptly because it will be beneficial to policy‐makers and on‐site nurses.…”

Section: Discussionmentioning

confidence: 99%

Construction and usability of community health nursing database in rural north‐eastern Thailand

Arakawa

Ota

Piyabanditkul

et al. 2018

International Nursing Review

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515-523Introductions: Digitization could be incorporated in rural areas of resource-poor countries because information gathered by nurses working on-site could be better used. Background: For effective management of community health information, the usage and maintenance of digital records are important. Digitization of information provides essential information for informing health policy. Aim: To develop a sustainable database to effectively collect and manage community health information and nursing practice. Methods: This study used a mixed method design. Phase 1 involved the development of a database system through repeated systematic focus group discussions with community health nurses. Phase 2 involved a practical trial examination of the developed system with both objective and subjective evaluations. Results: A nursing database system was developed with templates designed for the major health problems of communities. The templates were composed of multiple-choice items and a free-text field that allowed records to be more detailed than handwritten records and maintained in standardized formats. This enables accumulation of data that were less likely to be influenced by the variance of ability in each nurse. Discussion and conclusion: A multifaceted evaluation of the database system suggested that it could improve the efficiency of information management and contribute to the improvement of nursing care quality through standardization of the recording pattern. Implications for nursing and health policy: The nursing database will enable high-quality information storage that will potentially better inform health and healthcare policies as well as enable visualization of data concerning nursing care challenges and activities within the relevant communities. This information is Correspondence address: Naoko Arakawa, Department of Nursing, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; Tel: 81-568-51-1111; Fax: 81-568-51-5370; E-mail: n-maruyama@isc.chubu.ac.jp. FundingThis study was carried out upon receiving a JSPS KAKENHI Grant-in-Aid for Young Scientists (B)15K20819 as well as a research grant from the Mitsubishi Foundation. Conflict of interestNo conflict of interest has been declared by the authors. © 2018 International Council of NursesThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.Original Article essential for policy development and implementation in areas of human and fiscal resource allocations and meeting training/education needs.Keywords: Chronic Diseases, Community Health Nursing, Database System, Electronic Health Records, Information Technology, Resource-Poor Countries, Rural Areas, System Usability, Thailand IntroductionInformation and communication technology (ICT) is an effective tool to promote health care in resource-poor countr...

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Reducing Emergency Room Visits and In‐Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data

Cited by 31 publications

References 17 publications

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship‐based care

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship‐based care

Emergency Department Utilization among Underserved African American Older Adults in South Los Angeles

Construction and usability of community health nursing database in rural north‐eastern Thailand

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