Professional Case Management最新文献

{"title":"Reducing Readmissions Using Collaborative Care.","authors":"","doi":"10.1097/NCM.0000000000000799","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000799","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 3","pages":"E10"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755167","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Limitations to End of Life Care Planning for Patients on High Flow Nasal Cannula.","authors":"Julie Graham, Lindsay Richardson, Laura Maldoon, Jendi Durrant, Christina Kelley","doi":"10.1097/NCM.0000000000000800","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000800","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 3","pages":"122-124"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing 30-day Acute Care Readmissions for Heart Failure Patients Through Implementation of a Discharge Bundle.","authors":"Jason Lindsey, Teresa Welch","doi":"10.1097/NCM.0000000000000766","DOIUrl":"10.1097/NCM.0000000000000766","url":null,"abstract":"<p><strong>Purpose: </strong>Hospital readmissions have been a long-standing problem in the American health care system. Despite many efforts, programs, papers, and interventions identified and studied, 14% of all adult admissions result in a readmission. Readmissions are mostly considered preventable and are considered an indicator of care quality for a hospital. Due to unexpected readmissions, patients are at an increased risk for illness or injury, increased stress, financial strain, and diminished quality of life. Readmissions also negatively impact hospital systems related to decreased bed availability, stretched resources, and potential financial penalties and payment reductions. Patients with an admission related to heart failure are at an increased risk of readmission, with a national readmission rate of 23%.</p><p><strong>Primary practice setting: </strong>The quality improvement project was implemented on two telemetry units at an acute care hospital.</p><p><strong>Methodology and sample: </strong>A gap analysis identified procedural and organizational reasons for readmission in the heart failure population at an acute care hospital. Using evidence-based best practice guidelines established by the American Heart Association, American College of Cardiology, and the Heart Failure Society of America, a four-pronged proactive discharge bundle was implemented using the plan-do-study-act framework for continuous improvement. All patients admitted to the telemetry units with a primary or secondary diagnosis of heart failure received the discharge planning bundle: (1) an early assessment by the case management department, (2) patient-centered specialty heart failure education, (3) predischarge medication delivery, and (4) predischarge physician follow-up appointment scheduling within 7 days of discharge. A total of 133 patients were evaluated for inclusion in the heart failure cohort. Of those, 52 patients received the evidence-based intervention.</p><p><strong>Results: </strong>The evidence-based project was implemented over 7 weeks, September through October of 2023 on the medical telemetry units. Of the 52 patients receiving the evidence-based sample, two of the patients experienced a readmission due to heart failure (3.85%). Incidentally, it was found that patients without a readmission had an average of 2.3 completed interventions, while those with readmissions had an average of 1.5 interventions.</p><p><strong>Implications for case management practice: </strong>Case managers are an integral part of the care transition from the acute care setting back to the community. Often, it is the case manager leading this effort through various interventions. Findings from this quality improvement project suggest the use of the evidence-based, four-pronged approach to discharge planning for the heart failure patient population reduced the risk and rate of heart failure-related readmissions for the involved nursing units. These findings also surmise t","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":"81-92"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142074229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing 30-day Acute Care Readmissions for Heart Failure Patients Through Implementation of a Discharge Bundle.","authors":"","doi":"10.1097/NCM.0000000000000798","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000798","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 3","pages":"E9"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755166","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nurse Case Manager-Social Work Case Manager Collaboration: A \"Pocket\" of Interprofessional Teamwork in Health Care.","authors":"Vivian Campagna, Lorna Lee-Riley","doi":"10.1097/NCM.0000000000000792","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000792","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 3","pages":"116-118"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755165","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Artificial Intelligence: Potential for the Future.","authors":"Suzanne K Powell","doi":"10.1097/NCM.0000000000000790","DOIUrl":"10.1097/NCM.0000000000000790","url":null,"abstract":"<p><p>Artificial Intelligence (AI) is here to stay. Fear and reservations still abound; however, many large institutions are developing and researching new treatments for diseases that may help our patients/clients in the near future.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 3","pages":"79-80"},"PeriodicalIF":0.8,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143755140","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving the Quality of Whole-Person Healthcare Delivery: Critical Components of a Sickle Cell Disease Nurse Navigator Role.","authors":"Mitchell Knisely, Janet Prvu-Bettger, John J Strouse, Paula Tanabe","doi":"10.1097/NCM.0000000000000806","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000806","url":null,"abstract":"<p><strong>Purpose/objectives: </strong>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.</p><p><strong>Primary practice settings: </strong>Care for individuals with SCD.</p><p><strong>Findings/conclusions: </strong>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.</p><p><strong>Implications for case management practice: </strong>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.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144016997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sepsis Survivors' Functional Recovery and Symptom Experience Following Intensive Care Unit Hospitalization.","authors":"Daniel Liebzeit, Amiritha Kumar, Maria Hein, Yelena Perkhounkova, Anna Krupp","doi":"10.1097/NCM.0000000000000805","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000805","url":null,"abstract":"<p><strong>Purpose of study: </strong>The purpose is to describe sepsis survivors' functional recovery and symptom experience following Intensive Care Unit (ICU) hospitalization.</p><p><strong>Primary practice settings: </strong>Academic Medical Center, Community Living.</p><p><strong>Methodology and sample: </strong>This longitudinal observational study recruited participants during hospitalization at two adult ICUs in a single Midwestern academic medical center. Participants completed surveys to assess function and symptom experience at baseline (discharge), 1-month, 3-months, and 6-months post-discharge.</p><p><strong>Results: </strong>Participants were non-Hispanic Whites with mean age 55.4 years (SD = 17.0). The majority were discharged to home (78.6%), with 3 (21.4%) discharged to a skilled nursing facility or acute rehabilitation unit. Participants had notable improvements in mobility, self-rated health, and fatigue from discharge to 6-months post-discharge. Increases in mobility from discharge to 1 month, 3 months, and 6 months were statistically significant (α < .05). Decreases in fatigue from discharge to 1 month and 6 months were statistically significant (α < .05). Cognitive and social engagement and other symptom experience measures did not differ significantly during the study period.</p><p><strong>Implications for case management practice: </strong>Findings reveal trends in mobility recovery and symptom experience post-hospitalization, which are important considerations post-ICU sepsis hospitalization. This study reinforces the need to promote early mobilization of patients during hospitalization and work with patients to develop strategies for mobility recovery post-hospitalization, as part of a comprehensive plan which integrates a client's medical, behavioral, social, psychological, functional, and other needs. The authors encourage assessment of common symptoms, including pain, fatigue, anxiety, and sleep disturbance, experienced by sepsis survivors during and post-hospitalization. As a result, case managers will be better positioned to implement evidence-based interventions to promote recovery and reduce symptom burden and improve outcomes. Evidence-based interventions should include those that are centered on client's functional and symptom-related needs, preferences, safe mobility, and facilitate awareness of and connections with community supports and resources.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143765070","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of AHRQ Re-Engineered Discharge Toolkit on Adult Patient's 30-Day Readmission.","authors":"Rhea Anne Yumena","doi":"10.1097/NCM.0000000000000801","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000801","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Purpose of study: &lt;/strong&gt;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.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Primary practice setting: &lt;/strong&gt;The project site is a single medical center within a hospital system located in an urban area of Arizona.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methodology and sample: &lt;/strong&gt;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.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;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 [X2(1, N = 307) = 22.0; p = .001).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Implications for case management: &lt;/strong&gt;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 opportunities ","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-03-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143568472","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nurse-Led Care Coordination in a Transitional Clinic for Uninsured Patients With Diabetes.","authors":"Sarah Coiner, Alison Hernandez, Paula Midyette, Bela Patel, Michele Talley","doi":"10.1097/NCM.0000000000000732","DOIUrl":"10.1097/NCM.0000000000000732","url":null,"abstract":"<p><strong>Purpose/objectives: </strong>The purpose of this article is to inform the reader of the practice of the registered nurse care coordinator (RNCC) within an interprofessional, nurse-led clinic serving uninsured diabetic patients in a large urban city. This clinic serves as a transitional care clinic, providing integrated diabetes management and assisting patients to establish with other primary care doctors in the community once appropriate. The clinic uses an interprofessional collaborative practice (IPCP) model with the RNCC at the center of patient onboarding, integrated responsive care, and clinic transitioning.</p><p><strong>Primary practice setting: </strong>Interprofessional, nurse-led clinic for uninsured patients with diabetes.</p><p><strong>Findings/conclusions: </strong>Interprofessional models of care are strengthened using a specialized care coordinator.</p><p><strong>Implications for case management practice: </strong>Care coordination is a key component in case management of a population with chronic disease. The RNCC, having specialized clinical expertise, is an essential member of the interdisciplinary team, contributing a wide range of resources to assist patients in achieving successful outcomes managing diabetes. Transitional care coordination, moving from unmanaged to managed diabetes care, is part of a bundled health care process fundamental to this clinic's IPCP model. In a transitional clinic setting, frequent interaction with patients through onboarding, routine check-ins, and warm handoff helps support and empower the patient to be engaged in their personal health care journey.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":"43-49"},"PeriodicalIF":0.8,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140337133","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}