Comprehensive Care

Illness is a combination of pathophysiology and associated thoughts, emotions, and behaviors. Given the large number of treatments that are discretionary and preference sensitive, one goal is accurate diagnosis of patient preferences. Reliance on biomedical treatments (e.g., medication and procedures) may overlook important opportunities for improved health such as amelioration of stress and distress and training in more effective coping strategies.

An Integrated Case Management Model to Assist Pacific Youth Offenders and Their Families in Australia

Pasifika Support Services (PSS) was a program managed by a nongovernment organization, Mission Australia, and funded by the New South Wales Premiers Office to meet the needs of young offenders from a Pacific background. PSS ran from June 2005 to June 2009 and implemented a cost-effective integrated case management model with the New South Wales Police Force adapted to address social risk factors specific to Pacific youth offenders and family support networks. Sixty young people were reviewed regarding the outcomes achieved through their participation, further supported by an evaluation carried out by an external evaluator who found that 65% of participants did not reoffend after 18 months of completing the program. An importance of developing a shared approach to employing a holistic and intensive model of case management that affects individual, community, and organizational change through culturally relevant processes and practices, paired with a cross institutional commitment underpins the various outcomes discussed.

A System Analysis of Delay in Outpatient Respiratory Equipment Delivery

Objectives: To systematically assess barriers delaying home respiratory equipment requisition and to evaluate for temporal correlation between delays and emergency room or hospitalization episodes.Background: Initiation of home respiratory treatments is delayed because of delays in delivery of durable medical equipment (DME). This study assesses root causes of such delays from a system perspective. We also describe clinical consequences by measuring emergency room visits and hospitalization days for temporal correlations.Methods: We conducted a retrospective review of DME ordering records from April 2011 to March of 2012.Settings: Outpatient DME records in Pediatric Pulmonary Division.Results: Of 164 available orders studied, deliveries were made as followed: 31 (19%) within 24 hr: 18 (59%) oxygen orders and 10 (32%) nebulizer orders 50 (30%) within 1 week: 25 (50%) nebulizer orders and 10 (20%) oxygen orders Delays: 45 (27%) delivered > 1 month: Bilevel positive airway pressure (BPAP) = 16 (36%) Oxygen = 12 (26%) Cough assist device = 7 (16%) Nebulizer = 5 (11%) Miscellaneous devices = 5 (11%) Analysis of barriers includes (a) type of insurance, (b) human error, (c) communication barrier, (d) deficit in training or knowledge, (e) no clear policy, (f) differences in clinical policy/ standard, (g) no DME benefit, (h) no clinical justification, and (i) error in communication/record keeping. Six patients with 7 emergency department (ED) visits and 4 inpatient admissions, totaling 24 hospital days, were temporally associated with delays in delivery of equipment over 30 days.Conclusion: One half of commonly used DMEs were delivered within the first week. One quarter of more expensive required more steps for approval. Twenty-nine ED/hospital days with respiratory morbidities were temporally associated with delays.

Legal and Ethical Imperatives for Using Certified Sign Language Interpreters in Health Care Settings: How to “Do No Harm” When “It’s (All) Greek” (Sign Language) to You

Communication obstacles in health care settings adversely impact patient–practitioner interactions by impeding service efficiency, reducing mutual trust and satisfaction, or even endangering health outcomes. When interlocutors are separated by language, interpreters are required. The efficacy of interpreting, however, is constrained not just by interpreters’ competence but also by health care providers’ facility working with interpreters. Deaf individuals whose preferred form of communication is a signed language often encounter communicative barriers in health care settings. In those environments, signing Deaf people are entitled to equal communicative access via sign language interpreting services according to the Americans with Disabilities Act and Executive Order 13166, the Limited English Proficiency Initiative. Yet, litigation in states across the United States suggests that individual and institutional providers remain uncertain about their legal obligations to provide equal communicative access. This article discusses the legal and ethical imperatives for using professionally certified (vs. ad hoc) sign language interpreters in health care settings. First outlining the legal terrain governing provision of sign language interpreting services, the article then describes different types of “sign language” (e.g., American Sign Language vs. manually coded English) and different forms of “sign language interpreting” (e.g., interpretation vs. transliteration vs. translation; simultaneous vs. consecutive interpreting; individual vs. team interpreting). This is followed by reviews of the formal credentialing process and of specialized forms of sign language interpreting—that is, certified deaf interpreting, trilingual interpreting, and court interpreting. After discussing practical steps for contracting professional sign language interpreters and addressing ethical issues of confidentiality, this article concludes by offering suggestions for working more effectively with Deaf clients via professional sign language interpreters.

Risk Factors and Effects of Care Management on Hospital Readmissions Among High Users at an Academic Medical Center

Few studies have examined predictors of hospital readmission among high-using patients enrolled in a behaviorally oriented intensive care management program. The purpose of this case control study was to describe risk factors and the effectiveness of a complex care management program for hospital readmission among vulnerable patients at a large academic medical center. One hundred sixty-three patients enrolled in the University of Michigan Complex Care Management Program (UM CCMP) were hospitalized between January 2014 and March 2015. Sixty were readmitted within 30 days of discharge. Among all patients, the mean age was 51.1 years, 38.7% were non-White, 81.5% had Medicaid and/or Medicare, 50.3% were without stable housing, and 27.6% had significant psychiatric illnesses. Although mostly not statistically significant, multivariable risk of readmission was increased by having twice the mean number of hospitalizations in the last 6 months (odds ratio [OR] = 1.44, 95% CI [1.00, 2.06]), having chronic pain on a scheduled narcotic (OR = 1.49, 95% CI [0.67, 3.35]), and going to a primary care physician within 30 days of discharge (OR = 1.35, 95% CI [0.63, 2.89]). Risk was decreased by going to a specialist (OR = 0.54, 95% CI [0.23, 1.27]) and receiving moderate-intensity CCMP intervention (OR = 0.48, 95% CI [0.20, 1.19]). Among hospitalized high-using patients enrolled in the UM intensive care management program, readmission is likely significantly influenced by medical, behavioral, and social challenges. Care management appears most effective in preventing readmission among patients with mid- rather than high- or low-level needs. These findings at a single program should be explored in further, larger studies.

Attachment Theory and Neuroscience for Care Managers

This article describes a model for care managers that is based on attachment theory supplemented by knowledge from neuroscience. Together, attachment theory and basic knowledge from neuroscience provide for both an organizing conceptual framework and a scientific, measureable approach to assessment and planning interventions in a care plan.

Advanced Practice Nurse Transitional Care Model Promotes Healing in Wound Care

Optimally, transition in health care should be seamless and incorporate a well-thought-out patient-centered discharge plan; yet, many hospitalized patients are unprepared for discharge, thereby compromising patient safety and quality of care. Transition of care should include a broad range of time-limited services designed to ensure health care continuity to avoid poor outcomes among at-risk populations. This case study demonstrates that advanced practice nurses (APNs) are in the perfect position to bridge the existing gap, reduce readmissions, and improve patient health. Transition from hospital to home is stressful under the best of circumstances. Naylor’s transition of care model and Meleis’s transition theory provides the foundation for APNs to manage patients’ wounds across the continuum of care. The patient is educated and guided through the convoluted health care system, resulting in decreased discontinuity and improved outcomes and safety.Conclusion: A smooth transition between levels of care requires collaboration and care coordination of medical services and health care providers. The result of this continuity is improved patient outcomes, improved patient satisfaction, and reduced medical errors. APNs as care coordinators have the ability to bridge the existing gap between hospitalization and home while preventing readmission.