improving patient prioritization during hospital-homecare transition

Conditions: Diabetes Mellitus, Type 2; Congestive Heart Failure; Obstructive Pulmonary Disease; Dyspnea; Renal Failure

Summary: this research work is focused on building and evaluating one of the first evidence-based clinical decision support tools for homecare in the united states. the results of this study have the potential to standardize and individualize nursing decision making using cutting-edge technology and to improve patient outcomes in the homecare setting.

each year, more than 5 million patients are admitted to the approximately 12,000 homecare agencies across the united states. about 20% of homecare patients are rehospitalized during the homecare episode, with as many as 68% of these rehospitalizations occurring within the first two weeks of services. a significant portion of these rehospitalizations may be prevented by timely and appropriately targeted allocation of homecare services. the first homecare nursing visit is one of the most critical steps of the homecare episode. this visit includes an examination of the home environment, a discussion regarding whether a caregiver is present, an assessment of the patient's capacity for self-care, and medication reconciliation. a unique care plan is created based on this evaluation of the patient's needs. hence, appropriate timing of the first visit is crucial, especially for patients with urgent healthcare needs. however, nurses often have very limited and inaccurate information about incoming patients and patient priority decisions vary significantly between nurses. the investigators developed an innovative decision support tool called "priority for the first nursing visit tool" (prevent) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. in a recent efficacy pilot study of prevent, high-risk patients received their first homecare nursing visit a half day sooner as compared to the control group, and 60-day rehospitalizations decreased by almost half as compared to the control group. the proposed study assembles a strong interdisciplinary team of experts in health informatics, nursing, homecare, and sociotechnical disciplines to evaluate prevent in a pre-post intervention effectiveness study. specifically, the study aims are: aim 1) evaluate the effectiveness of the prevent tool on process and patient outcomes. using survival analysis and logistic regression with propensity score matching the researchers will test the following hypotheses: compared to not using the tool in the pre-intervention phase, when homecare clinicians use the prevent tool, high risk patients in the intervention phase will: a) receive more timely first homecare visits and b) have decreased incidence of rehospitalization and have decreased emergency department (ed) use within 60 days. aim 2) explore prevent's reach and adoption by the homecare admission staff and describe the tool's implementation during homecare admission. aim 2 will be assessed using mixed methods including homecare admission staff interviews, think-aloud simulations, and analysis of staffing and other relevant data. this innovative study addresses several national institute of nursing research strategic priorities, such as promoting innovation and using technology to improve health. mixed methods will enable us to gain in-depth understanding of the complex socio-technological aspects of hospital-homecare transition.

Eligibility criteria:
aim 1: inclusion criteria: 1. being a patient of either newyork-presbyterian (nyp)/columbia university irving medical center or newyork-presbyterian allen hospital; 2. being referred to visiting nurse services of new york (vnsny) homecare services 3. 18 years old or older. exclusion criteria: all other patients are going to be excluded. aim 2 : inclusion criteria: 1. working as an admission staff for vnsny 2. 18 years old or older. exclusion criteria: all other staff members are going to be excluded. for both study aims, there will be no exclusion based on sex, race, or ethnic group.

Keywords: home health clinical decisions support care transitions patient prioritization health informatics home care