Medicine and Health Sciences Commons^™

The Effect Of Focused Client Education On Case Management & Readmission Rates In Homeless Individuals With Co-Occurring Disorders Admitted To A Jail Diversion Program, Pallavi Rao, Mary Johnson

Graduate Publications and Other Selected Works - Doctor of Nursing Practice (DNP)

Background: Individuals with both mental illness(es) (MI) and substance use disorder (SUD) occurring simultaneously are known as having co-occurring disorders (COD). The rates of COD found among homeless individuals (H-COD) are higher than in the general population. The presence of both conditions prevents H-COD individuals from overcoming their hardships and places them at a higher risk of being involved in the criminal justice system.

Local Problem: Jail diversion programs (JDPs) admit a high rate of H-COD clients nationally and locally at the project site in Knoxville (JDP-K). The Office on Homelessness reported about 80% of those admitted to JDP-K are …

A New Opportunity For Occupational Therapists To Open Cases In Home Health, Amy Oselio, Bryan M. Gee, Kimberly Lloyd

The Open Journal of Occupational Therapy

As of January 1, 2022, licensed occupational therapists have the permanent ability to open home health cases for the first time since 1999. This ability creates opportunities for occupational therapists to case-manage in the home health setting and showcase the benefits of occupation-based interventions for their clients. Further, occupation-based interventions create opportunities to establish aging-in-place and other cost-saving strategies. Occupational therapists will need to inform their home health agencies about this new ability, emphasizing the benefits of a more substantial presence in home health episodes of care. They will also need to develop new skills in the admission process or …

Recognizing Barriers In The Elderly Population And Increasing Access To Case Management Services, Loveleena Alex

Doctor of Nursing Practice Projects

Abstract

Implementing case management can lead to fewer hospitalizations in the elderly population. Barriers influencing the number of hospitalizations include low socioeconomic status, transportation needs, health literacy, financial strain, multiple comorbidities, underserved populations, medication availability, availability of community resources, and access to primary care. A review of the available literature revealed that by addressing these barriers in a primary care setting and implementing case management, the number of hospitalizations can be decreased and the quality of life in the elderly population can be improved. This quality improvement project implemented a screening and referral process for chronic care management in the …

Forestalling: Decreasing Super-Utilizers In The Emergency Department Using Case Management Strategies, Kelly Chambers, Megan Gilmartin, Martha Narasimhan-Narayanan

Doctor of Nursing Practice Final Manuscripts

In 2019, it was estimated there were 18 million avoidable emergency department (ED) visits, totaling $32 billion in unnecessary healthcare spending. Super-utilizers (SU), individuals that seek care in the ED 3 or more times per year, account for a disproportionately large segment of healthcare consumption and costs. These patients inefficiently access the healthcare system and often fail to get the follow-up care that could prevent them from repeat ED visits.

This evidence-based project aimed to reduce unnecessary ED visits by at least 25% annually and have no use of the ED during the intervention period, by implementing social and medical …

Exploring The Relationship Between Student Expected Engagement And Referrals To The Behavioral Intervention Team, Makenzie R. Schiemann

USF Tampa Graduate Theses and Dissertations

Higher education administrators are tasked with supporting and retaining students with increasing needs. These needs often include emotional and mental health issues but can worsen to include suicidality and violence toward others. Traditional campus approaches for supporting students and intervening for violence, such as counseling and campus safety, have been reactionary rather than proactive. Behavioral Intervention Teams (BITs) have emerged as a mechanism for heading off violence before it occurs while also supporting students who may never engage in violence but need support. These teams were born out of the concept that violence is preventable and have grown into a …

Evidence-Based Best Practice For Discharge Planning: A Policy Review, Marissa Lewis

Student Scholarly Projects

Ineffective discharge planning produces poor patient healthcare outcomes, potential adverse events, and medical errors. A primary deterrent to successful discharge planning is communication, either within the interdisciplinary team or during handoff to the receiving transition of care facilities of home health, skilled nursing, or acute rehabilitation.

The purpose of the evaluation project was to determine if current policies, communication tools, and workflows of three healthcare organizations were based on evidence and make recommendations for policy revisions. The Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model (JHNEBP) was used with the Centers for Disease Control (CDC) Policy Process (POLARIS) …

The Design And Impact Of A Rural Community Supported Doula Program, Kalin Jean Gregory-Davis, Sandra Zapien, Erin Abigail Gregory-Davis, Maria Rossi, Victoria Hart

Larner College of Medicine Fourth Year Advanced Integration Teaching/Scholarly Projects

Objective: to evaluate the design and impact of a doula program in rural Vermont by exploring client demographics and perspectives on the doula care received. This research aims to better understand the population the program serves, the specific challenges they face, and how to mitigate these challenges in the perinatal and post-partum period with a social work model of doula care.

Design: a qualitative, descriptive study giving voice to the client experience of a doula program steeped in a social work model of care.

Methods: semi-structured interviews carried out in July and August of 2021. Interviews were coded and analyzed …

Intermediate Care Technicians-A Novel Workforce For Veterans Affairs Geriatric Emergency Departments, Kristina T. Snell, Thomas Edes, Colleen M. Mcquown

Journal of Geriatric Emergency Medicine

No abstract provided.

Case Management Of Primary Care Patients, Bernadette Webster

Doctor of Nursing Practice Projects

Case management (CM) offered in primary care is a collaboration, guided by the registered nurse, working to coordinate all aspects of care for the patient and the family. The purpose of this quality improvement/assurance project was to provide nurses in primary care with the education and methods of CM to assist in more effectively managing care for a patient after testing positive for COVID-19. An intervention was delivered to registered nurses (RN) in the primary care setting designed to improve knowledge and skill with case management for patients with high care needs or recently diagnosed with COVID-19. A templated note …

Implementation Of Community Health Worker Education Toolkit To Promote Compliance In Managed Care Organization, Lamonica Johnson

DNP Scholarly Projects

Community health workers provide case management and care coordination services to high-risk members enrolled in Louisiana Department of Health’s Medicaid program. Centers for Medicare and Medicaid Services require states entering contracts with managed care organizations to conduct external quality reviews by an independent External Quality Review Organization. Healthcare Effectiveness Data and Information Set are quality metrics managed by the National Committee for Quality Assurance. These metrics are reported annually and required by Louisiana Department of Health. Community health workers are required to demonstrate quality accreditation and meet state specific requirement compliance through documentation. The aim of this project was to …

An Education Program For Novice Nurses To Increase Case Management Knowledge, Emily Trefethen

Doctor of Nursing Practice (DNP) Projects

Problem: Heart failure (HF) is a chronic disease where the heart cannot deliver an adequate amount of blood that the body requires. HF is one of the costliest cardiovascular diseases plaguing public health in the United States (Go et al., 2014). HF is the main reason for hospitalizations in adults and a leading contributor to the rise in healthcare costs. Approximately 25% of Medicare patients are readmitted within 30-days of discharge (Go et al., 2013). To address excessive hospital readmissions, the Centers for Medicare and Medicaid Services (2019) initiated the Hospital Readmissions Reduction Program in October 2012 to reduce Medicare …

Supporting Positive Lifestyle Changes Among Patients With Diabetes Mellitus Type 2, Alison Tynan

Nursing | Senior Theses

The following thesis is a compilation of literature reviewed to formulate background research for a pilot study. The literature reviewed pertains to the potential benefit of added case management for patients with diabetes mellitus type 2. A proposed pilot study, based off of this research, aims to identify topics, tools, facts, and changes that can be made to case management to improve not just the biological aspects, like HbA1c levels, but the mental and emotional as well to allow for whole person care.

The primary question being asked is “what types of support do people with diabetes mellitus type 2 …

A Literature Review On The Benefits For An Interprofessional Educational Program To Increase Novice Nurse Awareness Of Case Management In Heart Failure, Emily Trefethen

DNP Qualifying Manuscripts

Abstract

Purpose/Objectives: The purpose of this literature review is to examine the potential value for an interprofessional education program to increase novice nurse awareness of case management in heart failure.

Primary Practice Setting: Acute care healthcare settings involving novice nurses.

Findings/Conclusions: Evidence demonstrates that interprofessional collaboration on transitional care interventions for HF patients reduces 30-day readmissions. Implementation of an interprofessional education program for novice nurses can be an effective intervention to decrease readmissions by increasing knowledge of the nurse case manager role and development of interprofessional relationships.

Implications for Case Management Practice: Increased awareness of heart failure case management is …

Adopting Complex Case Management Competencies, Phyllis Stark

Doctor of Nursing Practice (DNP) Projects

Improving disposition management of complex hospitalized patients is crucial to the success of acute care facilities. Most hospital patients discharge in less than 5 days, but there is a cohort of complex patients whose length of stay far-exceeds the norm (Centers for Medicare and Medicaid Service Website, n.d.). Today’s case managers are focused on patients who are discharging today or tomorrow in order to keep hospital census cycling through. This phenomenon known as “throughput” drives daily operations and is a measure of success. When case managers are faced with complex patients whose length of stay measured in weeks, months, or …

Case Managers’ Perceptions Of Effective Interventions, Julia Williamson

Nursing Theses and Capstone Projects

Case managers (CM) identify patients with high emergency department (ED) utilization and barriers to healthcare services. CM interventions need to be evaluated related to high ED utilization, identification of effective interventions, and improving patients’ self-management skills. Current literature supports the review and implementation of identified CM interventions to reduce non-emergent ED utilization, and improved patients’ health literacy, and self-management abilities. There is a lack in research related to CM perceptions’ of effective interventions to reduce ED utilization. The purpose of this study was to examine CM perceptions’ of patients’ low health literacy and self-management skills, identify barriers to self-care, and …

Evaluating The Discharge Process Improvement Initiative In Reducing The Length Of Stay, Maria Reina Ventura Siazon

Walden Dissertations and Doctoral Studies

Extended hospital length of stay (LOS) causes increased health care costs and incidence of never events, such as hospital-acquired infections, pressure ulcers, and falls, which are not reimbursed by Medicare. This study examined if there would be a statistically significant decrease in the LOS of patients after the implementation of a discharge process improvement initiative (DPII), The model for improvement and small tests of change concept were used to guide the DPII at a hospital in northern California. Sources of data included archival data obtained from the hospital's quality improvement department that showed LOS prior to and after the implementation …

Examining The Impact Of Hiv Medical And Social Case Management Program On Viral Load For Clients Living With Hiv/Aids In Nebraska, Abdulla Munir

Capstone Experience

Abstract

Case management (CM) is one of the standard practices that has been implemented since 1990 to help people living with HIV/AIDS (PLWHA) in the United States. The program is designed for low-income populations and it aims to address the barriers related to access to health care and improve the HIV outcomes. Previous studies identified a positive association with the provision of CM and improvement in viral outcomes. Increasing the viral suppression rates among HIV diagnosed individuals proved to reduce the risk of transmitting the infection, and disease incidence. Although CM program is provided to Nebraskans diagnosed with HIV, but …

Standardizing The Palliative Care Referral Process, Ronaviv M. Garcia

Master's Projects and Capstones

Standardizing the Palliative Care Referral Process

Problem: Heart failure (HF) is one of the most common causes of hospital admissions and emergency department visits in the United States. HF patients are at high risk for hospital readmission: 25% of HF patients discharged from the hospital are readmitted within 30 days of discharge, and 50% are readmitted within 6 months (Vedel & Khanossov, 2015).

Context: Palliative Care (PC) has been shown to be an effective way of managing distressing HF symptoms and thus of reducing hospital readmissions, yet patients are infrequently referred to PC services during their transition from hospital to …

Using Mhealth To Increase Treatment Utilization Among Recently Incarcerated Homeless Adults (Link2care): Protocol For A Randomized Controlled Trial, Jennifer M. Reingle Gonzalez, Michael S. Businelle, Darla Kendzor, Michele Staton, Carol S. North, Michael Swartz

Behavioral Science Faculty Publications

Background: There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive professional coordination of individualized care (ie, case management) during the period following their release from jail experience fewer mental health and substance use problems, are more likely to obtain stable housing, and are less likely to be reincarcerated. This is because case managers work to meet the various needs of their clients by helping them to overcome barriers to needed services (eg, food, clothing, housing, job training, substance abuse and mental health treatment, medical care, medication, social support, proof of identification, and legal aid). …

Rn Case Manager Case Consultation, Nancy A. Schug

Nursing Posters

Purpose:

Apply the Collaborative Care Management Practice Model to address:

• Complex transition planning
• Clinical progression
• Readmission risk

Promote professional growth

Increase knowledge of the ACMA Scope and Standards of Practice for RN Case Managers.

Use Of The Coleman Transition Model To Reduce Copd Readmissions, Sara Briggs

Doctor of Nursing Practice Projects

This paper explores the use of the Coleman Transition Model as an evidenced based intervention to reduce 30-day readmissions of Chronic Obstructive Pulmonary Disease (COPD) patients on a pulmonary unit. Nearly 20% of Medicare beneficiaries are re-hospitalized within 30 days after discharge, resulting in an annual cost of approximately $17 billion. Hospitals can engage in activities to lower their rate of readmissions. The evidenced based intervention includes robust case management using The Coleman Transition Model in hospitalized COPD patients to reduce readmissions. COPD is a prevalent, complex, and costly condition to manage. COPD is now the third leading cause of …

Causes Of Recidivism Among Mentally Ill Prerelease Offenders From The Perspective Of Former Correctional Mental Health Professionals, Rina Desiree Deneice Bradley Brown

Walden Dissertations and Doctoral Studies

The move toward reducing the prison population was driven by an increase in the number of reentry programs that focused on the needs of the offender, such as the provision of stable housing, employment, education, and sustaining strong familial bonds. While the literature supported these areas as being effective in reducing recidivism, there was no consensus that they were effective for offenders with mental illness (OMI). The purpose of this qualitative study was to analyze the impact of prerelease services for the OMI population from the perspective of former correctional mental health professionals who provided these services. The research questions …

Six-Month Post-Release Outcomes For Inmates With Traumatic Brain Injury In Supported Community Programming, Elizabeth O. Ahlers

Graduate School of Professional Psychology: Doctoral Papers and Masters Projects

Traumatic brain injury (TBI) is a serious public health issue. The incidence of TBI is much higher in the incarcerated population than in the general population, making this a uniquely vulnerable population. Methods: This study looks at data from the Jail Based Behavioral Health Services (JBBS) to examine recidivism rates among inmates participating in supportive programming. It also uses data from a state brain injury program to examine the impact of case management on community engagement in the justice-involved population with a history of brain injury. Results: Statewide data for a population of inmates who elect to participate …

Lessons Learned From The Quality Improvement Process In A Community Based Hospital: The Dissection Of Implementation Failure Of Use Of The Prism Mortality Risk Tool And Standardization Of Case Management To Reduce Readmissions In High Risk Patients, Mary K. Ziomkowski

Doctoral Projects

Hospital readmission, particularly within 30 days of discharge, is a wicked problem. Effective case management is an imperative component of high quality healthcare for the successful transition of patients across acute and post-acute settings. Patients with complex care needs endure an increased risk for negative outcomes, mortality, and hospital readmission. A small body of evidence suggests that early, targeted interventions aimed at high risk patients can mitigate complications and poor transitions. Patient complexity is an important consideration when establishing a comprehensive care management plan. Risk prediction tools are valuable for ensuring that high risk patients receive appropriate resource allocation. Case …

Characteristics Of Reported Symptoms Among Confirmed And Suspect Cases Of Zika Virus In Georgia, 2016, Ashton Thompson

Journal of the Georgia Public Health Association

Background: In May 2015, Zika virus was detected in Brazil. The virus has since spread through several countries in the Americas. Knowledge of the major symptoms of Zika virus infection was based on historic data from two previous outbreaks in the Pacific Islands. Currently-known Zika-specific symptoms include rash, conjunctivitis, arthralgia, and fever. Epidemiologists at the Georgia Department of Public Health (GDPH) began surveillance for travel-related Zika virus infections in January 2016. Surveillance data from GDPH contributes to better characterization of the current Zika clinical picture and more efficient triage of suspect cases for laboratory testing and prevention measures.

Methods: For …

Using Community Health Workers In Collaboration With Nurse Case Managers In Effecting Change In Quality Of Life For Heart Failure Patients, Patra Hull Reed

Doctor of Nursing Practice (DNP) Final Clinical Projects, 2016-2019

This project was designed to evaluate the effectiveness in improving the quality of life among heart failure patients with the addition of the role of Community Health Worker (CHW) to a current continuum case management model. The study also addressed the increased need for more appropriate and cost-effective chronic care management for heart failure patients. Hospitals and healthcare systems are being challenged to find innovative ways to decrease readmissions, decrease unnecessary emergency room visits, increase patient adherence, and manage chronic disease, all improving the patient’s overall quality of life. Studies show that approximately 76% of heart failure patients have a …

The Impact Of Intensive Case Management On Hospice Utilization, Debra Lowry Hummel

Doctoral Projects

Objective: The purpose of this study is to examine if patients enrolled in multi-disciplinary intensive case management program (ImPACT) alter the patient’s end-of-life path or setting of death.

Methods: The quality improvement project is a quantitative retrospective study that compared patients receiving standard primary care vs intensive case management (ImPACT) during 2/2013-1/2014. It is a secondary analysis of a larger study of a quality improvement evaluation that took place at the Veterans Administration facility in Palo Alto, Ca.

Results: Among the 82 patients who died, 19 were enrolled in ImPACT for approximately 249 days compared to 63 who received standard …

Effect Of Case Management On Frequency Of Emergency Department Visits By Persons With Mental Illness: A Systematic Review, Allison M. Stanton, Kayla C. Osoteo

Williams Honors College, Honors Research Projects

A problem in healthcare is the increasing number of emergency department visits by repeat users with a comorbid mental illness. These visits increase costs, patient wait times, demand for service, overcrowding, and fragmented care; they may decrease quality of care and effective treatment. The purpose of this study is to identify, review, and critically appraise the evidence about the effect of case management on repeat emergency department (ED) use in those with comorbid mental illness. A systematic review of 21 studies was performed. All explored mental illness, frequent visits to the ED, and interventions. These twenty-one studies were reviewed and …

Effect Of Home Telehealth On Vterans With Chronic Heart Failure, Yolanda Major

Walden Dissertations and Doctoral Studies

More than 5 million Americans have heart failure, with approximately 5% of those affected being veterans. As the number of patients with CHF continues to rise, new treatment options are needed to improve the quality of care. Current studies show Telehealth is one treatment option. The purpose of this scholarly project was to determine if veterans diagnosed with CHF were able to maintain optimal weight and blood pressure following participation in Care Coordination Home Telehealth (CCHT) program. The CCHT program provides care to veterans, through the use of monitoring devices placed in their home. Bandura's self-efficacy theory was used as …

Assessment Of Obesity As A Cardiovascular Disease Risk Factor In A Geriatric Rural Texas Community - A Six Month Follow-Up, Alberto Coustasse Md, Mba

Alberto Coustasse, DrPH, MD, MBA, MPH

Coustasse, Alberto, Assessment of Obesity as a Cardiovascular Disease Risk Factor in a Geriatric Rural Texas Community – A Six Month Follow-up. Master of Public Health Track, Public Health Administration, December 1999, 22 pp., 9 tables, 9 illustrations, bibliography, 7 titles. The health fair approach was used as a method to establish individual and population health status baselines and to provide a mechanism to follow-up with an elderly population in a rural Texas community. A controlled trial sample of forty-four seniors was initially screened in a primary care clinic in August 1998. Patients were reevaluated at six months and results …