Informatics’ Role in Integrating Population and Patient-level Knowledge to Improve Care Transitions in Role of nurse in care of elderly patient pdf Chronic Disease. Abstract Hospital discharges are times of increased vulnerability for people with chronic disease and often result in costly re-hospitalizations because of inadequate care coordination.
Although population and patient-centered models of complexity use different data sources, definitions, and methods, they share hospitalization rates as an outcome measure. Keywords: chronic disease, care coordination, severity of illness, care transitions, population health, health informatics. At the population level, existing claims support that information can be used to identify patients with multiple chronic diseases who have a high risk of readmission. Table 1 compares three population segmentation hierarchies. Nurses and pharmacists, supported by a claims-based electronic health record and alerts for complex cases, made outreach phone calls to recently discharged patients.
Avoided admissions are calculated by subtracting the 2009 hospitalization rate from the 2008 rate and multiplying by number of cases in the disease category, then dividing by 1,000. The CSCIM links individual and population levels and suggests that more complex segments of the population have differing needs for health services and integration of care. Role of Health Informatics Informatics can support the integration of population and individual level data about chronic disease complexity. Patient-centered information is increasingly available in the form of EHRs. EHRs are utilized in many primary-care offices and hospitals. Meaningful use currently requires the ability to develop registries for chronic disease and report on each quality measure.
In the hospital setting, nurses are not truly doctor’s assistants. At the population level, nurses implement the nursing care plan using the nursing process. The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. A nurse may have to choose between the duty to provide safe patient care and protecting the nurse’s own life during an emergency, standards and Authorized Duties for CNAs and CMAs. Total Number of Professionally Active Nurses, the practitioner must hold a current and valid registration with the Nursing and Midwifery Council.
The study found that readmissions were reduced by three percent at 30 days and by six percent at 120 days in the telehomecare group, although the difference was not statistically significant. However, people in the intervention group showed significantly higher satisfaction regarding their care. Unless the patient informs the office about a hospitalization, there is no action taken until the individual returns for an office visit. Thus, the opportunity for immediate education to correct misconceptions, medication reconciliation, and provision of additional supports is lost. Most hospitals have the ability to generate an electronic record of the patients discharged from their facility in the past 24 hours. Improving Decision Support in Primary Care This leads to a final informatics approach: development of a decision-support tool to assist in management of the most complex cases.
Based on Peek’s work on complexity domains, we know that the presence of chronic disease or even multiple chronic diseases is only one source of complexity. Integrating Individual and Population Knowledge A nurse care-coordinator in the primary care office would have access to the EHR, timely notification of discharge, awareness of pre-existing complexity, and population knowledge to prioritize outreach. An initial phone call could include assessment of how the patient is managing and what knowledge the patient has about the course of the hospitalization and the ongoing treatment. Conclusion The CSCIM demonstrates how informatics can improve information transfer at the time of care transitions. Care-transitions research continues to expand the types of approaches and the populations addressed.