The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admission: a systematic review protocol

Patient satisfaction and hospital re-admission rates are the two major outcomes for measuring quality of healthcare delivery. Interdisciplinary collaboration, a concept that describes coordination of care between multiple healthcare professionals and patients and families to deliver the highest quality of care across settings, is fundamental to improving patient outcomes. Home hospice care is palliative in nature and is a critical segment of patient care. To date, no systematic review has been undertaken to determine the effectiveness of structured interdisciplinary collaboration in the home hospice setting in relation to patient satisfaction and hospital readmission. The aim of the review was to synthesize the best available evidence on the effectiveness of structured interdisciplinary collaboration on patient satisfaction and hospital admission and re-admission rates for adults receiving home hospice services. Adults, male and female (18 years old or older), receiving home hospice services or transitioning from hospital to home hospice servicesThe studies that evaluate interdisciplinary collaboration among the hospice team providing home hospice services in the home care settingsIn this review, randomized controlled trials and quasi-experimental studies were considered for inclusion.Patient satisfaction and all cause hospital admissions and re-admission rates. Published and unpublished literature in the English language was sought from the inception of the databases through August 15, 2014. The databases searched included: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Nursing & Allied Health Source, Health Source: Nursing/Academic Edition and ProQuest Health Management. A search of grey literature and any relevant homecare/hospice websites was also performed. There were no studies located that met the inclusion requirements of this review. There were no text or opinion pieces that were specific to structured interdisciplinary collaboration among the hospice team in home care settings on patient satisfaction and hospital readmission. There is currently no evidence available to determine the effectiveness of structured interdisciplinary collaboration among hospice teams in home care settings in regard to patient satisfaction and hospital readmission. No conclusive recommendations can be made regarding the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission. Quantitative and qualitative research studies are urgently required to determine the effectiveness of structured interdisciplinary collaboration among home hospice teams in home care settings in regard to patient satisfaction and hospital readmission.

It Is Possible

In this issue, Kaboli and colleagues examined the relationship among hospital length of stay, readmission rates, and mortality for more than 4 million veterans hospitalized in Veterans Affairs acut...

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

Review questions/objectives The objective of this systematic review is to synthesise the best available evidence on the impact of the effectiveness of delegation interventions by the registered nurse (RN) to the unlicensed assistive personnel (UAP) and their impact on quality of care, patient satisfaction, and RN staff satisfaction. Inclusion criteria Types of participants The review will consider studies that include RNs and unlicensed assistive personnel in any patient care setting where delegation by the RN to the UAP occurs. For the purposes of this systematic review we will use the following definitions: Registered nurse: A person that has graduated from a nursing program and has been licensed to practice. Unlicensed assistive personnel: Persons that are in a position to assist the RN under the registered nurse’s direct supervision. Activities are generally restricted to patient care activities delegated to them by the RN based on the nursing process. Types of interventions This review will consider studies that evaluate the effectiveness of delegation interventions by the RN to the UAP and their impact on quality of care, patient satisfaction, and RN staff satisfaction. For the purposes of this systematic review we will use the following definition: RN-UAP delegation: “Entrusting the performance of a selected nursing task to an individual who is qualified, competent, and able to perform such tasks. The nurse retains the accountability for the total nursing care of the individual”. Comparator The comparator is to that of usual nursing cares delivery. Types of outcomes The outcomes to be examined are quality of care, patient satisfaction, and RN staff satisfaction measured by validated and reliable tools. Validated and reliable measurement tools are considered measurement tools that have been previously tested and found to have acceptable psychometric properties. TRUNCATED AT 350 WORDS

Public Awareness and Perceptions of Palliative and Comfort Care

A systematic review and meta-analysis on the association between quality of hospital care and readmission rates in patients with heart failure

HOSPITAL READMISSION IS COMMON AND EXPENsive, and longstanding variations in readmission rates nationwide suggest that the system of transitional care is flawed. The Centers for Medicare & Medicaid Services (CMS) began publicly reporting hospital readmission rates in 2009, leading hospitals and health care professionals to devote considerable attention and resources to reducing both readmission rates and disparities. The prospect of bundled payments for episodes of care, as described in the Patient Protection and Affordable Care Act of 2010, has further intensified this focus. Hospitals large and small have joined national initiatives, such as Hospital to Home, to exchange best practices, and they have been inundated with promising but largely unproven solutions for reducing readmission rates. In this issue of JAMA, Joynt and colleagues describe racial disparities in hospital readmission rates for 3 major clinical conditions and in so doing highlight a major challenge facing policies that reward and penalize hospitals on the basis of readmission rates. Using national Medicare data, the authors found that risk-adjusted 30-day readmission rates for heart failure, myocardial infarction, and pneumonia were higher for black patients than for white patients, even after adjustment for the proportion of patients at each site who were black, hospital teaching status, and other structural characteristics. The disparities also remained after adjustment for the proportion of patients covered by Medicaid at each site—a limited surrogate of socioeconomic status and financial stress. Moreover, readmission rates for heart failure and myocardial infarction were higher for white patients at minority-serving hospitals (ie, hospitals with relatively high proportions of black patients) than for black patients at non–minority-serving hospitals. Based on these findings, the authors conclude that financial incentives based on readmission rates may unfairly penalize minorityserving hospitals and thereby widen the gap in care for disadvantaged minorities. The study raises important questions about the unintended consequences of policies designed to improve the quality of health care. The Institute of Medicine’s landmark 2002 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report elevated the problem of racial and ethnic disparities to a national priority. Black patients are less likely to receive cardiovascular procedures, such as placement of implantable cardioverter-defibrillators, and are more likely to die of cardiovascular disease. Black patients are more likely to receive care at hospitals that provide lower quality of care, suggesting that hospitals have a large role in explaining disparities in care. There is some evidence that diseasebased quality-improvement programs reduce disparities, but a comprehensive approach to eliminating disparities has not been identified. Whether 30-day readmission rates are a good measure of hospital quality remains a subject of debate. According to one view, hospital readmission reflects a failure of the health care system. Patients are discharged without a complete understanding of their disease, including how to manage symptoms, when to take medications, and when and how to access follow-up care. Patients discharged to skilled nursing facilities are dependent on systems of care in place at those settings. According to another view, hospital readmission reflects factors that are intrinsic to a population of aging patients with complex disease processes, a high burden of comorbidity, impaired functional status, and limited social support. In this view, hospital readmission is not a failure, but is the right care at the right time. The risk models currently used by CMS to compare hospital outcomes do not incorporate race or socioeconomic status, even though prior studies have shown that both factors are associated with a higher risk of readmission. If quality of care differs by race, then excluding race from the risk models appropriately incentivizes hospitals and reinforces that disparate care is unacceptable. On the other hand, if race is a proxy for socioeconomic status and other factors unrelated to the system of care, exclusion of race from the risk models unfairly penalizes hospitals that care for vulnerable populations. The addition of financial penalties for hospitals treating vulnerable populations may paradoxically worsen care coordination and exacerbate health disparities. Because both sides are correct, a more progres-

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

PC-FACS

Less stick, more carrot: measuring and improving patient satisfaction with endoscopic procedures

Developing strategies for predicting and preventing readmissions in vascular surgery

InMay 2014, the Secretary of Defense ordered a comprehensive review of the Military Health System (MHS), which was published in August 2014. In brief, the MHS includes over 50 inpatient medical treatment facilities and provides care for 9.6 million beneficiaries, spending more than $50 billion per year. Approximately 22% of the MHS beneficiaries are over the age of 65, which parallels the civilian sector. The review focused on issues including quality of care and patient satisfaction in hopes of providing direction on how to improve the MHS. Although not mentioned in the report, providing inpatient and outpatient palliative care services is one important way to improve the MHS. Palliative care is specialized medical care with the goal to improve a person’s quality of life by relieving pain, symptoms, and the stress associated with serious illness. According to the World Health Organization, “Palliative care is a [team based] approach that improves the quality of life of patients and their families facing the problem[s] associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” Currently, the MHS has only two palliative care teams across all of its 56 facilities: one at Walter Reed National Military Medical Center and the other at Madigan Army Medical Center. Although the MHS is a leader in trauma and point of injury care, we are lagging far behind the Veterans Health Administration (VHA) and the civilian sector in providing essential palliative care services to our patients. The Veterans Healthcare Eligibility Reform Act of 1996 mandated that the VHA offer hospice and palliative care services to all veterans. Subsequently, in 2003, the VHA released a directive instructing all VHA facilities to formmultidisciplinary palliative care consult teams. Since 2003, the VHA has been providing robust palliative care services to our veterans, and by 2007, 42% of all veterans who died as VHA inpatients had received a palliative care consultation. Nationwide in the civilian sector, approximately 61% of hospitals with 50 or more beds provided hospital-based palliative care in 2012. Quality of life is paramount in palliative care, with an emphasis on symptom management, as well as spiritual and psychosocial well-being. Palliative care services are appropriate for patients of any age with a chronic or life-limiting illness. Most health professionals erroneously equate palliative care with hospice, believing it is synonymous with end-of-life care; however, it can and should be provided in conjunction with curative therapy at any point in an illness. To improve the quality of care and patient satisfaction, while reducing total cost, it is imperative for the MHS to incorporate palliative care services into its medical treatment facilities. Palliative care is interdisciplinary, with teams comprised of physicians, nurses, social workers, and chaplains as well as other disciplines. The interdisciplinary team supports patientcentered care, and fosters informed patient and family decision making. The team also assists in the coordination of services across care settings, such as home care and hospice. With more and more beneficiaries living with chronic and life-limiting diseases, the need for palliative care is only going to become more pressing. These patients will need palliative care clinicians with specialized training in pain and symptom management. Poor symptom management is associated with poor quality of life, and in turn, poor patient and family satisfaction. Hospital-based palliative care programs have been shown to improve symptoms and patient satisfaction, decrease total hospital costs, and, in some diseases, improve survival. Patients with metastatic non-small cell lung cancer given standard oncologic care plus early palliative care lived approximately 2 months longer than patients only given the standard oncologic care. A review done by El-Jawahri et al. examined 22 randomized controlled trials and concluded that palliative care services were associated with improvements in patients’ quality of life, family caregiver outcomes, satisfaction with care, and quality of care delivered at the end of life. Other research has shown that patients who receive palliative care report improved symptom management, improved prognostic understanding, and are less likely to receive chemotherapy near the end of life when chemotherapy is most risky and least beneficial. Lower rates of hospital admissions and decreased Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814. The views expressed in this article are those of the author and do not reflect the official policy of the Departments of the Army/Navy/Air Force, the Department of Defense, or the U.S. Government. doi: 10.7205/MILMED-D-15-00047

Value-Based Care: An Executive Briefing

Objective: There is a presumption that hospital readmission rates amongst persons aged ≥65 years are mainly dependent on the quality of care. In this study, our primary aim was to explore the association between 30-day hospital readmission for patients aged ≥65 years and socioeconomic characteristics of the studied population. A secondary aim was to explore the association between self-reported lack of strategies for working with older patients at primary health care centres and early readmission.Design: A cross-sectional ecological study and an online questionnaire sent to the heads of the primary health care centres. We performed correlation and regression analyses.Setting and subjects: Register data of 283,063 patients in 29 primary health care centres in the Region Örebro County (Sweden) in 2014.Main outcome measure: Thirty-day hospital readmission rates for patients aged ≥65 years. Covariates were socioeconomic characteristics among patients registered at the primary health care centre and eldercare workload.Results: Early hospital readmission was found to be associated with low socioeconomic status of the studied population: proportion foreign-born (r = 0.74; p < 0.001), proportion unemployed (r = 0.73; p < 0.001), Care Need Index (r = 0.74; p < 0.001), sick leave rate (r = 0.51; p < 0.01) and average income (r = −0.40; p = 0.03). The proportion of unemployed alone could explain up to 71.4% of the variability in hospital readmission (p < 0.001). Primary health care centres reporting lack of strategies to prevent readmissions in older patients did not have higher hospital readmission rates than those reporting they had such strategies.Conclusion: Primary health care centres localized in neighbourhoods with low socioeconomic status had higher rates of hospital readmission for patients aged ≥65. Interventions aimed at reducing hospital readmissions for older patients should also consider socioeconomic disparities.Key PointsIn Sweden, hospital readmission within 30 days among patients aged ≥65 has been used as a measure of quality of primary care for the elderly.However, in our study, elderly 30-day readmission was associated with low neighbourhood socioeconomic status.A simple survey in one Swedish region showed that the primary health care centres that lacked active strategies for working with aged patients did not have higher hospital readmission rates than those that reported having strategies.Interventions aimed at reducing elderly hospital readmissions should therefore also consider the socioeconomic disparities in the elderly.