Seamless Patient Care Research Articles

Spinal cord injuries: overcoming barriers to seamless care for patients.

Patients with spinal cord injuries (SCIs) often have complex needs that require multidisciplinary support in specialist centres. Optimal management depends on seamless transitions between service providers. Delays at any point potentially compromise clinical outcomes and efficient resource utilisation. The Spinal Advisory Working Group aims to develop and implement practical initiatives to improve SCI care, initially focusing on admission and discharge. A literature review identified few relevant papers. In addition, the generalisability of the findings of these papers to SCI centres in the UK is unclear. Therefore, further research is needed to, for example: establish best practice in the UK; quantify the associations between admission criteria and clinical and economic outcomes from a UK perspective; and determine the extent and impact of barriers that influence the transition of SCI patients between NHS care providers. Such research would enable the development of evidence-based strategies to overcome or minimise these barriers. In the meantime, pragmatic consensus guidelines would help standardise management, aid service optimisation, overcome inequities and, potentially, reduce bed blocking. The working group agreed that the robust inclusion and exclusion criteria developed by the Welsh Spinal Cord Injury Rehabilitation Centre could form the basis of a consensus guideline, to be piloted across the five SCI centres represented by members of the group.

Hospital information systems: experience at the fully digitized Seoul National University Bundang Hospital

The different levels of health information technology (IT) adoption and its integration into hospital workflow can affect the maximization of the benefits of using of health IT. We aimed at sharing our experiences and the journey to the successful adoption of health IT over 13 years at a tertiary university hospital in South Korea. The integrated system of comprehensive applications for direct care, support care, and smart care has been implemented with the latest IT and a rich user information platform, achieving the fully digitized hospital. The users experience design methodology, barcode and radio-frequency identification (RFID) technologies, smartphone and mobile technologies, and data analytics were integrated into hospital workflow. Applications for user-centered electronic medical record (EMR) and clinical decision support (CDS), closed loop medication administration (CLMA), mobile EMR and dashboard system for care coordination, clinical data warehouse (CDW) system, and patient engagement solutions were designed and developed to improve quality of care, work efficiency, and patient safety. We believe that comprehensive electronic health record systems and patient-centered smart hospital applications will go a long way in ensuring seamless patient care and experience.

The Oncology Care Model: A Critique

Rapidly increasing national health care expenditures are a major area of concern as threats to the integrity of the health care system. Significant increases in the cost of care for patients with cancer are driven by numerous factors, most importantly the cost of hospital care and escalating pharmaceutical costs. The current fee-for-service system (FFS) has been identified as a potential driver of the increasing cost of care, and multiple stakeholders are interested in replacing FFS with a system that improves the quality of care while at the same time reducing cost. Several models have been piloted, including a Center for Medicare & Medicaid Innovation (CMMI)-sponsored medical home model (COME HOME) for patients with solid tumors that was able to generate savings by integrating a phone triage system, pathways, and seamless patient care 7 days a week to reduce overall cost of care, mostly by decreasing patient admissions to hospitals and referrals to emergency departments. CMMI is now launching a new pilot model, the Oncology Care Model (OCM), which differs from COME HOME in several important ways. It does not abolish FFS but provides an additional payment in 6-month increments for each patient on active cancer treatment. It also allows practices to participate in savings if they can decrease the overall cost of care, to include all chemotherapy and supportive care drugs, and fulfill certain quality metrics. A critical discussion of the proposed model, which is scheduled to start in 2016, will be provided at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting with practicing oncologists and a Centers for Medicare & Medicaid Services (CMS) representative.

Application of home care in total hip replacement patients with minimally invasive OCM approach

Objective To explore the nursing effect of home care in patients with minimally invasive total hip arthroplasty(THA) in patients with minimally invasive surgery, and to provide comprehensive and seamless care for patients. Methods A total of 79 patients with THA were divided into observation group (38 cases)and control group(41 cases). The observation group received home care, including health education, telephone follow-up, home visits and other nursing measures. Control group followed the routine nursing education. Activity of Daily Living Scale(ADL), Functional Independence Measure(FIM) and Harris scores were compared between the two groups of patients when discharged and three months after discharge. Results In the observation group and the control group, the ADL, FIM and Harris scores were gradually increased at 3 months after discharge which had no difference when discharge(P>0.05). The ADL, FIM and Harris scores of the observation group were significantly higher than that in the control group at 3 months after discharge(P<0.01). Conclusions Implementation of home care can improve patients′ ability of daily life, the whole hip joint function recovery and hip function independence, thus it makes their quality of life better, achieving the goal of comprehensive rehabilitation. Key words: Elderly; Total hip arthroplasty; Rehabilitation; Quality of life; Home care

The Oncology Care Model: A Critique

Rapidly increasing national health care expenditures are a major area of concern as threats to the integrity of the health care system. Significant increases in the cost of care for patients with cancer are driven by numerous factors, most importantly the cost of hospital care and escalating pharmaceutical costs. The current fee-for-service system (FFS) has been identified as a potential driver of the increasing cost of care, and multiple stakeholders are interested in replacing FFS with a system that improves the quality of care while at the same time reducing cost. Several models have been piloted, including a Center for Medicare & Medicaid Innovation (CMMI)–sponsored medical home model (COME HOME) for patients with solid tumors that was able to generate savings by integrating a phone triage system, pathways, and seamless patient care 7 days a week to reduce overall cost of care, mostly by decreasing patient admissions to hospitals and referrals to emergency departments. CMMI is now launching a new pilot model, the Oncology Care Model (OCM), which differs from COME HOME in several important ways. It does not abolish FFS but provides an additional payment in 6-month increments for each patient on active cancer treatment. It also allows practices to participate in savings if they can decrease the overall cost of care, to include all chemotherapy and supportive care drugs, and fulfill certain quality metrics. A critical discussion of the proposed model, which is scheduled to start in 2016, will be provided at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting with practicing oncologists and a Centers for Medicare & Medicaid Services (CMS) representative.

From Cardiac Rehabilitation to Ambulatory Preventive Care: The Swiss Way

Over the last years, cardiac rehabilitation services have expanded their indication to include not just patients after myocardial infarction or surgery, but also a variety of non-acute cardiovascular disease (CVD) states like stable coronary artery disease, peripheral artery disease, neurovascular disease as well as asymptomatic patients with no history of CVD but with a constellation of cardiovascular risk factors, especially metabolic syndrome and diabetes mellitus. In 2015, 110 ambulatory cardiovascular prevention and rehabilitation programs existed in Switzerland: 57 for cardiac, 17 for peripheral artery disease and 36 for diabetes rehabilitation. Rehabilitative and preventive care is provided by a team of professionals including preventive cardiologists, exercise experts (physiotherapists and sports scientists), nurses, dieticians, psychologists, occupational therapists and social services experts. It seems reasonable to combine professional efforts by integrating prevention and rehabilitation for all high risk patients. The creation of cardiovascular prevention centers, which bring together professionals and patients in dedicated hospital or community settings is a promising first step. In 2015, 7 centers have been recognized as specialized cardiovascular prevention centers in Switzerland. Furthermore, community-based and patient-centered activities and programs have a great potential to contribute to improved preventive care and to support long-term adherence. A closer cooperation between professional preventive teams in prevention centers and the primary care physicians has a great potential to contribute to close this gap and to provide seamless primary and secondary preventive care for patients in need and the society.

Reducing hospital demand through community-based care

In 2010 and 2011 two deadly earthquakes struck the Canterbury region of New Zealand – placing even greater pressure on all parts of their health system. A new model of integrated care has helped Canterbury hospitals reduce the Average Length of Stay and readmission from elderly patients during the busy winter following these earthquakes. The Canterbury District Health Board (CDHB) predicted the region would run out of hospital beds by 2014 and fast-tracked its CREST programme. Community Rehabilitation Enablement Support Team (CREST) is a community-based rehabilitative supported discharge for older people. It also supports patients to be functionally independent to avoid future re-admissions. CREST is based on a collaborative care model, where a number of health professionals work together to manage care for the patient. The interdisciplinary CREST team consists of staff from Older Persons Health Specialist Services, community based care providers, general practitioners and allied health professionals. The Collaborative Care Management Solution (CCMS) is the shared information management platform for the programme. CCMS is used to enter and manage the patient’s care plan and goal ladder and any patient assessments, notes or medication information. The various healthcare providers responsible for the patient’s care – primary, secondary and community health professionals – can all access the information in real-time, make changes or updates and communicate with each other in a quick and efficient way. With CREST, clients improve their ability to function independently and the need for residential care or long-term home care is reduced. From a funding perspective, CREST uses a different funding model that is based on an alliance arrangement between the care providers and the funder. Care is funded for a team delivering the service and health outcomes, not for individual outputs. Each patient has a team of providers surrounding them, coordinating their care, and keeping them out of hospital. Data from CCMS is used to support a quality improvement process across all care providers involved and is critical to improving patient outcomes. CREST was introduced in April 2011, and more than 1,700 patients were kept out of hospital in the first year of the programme. More than 4,000 people have had their hospital length of stay reduced by management in the programme without a subsequent increase in readmission rates. Other benefits include better communication and teamwork, seamless care for patients, a reduction in errors and time savings. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116624– http://www.ijic.org/ The results speak for themselves. Demand for community aged-care dementia services increased by 6.6%, while demand for rest home care fell 6.7% and hospital care remained stable between 2011 and 2012. The region’s spending on aged care fell from $22.25 million in 2010 to $21.9m in 2011 as demand moved to more appropriate community care settings. CREST has since been extended to accept referrals directly from GPs, avoiding a hospital admission altogether. This presentation will outline learnings from this successful rehabilitation and admission avoidance service that could be adapted for managing older persons’ health in other countries, including the paradigm shift needed to implement a new model of community-based care.

Dependable Online Appointment Booking System for Nhis Outpatient in Nigerian Teaching Hospitals

The number of missed appointments in healthcare institutions in Nigeria caused problems, hence the need for integrated healthcare system to intervene and provide seamless care for patients. Appointment scheduling system lies at the intersection o f providing efficiency and timely access to health services. This research presents an online National Health Insurance Scheme (NHIS) Outpatient Medical Appointment Booking System where NHIS patients can access and view any available personnel or doctor scin order to book an appointment with the corresponding time as specified by the available doctor. The system was developed using PhP, macromedia dreamweaver, apache and MYSQL. This is to ensure that the application is robust, cheap and is able to ru n on different platforms. The system provides the platform to facilitate the booking and management of patients’ appointment bookings. Patients can also view their appointment reports. It also provides the healthcare workers an easy access to manage patie nts’ appointments and to generate relevant reports.

Hospital nurses' and physicians' use of information sources during their production of discharge summaries: a cross-sectional study.

Hospital nurses' and physicians' production and exchange of accurate information between levels of care are crucial for ensuring safe and seamless care for patients in transition. We report on a study in which we explored hospital providers' use of information sources when they prepared discharge information for colleges in the community health-care sector. In this cross-sectional study, 510 nurses and 236 physicians responded through a questionnaire. Our findings show that nurses and physicians use different information sources in patient records when they produce their discharge summaries.

Application of responsibility system holistic nursing care in the whole-course nursing mode

Objective To study the effect of responsibility system holistic nursing care on the perioperative patients in hepatobiliary surgery department.Methods Responsibility system holistic nursing care was performed in hepatobiliary surgery ward such as reformed the care mode,improved the working process,implemented grading nursing,scientific human configuration and perfected care quality supervision system and so on.Patients' specialist knowledge and understanding of the disease,patients' satisfaction,patients' awareness of primary nurses,score of nursing quality,direct nursing hour,nursing documents writing time were observed and compared before and after the nursing care was implemented.Results After the responsibility system holistic nursing care implemented,patients' specialist knowledge and understanding of the disease were significantly improved than that of before it implemented ( P ＜ 0.05 ).Patients' satisfaction and their awareness of primary nurses was 98.22％ and 93.96％,respectively,and significantly higher than 96.22％ and 89.67％ of before ( P ＜0.05).The score of nursing quality including the nursing of critically ill patients (98.00 ± 1.22),the technique of first aid (96.56 ± 1.22),basic nursing (99.10 ±0.22),disinfection and isolation (99.30 ±0.22 ) was significantly higher than (91.58 ± 1.22),(90.70 ± i.22 ),(91.84 ± 1.22 ),( 83.72 ± 1.22 ) that of before( P ＜ 0.05 ).After the care was implemented,direct nursing hour and nursing documents writing time was (368 ± 12 )min and( 20 ± 4)min,respectively,and that of before was( 329 ± 21 )min and (49 ± 11 )min,and the difference was statistically significant ( P ＜ 0.05 ).Conclusions The implementation of responsibility system holistic nursing care can provide comprehensive,full,professional,seamless care for patients and promote their perioperative safety and comfort,improve the satisfaction of patients and families. Key words: Patients' satisfaction; Nursing quality; Responsibility system holistic nursing care; Whole-course nursing mode

Chronic Kidney Disease in Canada's First Nations: Results of an Effective Cross-Cultural Collaboration

Chronic kidney disease (CKD) is a serious and growing threat to our First Nations peoples' health. Current evidence indicates more rapid progression of CKD in First Nations populations, leading to markedly increased morbidity and mortality. To address this serious health issue, three First Nations communities, Alderville, Hiawatha and Curve Lake, partnered with the Central East Local Health Integration Network (LHIN), the Peterborough Regional Health Center (PRHC) and local family and specialist physicians. A screening tool was developed based on reported best practices to screen all community members over the age of 19 years for CKD. A unique, highly efficacious project algorithm and an electronic database were created to ensure appropriate, seamless patient care and management in this complex, multi-stakeholder environment based on client risk and CKD stage. Over the course of nine months, the project succeeded in screening 83% of all community members over the age of 19 years; 30% of clients were found to have CKD stage two or greater. A strong correlation was found between diabetes and CKD in project participants. A significant number of clients were referred for specialist care. Critical to the success of this project was the effort made to develop collaborative partnerships among five stakeholder groups: the First Nations communities, the LHIN, PRHC, local family physicians and specialist physicians.

Promoting interprofessional care in the peri-operative environment

One of the key aspects of successful collaborative working is the relevant and effective exchange of information between professionals. Boundaries exist not only between health and social care in a community setting, but also in acute care between and within departments and professions. Patients continuously cross these boundaries during transfers and transitions, when nurses interact with other professionals and are in a prime position to demonstrate exemplary interprofessional relationships and seamless patient care to other staff and to students. Mentors act as role models for students of all professions and are expected to promote opportunities that will maximise student learning and enhance patient care. This article provides mentors with some suggestions for maximising these opportunities. Mentors are encouraged to reflect on practice-based learning opportunities for students, particularly situations that are challenging and involve critical judgement. The article focuses on learning opportunities in the peri-operative department, however the same challenges are experienced in other clinical areas and the principles of good interprofessional care can be applied to any team that aspires to work collaboratively.

Verification of Death by Nurses in Community Care Settings

The involvement of healthcare professionals, including nurses, does not stop once a patient has died. Caring for dying people at home requires the use of care pathways that include care after death. Nurses are the health professionals most commonly present at the time of a patient’s death. They are therefore ideally placed to verify that a person has died and provide support and information to the bereaved. Developing a local policy and training programme regarding verification of death supports health professionals, helps to avoid potential legal pitfalls and ensures standard procedures are followed. Having a policy in place promotes seamless care for patients and relatives, avoids delays after a patient has died and creates confidence in staff members undertaking the verification of death. This article will examine the procedures associated with verifying a patient’s death, the legal and clinical requirements, issues associated with expected and unexpected death and when to involve the coroner, spiritual and cultural concerns and information required by relatives. Conflicts of interest: none

Potential scope and impact of a transboundary model of nurse practitioners in aged care

Aged care is a growing issue in Australia and other countries. There are significant barriers to meeting the health needs of this population. Current services have gaps between care and lack communication and integration between care providers. Research was conducted in the Australian Capital Territory to investigate the potential role of the aged care nurse practitioner in health service delivery in aged care settings. A multimethod case study design was utilised, with three student nurse practitioners (SNP) providing care to aged care clients across three sectors of health service delivery (residential aged care facilities, general medical practices and acute care). Data collection consisted of in-depth interviews and journal entries of the SNP, as well as focus groups and surveys of multidisciplinary staff and patients over the age of 65 years in the settings frequented by the SNP. The aged care SNP were found to cross professional and organisational boundaries, cross intra- as well as interorganisational boundaries and to contribute to more seamless patient care as members of a multidisciplinary aged care team. The aged care nurse practitioner role consequently has the potential to function in a networked rather than a hierarchical manner, and this could be a key element in addressing gaps in care across care locales and between disciplines.

Doctors managing in primary care: An international focus

AbstractAs well as looking after their patients and running their own small businesses, family doctors have to build and sustain an increasingly complex web of long-term relationships. These doctors require an independent entrepreneurial spirit as well as an ability to influence others without having direct authority over them. They also need to be politically astute, to understand 'the big picture' of how health services function as a whole, but also be able to work through the detail to ensure seamless patient care. Finally, given the nature of primary care, and its place in healthcare systems, this paper concludes that those doctors who are by nature problem-solvers, tolerant of ambiguity and inherent optimists are those who thrive best in this particular management environment. The paper draws its arguments from the organisational context of health services and the position of primary care doctors within that system. It examines the future in terms of emerging health service trends and wider societal ...

Doctors managing in primary care: An international focus

As well as looking after their patients and running their own small businesses, family doctors have to build and sustain an increasingly complex web of long-term relationships. These doctors require an independent entrepreneurial spirit as well as an ability to influence others without having direct authority over them. They also need to be politically astute, to understand 'the big picture' of how health services function as a whole, but also be able to work through the detail to ensure seamless patient care. Finally, given the nature of primary care, and its place in healthcare systems, this paper concludes that those doctors who are by nature problem-solvers, tolerant of ambiguity and inherent optimists are those who thrive best in this particular management environment. The paper draws its arguments from the organisational context of health services and the position of primary care doctors within that system. It examines the future in terms of emerging health service trends and wider societal pressures. This leads to an analysis of the key management competences. What does it take to manage as a doctor in primary care and how can doctors prepare themselves for this role?

Under Surveillance, Yet Looked After: Telehomecare as Viewed by Patients and Their Spouse/Partners

In this research project, a group of heart patients were transferred from traditional hospital settings to home hospitalisation across sectors. The project involved patients with heart failure and arrhythmia. The aim was to understand the experiences and attitudes of patients and their spouses/partners with regard to the application of telehomecare technology as an option within home hospitalisation. A phenomenological hermeneutic approach was used to collect and interpret the findings and data. A triangulation of data collection techniques was applied using participation observation and qualitative interviews with patients and spouse/partner. Data were analysed from the perspective of the sociology of everyday life. The impact of home hospitalisation on patients is described according to several themes: security, freedom, increased awareness of own symptoms, being 'looked after' but annoyed with their spouse/partner. The patients experience a seamless cross-sector patient care process. The impact on the spouse/partner includes elements of increased responsibility, nervous tension, and invasion of privacy. Patients believe that home hospitalisation speeds up the process of returning to everyday life, both physically and mentally. It is important to be aware of certain anxieties experienced by the patient's spouse/partner about home hospitalisation, and these anxieties may also affect the patient.

A Multidisciplinary Model of Care for Childhood Cancer Survivors With Complex Medical Needs

Long-term survival for children with cancer is often achieved at a considerable cost in terms of medical and psychological sequelae. Although many survivors are well and require only routine follow-up and surveillance, a cohort of survivors require comprehensive management of complex, chronic medical issues by multiple subspecialists. For these survivors, care delivered within the context of an annual visit to a traditional hospital-based late effects clinic or by a primary care physician in the community is often not adequate. A specialized clinic was implemented at The Children's Hospital of Philadelphia that crosses disciplines and provides same-day, same-clinic access to oncology/survivorship, endocrinology, pulmonology, cardiology, nutrition, and psychology. This multidisciplinary approach supports clinical efficiency and fosters seamless patient-centered care both for patients with identified late effects and for those with the highest risk for problems because of intense treatment exposures. The model is described with a focus on clinic structure/process, clinical outcomes, and benefits to survivor, health care provider, and institution. The diverse roles for nursing within this model are highlighted.

Implementation of telehomecare technology: impact on chronically ill patients, healthcare professionals and the healthcare system

The findings in the study of diabetes patients showed that the use of DiasNet helped the patients gain an insight into their own disease as well as increasing their disease self-management skills. The project brought about changes in the tasks and duties performed by all professional groups in the diabetes team. Findings among the heart patients were as follows: Firstly, during the design and implementation phases of a telehomecare system, several types of controversies emerged as part of the inter-organisational and inter-professional agenda. These controversies involved competing claims of jurisdiction, controversies over knowledge technologies, or differences in network visions and network architecture. Secondly, the clinical decision-making and task-implementation became multidisciplinary and integrated with the implementation of telehomecare and was therefore complex in terms of the prescription and adjustment of patient medicine. Workflows between healthcare professionals across sectors changed from sequential to collective client flows. Pre-existing procedures for patient care, treatment, and responsibility were challenged. In addition, the number of tasks for the district nurses increased. Integration in the carrying out of clinical tasks increased fragmentation in the knowledge technologies in a network perspective. Thirdly, there was an impact on patients during home hospitalisation in terms of security, freedom, increased awareness of own symptoms, being ‘looked after’ but annoyed with their spouseypartner. The patients experienced a seamless cross-sector patient care process. The impact on the spouseypartner involved responsibility, nervous tension, and invasion of privacy. For the readers of the IJIC, it is of special interest to learn in the case of the diabetic patients that the use of a web-based Diabetes Insulin Advisory System gave the patients an insight into their own disease as well as increasing their disease self-management skills. The diabetes team experienced changes in their tasks and duties. Among the heart patients, we can discern emerging controversies in the design and implementation process when using telehomecare technology. These issues should be taken into account when initiating a

Care closer to home: past mistakes, future opportunities.

The Government White Paper on improving community health and care services (Our Health, Our Care, Our Say) proposes shifting care within particular specialties from hospital into community settings. The intention is to provide seamless care for patients when and where they want it, in more local and convenient settings. Professionals in primary and secondary care will need to respond by developing new ways of working to enable this policy to be effective. In this paper, we discuss the evidence of the effect of initiatives during previous health care reconfigurations to shift the balance of power from secondary to primary care. We also suggest a partnership model for primary and secondary care clinicians and discuss the potential advantages of working practices across the primary-secondary care divide. Summary Shifting care within particular specialties into community settings is emphasized in the Government's recent White Paper; Two innovations in recent years involving the primary-secondary health care interface have been specialist outreach clinics and general practitioners (GPs) with specialist interests; Both models demonstrate increased levels of patient satisfaction, but may not be cost-effective; It is essential that mistakes of the past are not repeated, but opportunities for better integration of primary and secondary care are not missed.