FEATURE
Reducing the Rate of Rehospitalization from Postacute Care: A Quality Improvement Project
Cynthia Jacelon1,2, PhD, RN-BC, CRRN, FAAN, Barbara Macdonald3, MS, RN, GCNS-BC, Fran Fitzgerald4, RN & Quality Council 1 College of Nursing, University of Massachusetts, Amherst, MA, USA 2 Jewish Geriatric Services, Longmeadow, MA, USA 3 Julian J. Leavitt Jewish Nursing Home, Longmeadow, MA, USA 4 Spectrum Home Health & Hospice Care, Longmeadow, MA, USA
Keywords
Abstract
Rehospitalization; long-term care; skilled care; home health care. Correspondence Cynthia Jacelon, College of Nursing, University of Massachusetts, 126 Skinner Hall, 651 N. Pleasant St. Amherst, MA 01003. E-mail: [email protected] Accepted July 4, 2014. doi: 10.1002/rnj.176
Purpose: To evaluate rehospitalizations and develop a strategy to reduce the number of individuals sent back to the hospital within 30 days of admission from postacute care services including skilled care, long-term care, and home care. Design: Using the Plan, Do, Study, Act (PDSA) format outlined by the Institute for Healthcare Improvement, we implemented and evaluated a quality improvement project. Methods: The number of rehospitalizations was calculated and chart audit was used to determine the reasons. Interventions were designed to decrease the number of reasons individuals had to return to the hospital. Findings: Five rehospitalizations were deemed preventable. Interventions were designed to improve staff knowledge. Conclusions: The effectiveness of interventions and rehospitalization rates continue to be monitored. The rehospitalization rates from these agencies are low. Low rehospitalization rates are good for clients and improve desirability as a source for care posthospitalization. Clinical Relevance: Understanding causes for rehospitalization, providing skills and knowledge aimed at the root causes of hospitalization, and reducing the rate of rehospitalization improves nursing practice and reimbursement.
Introduction Recently, much attention has been given to the issue of rehospitalization. However, most of the focus has been on hospital discharges and how acute care providers can reduce the incidence of rehospitalization. Less attention has been given to how postacute care agencies can affect the process. Using the Model for Improvement (Langley et al., 2009) to guide the process and the Jewish Geriatric Services – Chronic Care Model (JGS-CCM) (Jacelon,
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Furman, Rea, Macdonald, & Donoghue, 2011) as a framework, we evaluated rehospitalizations and developed a strategy to reduce the number of individuals we ought to send back to the hospital within 30 days of admission to postacute services. The Model for Improvement was developed to provide an easy, effective guide to accelerate the improvement process in healthcare institutions (Institute for Healthcare Improvement [IHI], 2014b). It includes a set of questions to define the improvement project, and a cyclical process
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with four steps to guide the improvement process (Langley et al., 2009). The defining questions are: “What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?” (p. 24). The steps to the improvement process include Plan, Do, Study, and Act (PDSA) (p. 98–99). Each of the steps in the quality improvement process will be described below as we describe the process used to reduce the rate of return to the hospital for newly admitted residents and clients. Plan The first step in the process is planning. According to Langley et al. (2009), the planning step of the quality improvement project includes determining who will be on the team, the aim of the project, and how and when data will be collected. Selecting the Team To create an effective team, the team must have three types of members: system leaders, technical experts, and day-today leaders (IHI, 2014b). The leadership of the healthcare system charged the Quality Council with exploring rehospitalization from the perspective of postacute care, including skilled and long-term care units and a visiting nurse agency. The Quality Council is a systemwide team of nurses with representatives from each entity of the postacute care system. They are responsible for monitoring and implementing quality initiatives across the system. The council members chose three key people to lead the rehospitalization initiative. The chosen group was comprised of the Scholar in Residence (Jacelon, Donoghue, & Breslin, 2010) who was an expert in rigorous process, had systemwide authority, and would oversee the project; the Director of Quality from the long-term care facility; and the nursing supervisor for the home care agency. Both the Director of Quality and the nursing supervisor had technical expertise and were the day-to-day leaders in their respective system entities. The project sponsor, the system leader who had the executive authority to support the project, was the Chief Nursing Officer (IHI, 2014b). The Scholar in Residence is a doctorally prepared nurse scientist who, as part of her faculty position, spends 1 day each week at the facility to build geriatric nursing capacity both in the clinical areas and in academe. The Scholar in Residence engages in advanced geriatric nursing practice and
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scholarship and provides leadership in the promotion of clinical excellence. (Jacelon et al., 2010).
Setting Aims: What are We Trying to Accomplish? Once the team was established, we focused on the first question in the PDSA cycle. The team was interested in determining (1) the rehospitalization rate for the nursing home and the home care agency, and (2) what the nursing staff could do to reduce the rate. We realized that before we could determine the specific aim, we needed to review the literature to determine the scope of the project and what was known about rehospitalization from the perspective of postacute care. The Literature The problem of rehospitalization for older adults has recently come into the spotlight. Frail older adults are discharged from the hospital after an acute illness and as many as 27% of those people receiving home care (Delta Health Technologies, 2012) and 23.5% (Berkowitz et al., 2011) of those discharged to skilled care are readmitted to the hospital within 30 days. This revolving door syndrome further compromises an already frail older adult and is costly for the healthcare system. Under the Affordable Care Act, beginning in 2013, hospitals are penalized for rehospitalizations of clients with three specific diagnoses (acute myocardial infarction, heart failure, pneumonia) (CMS, 2012), thereby exacerbating an already acute funding problem. The postacute care system that can effectively reduce the number of patients that return to the hospital will become a desirable partner for acute care facilities. Much of the research on rehospitalization to date has been from the perspective of the acute care hospital in coordination with postdischarge services trying to reduce the incidence of unsuccessful discharge where patients return to the hospital within 30 days of discharge from a previous hospital stay. In a large synthesis of the literature, Boutwell and Hwu (2009) found that interventions to reduce rehospitalizations could be identified as belonging to one of four major categories: (1) enhanced care and support during transitions; (2) improved patient education and self-management support; (3) multidisciplinary team management; and (4) patient-centered care planning at the end of life (p. 2). Many provider interventions have been tested such as Improved Case Management (Golden, Tewary, Dang, & Roos, 2010) and improving the appropriateness of referrals (Bowles et al., 2008). Some groups have
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taken a disease-specific approach (Carroll, Rankin, & Cooper, 2007; Naylor et al., 2004). Usually physicians, nurse practitioners, and case managers have implemented these interventions, not the nurse at the bedside. Berkowitz et al. (2011) are one of the few research groups that have addressed the problem of rehospitalization from the perspective of the receiving institution. In this case, the group used a historical comparison of discharge rates before and after an implementation of a physicianfocused intervention to evaluate the effectiveness of the intervention. The intervention had three components: standardization of physician admission practices, referral for palliative care consultation for patients who had a history of frequent hospital admissions, and root-cause analyses review of all cases where the older adult was returned to acute care. The research group developed a template for physicians to use at admission which included “the American Medical Directors admission history and physical template, care guidelines for common geriatric syndromes, medicine reconciliation, goals of care, and a question of how many times the patient had been hospitalized over the past 6 months” (p. 1131). Once the intervention was underway, admission records were audited to determine physician adherence to the template. Any patient who had been hospitalized three or more times in the previous 6 months was referred for a palliative care consult, and the information on healthcare proxy, patient wishes for treatment, and hospitalization were recorded on the medical record. Intervention fidelity was evaluated by a random audit of 40 medical records. The third component of the intervention was a Team Improvement for the Patient and Safety (TIPS)(p. 1131) meeting held twice monthly to review rehospitalizations that were deemed to be potentially avoidable. The interventions were successful in reducing rehospitalization by almost 20%. One important limitation of the work of Berkowitz and colleagues is that the changes in practice were entirely focused on the role of the physician, and did not consider the role of the staff nurse. The Professional Practice Model Having reviewed the literature, it was apparent to the team that the literature, particularly the work by Berkowitz and colleagues, was not congruent with the professional practice model used in our health system. According to our care model, the nurse and resident are at the center of the patient-centered care model (Jacelon et al., 2011). We believe that the nurse in postacute care is the care provider who has the most effect on the resi-
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dent’s stay, therefore nursing interventions would be a focus of the audit. Measuring Rehospitalization Once we had established a team, determined the scope of the literature, and developed the aims, we then had to determine how we would calculate the outcome measure of the rate of rehospitalization. We found that there are many ways to measure rehospitalization rates (America’s Health Insurance Plans [AHIP], 2012). Although AHIP uses all cause rehospitalizations, that choice is not universal. For example, beginning in fall of 2012 as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) are monitoring rehospitalization rates for three common diagnoses: pneumonia, heart failure, and heart attack. Eventually CMS will be adjusting hospital reimbursement based on the rehospitalization rate for these diagnoses. A lower rehospitalization rate is more desirable (CMS, 2012). However, our overall goals for evaluating the rate were a bit different. By meeting the aims we wanted to reduce residents’ stress related to traveling to the hospital or the emergency room and the disorientation that can occur when older frail individuals are moved from one care setting to another too many times in a short interval. It is to be noted that both AHIP and CMS are calculating this data based on the experience of the hospital. In this case, we were interested in the rate at which clients and residents left postacute care and returned to acute care. This raised some challenges in determining the rate. For example, would we count people who were sent to the emergency room and returned within a few hours? What about those people who were sent to the hospital, were not admitted, but held for observation for up to 3 days. Should these people be counted? Anticipating that this project would enhance the attractiveness as a destination for skilled care after hospitalization, the team decided that, to be most meaningful to referral organizations and to ourselves, the outcome measure for the nursing home should be “The number of individuals who were sent to the hospital and remained there overnight within 30 days after being admitted to skilled or long-term care.” This definition includes individuals who were sent to the hospital and were kept for evaluation at least overnight, without being admitted. It did not include short trips to the emergency room. For the home healthcare agency, the outcome measure was “the number of individuals admitted to an inpatient facility © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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or held for observation within 30 days of admission to home health care.” This measure would include individuals who were discharged from an acute care facility or nursing home. We included all cause rehospitalizations. This number would be reported internally as an actual number and internally and externally as a rate calculated as (# rehospitalized patients/total admissions from hospital 9 100). Audit Tool Once we determined the outcome measure, we developed an audit tool upon which to collect data. Based on the literature, the tool included demographic information, admission date, time and unit, where the resident was admitted from, the name of the admitting physician, discharge (from postacute care) date and time, number of hospital admissions during the last 6 months, code status, medical diagnoses, medications and change in medications in the previous 24 hours. We used several standardized instruments to capture data including the Cumulative Illness Rating Scale (Linn, Linn, & Gurel, 1968) and the Charlson Comorbidity Scale (Charlson, Pompei, Ales, & MacKenzie, 1987). These standardized measures were used to gather objective data about the health status of the client. The Care Transitions Measure (Coleman, Parry, Chalmers, Chugh, & Mahoney, 2007) was used as it is a short (three items), reliable instrument used to measure the client’s preparation for discharge. This measure is particularly useful in home care. The audit tool also included a measure of activities of daily living and instrumental activities of daily living, and a depression rating score. There was space for a narrative account of what precipitated the transfer to the hospital, and what happened to the patient while they were at the hospital. Protection of Human Subjects To adequately protect subjects, we submitted the study for review to the Institutional Review Board of the university with which the Scholar in Residence is affiliated. The study design called for medical record review that was not anonymous. The study was approved after expedited review. Names were removed from the data after the records were abstracted. Do The next phase of the quality cycle is to “Do.” In this step, the team carries out the plan. In addition to collecting data, the team keeps a record of unexpected opportu© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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nities and challenges related to the project and begin data analysis (Langley et al., 2009). Data Collection To establish our rehospitalization rate, beginning in January 2012, we retrospectively monitored all admissions and discharges occurring in 2011. We audited 100% of medical records of individuals who were readmitted to the hospital within 30 days of arriving at the nursing home, and a random sample of approximately 60% of medical records of individuals who were receiving home care and returned to the hospital within 30 days. Sixty percent of home care records were chosen for two reasons. First the number of rehospitalization in home care made review of all records unfeasible, second by reviewing 60% of home care records of clients who were rehospitalized, we reviewed approximately equal numbers of records from the nursing home and the home care agency. The process of data collection took 2 months. Study Analysis is the next phase of the quality improvement process. During this phase, the collected data are analyzed, the findings are compared with the expected outcomes, and the team summarizes and reflects on what was learned (IHI, 2014a). Findings During March 2012, the audit team reviewed the abstracted data from the medical records of those rehospitalized individuals. The team audited the medical records of 100% of rehospitalized individuals from the nursing home, and 60% of home care records. We had limited staff resources to audit home care records, so we decided that we would use a random numbers table to select 60% (n = 13) of records for review. The three members of the audit team reviewed each abstract. When the council met, each case was reviewed, and consensus was reached about the individual case. We used this strategy to minimize potential interrater challenges. By reaching consensus in a live meeting, the level of confidence in the decision was high. The narrative account of the events surrounding the rehospitalization was the most useful part of the audit tool. Each rehospitalization was rated as preventable, not preventable, or unable to determine. The preventable events were events that the nursing staff could have
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managed at the nursing home or at home. The not preventable events were those in which the audit team determined that the resident could not be managed in the nursing home or at home. In those situations labeled “unable to tell,” there was insufficient information in the medical record to make an informed decision about the nature of the event leading to transfer to the hospital. An example of an avoidable rehospitalization would be if an individual was sent from the nursing home to the hospital and was admitted for monitoring, that would be a case that could have been managed at the nursing home and been coded as preventable. If a person was sent to the hospital for heart block and required a pacemaker be inserted, this was not something that could be handled at the nursing home. In the home care agency, rehospitalization for a suspected rectal bleed was not considered to be a preventable rehospitalization whereas a client taken to the emergency room by a family member for a nonemergent condition without first consulting the home care nurse would be preventable. It is to be noted that a physician or nurse practitioner ordered all trips to the hospital. The decision for the trip to the hospital was often made based on the information provided by the staff nurse. Therefore, the nurse’s skills at assessment and management were critically important to the client outcome of rehospitalization. During 2011, the long-term care facility had 234 admissions. Of those, 180 were from hospitals, 14 from other skilled nursing facilities, and 40 from other sources (assisted living, home, etc.). Seventeen rehospitalizations within 30 days of admission to the nursing home occurred. These rehospitalizations occurred to 17 individual people. The rehospitalization rate was calculated as 7.26% of all admissions or 9.44% of admissions from acute care settings. This rate is less than half the reported readmit rate of 25%–28% of rehospitalized residents from nursing homes in Massachusetts (Berkowitz et al., 2011). For the home care agency, during 2011, there were 416 admissions. Of those, 73 were from hospitals, 46 from skilled care, and 297 from other sources. Twenty-two rehospitalizations within 30 days of admission to the home care agency occurred. These admissions did not represent 22 separate individuals, as some individuals were rehospitalized more than once. The rehospitalized rate was calculated as 18% of all admissions. This rate is significantly lower than the national average rate of rehospitalizations from home care at 27% (Delta Health Technologies, 2012).
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When analyzing the reasons for rehospitalization of residents from the long-term care facility, the team determined that three rehospitalizations could have been prevented, eight were not preventable, and in six cases the Quality Council could not determine if the nurse could have prevented the rehospitalization. Of the 22 rehospitalizations from the home healthcare agency, 13 records were audited. Of those cases audited, two were deemed preventable, nine were not preventable, and two were undetermined. From the data on rehospitalizations that could have been prevented, four areas for improvement emerged. These areas included physical assessment, pain assessment and management, delirium diagnosis and management, and atypical presentation of illness. Enhanced skills in these areas could potentially reduce the rehospitalization rate. Even though the number of rehospitalizations that were preventable by the nurse was very small, the cost of rehospitalization is so high for the client and the healthcare system that preventing one event could reduce client stress and save thousands of dollars for the healthcare system. Act The fourth step of the quality improvement cycle is act. In this step, the team refines the changes based on what was learned during the test (IHI, 2014a). Once we had determined the cause of preventable rehospitalizations, we developed strategies to improve the staff knowledge. We addressed each of the four areas by improving knowledge, skills, and attitudes. Physical Assessment During the time when we were engaged in this project, the institution was fortunate enough to have a graduate nursing student completing clinical hours for her advanced physical assessment course at the agency. We arranged for the student to use some of her clinical hours to give in-service education sessions to all nurses to increase knowledge and skill in each of the physical assessment areas found to be problematic. The first session focused on head-to-toe assessment with a review of each system. The second session was focused on the areas of weakness as identified in the rehospitalization chart review. This session included in-depth discussion and practice of abdominal and respiratory assessment. To affect attitudes, the graduate student used case © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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studies to improve the self-efficacy of the nurses to perform physical assessment and accurately report their findings. Improving assessment skills of the staff nurses could aid in early detection of common abdominal symptoms such as constipation and impaction. Enhanced respiratory assessment skills could help nurses identify respiratory problems earlier, thereby having the interdisciplinary team initiate treatment earlier, possibly preventing a respiratory situation requiring hospitalization. Pain Assessment and Management The agency consults with a nationally known pain management clinical nurse specialist (CNS). To improve the nurse’s knowledge and skill in pain assessment and management, the agency invited the pain CNS to provide education regarding pain assessment and management and to increase consultations with staff on individual residents and clients. The pain CNS improved attitudes regarding the nurse’s ability to manage resident’s pain by dispelling myths regarding various medications and by providing individual consultation with nurses and residents. Improved assessment and management of pain, either pain that was present at admission or pain that developed during the stay in postacute care, could help the nurse more effectively manage the pain and seek consultation for pain management with the physician, nurse practitioner, or pain CNS to reduce the need for rehospitalization. Delirium and Atypical Presentation of Illness The leadership and quality team used every opportunity during reports on clients and in staff meetings to talk about delirium, use of the Confusion Assessment Method, and the possibility of unusual resident or client behaviors possibly being delirium and a possible symptom of atypical presentation of illness. We used these strategies to raise attention to these common problems of health management for older adults. Increasing awareness of delirium and atypical presentation of illness can enhance the nurse’s ability for early detection of changes in a client’s condition, thereby initiating treatment earlier and preventing rehospitalization for urgent care. Debriefing Sessions For the year following the data collection phase (2012), the assistant director of nursing in the nursing home and © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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the care supervisor in the home care agency, met with the nurses working with each person who was rehospitalized after the event to discuss what happened and whether the rehospitalization could have been prevented. As we found during data collection, the reasons for rehospitalization were complicated; it was not usually one action or symptom that led to the rehospitalization. Often the reasons for hospitalization were beyond the control of the nurse. These situations included family members who insisted the resident be hospitalized, or in the case of the resident being at home, taking the client to the emergency room. Sometimes physicians who were not familiar with the agency and the nurses would order rehospitalization when the person could have been managed by the agency. Sometimes, the client’s condition changed, or developed a new problem and required hospitalization. Nonetheless, the nurses who worked directly with the client had an important role in assessing the client and presenting the findings to the physician or nurse practitioner, and conveying the possible scope of interventions for the client to stay in the current setting, which was critical to reducing the incidence of rehospitalization. Monitor Rehospitalization Rates During 2012 and 2013, we continued to monitor rehospitalization rates in the long-term care facility and the home care agency. The rates for both agencies have continued to be well below the national average. If we identified an increase in the rates, we would begin a new PDSA cycle. We have also continued to review each case of rehospitalization with the nurses to determine if there could have been an alternative to rehospitalization. Discussion The quality improvement project was unique in that we focused on the role of the postacute care staff nurse in preventing rehospitalization. Using the PDSA framework can help nurses to identify clinical situations such as rehospitalization that can affect the quality of care, client outcomes, and the subsequent reputation of their postacute care agencies. The staff nurse is instrumental in early detection and management of potential problems. Assessment of health status including physical changes, mental status, and atypical presentation of illness as well as effective pain management are critical skills for reducing rehospitalization of individuals who are in postacute care settings. Following the PDSA format, we were able
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Key Practice Points PDSA is a useful framework for quality improvement. The incidence of rehospitalization can be reduced. Rehospitalization is expensive to the client and the facility. Assessment is the key to preventing unnecessary rehospitalization.
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care. As rehospitalization receives increasing attention, nurses will play an important role in prevention. Acknowledgments This work was partially funded by the Scholar in Residence Grant, Jewish Geriatric Services, Inc.
References to design an effective program to improve the skills of nurses in these critical areas and provide important information about the quality of the programs. In the absence of other differences in residents and clients, the rehospitalization rates continue to be well below the national average. This quality improvement project is the first of its kind reported in the literature. To date, no group has published reports of the incidence of rehospitalization from the perspective of the nurse in postacute care. Understanding the role of the nurse in postacute care in reducing rehospitalization whenever possible is critical to create a healing environment for clients and provide the most cost-effective care. Conclusions Reducing the number of rehospitalizations is good for everyone. It is good for the resident who is receiving the appropriate level of care and can be supported without the stress of frequent moves from one level of care to another. It is good for the referring hospital as it can transfer patients to the home care, skilled, and long-term care agencies with confidence that we can adequately manage the patients they send. The low rehospitalization rates provide confidence to the hospitals that Medicare will not penalize them for rehospitalizations if they discharge their clients to us. A low rehospitalization rate is good for the facility as we can use this rate to demonstrate the effectiveness of the care provided at the agencies. The PDSA framework is easy to use and can be used to guide high-quality improvement projects. In this report, we have demonstrated how the PDSA process can be used to evaluate and improve the quality of care across healthcare settings. The PDSA framework can be easily applied to healthcare settings across the continuum of care. Rehabilitation nurses across settings should be aware of the effect of their practice decisions of client outcomes and the cost of
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America’s Health Insurance Plans (AHIP). (2012). Working Paper: Simple Methods of Measuring Hospital Readmission Rates. AHIP Center for Policy Research, 12 pp. Berkowitz, R., Jones, R., Reider, R., Bryan, M., Schreibner, R., Verney, S. et al. (2011). Improving disposition outcomes for patients in a geriatric skilled nursing facility. Journal of the American Geriatric Society, 59, 1130–2011. Boutwell, A., Hwu, S. (2009). Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence. Cambridge, MA: Institute for Healthcare Improvement. Bowles, K., Ratcliffe, S., Holmes, J., Liberatore, M., Nydick, R., & Naylor, M. (2008). Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients’ 12-week outcomes. Medical Care, 46(2), 158–166. Carroll, D., Rankin, S., & Cooper, B. (2007). The effects of a collaborative peer advisor/advanced practice nurse intervention: Cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. Journal of Cardiovascular Nursing, 22(4), 313–319. Centers for Medicare & Medicaid Services (CMS). (2012). Readmissions Reduction Program. Retrieved from: http:// www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/Readmissions-Reduction-Program.html. Charlson, M., Pompei, P., Ales, K., & MacKenzie, C. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Disease, 40(5), 373–383. Coleman, E., Parry, C., Chalmers, S., Chugh, A., & Mahoney, E. (2007). The central role of performance measurement in improving the quality of transitional care. Home Healthcare Services Quarterly, 26(4), 93–104. Delta Health Technologies. (2012). The Delta Study to Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations Through Home Care. Altoona, PA: Delta Health Technologies and Fazzi Associates, Inc. Retrieved from: http://www.deltahealthtech.com/assets/research/ ReduceHospitalizations.pdf
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Golden, A., Tewary, S., Dang, S., & Roos, B. (2010). Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. The Gerontologist, 50(4), 451–458. Institute for Healthcare Improvement. (2014a). Plan-DoStudy-Act (PDSA) Worksheet. Retrieved from: http://www. ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet. aspx Institute for Healthcare Improvement. (2014b). Science of Improvement: How to Improve. Retrieved from: http:// www.ihi.org/resources/Pages/HowtoImprove/Scienceof ImprovementHowtoImprove.aspx Jacelon, C., Donoghue, L., & Breslin, E. (2010). Scholar in residence: An innovative application of the scholarship of engagement. Journal of Professional Nursing, 26(1), 33–43. Jacelon, C., Furman, E., Rea, A., Macdonald, B., & Donoghue, L. (2011). Creating a professional practice model for postacute care. Journal of Gerontological Nursing, 37(3), 53–60. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Franscisco, CA: Jossy-Bass. Linn, H., Linn, M., & Gurel, L. (1968). Cumulative illness rating scale. Journal of American Geriatrics Society, 16(5), 622–626.
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Naylor, M., Brooten, D., Campbell, R., Mailin, G., McCauley, K., & Schwartz, J. (2004). Transitional care of older adults with heart failure: A randomized controlled trial. Journal of the American Geriatrics Society, 52, 675–684.
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Reducing the Rate of Rehospitalization from Postacute Care: A Quality Improvement Project
Cynthia Jacelon1,2, PhD, RN-BC, CRRN, FAAN, Barbara Macdonald3, MS, RN, GCNS-BC, Fran Fitzgerald4, RN & Quality Council 1 College of Nursing, University of Massachusetts, Amherst, MA, USA 2 Jewish Geriatric Services, Longmeadow, MA, USA 3 Julian J. Leavitt Jewish Nursing Home, Longmeadow, MA, USA 4 Spectrum Home Health & Hospice Care, Longmeadow, MA, USA
Keywords
Abstract
Rehospitalization; long-term care; skilled care; home health care. Correspondence Cynthia Jacelon, College of Nursing, University of Massachusetts, 126 Skinner Hall, 651 N. Pleasant St. Amherst, MA 01003. E-mail: [email protected] Accepted July 4, 2014. doi: 10.1002/rnj.176
Purpose: To evaluate rehospitalizations and develop a strategy to reduce the number of individuals sent back to the hospital within 30 days of admission from postacute care services including skilled care, long-term care, and home care. Design: Using the Plan, Do, Study, Act (PDSA) format outlined by the Institute for Healthcare Improvement, we implemented and evaluated a quality improvement project. Methods: The number of rehospitalizations was calculated and chart audit was used to determine the reasons. Interventions were designed to decrease the number of reasons individuals had to return to the hospital. Findings: Five rehospitalizations were deemed preventable. Interventions were designed to improve staff knowledge. Conclusions: The effectiveness of interventions and rehospitalization rates continue to be monitored. The rehospitalization rates from these agencies are low. Low rehospitalization rates are good for clients and improve desirability as a source for care posthospitalization. Clinical Relevance: Understanding causes for rehospitalization, providing skills and knowledge aimed at the root causes of hospitalization, and reducing the rate of rehospitalization improves nursing practice and reimbursement.
Introduction Recently, much attention has been given to the issue of rehospitalization. However, most of the focus has been on hospital discharges and how acute care providers can reduce the incidence of rehospitalization. Less attention has been given to how postacute care agencies can affect the process. Using the Model for Improvement (Langley et al., 2009) to guide the process and the Jewish Geriatric Services – Chronic Care Model (JGS-CCM) (Jacelon,
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Furman, Rea, Macdonald, & Donoghue, 2011) as a framework, we evaluated rehospitalizations and developed a strategy to reduce the number of individuals we ought to send back to the hospital within 30 days of admission to postacute services. The Model for Improvement was developed to provide an easy, effective guide to accelerate the improvement process in healthcare institutions (Institute for Healthcare Improvement [IHI], 2014b). It includes a set of questions to define the improvement project, and a cyclical process
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with four steps to guide the improvement process (Langley et al., 2009). The defining questions are: “What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?” (p. 24). The steps to the improvement process include Plan, Do, Study, and Act (PDSA) (p. 98–99). Each of the steps in the quality improvement process will be described below as we describe the process used to reduce the rate of return to the hospital for newly admitted residents and clients. Plan The first step in the process is planning. According to Langley et al. (2009), the planning step of the quality improvement project includes determining who will be on the team, the aim of the project, and how and when data will be collected. Selecting the Team To create an effective team, the team must have three types of members: system leaders, technical experts, and day-today leaders (IHI, 2014b). The leadership of the healthcare system charged the Quality Council with exploring rehospitalization from the perspective of postacute care, including skilled and long-term care units and a visiting nurse agency. The Quality Council is a systemwide team of nurses with representatives from each entity of the postacute care system. They are responsible for monitoring and implementing quality initiatives across the system. The council members chose three key people to lead the rehospitalization initiative. The chosen group was comprised of the Scholar in Residence (Jacelon, Donoghue, & Breslin, 2010) who was an expert in rigorous process, had systemwide authority, and would oversee the project; the Director of Quality from the long-term care facility; and the nursing supervisor for the home care agency. Both the Director of Quality and the nursing supervisor had technical expertise and were the day-to-day leaders in their respective system entities. The project sponsor, the system leader who had the executive authority to support the project, was the Chief Nursing Officer (IHI, 2014b). The Scholar in Residence is a doctorally prepared nurse scientist who, as part of her faculty position, spends 1 day each week at the facility to build geriatric nursing capacity both in the clinical areas and in academe. The Scholar in Residence engages in advanced geriatric nursing practice and
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scholarship and provides leadership in the promotion of clinical excellence. (Jacelon et al., 2010).
Setting Aims: What are We Trying to Accomplish? Once the team was established, we focused on the first question in the PDSA cycle. The team was interested in determining (1) the rehospitalization rate for the nursing home and the home care agency, and (2) what the nursing staff could do to reduce the rate. We realized that before we could determine the specific aim, we needed to review the literature to determine the scope of the project and what was known about rehospitalization from the perspective of postacute care. The Literature The problem of rehospitalization for older adults has recently come into the spotlight. Frail older adults are discharged from the hospital after an acute illness and as many as 27% of those people receiving home care (Delta Health Technologies, 2012) and 23.5% (Berkowitz et al., 2011) of those discharged to skilled care are readmitted to the hospital within 30 days. This revolving door syndrome further compromises an already frail older adult and is costly for the healthcare system. Under the Affordable Care Act, beginning in 2013, hospitals are penalized for rehospitalizations of clients with three specific diagnoses (acute myocardial infarction, heart failure, pneumonia) (CMS, 2012), thereby exacerbating an already acute funding problem. The postacute care system that can effectively reduce the number of patients that return to the hospital will become a desirable partner for acute care facilities. Much of the research on rehospitalization to date has been from the perspective of the acute care hospital in coordination with postdischarge services trying to reduce the incidence of unsuccessful discharge where patients return to the hospital within 30 days of discharge from a previous hospital stay. In a large synthesis of the literature, Boutwell and Hwu (2009) found that interventions to reduce rehospitalizations could be identified as belonging to one of four major categories: (1) enhanced care and support during transitions; (2) improved patient education and self-management support; (3) multidisciplinary team management; and (4) patient-centered care planning at the end of life (p. 2). Many provider interventions have been tested such as Improved Case Management (Golden, Tewary, Dang, & Roos, 2010) and improving the appropriateness of referrals (Bowles et al., 2008). Some groups have
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taken a disease-specific approach (Carroll, Rankin, & Cooper, 2007; Naylor et al., 2004). Usually physicians, nurse practitioners, and case managers have implemented these interventions, not the nurse at the bedside. Berkowitz et al. (2011) are one of the few research groups that have addressed the problem of rehospitalization from the perspective of the receiving institution. In this case, the group used a historical comparison of discharge rates before and after an implementation of a physicianfocused intervention to evaluate the effectiveness of the intervention. The intervention had three components: standardization of physician admission practices, referral for palliative care consultation for patients who had a history of frequent hospital admissions, and root-cause analyses review of all cases where the older adult was returned to acute care. The research group developed a template for physicians to use at admission which included “the American Medical Directors admission history and physical template, care guidelines for common geriatric syndromes, medicine reconciliation, goals of care, and a question of how many times the patient had been hospitalized over the past 6 months” (p. 1131). Once the intervention was underway, admission records were audited to determine physician adherence to the template. Any patient who had been hospitalized three or more times in the previous 6 months was referred for a palliative care consult, and the information on healthcare proxy, patient wishes for treatment, and hospitalization were recorded on the medical record. Intervention fidelity was evaluated by a random audit of 40 medical records. The third component of the intervention was a Team Improvement for the Patient and Safety (TIPS)(p. 1131) meeting held twice monthly to review rehospitalizations that were deemed to be potentially avoidable. The interventions were successful in reducing rehospitalization by almost 20%. One important limitation of the work of Berkowitz and colleagues is that the changes in practice were entirely focused on the role of the physician, and did not consider the role of the staff nurse. The Professional Practice Model Having reviewed the literature, it was apparent to the team that the literature, particularly the work by Berkowitz and colleagues, was not congruent with the professional practice model used in our health system. According to our care model, the nurse and resident are at the center of the patient-centered care model (Jacelon et al., 2011). We believe that the nurse in postacute care is the care provider who has the most effect on the resi-
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dent’s stay, therefore nursing interventions would be a focus of the audit. Measuring Rehospitalization Once we had established a team, determined the scope of the literature, and developed the aims, we then had to determine how we would calculate the outcome measure of the rate of rehospitalization. We found that there are many ways to measure rehospitalization rates (America’s Health Insurance Plans [AHIP], 2012). Although AHIP uses all cause rehospitalizations, that choice is not universal. For example, beginning in fall of 2012 as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) are monitoring rehospitalization rates for three common diagnoses: pneumonia, heart failure, and heart attack. Eventually CMS will be adjusting hospital reimbursement based on the rehospitalization rate for these diagnoses. A lower rehospitalization rate is more desirable (CMS, 2012). However, our overall goals for evaluating the rate were a bit different. By meeting the aims we wanted to reduce residents’ stress related to traveling to the hospital or the emergency room and the disorientation that can occur when older frail individuals are moved from one care setting to another too many times in a short interval. It is to be noted that both AHIP and CMS are calculating this data based on the experience of the hospital. In this case, we were interested in the rate at which clients and residents left postacute care and returned to acute care. This raised some challenges in determining the rate. For example, would we count people who were sent to the emergency room and returned within a few hours? What about those people who were sent to the hospital, were not admitted, but held for observation for up to 3 days. Should these people be counted? Anticipating that this project would enhance the attractiveness as a destination for skilled care after hospitalization, the team decided that, to be most meaningful to referral organizations and to ourselves, the outcome measure for the nursing home should be “The number of individuals who were sent to the hospital and remained there overnight within 30 days after being admitted to skilled or long-term care.” This definition includes individuals who were sent to the hospital and were kept for evaluation at least overnight, without being admitted. It did not include short trips to the emergency room. For the home healthcare agency, the outcome measure was “the number of individuals admitted to an inpatient facility © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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or held for observation within 30 days of admission to home health care.” This measure would include individuals who were discharged from an acute care facility or nursing home. We included all cause rehospitalizations. This number would be reported internally as an actual number and internally and externally as a rate calculated as (# rehospitalized patients/total admissions from hospital 9 100). Audit Tool Once we determined the outcome measure, we developed an audit tool upon which to collect data. Based on the literature, the tool included demographic information, admission date, time and unit, where the resident was admitted from, the name of the admitting physician, discharge (from postacute care) date and time, number of hospital admissions during the last 6 months, code status, medical diagnoses, medications and change in medications in the previous 24 hours. We used several standardized instruments to capture data including the Cumulative Illness Rating Scale (Linn, Linn, & Gurel, 1968) and the Charlson Comorbidity Scale (Charlson, Pompei, Ales, & MacKenzie, 1987). These standardized measures were used to gather objective data about the health status of the client. The Care Transitions Measure (Coleman, Parry, Chalmers, Chugh, & Mahoney, 2007) was used as it is a short (three items), reliable instrument used to measure the client’s preparation for discharge. This measure is particularly useful in home care. The audit tool also included a measure of activities of daily living and instrumental activities of daily living, and a depression rating score. There was space for a narrative account of what precipitated the transfer to the hospital, and what happened to the patient while they were at the hospital. Protection of Human Subjects To adequately protect subjects, we submitted the study for review to the Institutional Review Board of the university with which the Scholar in Residence is affiliated. The study design called for medical record review that was not anonymous. The study was approved after expedited review. Names were removed from the data after the records were abstracted. Do The next phase of the quality cycle is to “Do.” In this step, the team carries out the plan. In addition to collecting data, the team keeps a record of unexpected opportu© 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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nities and challenges related to the project and begin data analysis (Langley et al., 2009). Data Collection To establish our rehospitalization rate, beginning in January 2012, we retrospectively monitored all admissions and discharges occurring in 2011. We audited 100% of medical records of individuals who were readmitted to the hospital within 30 days of arriving at the nursing home, and a random sample of approximately 60% of medical records of individuals who were receiving home care and returned to the hospital within 30 days. Sixty percent of home care records were chosen for two reasons. First the number of rehospitalization in home care made review of all records unfeasible, second by reviewing 60% of home care records of clients who were rehospitalized, we reviewed approximately equal numbers of records from the nursing home and the home care agency. The process of data collection took 2 months. Study Analysis is the next phase of the quality improvement process. During this phase, the collected data are analyzed, the findings are compared with the expected outcomes, and the team summarizes and reflects on what was learned (IHI, 2014a). Findings During March 2012, the audit team reviewed the abstracted data from the medical records of those rehospitalized individuals. The team audited the medical records of 100% of rehospitalized individuals from the nursing home, and 60% of home care records. We had limited staff resources to audit home care records, so we decided that we would use a random numbers table to select 60% (n = 13) of records for review. The three members of the audit team reviewed each abstract. When the council met, each case was reviewed, and consensus was reached about the individual case. We used this strategy to minimize potential interrater challenges. By reaching consensus in a live meeting, the level of confidence in the decision was high. The narrative account of the events surrounding the rehospitalization was the most useful part of the audit tool. Each rehospitalization was rated as preventable, not preventable, or unable to determine. The preventable events were events that the nursing staff could have
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managed at the nursing home or at home. The not preventable events were those in which the audit team determined that the resident could not be managed in the nursing home or at home. In those situations labeled “unable to tell,” there was insufficient information in the medical record to make an informed decision about the nature of the event leading to transfer to the hospital. An example of an avoidable rehospitalization would be if an individual was sent from the nursing home to the hospital and was admitted for monitoring, that would be a case that could have been managed at the nursing home and been coded as preventable. If a person was sent to the hospital for heart block and required a pacemaker be inserted, this was not something that could be handled at the nursing home. In the home care agency, rehospitalization for a suspected rectal bleed was not considered to be a preventable rehospitalization whereas a client taken to the emergency room by a family member for a nonemergent condition without first consulting the home care nurse would be preventable. It is to be noted that a physician or nurse practitioner ordered all trips to the hospital. The decision for the trip to the hospital was often made based on the information provided by the staff nurse. Therefore, the nurse’s skills at assessment and management were critically important to the client outcome of rehospitalization. During 2011, the long-term care facility had 234 admissions. Of those, 180 were from hospitals, 14 from other skilled nursing facilities, and 40 from other sources (assisted living, home, etc.). Seventeen rehospitalizations within 30 days of admission to the nursing home occurred. These rehospitalizations occurred to 17 individual people. The rehospitalization rate was calculated as 7.26% of all admissions or 9.44% of admissions from acute care settings. This rate is less than half the reported readmit rate of 25%–28% of rehospitalized residents from nursing homes in Massachusetts (Berkowitz et al., 2011). For the home care agency, during 2011, there were 416 admissions. Of those, 73 were from hospitals, 46 from skilled care, and 297 from other sources. Twenty-two rehospitalizations within 30 days of admission to the home care agency occurred. These admissions did not represent 22 separate individuals, as some individuals were rehospitalized more than once. The rehospitalized rate was calculated as 18% of all admissions. This rate is significantly lower than the national average rate of rehospitalizations from home care at 27% (Delta Health Technologies, 2012).
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When analyzing the reasons for rehospitalization of residents from the long-term care facility, the team determined that three rehospitalizations could have been prevented, eight were not preventable, and in six cases the Quality Council could not determine if the nurse could have prevented the rehospitalization. Of the 22 rehospitalizations from the home healthcare agency, 13 records were audited. Of those cases audited, two were deemed preventable, nine were not preventable, and two were undetermined. From the data on rehospitalizations that could have been prevented, four areas for improvement emerged. These areas included physical assessment, pain assessment and management, delirium diagnosis and management, and atypical presentation of illness. Enhanced skills in these areas could potentially reduce the rehospitalization rate. Even though the number of rehospitalizations that were preventable by the nurse was very small, the cost of rehospitalization is so high for the client and the healthcare system that preventing one event could reduce client stress and save thousands of dollars for the healthcare system. Act The fourth step of the quality improvement cycle is act. In this step, the team refines the changes based on what was learned during the test (IHI, 2014a). Once we had determined the cause of preventable rehospitalizations, we developed strategies to improve the staff knowledge. We addressed each of the four areas by improving knowledge, skills, and attitudes. Physical Assessment During the time when we were engaged in this project, the institution was fortunate enough to have a graduate nursing student completing clinical hours for her advanced physical assessment course at the agency. We arranged for the student to use some of her clinical hours to give in-service education sessions to all nurses to increase knowledge and skill in each of the physical assessment areas found to be problematic. The first session focused on head-to-toe assessment with a review of each system. The second session was focused on the areas of weakness as identified in the rehospitalization chart review. This session included in-depth discussion and practice of abdominal and respiratory assessment. To affect attitudes, the graduate student used case © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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studies to improve the self-efficacy of the nurses to perform physical assessment and accurately report their findings. Improving assessment skills of the staff nurses could aid in early detection of common abdominal symptoms such as constipation and impaction. Enhanced respiratory assessment skills could help nurses identify respiratory problems earlier, thereby having the interdisciplinary team initiate treatment earlier, possibly preventing a respiratory situation requiring hospitalization. Pain Assessment and Management The agency consults with a nationally known pain management clinical nurse specialist (CNS). To improve the nurse’s knowledge and skill in pain assessment and management, the agency invited the pain CNS to provide education regarding pain assessment and management and to increase consultations with staff on individual residents and clients. The pain CNS improved attitudes regarding the nurse’s ability to manage resident’s pain by dispelling myths regarding various medications and by providing individual consultation with nurses and residents. Improved assessment and management of pain, either pain that was present at admission or pain that developed during the stay in postacute care, could help the nurse more effectively manage the pain and seek consultation for pain management with the physician, nurse practitioner, or pain CNS to reduce the need for rehospitalization. Delirium and Atypical Presentation of Illness The leadership and quality team used every opportunity during reports on clients and in staff meetings to talk about delirium, use of the Confusion Assessment Method, and the possibility of unusual resident or client behaviors possibly being delirium and a possible symptom of atypical presentation of illness. We used these strategies to raise attention to these common problems of health management for older adults. Increasing awareness of delirium and atypical presentation of illness can enhance the nurse’s ability for early detection of changes in a client’s condition, thereby initiating treatment earlier and preventing rehospitalization for urgent care. Debriefing Sessions For the year following the data collection phase (2012), the assistant director of nursing in the nursing home and © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 12–19
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the care supervisor in the home care agency, met with the nurses working with each person who was rehospitalized after the event to discuss what happened and whether the rehospitalization could have been prevented. As we found during data collection, the reasons for rehospitalization were complicated; it was not usually one action or symptom that led to the rehospitalization. Often the reasons for hospitalization were beyond the control of the nurse. These situations included family members who insisted the resident be hospitalized, or in the case of the resident being at home, taking the client to the emergency room. Sometimes physicians who were not familiar with the agency and the nurses would order rehospitalization when the person could have been managed by the agency. Sometimes, the client’s condition changed, or developed a new problem and required hospitalization. Nonetheless, the nurses who worked directly with the client had an important role in assessing the client and presenting the findings to the physician or nurse practitioner, and conveying the possible scope of interventions for the client to stay in the current setting, which was critical to reducing the incidence of rehospitalization. Monitor Rehospitalization Rates During 2012 and 2013, we continued to monitor rehospitalization rates in the long-term care facility and the home care agency. The rates for both agencies have continued to be well below the national average. If we identified an increase in the rates, we would begin a new PDSA cycle. We have also continued to review each case of rehospitalization with the nurses to determine if there could have been an alternative to rehospitalization. Discussion The quality improvement project was unique in that we focused on the role of the postacute care staff nurse in preventing rehospitalization. Using the PDSA framework can help nurses to identify clinical situations such as rehospitalization that can affect the quality of care, client outcomes, and the subsequent reputation of their postacute care agencies. The staff nurse is instrumental in early detection and management of potential problems. Assessment of health status including physical changes, mental status, and atypical presentation of illness as well as effective pain management are critical skills for reducing rehospitalization of individuals who are in postacute care settings. Following the PDSA format, we were able
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Key Practice Points PDSA is a useful framework for quality improvement. The incidence of rehospitalization can be reduced. Rehospitalization is expensive to the client and the facility. Assessment is the key to preventing unnecessary rehospitalization.
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care. As rehospitalization receives increasing attention, nurses will play an important role in prevention. Acknowledgments This work was partially funded by the Scholar in Residence Grant, Jewish Geriatric Services, Inc.
References to design an effective program to improve the skills of nurses in these critical areas and provide important information about the quality of the programs. In the absence of other differences in residents and clients, the rehospitalization rates continue to be well below the national average. This quality improvement project is the first of its kind reported in the literature. To date, no group has published reports of the incidence of rehospitalization from the perspective of the nurse in postacute care. Understanding the role of the nurse in postacute care in reducing rehospitalization whenever possible is critical to create a healing environment for clients and provide the most cost-effective care. Conclusions Reducing the number of rehospitalizations is good for everyone. It is good for the resident who is receiving the appropriate level of care and can be supported without the stress of frequent moves from one level of care to another. It is good for the referring hospital as it can transfer patients to the home care, skilled, and long-term care agencies with confidence that we can adequately manage the patients they send. The low rehospitalization rates provide confidence to the hospitals that Medicare will not penalize them for rehospitalizations if they discharge their clients to us. A low rehospitalization rate is good for the facility as we can use this rate to demonstrate the effectiveness of the care provided at the agencies. The PDSA framework is easy to use and can be used to guide high-quality improvement projects. In this report, we have demonstrated how the PDSA process can be used to evaluate and improve the quality of care across healthcare settings. The PDSA framework can be easily applied to healthcare settings across the continuum of care. Rehabilitation nurses across settings should be aware of the effect of their practice decisions of client outcomes and the cost of
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America’s Health Insurance Plans (AHIP). (2012). Working Paper: Simple Methods of Measuring Hospital Readmission Rates. AHIP Center for Policy Research, 12 pp. Berkowitz, R., Jones, R., Reider, R., Bryan, M., Schreibner, R., Verney, S. et al. (2011). Improving disposition outcomes for patients in a geriatric skilled nursing facility. Journal of the American Geriatric Society, 59, 1130–2011. Boutwell, A., Hwu, S. (2009). Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence. Cambridge, MA: Institute for Healthcare Improvement. Bowles, K., Ratcliffe, S., Holmes, J., Liberatore, M., Nydick, R., & Naylor, M. (2008). Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients’ 12-week outcomes. Medical Care, 46(2), 158–166. Carroll, D., Rankin, S., & Cooper, B. (2007). The effects of a collaborative peer advisor/advanced practice nurse intervention: Cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. Journal of Cardiovascular Nursing, 22(4), 313–319. Centers for Medicare & Medicaid Services (CMS). (2012). Readmissions Reduction Program. Retrieved from: http:// www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/Readmissions-Reduction-Program.html. Charlson, M., Pompei, P., Ales, K., & MacKenzie, C. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Disease, 40(5), 373–383. Coleman, E., Parry, C., Chalmers, S., Chugh, A., & Mahoney, E. (2007). The central role of performance measurement in improving the quality of transitional care. Home Healthcare Services Quarterly, 26(4), 93–104. Delta Health Technologies. (2012). The Delta Study to Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations Through Home Care. Altoona, PA: Delta Health Technologies and Fazzi Associates, Inc. Retrieved from: http://www.deltahealthtech.com/assets/research/ ReduceHospitalizations.pdf
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Golden, A., Tewary, S., Dang, S., & Roos, B. (2010). Care management’s challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. The Gerontologist, 50(4), 451–458. Institute for Healthcare Improvement. (2014a). Plan-DoStudy-Act (PDSA) Worksheet. Retrieved from: http://www. ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet. aspx Institute for Healthcare Improvement. (2014b). Science of Improvement: How to Improve. Retrieved from: http:// www.ihi.org/resources/Pages/HowtoImprove/Scienceof ImprovementHowtoImprove.aspx Jacelon, C., Donoghue, L., & Breslin, E. (2010). Scholar in residence: An innovative application of the scholarship of engagement. Journal of Professional Nursing, 26(1), 33–43. Jacelon, C., Furman, E., Rea, A., Macdonald, B., & Donoghue, L. (2011). Creating a professional practice model for postacute care. Journal of Gerontological Nursing, 37(3), 53–60. Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Franscisco, CA: Jossy-Bass. Linn, H., Linn, M., & Gurel, L. (1968). Cumulative illness rating scale. Journal of American Geriatrics Society, 16(5), 622–626.
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Naylor, M., Brooten, D., Campbell, R., Mailin, G., McCauley, K., & Schwartz, J. (2004). Transitional care of older adults with heart failure: A randomized controlled trial. Journal of the American Geriatrics Society, 52, 675–684.
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