Social Determinants of Health Screening, Referral, and Outcomes: Toward an Evidence-Based Simulation Model.

A more complete conceptual model of the social determinants of health (SDOH) screening and referral process is needed to identify effective interventions to address unmet social needs that impact health outcomes. The objective was to develop an evidence-based, complex, multi-factorial model that makes explicit the behaviors and experiences of both patients and the care team (factors) who use an SDOH platform to facilitate patient connections to community resources. The resulting model organized 88 factors among five main stages in the process and among health outcomes.

Artificial Intelligence in Nursing: Perspectives from Norwegian Nurses.

Nurses continue to face challenges in leading health information technology innovations such as Artificial Intelligence (AI). There is an acknowledged need to explore the attitude of nurses towards AI and nurses' acceptance of AI in clinical settings. We sought to address this gap in knowledge about the perceptions of AI by nursing-related professionals in their work and as a content area in the education of nursing students.

Risk of Rehospitalization or Emergency Department Visit is Significantly Higher for Patients who Receive Their First Home Health Care Nursing Visit Later than 2 Days After Hospital Discharge.

Objectives: This study explored the association between the timing of the first home health care nursing visits (start-of-care visit) and 30-day rehospitalization or emergency department (ED) visits among patients discharged from hospitals.

Design: Our cross-sectional study used data from 1 large, urban home health care agency in the northeastern United States.

Setting/participants: We analyzed data for 49,141 home health care episodes pertaining to 45,390 unique patients who were admitted to the agency following hospital discharge during 2019.

Addressing the Gap in Data Communication from Home Health Care to Primary Care during Care Transitions: Completeness of an Interoperability Data Standard.

In a future where home health care is no longer an information silo, patient information will be communicated along transitions in care to improve care. Evidence-based practice in the United States supports home health care patients to see their primary care team within the first two weeks of hospital discharge to reduce rehospitalization risk. We sought to identify a parsimonious set of home health care data to be communicated to primary care for the post-hospitalization visit.

Transitions of Care: Completeness of the Interoperability Data Standard for Communication from Home Health Care to Primary Care.

Data sharing is necessary to address communication deficits along the transitions of care among community settings. Evidence-based practice supports home healthcare (HHC) patients to see their primary care team within the first two weeks of hospital discharge to reduce rehospitalization risk. A small subset of patient data collected at HHC admission is mandated to be transmitted to primary care, predominantly by fax.

Exploring Reasons for Delayed Start-of-Care Nursing Visits in Home Health Care: Algorithm Development and Data Science Study.

Background: Delayed start-of-care nursing visits in home health care (HHC) can result in negative outcomes, such as hospitalization. No previous studies have investigated why start-of-care HHC nursing visits are delayed, in part because most reasons for delayed visits are documented in free-text HHC nursing notes.

Objective: The aims of this study were to (1) develop and test a natural language processing (NLP) algorithm that automatically identifies reasons for delayed visits in HHC free-text clinical notes and (2) describe reasons for delayed visits in a large patient sample.

Preparing for the Improving Medicare Post-Acute Care Transformation Act: Incorporating A Sociotechnical Perspective to Enhance a Health Information Technology Evaluation Framework Applied to Post-Acute Care.

The Improving Medicare Post-Acute Care Transformation Act, which mandates electronic sharing of standardized patient data by post-acute care clinical settings, will likely spur further health information technology adoption and evaluation. To support evaluation, the study objective was to clarify components of an evidence-based health information technology evaluation framework, Health Information Technology Reference-based Evaluation Framework, by using the framework in home healthcare and incorporating a sociotechnical perspective in the health information technology evaluation. With 36 observations among three diverse home healthcare agencies, researchers conducted a recorded think-aloud process as nurses documented the home healthcare admission in the EHR.

An integrative review of chronic illness mHealth self-care interventions: Mapping technology features to patient outcomes.

Mobile health (mHealth)-hand-held technologies to address health priorities-has significant potential to answer the growing need for patient chronic illness self-care interventions. Previous reviews examined mHealth effect on patient outcomes. None have a detailed examination and mapping of specific technology features to targeted health outcomes.

Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days.

Factors Associated with Timing of the Start-of-Care Nursing Visits in Home Health Care.

Objectives: Home health care patients have critical needs requiring timely care following hospital discharge. Although Medicare requires timely start-of-care nursing visits, a significant portion of home health care patients wait longer than 2 days for the first visit. No previous studies investigated the pattern of start-of-care visits or factors associated with their timing.

Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation.

Background: Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations.

An integrative review and theoretical examination of chronic illness mHealth studies using the Middle-Range Theory of Self-care of Chronic Illness.

Self-management, or self-care, by individuals and/or families is a critical element in chronic illness management as more care shifts to the home setting. Mobile device-enhanced health care, or mHealth, is being touted as a means to support self-care. Previous mHealth reviews examined the effect of mHealth on patient outcomes, however, none used a theoretical lens to examine the interventions themselves.

Incorporating home healthcare nurses' admission information needs to inform data standards.

Objective: Patient transitions into home health care (HHC) often occur without the transfer of information needed for critical clinical decisions and the plan of care. Owing to a lack of universally implemented standards, there is wide variation in information transfer. We sought to characterize missing information at HHC admission.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

Objectives: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer.

Design: Observational field study.

Setting And Participants: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs).

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

Objectives: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

Design: Observational field study.

Settings And Participants: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics.

Incongruence of Patient Problem Information Across Three Phases of Home Care Admission: There's a Problem with the Problem List.

In home health care, the patient problem list is an important component of the admission and care planning processes and determines the subsequent care received. We examined the information received from the referring facilities and its relationship with the final patient problem list generated at home health care admission. Researchers observed 12 admissions and collected available documents related to the admission and care planning process.

Availability and Quality of Information Used by Nurses While Admitting Patients to a Rural Home Health Care Agency.

Home health care admission nurses need high quality patient information but that information is not uniformly available. Despite this challenge, these nurses must make four critical decisions at patient admission to construct the plan of care: (1) patient problems to address in the home health care episode; (2) patient medication management; (3) services in addition to skilled nursing; and (4) skilled nursing visit pattern. We observed 12 in-home admissions at a rural home health care agency and interviewed nurses before and after about these decisions.

Knowledge Elicitation of Homecare Admission Decision Making Processes via Focus Group, Member Checking and Data Visualization.

Researchers elicit knowledge related to expert decision-making processes to inform information technology design and related interventions. However, in healthcare, many subject matter experts have limited time for such endeavors. In addition, researchers need to analyze voluminous amounts of qualitative data.

Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care.

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them.

Digitalization of Patient Information Process from Hospital to Community (Home) Care Nurses: International Perspectives.

For older people who transition from hospital to home, home care is an increasingly important and effective way of managing chronic illness with skilled nursing care in the home. Communication between clinicians across care settings is fundamental for continuity of care. Poor communication of patient information is acknowledged to be a root cause of sentinel events.

Home Care Admission Information: What Nurses Need and What Nurses Have. A Mixed Methods Study.

Effective communication between clinicians across care settings is fundamental for continuity of care and decreased risk of errors. The home care admission often starts without important information needed for formulation of the plan of care. We conducted a mixed methods analysis to investigate home care admission information from two perspectives: qualitative information regarding information nurses reported they needed during an admission, and quantitative information regarding information actually available.

Assessment of Evaluation Frameworks for Design of a Sexual Risk Prevention Game for Black Adolescent Girls.

Adolescent sexual risk behavior (SRB), a major public health problem affects urban Black adolescent girls increasing their health disparities and risks for sexually transmitted infections. Collaborating with these adolescents, we designed a game for smartphones that incorporates elements of trauma-informed care and social cognitive theory to reduce SRB. Game researchers promote use of a comprehensive, multipurpose framework for development and evaluation of games for health applications.

Data Visualization of Home Care Admission Nurses' Decision-Making.

The hospital to home care admission process is when nurses make important decisions about the post-transition episode, including medication reconciliation, plan of care, future visit patterns, and the inclusion of other disciplines. It is not clear how nurses get and use information to support decision-making. We conducted a focus group case study with six admitting home health nurses at a rural agency in Pennsylvania.

Patient Health Goals Elicited During Home Care Admission: A Categorization.

Home care agencies are initiating "patient health goal elicitation" activities as part of home care admission planning. We categorized elicited goals and identified "clinically informative" goals at a home care agency. We examined patient goals that admitting clinicians documented in the point-of-care electronic health record; conducted content analysis on patient goal data to develop a coding scheme; grouped goal themes into codes; assigned codes to each goal; and identified goals that were in the patient voice.