Quantitative Tools Addressing Readmissions -Myassignmenthelp.Com

Question: Discuss About The Quantitative Tools Addressing Readmissions? Answer: Introduction: Repeated hospitalisation is mainly dependent on the type and severity of psychiatric disorder. Repeated hospitalisation also reflects environmental and social aspects. Along with this, it also reflects deficiencies in pre and post discharge treatment. Readmissions can affect both patients and their families and hospitals1. Both patient families and hospital can experience psychological strain and financial burden. Hospital readmissions can be prevented by providing holistic care during the hospital stay, planned discharge and transition and adequate follow-up. Reduction in the hospital readmissions can be helpful in improving acceptance of the psychiatric patient in the society and improving confidence of the patient2. Usually, hospital readmissions within 30 days is considered as poor clinical outcome in case of psychiatric disorders. This accounting outcome might be due to inadequate community-based care after discharge, self-care and difficulties in adherence to the psychiatric medication. It has been estimated that approximately 9 % patients with principal mood disorders were readmitted and 12 % patients with any diagnosis of mood disorders were readmitted. It has been estimated that approximately 16 % patients with principal schizophrenia were readmitted and 19 % patients with any diagnosis of schizophrenia were readmitted. Adequate care at home can be used as a good indicator for reduced readmission for psychiatric disorders. However, it has been estimated that only 1 6 % patients with mood disorders and schizophrenia receive proper care at home3. Initial cost for the management of psychiatric disorders is lower as compared to the other conditions. However, readmission cost for psychiatric d isorders is more as compared to other disorders. As compared to other conditions, patients with psychiatric conditions like mood and schizophrenia are with more discharge disposition of home-care or self-care. 89 % patients with mood disorders and 78 % patients with schizophrenia are with discharge disposition of home-care or self-care. 62 % patients with other than psychiatric conditions are with discharge disposition of home-care or self-care4. Mood disorder and schizophrenia are the major causes of hospital readmissions along with other causes like alcohol related disorders and substance related disorders. Male patients (14 %) are more prone to readmissions as compared to the female patients (12 %). 12.5 %, 14.5 % and 12.6 % patients were readmitted between age group 18-44, 45-64 and above 65 respectively. Patient level predictors of hospital readmissions can be confounding however system level predictors like capacity, structure or treatment of organisation can be definite predictors of hospital readmissions. Patient level predictors like length of stay and patient receiving aftercare are the confounding predictors of hospital readmissions. To determine whether counselling delivered telephonically by mental health professional instantly followed by discharge is efficient in reducing risks of hospital readmissions according to interRAI MH. Design and setting: A matched cross over study will be implemented for the reduction of hospital readmission for psychiatric patients. This pre-post-test design study will be conducted between January 1, 2016 to October 31, 2016. Pre and post test, can be helpful in evaluating impact of intervention because parameters prior to and after completion of intervention can be compared in the same population. Pre and post intervention can be useful in measuring value addition to the samples in the programme. This programme will be implemented in the 15 hospitals of the Ontario Hospital Association and Health Quality Ontario. Evaluation of the implemented programme will be carried out between January 2016 to October 2016. In this study, 2000 patients will be enrolled from the different Ontario Hospitals based on the mentioned exclusion and inclusion criteria. These number of patients will be enrolled because it will give power for statistical significance. Out of these, 1000 patients will be randomised to the c ontrol arm. For control arm patients, normal discharge will be provided followed by normal care. Remaining 1000 patients will be randomised to intervention arm and to these patients normal discharge will be provided followed by telephone based . Telephone based counselling will be provided for the duration of 4 weeks. Blocked randomisation schedule and two sets of sealed envelopes will be prepared for the randomisation. One set of envelop will be labelled as control arm and another as intervention arm. Patients will be allowed to open the folders and they will be allocated to control and intervention arm based on their envelops5. Inclusion criteria: Patients enrolled in the study need to meet following criteria : a) all the patients should be above age 18 years, b) should be admitted to the hospital for more than 4 hours, c) patients should be discharged home, d) should have working telephone, e) should speak English, f) devoid of medical record of cognitive impairment, g) screen positive for mood disorder and schizophrenia and g) should have life expectancy of more than 90 days. Exclusion criteria: a) patient should not be planned for inpatient rehabilitation, nursing home or other healthcare facilities after discharge, b) suicidal tendency, c) alcohol and/or drug dependence, and d) in police custody6. Strengths and limitations: Strengths: Environmental factors can influence internal validity of study design. However, in this study, control group will be incorporated along with intervention group. Hence, it would be helpful in neutralising environmental effect. Population external validity will be the strength of this study because results of this study can not be generalised to patients without intervention for psychiatric disorders. Limitations: Maturation and carryover effect can affect internal validity in this study design. Maturation can occur due to change in participants for pre-test to post-test. Carryover effect occur due to influence of pre-test on the outcome of post-test. Ecological external validity can be limitation in this study design because home environment can be different from the hospital environment7, 8. Though this study is associated with limitations, this study is more useful as compared to other designs because it gives data about the real world study. Results of this study can be used as evidence for the future studies. Control and intervention groups can be compared in this study. Statistical power can be obtained in this study. Rationale for evaluation programme: Data related to hospital readmissions will be collected for the duration of 6 months. Evaluation of the programme will be helpful for the amendment and improvement of the evaluation programme. For the reduction of the hospital readmissions, counselling should be provided to the patients and family members. Hence, telephone-based counselling will be provided to reduce risk of hospital readmissions. Risks of readmissions include interRAI variables like prior hospitalizations, greater severity in several clinical conditions such as psychosis, presence of a secondary substance use diagnosis, and being unemployed. Counselling will comprise of aspects like improve patient engagement and adherence to the intervention9. Data collection: There are different sources of data like existing data and new data. Existing data comprising of information given by OHA/HQO and HIS. It includes health service use, diagnoses, living arrangements and employment, mental health symptoms, substance use, and functioning, and rehospitalization CAP. New data will be collected by trained research nurse. Equivalent data will be collected pre-intervention and post-intervention. After the completion of four weeks counselling sessions to the patients, telephone survey will be conducted to assess hospital readmission status and treatment utilization for psychiatric condition. Data will comprise of baseline data of patients, duration of index hospitals stay, diagnosis during hospital admission, symptoms and comorbidities. Information related to living conditions, employment status, abusive substance use and functioning will also be collected. Data related to hospital admissions in the six months prior to index admission will also be collected. Health information system (HIS) will be helpful in gathering personalised information about the patient in terms of discharge summaries, prescribed medicines, results of diagnostic laboratory test, clinical and imaging biomarkers. HIS will be helpful in improving patient safety, improving quality of intervention and avoiding unnecessary readmissions10. Dependent variables: Period between discharge and readmission will be considered as the dependent variable. Collected data like baseline data of patients, duration of index hospitals stay, diagnosis during hospital admission and comorbidities will be corelated with readmissions within timeline of 30, 60 and 90 days. Readmissions within 30, 60 and 90 days will be compared with each other. It will be helpful in corelating severity of disease, type of disease, prescribed medicines and age of the patient with each of the readmission timeline. This programme will also assess the measures for readmission of the psychiatric patients. Readmission data will be helpful in answering the proposal question11,12. Independent variables : Demographic factors, medical treatment and healthcare utilization are the risk factors mainly responsible for the readmission of psychiatric patients. Demographic factors include sex, age, income and management level. Age will be important independent variable because with the increase in the age there will be more severity of the psychiatric disease. Comparison among male and female will be analysed for hospital readmissions because from the literature it is evident that male is more prone to hospital readmissions as compared to female. This study will be helpful in further validating more susceptibility of male towards hospital readmissions. Unemployment and illiteracy are the prominent reasons responsible for the hospital readmissions in the psychiatric patients. Hence, income and education level will be assessed as independent variable in this study. Accurate administration of the medicines for psychiatric conditions and adequate utilization of healthcare facilities will be helpf ul in reducing hospital readmissions11,12. Evaluation strategy: This proposal will incorporate engagement of the skilled healthcare professionals for the evaluation of hospital readmissions. It will also include training for medical professionals for evaluation of hospital readmissions. Healthcare professional will be trained for compilation, analysis and interpretation of the results. Fixed tabular formats will be prepared for compilation of the results. Statistical Package for the Social Sciences (SPSS) will be used for the analysis the data. Trained statistician will be recruited for the statistical evaluation of the data13. Several activities will be planned for the effective evaluation of the implemented programme for hospital readmission reduction programme. Medical and nursing staff will be trained for the discharge activities and readmission evalaution by programme coordinator. On monthly basis meetings will be implemented for the evaluation of implementation of the programme. Stakeholders of this meeting will comprise of project coordinator, the staff nurses and medical specialist, senior level registered nurse and residents. Different interRAI variables like prior hospitalizations, greater severity in several clinical conditions such as psychosis, presence of a secondary substance use diagnosis, and being unemployed will be enquired by the stakeholders of the evaluation programme. Comparison will be done for these interRAI indicators before and after the implementation of the programme. Telephonic call will be arranged for recruited patients twice a week for the duration of four weeks14. Outcomes: Primary endpoint of this programme will be hospital readmission within 30 days followed by within 60 days and 90 days. Hospital readmissions will be measured in two different ways : 1) data retrieval from the hospital records and 2) self-reporting by the patients. Secondary outcomes will include length of hospital stay after readmission, time to hospital readmission, frequency and duration of readmission, total number of general practitioner or emergency department visits and patient satisfaction in discharge process. Separate medical records will be maintained for the patients, those cant be contacted within four weeks of counselling session15,16. In the initial phase, balance of patient characteristics will be measured because it should be equally distributed among control and intervention group due to randomisation. Descriptive statistics will be used for the analysis of patient psychiatric characteristics. Differences between the pre and post test will be evaluated by applying chi-square or Student t-tests. Statistical analysis will be carried out separately for hospital readmissions within 30, 90 and 180 days. Percentage of hospital readmissions in the individual hospitals will be calculated. Readmission rate will be compared with varied factors like patient related factors (demographic status, educational status, living conditions and employment status), disease related factors (severity of the disease, types of symptoms) and hospital related factors (utilization of healthcare facilities). Biasness due to different set up of hospitals will be reduced by categorising hospitals in the different groups. External validity wil l be monitored by controlling hospital characteristics. These hospital characteristics include region, hospital proximity and patient discharge volume. Subgroup analysis will also be performed. Patients admitted to the hospital prior to the index hospitalisation will be at higher risk of readmission. Hence, subgroup analysis is required in these patients. Age, sex, discharge diagnosis and total number of readmissions in the last six months prior to index admission will be used as covariates or confounding factors2, 17, 18. Hospital readmissions evaluation programme can be affected by multiple factors like evaluation design, variables affecting design and outcome of the evaluation programme, alternatives to hospital readmissions, changes in readmissions with respect to different patient and impact of different stakeholders in the evaluation programme. Hence, multivariate analysis will be used in this evaluation programme because it can give statistical outcome considering multiple fa ctors. Confidence interval will be computed from the observed data. For each parameter confidence interval will be computed for prior and after hospital readmission. 5 % confidence interval will be considered as statistically significant. Comparison will be made prior and hospital admission. Table 1 : Evaluation team involved in programme will be as follows19 : Team Members Role and task Principal investigator Main task in the evaluation process is to oversee evaluation implementation, submitting reports and having ultimate responsibility of the program. Project coordinating person Trained statistician Internal evaluator The main role will be overseeing administrative and fiscal functions Statistics task. Internal evaluator will be responsible in conducting surveys, gathering information and analyzing data External evaluator This will be responsible in designing and guiding the evaluation process of the program process. He/she will review internal findings, engaging in external assessments and offers reports to funder. Table 2 : Baseline characteristics of study population20,21 Characteristics Pre-test Post-test Patients (n) 1000 1000 Age, mean (SD), years Male % Female % Employment status Employed Un-employed Educational status Schooling College Graduation Readmission to the hospital within 6 months of index admissions Length of index hospital stay Table What is the prevalence of the problem? Does the patients status affected by mood status, history of hospitalization, substance abuse, living status, employment status ? How many individuals are participating? What are the changes in performance? How many/what resources are used during implementation? How many participants are attending telephonic counselling sessions ? Is there a change in quality of life? Is there a change in health measures? Is there a difference between before and after? Has the patient displayed potential risk as per CAP guideline? What is the readmission frequency of the patient, 30,90 or 180 ? What is the first readmission time for 30, 90 and 180 days time points ? What is first readmission duration for first readmission for 30, 90 and 180 days time points ? HIS Table 4: Healthcare utilization and patient satisfaction four weeks during counselling20,21 Characteristics Pre-test Post-test Cl value Patients (n) 1000 1000 Length of index hospital stay Readmissions Readmissions within 30 days Readmissions within 60 days Readmissions within 90 days Time for first readmission Number of readmissions within 30, 60 and 90 days. Duration of first readmission Other healthcare utilization General practitioner visits Emergency department visits Patient satisfaction with discharge procedure Table 5: Programme outcome and outcome measures20,21: Outcome Outcome measures Clinical efficacy Whether psychiatric symptoms will be improved in the intervention group as compared to the control group Patient efficacy Whether intervention group will he having less number of hospital readmissions as compared to the control group. Healthcare staff fidelity Healthcare professionals execution of the programme protocol will be evaluated: How many post-discharge counselling sessions will be attended by healthcare professional telephonically. How much time healthcare professional will spend on each post-discharge counselling session. How much time healthcare professional will spend on weekly post-discharge counselling session. Success in recruitment and randomization How many actually enrolled patients will be eligible for participation in the programme. Record will be maintained for the drop-out participants prior to completion of the study. Baseline characteristics of both control and intervention arm will be compared. Success of counselling session Percent participants receiving counselling session. Percent participants attending primary healthcare providers within two weeks of discharge. Percent participants contacted telephonically post-discharge. References: Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of post-concussion syndrome following mild head injury. Journal of clinical and experimental neuropsychology. 2001; 23(6):829-36. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011; 306:1688-98. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. 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