A disease management study conducted in home care with 303 patients with diabetes, heart failure, or both revealed information deficits that make disease and quality management difficult. Nurses used a guideline checklist to indicate the amount and type of information available to them on admission and by the end of the episode of care. Nurses reported having data on 7% to 94% of the data elements. Whether a lipid profile had been done, the HbA1C (glycosolated hemoglobin test, also called a hemoglobin A1C) levels, or ejection fractions were known for 7%, 17%, and 18%, respectively. When nurses reported information related to ACE-I use (N = 183), they reported that 76% of patients were on ACE-I (angiotensin-converting enzyme inhibitor) or acceptable alternative for heart failure. But no information was reported on ACE-I use for 12% of the patients (N = 24). Potential solutions to these deficits in information and quality include increased use of guidelines in home care, guideline checklists, information transfer forms, nurse activism to request information, and the adoption of the electronic health record.
Anderson, M.A., & Helms, L. ( 1993). An assessment of discharge planning models: Communication in referrals for home care. Orthopaedic Nursing, 12(4), 41-49.
2.
Anderson, M.A., Helms, L., Black, S., & Myers, D.K. ( 2000). A rural perspective on home care communication about elderly patients after hospital discharge. Western Journal of Nursing Research, 22, 225-243.
3.
Astm. (2009). E2369-05e1 standard specification of the continuity of care record. Retrieved July 30, 2009, from http://www.astm.org/Standards/E2369.htm
4.
Audet, A., Doty, M., Shamasdin, J., & Schoenbaum, S. (2005). Physicians’ views on quality of care: Findings from the commonwealth fund national survey of physicians and quality of care. New York: Commonwealth Fund.
5.
Baumhakel, M., Muller, U., & Bohm, M. ( 2009). Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. European Journal of Heart Failure, 11, 299-303.
6.
Bicket, D.P. ( 2002). Using ACE inhibitors appropriately. Journal of the American Academy of Family Physicians, 66, 461-468.
7.
Bowles, K.H., Holland, D.E., & Horowitz, D.A. (2009). Comparing in-person home care, home care with telephone contact, or home care with telemonitoring: Outcomes of different disease management delivery methods. Journal of Telemedicine and Telecare, 15, 344-350.
8.
Brega, A.G., Jordan, A.K., & Schlenker, R.E. (2003). Practice variations in home health care. Home Health Services Quarterly, 22(3), 41-64.
9.
Brown, E.L., Raue, P.J., Mlodzianowski, A.E., Meyers, B.S., Greenberg, R.L., & Bruce, M.L. ( 2006). Transition to home care: Quality of mental health, pharmacy, and medical history information. International Journal of Psychiatry in Medicine, 36, 339-349.
10.
Centers for Medicare and Medicaid Services. ( 2005). OASIS overview. Retrieved July 25, 2008 , from http://www.cms.hhs.gov/oasis/
11.
Clancy, C. ( 2009). Reengineering hospital discharge: A protocol to improve patient safety, reduce costs, and boost patient satisfaction. American Journal of Medical Quality, 24, 344-346.
12.
Clare, J., & Hofmeyer, A. ( 1998). Discharge planning and continuity of care for aged people: Indicators of satisfaction and implications for practice. Australian Journal of Advanced Nursing, 16, 7-13.
13.
CMS Policy Council. (2006). Post-acute care reform plan policy council document. Retrieved August 2, 2009, from http://www.cms.hhs.gov/SNFPPS/Downloads/pac_reform_plan_2006.pdf
14.
Criteria Committee of the New York Heart Association. ( 1994). Nomenclature and criteria for diagnosis of diseases of the heart and great vessels (9th ed.). Boston: Little Brown.
15.
De Wit, R., & Van Dam, F. (2001). From hospital to home care: A randomized controlled trial of a pain education programme for cancer patients with chronic pain. Journal of Advanced Nursing, 36, 742-754.
16.
Department of Health and Human Services. ( 2009). Health information technology for the future of health and care. Retrieved July 30, 2009, from http://healthit.hhs.gov/portal/server.pt?open=512&objID=1204&parentname=CommunityPage&parentid=8&mode=2&in_hi_userid=10741&cached=true
17.
Fairchild, D.G., Hogan, J., Smith, R., Portnow, M., & Bates, D.W. ( 2002). Survey of primary care physicians and home care clinicians . Journal of General Internal Medicine, 17, 253-261.
18.
Gingerich, B.S. ( 2009). Client teaching guides for home health care. Home Health Care Management & Practice, 21, 145-146.
19.
Hahn, K.A., Ferrante, J.M., Crosson, J.C., Hudson, S.V., & Crabtree, B.F. (2008). Diabetes flow sheet use associated with guideline adherence. Annals of Family Medicine , 6, 235-238.
20.
Helleso, R., & Lorensen, M. ( 2005). Inter-organizational continuity of care and the electronic patient record: A concept development. International Journal of Nursing Studies, 42, 807-822.
21.
Health Level Seven. (2009). HL7 continuity of care document, healthcare IT interoperability standard, is approved by balloting process and endorsed by healthcare IT standards panel . Retrieved July 30, 2009, 2009, from http://www.hl7.org/documentcenter/public/pressreleases/20070212.pdf
22.
Horowitz, D.A., Loh, R., & Goldberg, L. ( 2004). Program for the management of heart failure. University of Pennsylvania health system intranet document. Unpublished manuscript.
23.
Horowitz, D.A., & Schwartz, S. ( 2007). Program for the management of diabetes. University of Pennsylvania health system intranet document. Unpublished manuscript.
24.
Howard, P.A., Shireman, T.I., Dhingra, A., Ellerbeck, E.F., & Fincham, J. ( 2007). Patterns of ACE inhibitor use in elderly Medicaid patients with heart failure. American Journal of Geriatric Cardiology , 11, 287-294.
25.
Institute of Medicine. (2000). To err is human: Building a safer health system (L. T. Kohn, J. M. Corrigan & M. S. Donaldson, Eds.). Washington, DC : National Academies Press.
26.
Institute of Medicine. (2001). Crossing the quality chasm: A new health care system for the 21st century . Washington, DC: National Academies Press.
27.
Jewell, S.E. ( 1993). Discovery of the discharge process: A study of patient discharged from a care unit for elderly people. Journal of Advanced Nursing, 18, 1288-1296.
28.
The Joint Commission. (2006). 2007 Hospital/critical access hospital national patient safety goals. Retrieved July 30, 2009, from http://www.jointcommission.org/PatientSafety/National-PatientSafetyGoals/07_hap_cah_npsgs.htm
29.
The Joint Commission. (2008). 2009 joint commission standards. Retrieved July 25, 2008, from http://www.jointcommission.org/Standards/SII/sii_hap.htm
30.
The Joint Commission on the Accreditation of Healthcare Organizations. (2007). Improving hand-off communication (M. Pillow, Ed.). Oakbrook Terrace, IL : Joint Commission Resources.
31.
The Joint Commission on the Accreditation of Healthcare Organizations. (2008). The joint commission accreditation program: Home care national patient safety goals. Retrieved October 18, 2009, from http://www.jointcommission.org/NR/rdonlyres/ABD0D499-A95A-4E33-BA18-6064EBA6C0B3/0/OME_NPSG.pdf
32.
Kripalani, S., LeFevre, F., Phillips, C.O., Williams, M.V., Basaviah, P., & Baker, D.W. ( 2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. Journal of the American Medical Association , 297, 831-841.
33.
Miller, C. ( 2006). Using standards of care to drive evidence-based clinical practice and outcomes for diabetes mellitus. Home Healthcare Nurse, 24, 307-312.
34.
National Quality Forum. (2009). Addressing national priorities. Retrieved July 27, 2009, from http://www.qualityforum.org/Setting_Priorities/Addressing_National_Priorities.aspx
35.
Rittenhouse, D.R., & Shortell, S. M. (2009). The patient-centered medical home: Will it stand the test of health reform? Journal of the American Medical Association, 301, 2038-2040.
36.
Satzinger, W., CourteWienecke, S., Wenng, S., & Herkert, B. ( 2005). Bridging the information gap between hospitals and home care services: Experience with a patient admission and discharge form. Journal of Nursing Management, 13, 257-264.
37.
Setter, S.M., Corbett, C.F., Campbell, R.K., Cook, D., & Gates, B.J. ( 2003). A survey of the perceptions, knowledge, and use of A1C values by home care patients and nurses. Diabetes Educator , 29, 144-152.
38.
Siegler, E.L., Murtaugh, C.M., Rosati, R.J., Schwartz, T., Razzano, R., Sobolewski, S., et al. (2007). Improving communication at the transition to home health care: Use of an electronic referral system. Home Health Care Management & Practice, 19, 267-271.
39.
Stevenson, L., McRae, C., & Mughal, W. ( 2008). Moving to a culture of safety in community home health care. Journal of Health Services Research & Policy, 13(Suppl. 1), 20-24.
