Online Program

Enhanced care coordination logic model construction to reduce nursing home resident hospitalizations and improve quality of life

Tuesday, November 5, 2013 : 10:54 a.m. - 11:06 a.m.

Elizabeth A. Thomas, RNC, PhD, MPH, APHN-BC, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX
Lisa Campbell, DNP, RN, APHN-BC, School of Nursing, Texas Tech Health Science Center, Victoria, TX
The costs of hospitalization for nursing home residents (nosocomial infections, iatrogenic injury, cognitive decline), families (emotional distress, financial burden) and health care facilities (penalties and sanctions for re-hospitalizations) indicate an urgent need for care coordination, utilizing all available resources to address complex factors contributing to preventable hospitalizations. Focusing on a Centers for Medicare and Medicaid Services grant, graduate population health nursing students constructed a logic model for care coordination between nursing homes and acute care facilities. A Logic Model template delineated essential elements: Inputs, Outputs (Activities, Participation), and Outcomes. Processes were indicated by arrows. An Assumption statement initiated dialogue and aided in identifying External Factors expected to be constraining forces that would limit program design. The need for care coordination bridging communication gaps between hospital staff, nursing home staff, nursing home residents, residents' families, and community support services was identified. A program, combining communication/ informatics technologies, nursing home staff education and community health workers (CHWs) as team members in nurse-run care coordination was developed. The CHWs would build, support and enhance communicate between care providers, residents and families across care settings to minimize hospitalization, care disruption, resident health decline and maximize quality of life. The iterative process led to care coordination program development, combining communication technologies, collaboration across care settings, and adding CHWs to care coordination. This process could be used by care providers, health system executives, and nursing homes, working with residents, families and community stakeholders, to create a collaborative partnership to reduce preventable hospitalizations of nursing homes residents.

Learning Areas:

Chronic disease management and prevention
Program planning
Public health or related nursing

Learning Objectives:
Describe the three essential elements of the logic model in elder care program planning. Identify at least two components necessary to implement an enhanced care coordination program in nursing homes. Discuss the cost-benefit of implementing an enhanced care coordination program in nursing homes.

Keyword(s): Nursing Homes, Community Health Programs

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: My qualifications include a PhD in Nursing, (health systems and vulnerable populations concentrations), a MPH (family-child concentration) and a MSN (maternal-infant concentration); over six years of experience as lead faculty for online population health/epidemiology and community health courses in masters and doctoral nursing programs; board certification as an Advanced Public Health Nurse (APHN-BC) and extensive experience in community health program delivery, as a rural perinatal case manager, and program development with the Nurse Family Partnership.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.