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

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.