Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes
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| Language: | English |
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Xavier University / OhioLINK
2018
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| Online Access: | http://rave.ohiolink.edu/etdc/view?acc_num=xavier1524395520207456 |
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ndltd-OhioLink-oai-etd.ohiolink.edu-xavier15243955202074562021-08-03T07:06:26Z Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes Brumm, Susan D. Health Care Health Care Management Medicine Nursing Transition Care transitions of care readmissions diabetes telehealth remote monitoring veterans handoff to primary care inpatient to outpatient glycated hemoglobin A1c integration of care continuity of care complex adaptive chronic care Diabetes is a disease more prevalent in the veteran population and contributes to higher readmission rates. The Veteran Affairs is the largest integrated health care system in the United States which made it possible to investigate continuity of care from inpatient to outpatient. This project involved the testing of a post-discharge transition program to reduce readmissions and glycated hemoglobin. The model for improvement was the method used and the framework applied was the complex adaptive chronic care which compels change in communication and integration of care. Project aims were to increase collaboration between inpatient and the Patient Aligned Care Team nurses using a written handoff note from an inpatient nurse practitioner who was the diabetes educator after a 30-day transition program. If titration of insulin was still needed after the transition program, the handoff note was sent to a pharmacist. The final aim was to monitor the percentage of patients consenting to telehealth using remote monitoring. Implementation of the project included using small tests of change (plan-do-study-act cycles) and took place from September, 2017 to February, 2018. Process measures monitored were the percentage of patients who had a handoff signed by the nurse or pharmacist and percentage of patients consenting to remote monitoring post discharge. Population outcomes monitored were the percent of uncontrolled diabetes patients who were readmitted 60-days post-discharge and the monthly percentage of patients with glycated hemoglobin >9.0% in the medical center. Readmissions continued a downward trend during the project period. The author recommends continuation of the post-discharge transition care program and further evaluation of costs and benefits. 2018-04-23 English text Xavier University / OhioLINK http://rave.ohiolink.edu/etdc/view?acc_num=xavier1524395520207456 http://rave.ohiolink.edu/etdc/view?acc_num=xavier1524395520207456 unrestricted This thesis or dissertation is protected by copyright: all rights reserved. It may not be copied or redistributed beyond the terms of applicable copyright laws. |
| collection |
NDLTD |
| language |
English |
| sources |
NDLTD |
| topic |
Health Care Health Care Management Medicine Nursing Transition Care transitions of care readmissions diabetes telehealth remote monitoring veterans handoff to primary care inpatient to outpatient glycated hemoglobin A1c integration of care continuity of care complex adaptive chronic care |
| spellingShingle |
Health Care Health Care Management Medicine Nursing Transition Care transitions of care readmissions diabetes telehealth remote monitoring veterans handoff to primary care inpatient to outpatient glycated hemoglobin A1c integration of care continuity of care complex adaptive chronic care Brumm, Susan D. Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| author |
Brumm, Susan D. |
| author_facet |
Brumm, Susan D. |
| author_sort |
Brumm, Susan D. |
| title |
Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| title_short |
Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| title_full |
Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| title_fullStr |
Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| title_full_unstemmed |
Readmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes |
| title_sort |
readmissions, telehealth, and a handoff to primary care in veterans with diabetes |
| publisher |
Xavier University / OhioLINK |
| publishDate |
2018 |
| url |
http://rave.ohiolink.edu/etdc/view?acc_num=xavier1524395520207456 |
| work_keys_str_mv |
AT brummsusand readmissionstelehealthandahandofftoprimarycareinveteranswithdiabetes |
| _version_ |
1719454170266730496 |