Care Management Journals : Journal of Case Management ; the Journal of Long Term Home Health Care

Pasifika Support Services (PSS) was a program managed by a nongovernment organization, Mission Australia, and funded by the New South Wales Premiers Office to meet the needs of young offenders from a Pacific background. PSS ran from June 2005 to June 2009 and implemented a cost-effective integrated case management model with the New South Wales Police Force adapted to address social risk factors specific to Pacific youth offenders and family support networks. Sixty young people were reviewed regarding the outcomes achieved through their participation, further supported by an evaluation carried out by an external evaluator who found that 65% of participants did not reoffend after 18 months of completing the program...

OBJECTIVES: To systematically assess barriers delaying home respiratory equipment requisition and to evaluate for temporal correlation between delays and emergency room or hospitalization episodes. BACKGROUND: Initiation of home respiratory treatments is delayed because of delays in delivery of durable medical equipment (DME). This study assesses root causes of such delays from a system perspective. We also describe clinical consequences by measuring emergency room visits and hospitalization days for temporal correlations...

Illness is a combination of pathophysiology and associated thoughts, emotions, and behaviors. Given the large number of treatments that are discretionary and preference sensitive, one goal is accurate diagnosis of patient preferences. Reliance on biomedical treatments (e.g., medication and procedures) may overlook important opportunities for improved health such as amelioration of stress and distress and training in more effective coping strategies.

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Optimally, transition in health care should be seamless and incorporate a well-thought-out patient-centered discharge plan; yet, many hospitalized patients are unprepared for discharge, thereby compromising patient safety and quality of care. Transition of care should include a broad range of time-limited services designed to ensure health care continuity to avoid poor outcomes among at-risk populations. This case study demonstrates that advanced practice nurses (APNs) are in the perfect position to bridge the existing gap, reduce readmissions, and improve patient health...

Few studies have examined predictors of hospital readmission among high-using patients enrolled in a behaviorally oriented intensive care management program. The purpose of this case control study was to describe risk factors and the effectiveness of a complex care management program for hospital readmission among vulnerable patients at a large academic medical center. One hundred sixty-three patients enrolled in the University of Michigan Complex Care Management Program (UM CCMP) were hospitalized between January 2014 and March 2015...

This article describes a model for care managers that is based on attachment theory supplemented by knowledge from neuroscience. Together, attachment theory and basic knowledge from neuroscience provide for both an organizing conceptual framework and a scientific, measureable approach to assessment and planning interventions in a care plan.

Communication obstacles in health care settings adversely impact patient-practitioner interactions by impeding service efficiency, reducing mutual trust and satisfaction, or even endangering health outcomes. When interlocutors are separated by language, interpreters are required. The efficacy of interpreting, however, is constrained not just by interpreters' competence but also by health care providers' facility working with interpreters. Deaf individuals whose preferred form of communication is a signed language often encounter communicative barriers in health care settings...

OBJECTIVE: This article examined individual characteristics associated with having higher costs in a 5-year period to identify patients that may potentially benefit from case management. METHODS: Florida Medicaid claims data from 2005 to 2010 were used to examine the characteristics, diagnoses, and services (in 2005) associated with individual costs in 5 future years (2006-2010). The data were divided into estimation and prediction samples with regression models estimated using diagnoses and service use in 2005 to predict future costs...

Previously, we have used a multidisciplinary team (MDT) approach to individualize rehabilitation of very old stroke patients as a means to establish intervention points for addressing impaired activities of daily living (ADL). However, this previous study was limited because of a lack in describing the communication process over time. This case study characterized the MDT communication process in the rehabilitation of an 84-year-old patient over the course of 15 weeks. The MDT consisted of 3 nurses, 1 doctor, 6 therapists, and the patient/families...

A knowledge translation project involving an academic-practice partnership and guided by action-oriented research was used for exploring barriers that impact management of homebound heart failure patients. The intervention process followed an action research model of interaction, self-reflection, response, and change in direction. External facilitators (academia) and internal facilitators (practice) worked with clinicians to identify a topic for improvement, explore barriers, locate the evidence compare current practice against evidence-based practice recommendations, introduce strategies to "close the gap" between actual practice and the desired practice, develop audit criteria, and reevaluate the impact...

BACKGROUND: Despite compelling evidence showing that social networks and social support are associated with depression, relatively little research is available on this topic for older Koreans at high risk of depression. This article aimed to examine the relationship among different types of social networks (family vs. friends), social support (instrumental vs. emotional), and perceived general health among older Koreans at high risk of depression. We would then test for possible differences in pathways between two age groups (60-74 years vs...

AIM: To investigate important case management goals and key influences on the achievement of the goals in community aged care practice from the perspectives of case managers in Australia. METHODS: We surveyed 154 case managers, representing 17.1% of the target population in the State of Victoria, Australia. The key information collected was case managers' characteristics and their selections of important case management goals. We also conducted 33 interviews with 47 case managers to explore their perceptions of important case-managed community aged care goals and the key influences on the achievement of these goals...

A factor contributing to uncontrolled hypertension in older persons is medication nonadherence. Older Black men in a rural cardiology clinic were not taking blood pressure medication as prescribed resulting in uncontrolled hypertension. A nurse protocol to assist with self-administration of hypertensive medication was proposed to address the problem. This qualitative key informant study identified a purposive sample of 10 hypertensive Black men who were 65-70 years of age and nonadherent in taking their medication...

This evaluation was designed to examine the perspectives of 15 frontline staff who implemented a managed care program and 154 high-risk, high-cost disabled Medicaid clients who were participants in the program. Results indicated that positive relationships between staff and clients played a key role in facilitating program implementation. Challenges included finding ways to provide a wide breadth of services including food, shelter, and transportation; handling difficulties following from staff turnover; and creating transitions of care for clients to community health clinics...

OBJECTIVES: The current cross-cultural study examines the pathways underlying different formations of social networks and social support systems, which affect depression symptoms among older Korean immigrants and non-Hispanic Whites in the United States. METHOD: Data for this study came from a panel survey of 223 older Korean American immigrants and 201 non-Hispanic White older adults 65 years of age and older living in Los Angeles. Structural equation modeling (SEM) is used to test the proposed conceptual model designed to explain the direct and indirect relationships between social networks and social support on depression symptoms...

Numerous studies have demonstrated the short-term effectiveness of the Cash and Counseling model option of participant-directed home and community-based personal care service programs for Medicaideligible recipients with disabilities requiring long-term care. However, long-term experiences with participant-directed services have yet to be examined for these individuals. We addressed this gap in the literature through participatory action research and qualitative content analysis. Working together as coresearchers with members of the National Participant Network, a peer organization for people interested in or enrolled in participant-directed services, we interviewed 17 adults enrolled in one state's Cash and Counseling-based program...

Women enrolled in Florida's Temporary Assistance for Needy Families (TANF) program experience high rates of chronic health problems and often lack a usual source of care. Thus, in this study, we aimed to identify variables related to being in a usual source of care at time of study enrollment and determine whether a public health nursing case management intervention affected the obtainment of a usual source of care. To achieve these aims, we conducted a secondary analysis of a randomized controlled trial of a public health nursing case management intervention, which included women with chronic health conditions enrolled in TANF (n = 432)...

This study examined differences in perceived benefits of home-delivered meals between older adults living alone and those living with others. Recommendations were also discussed to enhance services by examining differences between these two subgroups. This study used secondary data analysis focusing on two open-ended questions that were collected in a client satisfaction survey conducted by AgeOptions, the Area Agency on Aging (AAA) in suburban Cook County, Illinois. Out of 199 older adults or their caregivers who participated in the survey, 126 (63...

Many case managers in mental health settings occasionally experience a client's suicide, and this can be an emotionally devastating event. The symptoms of schizophrenia, including the difficulties those client face in forming trusting relationships with others, brings special challenges to the case manager's recovery because of the efforts put into developing that relationship. The purposes of this article are to describe a range of possible reactions of case managers following the suicide of a client with schizophrenia and how those persons can be helped to make a positive recovery from such an event...