Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation

Abstract

Background: Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient's capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits.

Objective: This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT.

Methods: Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data.

Results: The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021.

Conclusions: Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting.

Trial registration: ClinicalTrials.gov NCT04136951; https://ichgcp.net/clinical-trials-registry/NCT04136951.

International registered report identifier (irrid): PRR1-10.2196/20184.

Keywords: PREVENT; RE-AIM framework; clinical decision support system; effective implementation; homecare agencies; rehospitalization.

Conflict of interest statement

Conflicts of Interest: KB and MT are co-inventors of a decision support tool called “Priority for the First Nursing Visit Tool” (PREVENT), which under governing University policy is Clinical Trial intellectual property being studied in this research (“I Interest”). The intellectual property is assigned to the University of Pennsylvania.

©Maryam Zolnoori, Margaret V McDonald, Yolanda Barrón, Kenrick Cato, Paulina Sockolow, Sridevi Sridharan, Nicole Onorato, Kathryn Bowles, Maxim Topaz. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 22.01.2021.

Figures

Figure 1

Study workflow and design. PREVENT: Priority for the First Nursing Visit Tool; RE-AIM: Reach, Effective-ness, Adoption, Implementation, and Maintenance; VNSNY: Visiting Nurse Service of New York.