Variables

The variables included in this study were based upon information available in an existing data set. The proposed methods included information from intake forms, the CCT, progress notes, and from an ED visit form. The progress note information was the proposed source for problem identification (e.g. potentially inappropriate medication use or care transition problems

(dependent variable Aim 1D)). The ED visit form was the proposed source of information about ED use (dependent variable Aim 1E). Data was not available from these forms in the existing data set. Therefore, these variables were not included. The following table (Table 10) shows the proposed variables and lists the availability of the information in the existing data set.

Table 10. Proposed variable collection and variables in existing RHWP data set

Proposed Variables Definition

Variable in

Existing Data Set Patient Intake Form

Predisposing- Traditional Domain

Age Years Yes

Gender Male/Female Yes

Race/Ethnicity Caucasian/African-American/Native American/Asian/Hispanic/Other

Yes

Education Years of education;

GED (Yes/No)

Yes Enabling – Traditional Domain

Insurance Medicare/Medicaid/ Medicare-Medicaid

Dual Eligible/Other

Yes

Primary care provider (PCP) Yes/No Yes

Years of residence Number of years residing in the apartment building

Yes Social network Relationship of contact (if need

something or are sick);

Help or aid in the home (Yes/No)

Yes

Enabling- Vulnerable Domain

Transportation source Ability to drive (Yes/No);

If No, method of transportation

Yes Telephone access Telephone (Yes/No);

Cell phone (Yes/No)

No Assistive devices (walker, cane,

wheelchair)

Yes/No;

Type

Yes Activities of daily living (ADL):

bathing, dressing, toileting, transferring, continence, feeding

Independent/Dependent Yes

Need- Traditional Domain Past Medical History:

Alzheimer’s disease or problems with your memory; ankle/leg swelling; arthritis; asthma; COPD;

cancer; CAD / heart disease MI / heart attack (year); high blood pressure/hypertension; high cholesterol; stroke; diabetes/high blood sugar; seizures; visual impairment; hearing impairment;

kidney impairment; loss of feeling/numbness burning in legs or feet; osteoporosis; Parkinson’s disease; sciatica or chronic back pain; diarrhea; GERD;

constipation; urinary incontinence;

inflammatory bowel; thyroid problem; weight loss > 10 lb. in last year (intentional); headaches / migraines; insomnia

Yes/No;

Type and number of chronic conditions

Yes

Medication use Number of medications No

Need- Vulnerable Domain

Past mental health history: Yes/No; Yes

Schizophrenia; bipolar disorder;

depression

Type and number of mental health conditions

Substance abuse history Alcohol Consumption (Yes/No);

Amount of alcohol per week;

Illicit drugs (Yes/No);

Description of illicit drugs

Yes

Health Behavior (Use of Health Services)

Hospital admission Date of last admission;

Hospital;

Reason;

Number of visits in last 6 months

Yes

RHWP use Number of clinic visits Yes

Progress Note for Clinic Visits

Date of visit Date No

Chief complaint Text No

Subjective Text (includes social history) No

Objective General appearance and physical

findings: vitals (BP, pulse, weight, pain (vitals flow sheet);point of care test (BG, A1C, lipids - point of care flow sheet); targeted exam based on symptoms

No

Assessment Text No

Plan Text No

Targeted counseling Inhaler/glucometer use No

Return to clinic Number of weeks No

Professions involved Pharmacy/Nursing/Social Work No

ED Visit Form

Date of ED visit Date No

Description of reason for visit Text No

ED visited Name of hospital No

Care provided in ED Text No

Outcome of ED visit Text No

Other notes Text No

The proposed methods included collecting information from the Medication Discrepancy Tool.⁹⁷ The MDT examines causes and contributing factors of medication discrepancies from a patient level (e.g. patient did not fill prescription), system level (e.g. conflicting information from different informational sources or confusion between brand and generic names), and resolution of the discrepancy (e.g. encouraged patient to call PCP or specialist about the problem).⁹⁷ This tool was not adopted for use in the RHWP. In addition, a checklist to determine if a potentially inappropriate medication was present and the participant’s number of potentially inappropriate medications based upon the Beers Criteria for Inappropriate Medication Use in Older Adults was proposed.⁹⁸ Medication lists were not available in the existing data set, so this was not included in the study. Validated tools, such as the Geriatric Depression Scale⁹⁹, were not a part of this existing data set and therefore, not included.

Information from a modified form for the RHWP clinic, the RWHP Care Coordination Tool (CCT), was collected in the existing data set. In order to measure care coordination activities and outcomes of the RHWP, this adapted tool was developed from the Medical Home Care

Coordination Measurement Tool (CCMT) used in pediatric clinics published in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas.¹⁰⁰ Information collected from the RHWP Care Coordination Tool (CCT) included care coordination activities needed, activities performed to fulfill care coordination needs, faculty type involved in the process, total faculty time, outcomes prevented, and outcomes that occurred due to care coordination activities.

The variables collected from the CCT form are described in Table 11 and align with what was proposed.

Table 11. Variables collected from the RHWP Care Coordination Tool (CCT)

CCT Variable Description

Faculty team composition Nursing (NP)

Pharmacy (PharmD) Medicine (MD) Social Work (SW) Psychology (Doctoral) Gerontology

Faculty team visit time Number (minutes)

Care coordination activities/needs categories Type of care coordination activities/needs, Number of care coordination activities/needs Make appointments

Follow-up/Referral management

Order: Prescriptions/Prescription delivery; Supplies (e.g. glucometer, walker); Home health care services; Laboratory tests; Other

Reconcile discrepancies: Medication-related; Adherence issues; Other Education/Counseling

Coordination of social services: Agencies (e.g. SSI); Insurance; Transportation; Other Disease management

Disease monitoring Medication management Home visit

Other

Activity performed to fulfill care coordination needs categories

Activity to fulfill care coordination needs, Number of care coordination activities to fulfill needs

Develop/modify written care plan Meeting/case conference

Monitoring

Social work assessment Social work enrollment

Patient education/counseling (face-to-face): Psychosocial support; Practical concerns (e.g.

financial, insurance, transportation); Family/support system concerns; Emotional

concerns (e.g. distress, depression, anxiety); Medication-related; Disease-related; Other Home visit

Other

Outcomes prevented categories

Type of outcome prevented, Number of outcomes prevented, Degree of certainty ER visit

Subspecialist visit

Hospitalization (admission) Visit to PCP office/clinic Lab/X-ray

Specialized therapies (PT, OT, etc.) Inappropriate medication use Adverse drug event

Nursing home stay Other

Outcomes occurred categories

Type of outcome occurred and number of outcomes occurred

Advised family/patient on home management Patient knowledge or skill

Referral to ER

Referral to subspecialist Referral for hospitalization Referral for PCP office visit Referral to lab/ x-ray

Referral to community agency

Referral to psych. (LCSW, LMFT, LPC, etc.) Referral to specialized therapies

Referral to social work on site Referral to APS

Referral to support group

Ordered prescription, equipment, etc.

Reconciled discrepancies (including missing data, miscommunications, adherence issues, medication issues)

Reviewed labs, specialist reports, etc.

Set up family/caregiver meeting Advocacy for patient

Met patient’s immediate needs, questions, concerns Unmet needs

Not applicable/don’t know Outcome pending

Other

2.2.4.3 Data Analysis

Aim 1C

Descriptive statistics (means, SD, frequency, %) were used to characterize the predisposing (e.g.

age, gender, ethnicity/race, education level), enabling (e.g. insurance type, PCP, years of residence, social network, transportation source, telephone access, use of assistive devices, Activities of Daily Living), and need (e.g. type and number of chronic conditions, type and number of mental health conditions, substance abuse history) factors and use of health services

or health behaviors (e.g. ED visits, hospitalizations, PCP visits, use of RHWP clinic) of the RHWP participants. Descriptive statistics were also reported for the CCT.

Proposed descriptive statistics from the participant’s progress note (e.g. number of clinic visits per patient, main patient reasons for clinic use (chief complaint)); from the ED visit form (e.g.

number of ED visits per patient, main reasons for ED visit, care provided in the ED, and outcome of ED visit); validated tools (e.g. Geriatric Depression Scale⁹⁹); and summary information from patient visits, including but not limited to problems identified (e.g. potentially inappropriate medication use or care transition problem) are not reported since this information was not available in the existing data set.

Aim 1D

The dependent variable, presence of a care transition problem, was not available in the existing data set. This aim was not addressed.

Aim 1E

The dependent variable, ED use from the ED visit form, was not available in the existing data set. This aim was not addressed.

In document Identifying Problems during Transitions of Care and Reasons for Emergency Department Utilization in Community-Dwelling Older Adults (Page 92-100)