Summary of protocol 1 & 2:
Intervention: Increase percentage of post-hospitalization follow up phone calls in order to decrease 30-day rehospitalization/readmission rates. Key stakeholders include patients and their families, physicians/healthcare teams, hospital administrations/clinic administration.
Protocol #3.
- Identify a patient or community group that contributes to or is involved in the principal behavior you are attempting to improve with your intervention.
Initially in small group we had discussed the role of the patient. However, thinking about this more, if my intervention is to encourage more hospital physicians/health care teams to follow up with recently hospitalized patients after discharge, the group to focus on might be the physicians/care teams (nurses, nurse care managers, pharmacists).
2. Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention. This can be an extension/based on expected findings (or previously published literature) from your answers to Homework #3. Figures are always very useful... keep it simple.
Since we are attempting to change provider behavior, this might be more amenable to a Theory of planned Behavior framework. (figure didn't transfer but below is the model based on Table 4)
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- Behavior: implement f/up dc phone call to patient
- Behavioral intention: operationalize physician/team desire to f/up with patients even after leaving service/discharge to home
- Attitude toward behavior: most care teams think, it’d be nice to follow up with patients after discharge, but once pt is off the service, no longer our responsibility
- Subjective norm: the culture is such that following up with discharged patients is not as important as current inpatient issues
- perceived behavioral control:
- a) physician care teams have ability to conduct f/up calls; perhaps time constraints/busy service leads to perception that care teams cannot follow up w/ discharged patients
- b) Teams may have the time/resources to make these calls- but do care teams believe f/up calls can make a difference in pts after hospital care
3. Identify how one or more of your specific interventions will target one or more of these key factors contributing to the behavior of interest.
The intervention aims to improve the culture of patient handoffs/fragmentation of care by encouraging behaviors of close follow up (through the post-discharge phone call). Education of hospital providers that there are health outcomes and financial consequences of readmissions is part of this education.
Encouraging hospital administrations/incentivizing a hospital/clinic culture that supports providers care for patients even after inpatient/hospitalization is important for changing attitudes, and subjective norms regarding post-discharge phone follow up.
4. Create a framework that draws upon a socio-ecological framework to orient your target behavior within a larger context. ie, what are some of broader, external forces that influence the individual behavior of interest...see Figure 2 of “Theory at a Glance.”
Social and Economic Policies – reducing readmissions/costs is now tied to reimbursement policies/medicare reimbursement
Institutions – hospitals, because of the above policies, are now incentivized to enact interventions to try and reduce their own readmission rates. Administration will play a role in design of systems/programs to carry out d/c follow up calls.
Neighborhoods and Communities. Physicians/care teams, both inpatient and outpatient; as well as patients and their families are the groups the policies will affect.
Living Conditions – homeless/not homeless, ability to do adls/iadls. Living conditions may play a role on targeting who best to target post-discharge interventions—living conditions may drive who is most likely to suffer a readmission; addressing these barriers in the intervention will be important.
Social Relationships – Involvement of patient families/social support is also an aspect of the post- discharge follow up. Social support may also play a role, such as living conditions, in who is high risk for readmission.
Individual Risk Factors – We know that age, frailty, severity of disease are risk factors for readmission.
Pathophysiological Pathways – Unnecessary readmissions occur for variety of reasons that could potentially be addressed through the intervention, including: lack of access to medicines (either had problems filling rx); functional impairments 2/2 poor home-care planning/home health access; new information from pending workup/lab that change best management after patient has discharged.
Individual/Population – improving the quality of care and health of the individual is the primary goal in this intervention. Those who experience readmissions have higher odds of poor outcome or mortality than those who do not.