Responding to the Changing Face of the Social Determinants of Health The social determinants of health (SDoH) are at the top of every health care organization's priority list. The ability to respond to these nonclinical client needs is driving the financial sustainability, if not survivability, of facilities and programs across the globe. Although a number of traditional populations have been long identified with the SDoH, the face of those clients and communities is changing. With these demographic shifts come new ethical challenges for case managers, particularly in response to prevailing personal biases. With the case management positioned on the front lines of care, the workforce must be able to identify and respond ethically and effectively to the emerging new face of the SDoH.

The Impact of Case Management on Reducing Readmission for Patients Diagnosed With Heart Failure and Diabetes Purpose of the Study: To determine the impact of integrated case management services versus treatment as usual (TAU) for patients diagnosed with diabetes and concomitant heart failure. Primary Setting: This medical chart review was conducted at a single-site facility. The retrospective study design can be implemented at other facilities with a similar landscape. Methods: A retrospective, descriptive, comparative analysis of integrated case management services compared with TAU from a medical chart review of 68 patients from September 1, 2015, through July 31, 2017. A medical chart review was conducted to generate the study sample for data collection and analysis. The data were organized, cleaned, and prepared and then analyzed. The data were analyzed using SPSS and verified with SAS and R. Applied were descriptive statistics and statistical tests—t test, χ2 test, Mann–Whitney U test, and Logistic Regression. Results: For the integrated case management group, there were 18.4% who readmitted whereas 81.6% did not. For the TAU group, there were 52.6% who readmitted and 47.4% who did not. The association between readmission and case management was χ2 (1, n = 68) = 6.372, p = .012. Nursing Implications: Integrated case management services were statistically significant in reducing readmission for the sample. Demographics tested in this study were not significant predictors for readmission. Extending length of stay for patients who are not medically ready for discharge should be considered because there is a cost difference, as there is evidence of readmission reduction. Policy and procedural amendments can be obtained from this study.

The Impact of Case Management on Reducing Readmission for Patients Diagnosed With Heart Failure and Diabetes No abstract available

Impact of Pharmacist-Driven Heart Failure in-Home Counseling on 30-Day Readmission Rates Purpose/Objective: This study examines the impact of a pharmacist-driven intervention specific to heart failure patients with the goal of reducing readmission rates and improving quality of life in this population. Findings/Conclusions: A total of 21 patients were included in the study. Twelve patients were female and 9 were male. The mean age was 76 years with a range of 65–93 years. Two of the 21 patients were readmitted within 30 days. One of the 2 readmitted patients died soon after admission was in the final stages of his or her disease and passed away soon after; it is unlikely for a home visit to have altered their path. This study did not meet the goal sample size due to some unforeseen limitations. However, the limited data that were obtained suggest a strong basis for further research. Implications for Case Management Practice: During a patient's transition in care from hospital to home, he or she is most vulnerable for complications and readmission. Intervention during this time will not only improve patient care and quality of life but also contribute to a notable cost savings for each prevented readmission. Pharmacist intervention, as part of the health care team, during this tenuous time has shown to make a valuable impact.

Impact of Pharmacist-Driven Heart Failure in-Home Counseling on 30-Day Readmission Rates No abstract available

Factors That Influence Home Care Case Managers' Work and Workload Background: Home care services are increasing across Canada and in other developed nations. There has been increased pressure on home care programs to not only accept more clients more rapidly but also work more efficiently. Case management is an approach through which clients access and receive home care. With both rising numbers of clients and growing complexity among them, case managers' work and workload are also increasing. The demands on case managers and expansion in caseloads are happening without an increase in resources or funding. With case manager work increasing steadily, an understanding of the factors that influence their work and workload is vital. Purpose: The purpose of this study was to explore what factors influence case managers' work and workload. Methods: This study used an ethnographic approach. It took place in Alberta, Canada, in 3 home care offices in urban and suburban geographic areas. Purposive sampling was used, and participants included 28 home care case managers with predominantly long-term clients (>3 months on home care), 3 site managers, and 1 project lead. Data collection methods included semistructured interviews, nonparticipant observation, participant journaling, and focus groups. Results: Case manager works were portrayed in 2 key ways: the number and type of tasks a case manager was required to complete and the amount of time and energy needed to complete a task. The factors that influence case manager work and workload fall into 3 overarching categories: structural, operational, or individual factors. Discussion: The 3 overarching categories, as well as interactions between various factors, contribute to what is known about case managers' work and workload. Participants found it difficult to discuss the factors in isolation because the interaction and “messiness” of the factors were inherent in their actions and stories about their work and workload. Workload includes not only the easily captured work such as direct care and specific activities such as assessment but also diverse forms of invisible work such as problem solving, rapport building, and caseload management, as well as emotional work such as coping, stress management, and team support. Implications for Case Management: Case managers' work and workload in home care are important phenomena. In a climate of budgetary restraint and an aging population, which seemingly prefer home care as much as the system desires to provide it as a main option for care, it is important to capture, recognize, and legitimize an understanding of case managers' work and workload. Increased knowledge in this area could, in turn, transforms both home care and case management.

What Does It Mean to Be a Professional? No abstract available

Are You Reachable? No abstract available

Simplifying UR Processes in the Era of the Two-Midnight Rule No abstract available

Addressing Limitations in Health Literacy: Greater Understanding Promotes Autonomy and Self-Determination No abstract available