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Using a Transitional Care Management Screening Tool on Medicare Adult Patients with Chronic Conditions: Quality Improvement Project
Get PDFBackground
Within the United States, adult patients over the age of 65 are averaging give emergency room visits per year with potential admission. Patient hospital readmissions occur when a patient is discharged from the hospital and is readmitted within 30 days. This can occur due to medication noncompliance, premature discharge, or the most common reason, lack of adequate provide follow-up as an outpatient.
Project Goals
1. Implement a transitional care management screening tool within the primary care practice with Medicare adult patients with chronic conditions to improve post hospitalization follow up appointments with PCP.
2. Designate a medical assistant to take on the role of TCM representative within the office and complete the initial screening with patients prior to their visit.
3. Track patient TCM visits within 30 days of hospital discharge and plan.
Methods
Transitional care management screening was conducted via telephone in Medicare patients over the age of 65. If patients screened positive to being discharged within 14 days of the screening call, an in-office screening visit was scheduled with the provider. Following implementation of the project, patients were contacted to determine if they had visited an emergency room or been admitted to the hospital since screening.
Results
There was a total of 32 participants, ages 65 to 93 with a mean of 71.5. Of the total 32 participants, 17 were male (53.125%) and 15 were female (46.875%). Of the total 32 patients followed during the study, seven patients (21.875%) had been recently hospitalized within the past 14 days of being screened. The seven patients were seen in the office for an in-person TCM visit with the provider. By the end of the study, all seven patients have not been readmitted and none of the remaining 25 patients have been hospitalized.
Conclusion
It was shown that consistent transitional care management screening of Medicare patients can reduce hospital readmission. The goal of transitional care management is to improve community health and manage comorbid conditions closely while encouraging use of the primary care office for non-urgent acute visits to avoid hospital visits
Implementing a Nurse Education Seminar to Improve Chlorhexidine 4% Compliance on a Cardiac Surgical Unit
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Analysis of Microbial Community Structure Reveals Significant Differences Between River Basins on the Dingle Peninsula of Ireland
Get PDFThe Feohanagh, Milltown, and Owenmore rivers of the Dingle Peninsula on the southwest coast of Ireland drain conjoined basins of approximately equal size and shape. While these rivers occupy similar spaces of land, the land surrounding the basins serves different purposes and varies substantially in land-use and land-cover (LULC). Our specific aim was to compare the planktonic microbial communities at the outflow region of the rivers for spatial and temporal variation. Five water samples were taken from each of the three rivers at two different timepoints, and Illumina sequencing of the 16S and ITS rRNA regions was conducted to identify bacterial and fungal species, respectively. Statistically significant differences in both community composition and absolute abundance were observed between rivers and also within rivers between timepoints. We are continuing our analyses to identify the significant species driving the observed differences by looking at subgroups representing the top 80% of microbial biomass, the bottom 20% of microbial biomass, and the dominant species represented by more than 100,000 individual genomes/sample. We will also present the results of analyses to correlate observed differences with differences in LULC between the three river basins
The Transformative Effects of a Physical Fitness Program for Individuals with Autism Spectrum Disorder
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Autonomous Drone Mission
Get PDFThis project aims to develop a fully autonomous drone capable of performing a precise flight path that includes takeoff, navigation, a ring pick-up, and a ring drop-off. The pick-and-drop system features a custom-designed, silicone and 3D-printed servo motor claw mechanism for reliable ring handling, integrated into a lightweight drone frame. The implementation of the drone includes the use of a Cube Black as the flight controller, a Here4 rover and base module as the real-time kinematic (RTK) navigation modules, 4S (15.2V) Lipo battery, four APD 40F3 ESCs, two RFD900x-US Telemetry modules, and four KV900 motors. The combination of gyroscopes, accelerometers, and RTK modules provide real-time feedback to support stable flight and centimeter-precise navigation through the course. The wooden posts for the assistance of the ring pick-up and drop-off and the 3D-printed ring were also custom-designed. Autonomous missions were programmed using waypoint mapping via Mission Planner. Testing was conducted outside of the West Campus building. Current outcomes include successfully flying the drone manually and autonomously through Mission Planner, as well as connecting and receiving signals from four different satellites: GPS (USA), GLONASS (Russia), Beidou (China), and Galileo (Europe). Overall, this abstract presents the development of an autonomous drone that can complete a flight mission with centimeter-level accuracy
