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This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.

Background/Aims Coronary artery bypass graft surgery requires specialised long-term follow up, and non-adherence to a care plan may lead to complications. This study aimed to assess the effects of SMS reminders on adherence to medication and care plans among patients who had been discharged from hospital after coronary artery bypass graft surgery. Methods A randomised controlled trial was performed in Iran, with eligible patients divided into an intervention (n=40) and a control (n=40) group. All participants completed a questionnaire measuring their adherence to their medication and care plan 1 day before discharge from the hospital. The intervention group received SMS reminders about their treatment plan plus routine care, while the control group received routine care only. The study lasted for 6 weeks. One week after the completion of the intervention period, both groups filled in the questionnaire again and the results were compared. Independent and paired t-tests were used to assess the significance of results. Results There were no significant differences between the two groups before the intervention. Compared to baseline, the intervention group had significantly improved adherence to their medication and care plans (PConclusions An SMS reminder is a useful and cost-effective way to improve adherence to medication and care plans among patients discharged from hospital after coronary artery bypass graft surgery, as part of follow-up care.

In cross-sectional data, gaps in health insurance coverage are associated with worse health and lower utilization of preventive services. The authors investigated if these associations persisted 2-6 years after disruption of insurance coverage in a cohort of young adults. Data from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of participants who were ages 13-17 years in 1997, were analyzed. Annual interview data from 2007 through 2017 were included and analyzed in 2021. Health outcomes (general self-rated health, annual preventive care use, and work-related health limitations) in each year were regressed on insurance coverage status, classified as: continuous private coverage, continuous public coverage, gap in coverage, or year-round lack of coverage. In a series of models, insurance coverage status was lagged by 2, 4, or 6 years to capture long-term associations with health outcomes. The analytic sample included 8197 young adults contributing 49,580 observations. Contemporaneous gaps in coverage were associated with 17% lower odds of reporting better self-rated health (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.78, 0.88

Emerging evidence on the disproportionate impact of COVID-19 on people with intellectual and developmental disabilities (IDD) points to the underlying risk and burden of infectious diseases (IDs) in this population. The objective of this study was to examine the risk of ID-related emergency department (ED) visits, subsequent hospitalizations, and hospital-based mortality during ID-related visits among adults with IDD compared to those without IDD. The authors conducted a retrospective study using data from the 2016 Nationwide Emergency Department Sample. The sample included 94,928 adults with IDD identified using ICD-10-CM codes, and age- and sex-matched 284,763 non-IDD adults in a 1:3 case-control ratio. A Poisson regression model was used to compare the risk of ID-related ED visits, subsequent hospitalizations, and hospital-based mortality during ID-related visits between adults with and without IDD. Covariates included sociodemographic and hospital characteristics. Results showed that adults with IDD are at a higher risk for ID-related ED visits, subsequent hospitalization, and mortality during ID-related ED visits compared to non-IDD adults. Adults with IDD continued to experience higher risks even after accounting for sociodemographic, hospital, and clinical characteristics. Septicemia and respiratory tract infections are the leading causes of ED visits, hospitalization, and mortality. This study found substantial disparities in ID-related ED visits, subsequent hospitalization, and mortality among the burdens for adults with IDD. These observations underscore the importance of integrated strategies to reduce ID-related morbidity among adults with IDD.

Health care providers are increasingly using clinical measures derived from electronic health records (EHRs) for risk stratification and predictive modeling. EHR-specific data elements such as prescriptions, laboratory results, and vital signs have been shown to improve risk prediction models. In this study, the value of EHR-based blood pressure (BP) values was assessed in predicting health care costs (ie, total, medical, and pharmacy) and key utilization end points (ie, hospitalization, emergency department use, and being among the highest utilizers). The study population included 37,451 patients of a large integrated delivery system in the mid-western United States with complete EHR data files, who were 18-64 years old, had continuous insurance at an affiliated health plan, and had eligible BP records. Both EHRs and insurance claims of the study population were used to extract the predictors (ie, demographics, diagnosis, and BP values) and outcomes (ie, costs and utilizations). Predictors were extracted from 2012 data, whereas concurrent and prospective outcomes were extracted from 2012 to 2013 data. Three base models (BMs) were constructed to predict each of the outcomes. The first BM no. 1 used demographics. The second BM no. 2 added the Charlson comorbidity index to BM no. 1, whereas the third BM no. 3 added the Adjusted Clinical Group Dx-PM case-mix score to BM no. 1. BP was specified as means, ranges, and classes. Adding BP ranges to BM no. 1 and BM no. 2 showed the greatest improvements when predicting costs and utilization. More specifically, adjusted R2 and area under the curve of BM no. 2 improved by 32.9% and 14.1% when BP ranges were added to predict concurrent total cost and hospitalization, respectively. The effect of BP measures on improving the risk stratification models was diminished when predicting prospective outcomes after adding the measures to BM no. 3 (ie, the more comprehensive diagnostic model), specifically when represented as BP means. Given the increasing availability of BP information, this research suggests that these data should be integrated into provider-based population health analytic activities. Future research should focus on subpopulations that benefit the most from incorporating vital signs such as BP measures in risk stratification models.

Identifying patients' social determinants of health (SDoH) can improve patient outcomes but may increase clinicians' documentation time. However, there is limited evidence of how many physicians document SDoH and the associated burden. To address this gap, this study examines documentation of SDoH and after-hours electronic health record (EHR) work among a nationally representative sample of US office-based physicians. This was a cross-sectional analysis of the 2018-2019 National Electronic Health Records Survey. A survey design-adjusted bivariate analysis was used to estimate the prevalence of SDoH documentation and compare this activity between physicians' and practices' characteristics. A modified multivariable Poisson model was used to estimate prevalence ratios of SDoH documentation and after-hours work. The study sample included a weighted sample of 303,389 US physicians (31.5%, female; 72.5%, aged ≥50 years; 48.8% primary care specialty). Of those, 84.3% reported documenting patients' SDoH information. Physicians documenting patients' SDoH tend to be younger (

Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.

OBJECTIVES: Unintended events (UEs) are prevalent in healthcare facilities, and learning from them is key to improve patient safety. The Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method is a root cause analysis method used in healthcare facilities. The aims of this systematic review are to map the use of the PRISMA-method in healthcare facilities worldwide, to assess the insights that the PRISMA-method offers, and to propose recommendations to increase its usability in healthcare facilities. METHODS: PubMed, EMBASE.com, CINAHL, and The Cochrane Library were systematically searched from inception to February 26, 2020. Studies were included if the PRISMA-method for analyzing UEs was applied in healthcare facilities. A quality appraisal was performed, and relevant data based on an appraisal checklist were extracted. RESULTS: The search provided 2773 references, of which 25 articles reporting 10,816 UEs met our inclusion criteria. The most frequently identified root causes were human-related, followed by organizational factors. Most studies took place in the Netherlands (n = 20), and the sample size ranged from 1 to 2028 UEs. The study setting and collected data used for PRISMA varied widely. The PRISMA-method performed by multiple persons resulted in more root causes per event. CONCLUSIONS: To better understand UEs in healthcare facilities and formulate optimal countermeasures, our recommendations to further improve the PRISMA-method mainly focus on combining information from patient files and reports with interviews, including multiple PRISMA-trained researchers in an analysis, and modify the Eindhoven Classification Model if needed.

Health care organizations are increasingly incorporating social care programs into medical care delivery models. Recent studies have identified burnout as a potential unintended consequence of this expansion. Successful implementation of these programs requires investment in the health care team, although understanding the impact of this expansion on nonphysician team members remains limited. Utilizing a theory-informed model for organizational behavior change, the authors aim to characterize the perceived elements of capacity to address patients' social needs within a heterogenous group of health care workers, and to examine the association of these behavioral conditions with burnout. A cross-sectional analysis was conducted of a survey of ∼1900 health care staff from 46 organizations in a large delivery system. Exploratory factor analysis identified factors contributing to the "Perceived Capacity to Address Social Needs" domain; Motivation, Organizational Reinforcement, and 3 task-specific capacities (Identification of social needs, Providing care for patients with social needs, and Linkage to social needs resources). Logistic regression found both a lower sense of motivation (OR 0.71, 95% CI 0.59-0.86), and organizational reinforcement (OR 0.51, 95% CI 0.42-0.62) associated with a higher rate of burnout. These associations with burnout differed by organizational role, suggesting role-specific relationships between these behavioral conditions. As health care has evolved into team-based interventions, staff across the care spectrum are now tasked with addressing larger social issues that affect their patients. A systems approach, aligning organizational priorities and staff motivations, in addition to task-specific skill sets is likely necessary to prevent burnout in this setting.

Objectives This study aimed to determine whether patients in teaching hospitals are at higher risk of suffering from an adverse event during the summer trainee changeover period. Methods We performed a retrospective analysis of data from the Medicare Patient Safety Monitoring System, a medical-record abstraction-based database in the United States. Hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure were studied. Admissions were divided into nonsurgical (acute myocardial infarction, heart failure, or pneumonia) and surgical. Adverse event rates in July/August were compared with the rest of the year. Hospitals were stratified into major teaching, minor teaching, or nonteaching. Results were adjusted for patient demographics, comorbidities, and hospital characteristics. Outcomes were the adjusted odds of having at least 1 adverse event in July/August versus the rest of the year. Results We included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event in a major teaching hospital in July/August was 0.83 (95% confidence interval [CI], 0.69-0.98) for nonsurgical patients and 1.09 (95% CI, 0.84-1.40) for surgical patients. In minor teaching hospitals, the adjusted ORs were 0.96 (95% CI, 0.88-1.04) for nonsurgical patients and 0.99 (95% CI, 0.87-1.12) for surgical patients. In nonteaching hospitals, the adjusted ORs were 0.98 (95% CI, 0.91-1.06) for nonsurgical patients and 1.10 (95% CI, 0.96-1.24) for surgical patients. Conclusions Patients admitted to teaching hospitals in July/August are not at increased risk of adverse events. These findings should reassure patients and medical educators that patients are not excessively endangered by admission to the hospital during these months.

The aim of this study was to compare the current fall prevention nursing practices with the evidence-based practices recommended in clinical practice guidelines according to the risk of falling and specific risk factors.The standardized nursing statements of 12,277 patients were extracted from electronic nursing records and classified into groups according to the risk of falling and individual patients' specific risk factors. The mean frequencies of the fall prevention practices in 10 categories derived from clinical practice guidelines were compared among the groups. We additionally analyzed the differences in the mean frequencies of tailored fall prevention practices according to individual patients' specific risk factors.The nurses documented more fall prevention practices for patients at a high risk of falling and nonfallers than for patients at a low risk of falling and fallers. Specifically, the difference in nursing practices related to environmental modifications was largest between patients at a high risk of falling and those at a low risk of falling. There were also large differences in the nursing practices related to mental status, dizziness/vertigo, and mobility limitations between fallers and nonfallers. There was more documentation of tailored fall prevention practices related to mobility limitations for patient with mild lower limb weakness than for those with good power and balance. In contrast, patients with severe lower limb weakness had received fewer fall prevention practices related to mobility limitations.The present findings emphasize that individual risk-specific nursing interventions in addition to universal precautions are crucial for preventing falls among patients.

Achieving health equity requires a diversity of perspectives, values, and insights, yet the composition of the United States’ nursing workforce does not reflect the communities where they practice. Nurse leaders can advance health equity and exemplary clinical outcomes by creating diverse, equitable, and inclusive health care teams. Such teams are well-equipped for organizational learning, a crucial process for advancing health equity. Nurse leaders advance health equity by fostering diversity, equity, inclusion, and thus organizational learning in the workplace.

The NHS is facing an unprecedented backlog in both patient care and building maintenance, with severe implications for service delivery, finance and population wellbeing. This article is the first in a series discussing modular healthcare facilities as a potential solution to these issues, providing flexible and cost-effective spaces to allow services to increase capacity without sacrificing care quality. The first of three instalments, this paper will outline the problems facing the NHS estate, many of which have been exacerbated to critical levels by the COVID-19 pandemic, and what this means for service delivery. It will then make the case for modular infrastructure, outlining the potential benefits for healthcare services, staff and patients alike. Using modern methods of construction, this approach to creating physical space in healthcare can provide greater flexibility and a reduced impact on the environment. The next two articles in this series will go on to provide detailed case studies of successful modular implementation in NHS trusts, an analysis of the cost implications and guidance on the commissioning process and building a business case.

Background : As the COVID-19 pandemic continues, health care systems around the world have changed care delivery in significant ways. Racial and ethnic disparities have emerged for COVID-19 infection rates, morbidity, and mortality. Inequities in care and underutilization of interpretation for patients who use a language other than English (LOE) for care existed prior to this era. We sought to evaluate interpreter use in a pediatric emergency department (ED) as changes associated with COVID-19 were implemented. Methods : ED records were reviewed from December 1, 2019 to July 31, 2020. Patients were classified as having LOE if they preferred a language other than English and consented to interpretation. We used statistical process control to analyze changes in interpreter use over time, relative to the onset of COVID-19–related operational changes. Beginning March 1, 2020, in-person interpreters were no longer available and staff were encouraged to communicate from outside the patient room when possible; this change served as our exposure of interest. Interpreter use for LOE patients, overall and by triage acuity level, was our outcome. Results : A total of 26,787 encounters were included. The weekly mean proportion of encounters that used interpretation for patients with LOE increased from 59% to 73% after the onset of COVID-19; this increase met criteria for special cause variation. Interpretation modality changed to being mostly by phone from previously by video or in-person. Conclusions : Operational changes in the ED related to COVID-19 were associated with increased interpreter use. Possible explanations include lower patient volumes or changes in model of care that encouraged interpreter use by a variety of modalities.

The process of commissioning and planning a new building can be complex, requiring a combination of skills, expertise and motivation from several different stakeholders. The first article in this series on healthcare infrastructure made the case for more modular facilities in the NHS, to increase capacity and help services address the growing care backlog. This article, the second in a series of three, will discuss the process of commissioning a modular facility, drawing on two in-depth case studies to provide insight from healthcare managers who have successfully completed such a project. This includes exploration of the circumstances that led the trusts to consider a modular solution, the challenges they faced, how they overcame those challenges and the benefits they have observed in their services so far. A guide to the key considerations and recommendations for commissioning and planning a modular facility is also provided for trusts looking for ways to expand their service capacity.

Coordination of medication prescribing is important in the care of patients with multiple chronic conditions (MCC) given the involvement of multiple providers and multiple medications used to manage MCC. The objective of this study was to identify physician and practice factors associated with physicians' coordination of prescribing for complex patients with MCC.Our cross-sectional study used a 33-item anonymous, online survey to assess physicians' coordination practices while prescribing for patients with MCC. We sampled primary care physicians (PCPs), psychiatrists, and oncologists across the United States. Coordination of medication prescribing was measured on a 7-point Likert-type scale. χ2, Fisher exact test, and binomial logistic regression, adjusted for factors and covariates, were used to determine differences in coordination of prescribing. Average marginal effects were calculated for factors.A total of 50 PCPs, 50 psychiatrists, and 50 oncologists participated. Most psychiatrists (56%) and oncologists (52%) reported frequently coordinating prescribing with other physicians, whereas less than half of the PCPs (42%) reported frequently coordinating prescribing. Female physicians were 25% points more likely to report coordinating prescribing than male physicians (P = 0.0186), and physicians not using electronic medical records were 30% points more likely to report coordinating prescribing than physicians using electronic medical records (P = 0.0230). Four additional factors were associated with lower likelihood of coordinating prescribing.Physician and practice factors may influence differences in coordination of medication prescribing, despite physician specialty. These factors can provide a foundation for developing interventions to improve coordination of prescribing practices for MCC.

Purpose This study was conducted to measure the impact of a volunteer “Transition Guide” on patient experience and psychological stress during the transition from ICUs to general medical and surgical wards. Methods Between July 2017 and February 2020, medical and surgical patients from nine ICUs at a single tertiary care hospital were accompanied by a uniquely trained volunteer Transition Guide to aid them at the time of transfer to general medical/surgical wards, when available. If a Transition Guide was not available, they were transferred without one. The following day, patients were surveyed with a tool assessing overall satisfaction, multiple aspects in the domain of communication, and psychological stress associated with the transition process. When available, family members and ward nurses who admitted patients from the ICU were surveyed. Results Target enrollment was 300 patients in each group. Due to COVID-19 and institutional restrictions on volunteers, only 264 underwent transfer with a Guide, while 305 transferred without. Of all patients approached, 96% without a Guide and 95% with a Guide completed the survey. Patients who were accompanied by a Transition Guide reported a better overall transition, better communication, greater understanding, better resolution of concerns, and less stress than those who did not have a Transition Guide (p < 0.05 for all). Conclusion Among a cohort of formerly critically ill patients subsequently transferred to general medical and surgical wards, the presence of a volunteer Transition Guide significantly improved patient experience, enhanced patient communication and understanding, and reduced stress associated with the transfer process. Hospitals may consider this expanded and specialized role for volunteerism in the health care setting to improve patient-centered outcomes.

The COVID-19 pandemic has surfaced many ethical challenges for nurse leaders who need the courage, ability, and support to make the right decisions. This paper discusses 3 ethical challenges: workforce shortages, staff assignments, and moral distress. It also offers strategies to leverage our code of ethics to navigate these situations.

Over the last 2 years, nursing leaders have operated in a fluid and disruptive environment, constantly adapting to changes in the workplace. The global pandemic challenged these leaders on various fronts: workforce, technology, and regulatory, threatening the status quo of traditional orderly change. Factors external to organizations and a highly contagious disease were forcing rapid hourly and daily changes. Today, nursing leader skills are also morphing, requiring a revisit of the competencies needed for visionary leadership. Traditional models of leadership need to shift from transformational to disruptive. This article reviews and offers suggestions for competencies needed in the future by nurse leaders.

Background: Considering the importance of cardiovascular disease (CVD) risk prediction for healthcare systems and the limited information available in the Middle East, we evaluated the SCORE and Globorisk models to predict CVD death in a country of this region. Methods: We included 24 427 participants (11 187 men) aged 40-80 years from four population-based cohorts in Iran. Updating approaches were used to recalibrate the baseline survival and the overall effect of the predictors of the models. We assessed the models’ discrimination using C-index and then compared the observed with the predicted risk of death using calibration plots. The sensitivity and specificity of the models were estimated at the risk thresholds of 3%, 5%, 7%, and 10%. An agreement between models was assessed using the intra-class correlation coefficient (ICC). We applied decision analysis to provide perception into the consequences of using the models in general practice; for this reason, the clinical usefulness of the models was assessed using the net benefit (NB) and decision curve analysis. The NB is a sensitivity penalized by a weighted false positive (FP) rate in population level. Results: After 154 522 person-years of follow-up, 437 cardiovascular deaths (280 men) occurred. The 10-year observed risks were 4.2% (95% CI: 3.7%-4.8%) in men and 2.1% (1.8-2%.5%) in women. The c-index for SCORE function was 0.784 (0.756-0.812) in men and 0.780 (0.744-0.815) in women. Corresponding values for Globorisk were 0.793 (0.766- 0.820) and 0.793 (0.757-0.829). The deviation of the calibration slopes from one reflected a need for recalibration; after which, the predicted-to-observed ratio for both models was 1.02 in men and 0.95 in women. Models showed good agreement (ICC 0.93 in men, and 0.89 in women). Decision curve showed that using both models results in the same clinical usefulness at the risk threshold of 5%, in both men and women; however, at the risk threshold of 10%, Globorisk had better clinical usefulness in women (Difference: 8%, 95% CI: 4%-13%). Conclusion: Original Globorisk and SCORE models overestimate the CVD risk in Iranian populations resulting in a high number of people who need intervention. Recalibration could adopt these models to precisely predict CVD mortality. Globorisk showed better performance clinically, only among high-risk women.

Several patient demographics such as race/ethnicity and comorbid chronic conditions are associated with severity of illness among COVID-19 patients. This study examines national data of COVID-19 patients to estimate the likelihood that these characteristics are associated with a hospital admission, admission to an intensive care unit (ICU), and length of hospital stay. Using logistic regressions, the authors found that minority populations (Black, Asian, and Hispanic) were 21% to 35% more likely to be hospitalized than Whites. Moreover, patients with multiple chronic conditions also were more likely to be hospitalized, admitted to the ICU, and had longer lengths of stay. Results highlight the need to target vaccines to the most vulnerable populations during COVID-19 but also for future outbreaks.

Background Using an on-site pharmacy or medication to bedside (MTB) program allows patients to obtain prescriptions and education before discharge, potentially improving adherence and preventing harm. The aim of this project was to improve discharge processes for pediatric acute care patients by increasing the proportion of oral antibiotics (1) prescribed to the on-site pharmacy from 15% to 70% and (2) delivered to bedside from 0% to 50%. Methods The Model for Improvement was used to iteratively implement interventions: increased on-site pharmacy capabilities, MTB program creation and streamlined enrollment, and secure electronic health record (EHR) messaging between clinicians and pharmacy staff regarding prescriptions. Process measures were proportion of antibiotics prescribed to the on-site pharmacy and delivered to bedside. Outcomes included surveys of family satisfaction with discharge medication education and discharge medication–related safety reports. Discharged before noon (DBN) was the balancing measure. Aims were analyzed using statistical process control charts and chi-square tests. Results A total of 1,908 antibiotics were prescribed over 28-months. On-site pharmacy prescriptions increased from 15% to 46% after pharmacy capabilities increased, then to 86% after MTB program launch, optimized workflow, and initiation of EHR messaging. Bedside medication delivery increased from 0% to 58% with these interventions. Family satisfaction with discharge medication education and frequency of discharge medication–related safety reports was not significantly different pre- and postintervention. DBN varied throughout the study. Conclusion Through clinician and pharmacy staff partnership, this initiative increased on-site pharmacy use and discharge antibiotics delivered to bedside. Key interventions included increased pharmacy capabilities, MTB program with streamlined workflow, and EHR–based communication.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the United States, and timely treatment is imperative. Delay in treatment of PPH can lead to significant blood loss and increased morbidity and mortality. Supplies and medications essential for treating PPH are typically not located in close proximity to the hemorrhaging patient, leading to inefficiency and delay in timely response to hemorrhage. Methods: An in situ hemorrhage simulation was created dictating the collection of a prespecified list of supplies commonly used in response to PPH on labor and delivery (L&D). Baseline data were collected, then Lean Six Sigma tools were used to construct a process map, including recording times and cumulative distance traveled for collection of each item. The simulation was repeated after development, creation, and deployment of each intervention. For the first intervention, a PPH cart was created containing the supplies most used in response to PPH. Second, a PPH medication kit was created consisting of a refrigerated box containing all medications typically administered during a PPH. Results: The average time to collect a prespecified list of supplies and medications in response to a PPH scenario was 11 minutes 5 seconds (standard deviation [SD] = 3 minutes 33 seconds), with an average cumulative distance traveled of 4,092 feet. Following Intervention 1, the time decreased to 4 minutes 0 seconds, with 918 feet traveled (only one trial performed). Intervention 2 further reduced the average time and cumulative distance to 2 minutes 14 seconds (SD = 16 seconds) and 462 feet, respectively. This represents a 79.8% reduction in time and an 88.7% reduction in distance from baseline to postintervention. Conclusion: A PPH cart and medication kit can significantly reduce the amount of time and distance traveled to obtain materials necessary to treat hemorrhage, thus optimizing a team's ability to efficiently treat PPH.

The digital era is introducing technological innovations that create valuable data resources and provide opportunities to health care providers to more effectively communicate, treat, and manage patient populations. However, in order to achieve effective and financially viable population management solutions, a number of elements are required. These include domain expertise in the health care spectrum, application of appropriate technologies, and analytics that address effectiveness and valuation issues (eg, cost, revenue streams) in generating proposed solutions in population management. This work provides a conceptual framework that illustrates the various elements essential to achieve success in population health management with an emphasis on behavioral health. These elements include domain-specific knowledge of medical ailments, application and management of appropriate technologies including digital platforms, and data and analytic approaches such as actuarial and financial informatics that are essential to achieving a sustainable valuation in managing the health of a population.

Nursing advocacy serves as the bedrock for supporting problems affecting nursing practice, the nursing profession as a whole, and health care issues. Every nurse has a professional mandate to advocate for the profession and answer the call to action to be the voice in all issues affecting nursing and patient care. Dr. Nicolette Fiore-Lopez shares her personal insights by providing examples of political advocacy in the nursing arena and how one may overcome the fears of conversing with congressional leaders. She addresses the why, the how, and the interface between advocacy and nursing practice. Grounded in the advocacy mission of the American Organization for Nursing Leadership, Dr. Fiore-Lopez reminds us that advocacy is our responsibility as nurses, and we should be able to speak about our profession and the legislative issues that affect it.

The COVID-19 pandemic has forever changed health care, spurring a revolution in digital health technologies. Across the world, hundreds of thousands of health care systems are considering a central question: how do we connect with our patients? Digital health has been used as a stopgap in many cases to continue the essential functions of health systems. As the post-pandemic world and our "new normal" come into focus, further needs will have to be met with a digital patient interaction, with an eye toward value transformation. One barrier to fully leveraging digital tools is the lack of a framework for classifying the type of digital health care. This can limit our ability to design, deploy, evaluate, and communicate through digital means. This article presents 3 categories of digital health and their relationships to value metrics: (1) telehealth or direct care delivery, (2) digital access tools, and (3) digital monitoring. An evidence-based discussion reveals past successes, current promises, and future challenges in reducing defects in value through digital care. In the coming years, value transformation will become more crucial to the success of health care systems. By using the taxonomy in this article, health systems can better implement digital tools with a value-driven purpose. Defining the role of digital health in the post-pandemic world is needed to assist health systems and practices to build a bridge to value-based care.

This study aimed to comprehensively evaluate whether income affects long-term health outcomes for older patients who underwent percutaneous coronary intervention (PCI) provided by a universal health coverage system. Data were from the Latter Stage Elderly Healthcare Insurance database in Fukuoka Prefecture, Japan. A total of 5625 individuals aged ≥65 years who underwent PCI in 2014-2016 were included. Cox proportional hazards models were used to assess the association between income status and the incidence of health outcomes. With a median follow-up of 1095 days, 554 acute myocardial infarction (AMI) cases, 1075 stroke cases, 1690 repeat revascularization cases, and 1094 deaths were observed. Risk of all-cause mortality decreased significantly with increasing income level in both unadjusted and adjusted Cox regression models. Patients in the low-income level had a significantly higher rate of AMI (log-rank

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future.

This case study reflects the journey taken by multiple individuals as they considered the doctor of nursing practice (DNP) evolution within one suburban acute care setting. The DNP education that the chief nursing officer (CNO) experienced led to a major change for all the nursing leaders in the organization. Two CNOs provide their unique path and insights to building a leadership team composed primarily of DNP-prepared leaders, sustaining the momentum, and fostering further growth in an isolated area of West Texas. Findings from a qualitative study on the perceived impact of the DNP education and actionable steps are shared.

Abtract During the COVID-19 pandemic, hospitals across the United States were tasked to develop partnerships with other hospitals and community organizations to overcome the unexpected challenges. The aim of this study is to examine COVID-19 case-fatality rates and explore their relationship with hospital-community partnerships. This study employed a cross-sectional design using a multilevel generalized linear model with a Poisson regression distribution and publicly available COVID-19 mortality data from February to October 2020 across 2526 hospital service areas (HSAs). HSAs with a greater number of partnerships were found to have a reduced risk of higher case-fatality rates than those with fewer health system partnerships. The findings indicated the need for greater cooperation between individual health care systems, state and local governments, and community programs for better outcomes in the ongoing and evolving COVID-19 pandemic, and to be better prepared for future pandemics or large-scale public health crises. This study provides the necessary insights for policy makers, hospital administrators, and public health leaders to understand the critical importance of community partnerships and their influence on reducing the COVID-19 case-fatality rate, as well as their potential effects on improving the health of vulnerable populations as a means to achieve the Centers for Disease Control and Prevention's goal of achieving health equity. This research illustrates the need for further inquiries into the importance of these health care partnerships for positive health care outcomes.

With growing recognition of the adverse health impacts of unmet social needs, Medicaid managed care organizations (MMCOs) are increasingly focusing on addressing the social needs of Medicaid enrollees as part of a holistic approach to care. Information and knowledge sharing among MMCOs pertaining to lessons learned and promising practices from their social determinants of health (SDOH) targeted efforts can help identify successful practical approaches for navigating common challenges, developing robust SDOH programming, and effectively delivering whole-person care. Using data from interviews with 28 representatives of 8 national and regional MMCOs, this qualitative study describes the perspectives of MMCO representatives on the lessons learned and emerging promising practices from addressing SDOH among their Medicaid enrollees. Participants discussed the importance of member and community-centeredness, structured programming, and delivery system realignment in the effective delivery of whole person care. Ten lessons learned and emerging promising practices are discussed. Findings from this study suggest that success in addressing the social needs of Medicaid beneficiaries may be achieved through adaptive, data-driven, member- and community-centric efforts by MMCOs, facilitated by system-level changes that formally integrate social services within health care. Lessons learned and promising practices can serve as a foundation for identifying and evaluating best practices and guidelines for effective MMCOs' SDOH-related programming.

Aim To describe and synthesize evidence for champions of domestic violence practice improvement in healthcare and highlight implications for leadership and nurse management. Background Globally, healthcare leaders have been tasked with improving service responses to domestic violence. Evidencing the role of champions, and how managers may harness champions in improving responses to domestic violence, is an important factor in successfully leading change in this field. Evaluation A scoping review was conducted using four electronic databases (Proquest, PubMed, Medline and PsycINFO). Key issues Eleven studies were included. Champion characteristics, roles, and factors influencing their impact were distilled. Barriers to the success of champions were identified as were four aspects of the champion role: mentor and expert advice; communication and engagement; strategic advocacy, coordination and project leadership; personal and emotional support. Conclusions The review highlighted that champions involved in domestic violence project implementation have unique aspect to their role, along with characteristics reported in the broader champion literature. As an emerging field, there is evidence that domestic violence champions play an important role in mentoring and supporting healthcare workers to effectively change their practice. Implications for nursing management Nurse managers and leaders need to understand the champion construct and the roles that champions enact to generate domestic violence and abuse system and practice change. Further research is required to provide guidance.

Medically hospitalized individuals have high rates of comorbid psychiatric, substance abuse, and behavioral disorders. Disruptive and sometimes aggressive behaviors may arise when mental health needs of patients go unrecognized or are inadequately addressed. Health care workers experience the most workplace violence compared with other professions, with nurses and nursing aides at highest risk. A Behavioral Emergency Support Team (BEST) model can be an effective approach to providing a customized response to a patient's agitation through identification of underlying clinical and environmental contributors to the onset of aggression as well as to provide behavioral education and support of nursing staff. Results from 2 years of BEST model use resulted in 124 events among 96 patients of whom 19 had repeated events. The most common reasons for codes were aggression (79%) and elopement threat/attempt (45%), and the most frequent patient diagnosis was cognitive impairment (54%). Development of a BEST model provides support to nurses that is not otherwise available for events that are disruptive to care in inpatient medical settings and help minimize the occurrence of workplace violence.

BACKGROUND Improved utilization of guideline-directed medical therapy (GDMT) in the management of heart failure with reduced ejection fraction (HFrEF) can reduce mortality, reduce heart failure hospitalizations, and improve quality of life. Despite well-established clinical guidelines, these therapies remain significantly underprescribed. The goal of this intervention was to increase prescribing of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), and beta-blockers at ≥ 50% target doses. METHODS The study team identified key drivers to adequate dosing of GDMT: (1) frequent and reliable follow-up visits for titration opportunities, (2) identification of actionable patients for therapy initiation and titration, and (3) reduction in prescribing practice variability. The interventions were implemented at an outpatient clinical site and consisted of three main components: (1) establishing a pharmacist-led heart failure medication titration clinic, (2) creation of a standardized titration protocol, and (3) utilization of a patient dashboard to identify eligible patients. RESULTS For patients seen in the titration clinic, in 14 months, the mean dose per patient increased from 31.3% to 70.5% of target dose for ACEI/ARB/ARNI, and from 45.8% to 85.4% for beta-blockers. At this clinical site, the percentage of HFrEF patients receiving > 50% of targeted dose increased from 39.7% to 46.7% for ACEI/ARB/ARNI, and from 39.5% to 42.9% for beta-blockers. For ACEI/ARB/ARNI, use of target doses was 5.9% higher (95% confidence interval [CI] = 3.6%-8.3%, p < 0.0001) for the intervention site, 0.2% higher (95% CI = -2.2%-2.5%, p = 0.89) during the intervention period, and 10.4% higher (95% CI = 6.9%-13.9%, p

Research has shown that the Universal Design for Learning (UDL) framework has significant potential for diverse learners in a variety of settings. Although UDL has been utilized in K-12 for some time, there are few publications utilizing this framework in academic nursing, staff development, or patient education. This concept analysis, using Rodgers' Evolutionary Concept Analysis, differentiated the surrogate terms, practical examples, antecedents, attributes and outcomes of UDL in higher education, based on 45 articles. The analysis represents an initial step in understanding how UDL application can further support nursing education and curricula design. Nursing students can directly benefit from two major aspects of UDL: (a) its emphasis on flexible curriculum, and (b) the variety of instructional practices, materials, and learning activities. As the student population in nursing continues to diversify, it is imperative to develop curricula that support diverse students effectively.

Background Perioperative services have been scrutinized in the context of cost containment in health care, particularly in the procurement and reprocessing of surgical instruments. Although solutions such as surgical instrument inventory optimization (IO) have been proposed, there is a paucity of literature on how to implement this change. The purpose of this project was to describe the implementation of an IO using Kotter's Change Model (KCM). Methods This study was conducted at a tertiary academic hospital across the four highest-volume surgical services. The IO was implemented using the steps outlined by KCM: (1) create coalition, (2) create vision for change, (3) establish urgency, (4) communicate the vision, (5) empower broad-based action, (6) generate short-term wins, (7) consolidate gains, and (8) anchor change. This process was evaluated using inventory metrics, operational efficiency metrics, and clinician satisfaction. Results Total inventory was reduced by 37.7%, with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1,333 hours per annum and labor cost savings of $39,995 per annum. Depreciation cost savings were $64,320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80.0% post-IO. Conclusion This is the first study to describe the successful implementation of KCM to facilitate change in the perioperative setting. This success contributes to the growing body of literature supporting KCM as a valuable change management tool in health care.

Background Inconsistent clinical educator preparation to guide students’ thinking, engage reflection, and provide immediate feedback impacts student's decision-making. Clinical coaching, a teaching framework, promotes one-to-one teaching, questioning, and feedback between the educator and student. There are limited studies measuring the impact of clinical coaching education on educators. Methods A quasi experimental design was conducted in 2019 with 36 clinical nursing instructors from two undergraduate programs. Data were collected using the Clinical Coaching Interactions Inventory: Educator Group Version. A match-paired Wilcoxon test was used for analysis of responses. Results Clinical educators reported a statistical increase in the use of one higher-order question—asking students to synthesize clinical knowledge and reasoning. Conclusions The findings suggest that a clinical coaching education program improves clinical nurse educators’ ability to engage students in synthesizing knowledge, which can help in prioritizing care. These findings may promote clinical coaching strategies for clinical faculty to improve clinical reasoning skills in students.

Introduction In today's complex healthcare setting nurses need Emotional Intelligence abilities. Emotional intelligence competencies are not typically included as part of the curricula in most professional nursing programs. Pre-licensure BSN students and RN to BSN students have different characteristics and enter nursing school with different levels of clinical experience. The purpose of this study is to understand the differences in measured Emotional Intelligence between traditional BSN students (pre-licensure) and RN to BSN students. Method The researchers used a quantitative two-group between-subjects design to measure the differences in EI scores of pre-licensure students and RN to BSN students. Results The findings from this study indicate differences exist in EI abilities between pre-licensure and RN to BSN students. Total EI was significantly higher for pre-licensure BSN students compared to RN to BSN students. Additional branch score findings are found in the full manuscript. Discussion Based on the findings of this study, the integration of EI content throughout the associate degree, traditional BSN, and RN to BSN program curricula should be a priority.

New graduate nurses report a lack of confidence in infusion therapy knowledge and skills. This quasi-experimental, pretest-posttest study examined knowledge and self-confidence when using innovative infusion therapy education in an associate degree nursing program. Participants (n = 42) had statistically significant improvements in post-testing knowledge (18.2 ± 3.19) compared to baseline (13.9 ± 2.55), 95% CI [3.157, 5.380], p

PURPOSE This study evaluated clinician adherence to the American College of Physicians Best Practice Advice for diagnosis of pulmonary embolism. DESIGN A prospective, single-center, descriptive design was utilized. METHODS A heterogeneous sample of 111 hemodynamically stable adult inpatients with a computed tomography pulmonary angiogram ordered was consented. Electronic medical records were reviewed for demographic and clinical variables to determine adherence. The 6 individual best practice statements and the overall adherence were evaluated by taking the sum of "yes" answers divided by the sample size. RESULTS Overall adherence was 0%. Partial adherence was observed with clinician-recorded clinical decisions rules and obtaining d-dimer (3.6% [4/111] and 10.2% [9/88], respectively) of low/intermediate probability scorers. Age adjustment of d-dimer was not recorded. Computed tomography pulmonary angiogram was the first diagnostic test in 89.7% (79/88) in low/intermediate probability patients. CONCLUSION In hemodynamically stable, hospitalized adults, adherence to best practice guidelines for diagnosis of pulmonary embolism was minimal. Clinical utility of the guidelines in hospitalized adults needs further evaluation. Systems problems (eg, lack of standardized orders, age-adjusted d-dimer values, information technology support) likely contributed to poor guideline adherence.

PURPOSE/AIMS The purpose of this quality improvement project was to examine the use of video-simulated scenarios and mobile technology to improve accuracy of emergency department (ED) nurses' triage using the Emergency Severity Index (ESI). DESIGN A quality improvement project with a pre/post educational intervention design consisting of a convenience sample (n = 33) of ED registered nurses (RNs) at a large tertiary hospital in the Midwest was used. METHODS A retrospective chart review (n = 495) was completed to obtain ESI accuracy for each triage RN. For 12 consecutive weeks, the ED RNs received different video simulations via mobile technology to determine the ESI level. After receiving their scores, the project team provided the RNs the correct ESI score with rationale via mobile technology. Post intervention, a retrospective chart review was conducted to evaluate RNs' ESI accuracy. RESULTS Results of this ED triage educational intervention to improve the accuracy of ED nurses' ESI scores were not significant; however, this novel approach may be considered in addition to other teaching strategies to improve outcomes. CONCLUSIONS Triage nurses' ESI scoring accuracy can be inconsistent. Therefore, to ensure patients are receiving prompt and appropriate care for their acuity level, it is important to continuously provide education on ESI scoring.

BACKGROUND Racial and ethnic disparities in healthcare safety have persisted for decades, particularly for patients with language barriers. Previous studies have investigated the frequency and nature of safety events impacting patients with language barriers; others have proposed solutions to fix them. A gap analysis, however, of how we are currently addressing safety issues and why these efforts have not been effective is lacking. METHOD This analysis uses reports from a patient safety event reporting system. Reports contain information regarding no-harm (near miss) events and events where harm may have reached the patient. Reports occurring with patients with a preferred language other than English were extracted and analyzed to determine whether the language barrier contributed to the safety event, the language barrier was mentioned in the resolution, and themes were mentioned for addressing language barriers. RESULTS A subset of 1553 events pertaining to non-English-speaking patients were first categorized as "likely" (3%), "plausibly" (10%), or "unlikely" (87%) related to the patient's language barrier. Second, events related to the patient's language barrier were categorized as directly addressing (19%), indirectly addressing (3%), not mentioning (69%) the language barrier, or containing insufficient information to determine whether the language barrier was addressed (7%). Third, thematic analysis revealed that the most common methods for addressing language barriers included presenting issues to interpreter services and subsequent use of interpreter services. CONCLUSIONS This study found that it is challenging to determine the direct role of certain social determinants of health (e.g., language barriers) in safety events. In many cases, the language barrier was not addressed in the event report. Furthermore, when the language barrier was addressed, solution themes typically involved weaker, less sustainable suggested actions.

Purpose of study Accountable Care Organizations (ACOs) aiming to reduce healthcare expenditure adopt strategies targeting costly postacute service utilization, asking "why not home?" as a part of the hospital discharge planning paradigm. This study examined the impact of an interventional approach to implement evidence-based interventions to improve transitions of care to the least restrictive next site of care on the rate of skilled nursing facility (SNF) admissions per 1,000, SNF length of stay (LOS), and total SNF cost. Primary practice setting The impact of the interventional approach for an ACO-attributed Medicare population, analyzing Medicare Shared Savings Plan Part A and Part B beneficiary claims data, was examined. Methodology and sample A pre-/postintervention analysis was conducted, for dates of service 12 months pre- and postintervention for patients admitted to any hospital within the integrated health care system. The outcome variables were defined as SNF admission rate, SNF LOS, cost of care (total SNF cost, SNF cost per admission), and hospital LOS prior to SNF discharge. Results There was early evidence of the effectiveness of the multifaceted interventions that involved the delivery of interprofessional team member education focused on the tenets of value-based care and discharging patients to the least restrictive setting, as appropriate. In the normalized data review, it was noted that the rate of SNF discharges per 1,000 patients changed from 73 per 1,000 patients in the preintervention period to 70 per 1,000 patients in the postintervention period. The total SNF cost in the postintervention period only increased by 3%, with a difference of $616,014, despite the 10% increase in the total ACO-attributed patient population during the same period. Implications for case management practice The results of this study imply that a multifaceted intervention with aims to shift the transitional care planning paradigm toward discharging to the least restrictive next site of care is an effective strategy for ACOs with aspirations to improve the utilization and expenditure in the postacute setting. The analyses suggest that providing education to interprofessional team members that reinforces the tenets of value-based care and the importance of asking, "why not home?" for every hospitalized patient, and leveraging technology-based insights positively impact discharge rates to SNF and other ACO outcomes.

PURPOSE The purpose of this clinical nurse specialist-led initiative was to reduce catheter-associated urinary tract infection rates to less than 1 infection per 1000 catheter days, to reduce catheter device utilization, and to improve staff adherence to documentation requirements on a traumatic brain injury rehabilitation unit. DESCRIPTION OF THE PROJECT Catheter-associated urinary tract infections are costly hospital-acquired infections increasing length of stay and morbidity for patients. Following an education intervention, a best practice initiative was implemented. Staff performance based on electronic health record documentation, infection rates, and device utilization were compared before and after a bundle of interventions including education, staff competency, simulation, and audits. OUTCOMES Catheter-associated urinary tract infection rates were reduced from 16.67 to 0 per 1000 catheter days and device utilization ratio from 0.122 to 0.056 per patient day. The unit maintained zero infections upon project completion. Following initiative implementation, documentation improved related to urinary catheter necessity, daily care interventions, patient education, and urine output. CONCLUSION This initiative resulted in reductions in device utilization and catheter infection rates, which were maintained following project completion. Adherence to documentation audit criteria also improved.

PURPOSE/OBJECTIVES Approximately 100,000 people in the United States are affected by sickle cell disease (SCD). Sickle cell disease represents one of the highest readmitting diagnoses at this organization. The purpose of this study is to determine the impact of implementing care coordination interventions to reduce hospital readmissions of patients with SCD. PRIMARY PRACTICE SETTING The setting for conducting the interventions took place at the flagship hospital of a seven hospital system in Houston, TX. The hospital is a not-for-profit, faith-based, 907-bed academic facility that provides highly specialized health services to the community and the world. The population of focus was adult patients (18 years of age and older) admitted to the hospital with a primary diagnosis of SCD. FINDINGS/CONCLUSION Two interventions were implemented: Disease-specific discharge education and scheduling postdischarge follow-up appointments prior to discharge. These interventions were conducted by bedside nurses, case managers, and SCD champions over a 6-month period. The 30-day readmission rate for SCD was reduced by 22%. There was also a 0.9-day reduction in length of stay and a 17% reduction in emergency, observation, and inpatient encounters of patients with SCD. IMPLICATIONS FOR CASE MANAGEMENT PRACTICES This project found that implementing evidence-based care coordination interventions can reduce the 30-day readmission rate for patients with SCD. Implementation of effective evidence-based care coordination is a key aspect to reducing hospital readmissions of patients with SCD. Partnering with community networks is also important in addressing readmission risk factors including management of social determinants of health that increase hospital visits. Consistent, patient-centered education using simple and convenient tools helps improve understanding, applicability, and self-care management.

Background Attrition rates are high for nursing programs. Attrition must be addressed to ensure nursing programs are financially sustainable and healthcare has an adequate supply of nurses. Purpose Identify factors impacting the success of students enrolled in the fundamental nursing course. Methods Retrospective file review of the previous seven cohorts (n = 351). Fifteen factors were investigated to determine their impact on successful completion of the fundamentals nursing course. Results Successful completion was significantly associated with race identified by the participants (χ2 = 10.84, p = 0.01) as participants who identified as white demonstrated higher success rates. Increasing ACT composite score (b = 0.95, p = 0.00) positively correlated with the student's success completion (CI = 1.26-5.38). Higher grade in General Psychology (b = 0.36, p = 0.02) positively correlated with successful completion (CI = 0.50-0.96). Recommendations and Conclusions Data can be used to evaluate current admission criteria and to develop support programs for students who may be at risk for not progressing well.