home health care case study

Home Care/ Home Health Case Studies

Home » Home Care/ Home Health Case Studies

A listing of Home Care/Home Health Case Studies . 

• T elehealth Helps Great Plains Health Patients Manage Their Conditions Confidently in the Comfort of Their Home to Improve Outcomes : In this case study, Great Plains Health chose a Tailored Ambulatory Care platform and Remote Patient Monitoring Program for Transitional Care from LeadingAge Silver Partner and CAST Supporter Philips to scale up their tailored ambulatory program. The effort produced 98% patient satisfaction scores and reduced hospital readmissions. The technology also improved the team’s ability to educate patients to care for themselves, to coordinate care, and to help patients reconcile their medications. Patients also enjoyed the security of monitoring.
• Evaluation of Selfhelp Community Services’ Virtual Senior Center : This case study explores how CAST Patron Selfhelp Community Services established a technology-driven program called the Virtual Senior Center (VSC) to enrich quality of life for socially isolated homebound older adults. 
• Reducing Blood Pressure among Engaged Participants through Multi-User Telehealth, Gamification, and Engagement Platform : This case study shows how technology company higi SH llc examined the relationship between ambulatory blood pressure (ABP) and patient engagement with a nationwide ABP kiosk platform deployed in pharmacies, grocery stores, and other community centers. Results showed a statistically significant relationship between frequency of engagement and lowering of systolic blood pressure. This study is applicable to the broader senior living market, as ABP kiosks provide an accessible, affordable, convenient and accurate means for individuals who cannot afford home BP devices to monitor their BP.
• Targeting the ‘Superusers’ of Healthcare With Telehealth : This case study describes how Banner Health monitored 135 clients who had at least 5 chronic health conditions. The project used a range of biometric sensors from LeadingAge Silver Partner and CAST Supporter Philips, and the Philips Lifeline personal emergency response system with automatic fall detection. In addition, program participants were matched with a multidisciplinary care team that included health coaches, nurses, social workers, pharmacists, and primary care “intensivists.” Outcomes included a 27% reduction in cost of care, a 32% reduction in acute and long-term care costs, and a 45% reduction in hospitalizations.
• Supporting Independence of Seniors through Remote Activity and Adherence Monitoring : Recover Healthcare had first-hand experience with some of the healthcare trends impacting their business and the long-term care industry as a whole, and were interested in leveraging technology to help address some of these challenges. Having already partnered with PointClickCare for over five years for their senior care facilities, Recover Healthcare saw an opportunity with PointClickCare’s acquisition of TouchStream Solutions and the possibilities of in-home remote monitoring.
• 2016 Shared Care Planning and Coordination Case Studies:  5 case studies highlight how providers went about implementing these technologies, the impacts they experienced, lessons they learned and pitfalls to avoid.
• Integrating Innovative Technology in the Home to Provide Enhanced Continuity of Care and Decreased Healthcare Costs for Older Adults : Element Care’s PACE (Program of All-Inclusive Care for the Elderly) program in Massachusetts North Shore, the Merrimack Valley and northeast region of Middlesex County implemented a Digital Avatar with Voice Activated Assistant Technology and Captioning to provide enhanced continuity of care in the home.  The technology was provided by Care.Coach.
• Using Technology to Reduce Social Isolation and Depression in Homebound Older Adults : Nonprofit Care at Home New Jersey (CAHNJ) has reduced social isolation and depression among study participants who used a touchscreen Telikin computer to communicate with family, friends, and CAHNJ personnel.
• Improving Medication Compliance, Quality of Life, and Peace of Mind through Voice Assistant Technology : Libertana Home Health in Sherman Oaks, CA implemented a voice assistance technology to improve medication compliance, quality of life, and peace of mind. The voice assistance technology was provided by Orbita.
• Senior Patient Engagement:Using Telehealth to Support Chronic Disease Self-Management : This case study explores how the “On4Care Mobile” solution from CAST Supporter Panasonic was used to monitor the health of 22 older adults who were clients of Pleasantville Senior Center in Pleasantville, NY.
• How telehealth is helping a provider to position itself as a partner to hospitals on avoiding readmission : This case study shows how Jewish Home Lifecare uses technology in all of its service lines and in all components of its Community Service Division. It is currently in the process of rolling out technology-enabled services in its sub-acute unit.
• Reduction of Hospital Readmissions through Telehealth among High-Risk Cardiac Patients : A new case study explores how Rockford Memorial Hospital in Rockford, IL, implemented a Heart & Vascular RPM program that helped reduce its readmission rates from 28% to 14% over 2 years.
• I mproving Medication Compliance, Quality of Life, and Peace of Mind through Voice Assistant Technology: Libertana Home Health in Sherman Oaks, CA implemented a voice assistance technology to improve medication compliance, quality of life, and peace of mind.   The voice assistance technology was provided by Orbita.
• TELEHEALTH AND REMOTE PATIENT MONITORING (RPM) – Provider Case Studies 2014:  Provider Case Studies 2014 was compiled to help a variety of organizations become familiar with real-life examples of telehealth implementation. The case studies also explore the impacts experienced by users of these technologies and the potential revenue streams and business models that support them
• CAST Case Study: Evangelical Homes of Michigan:  In July 2013, CAST Patron and LeadingAge Member Evangelical Homes of Michigan (EHM) learned about a newly formed, physician-based accountable care organization (ACO) called Northwest Ohio ACO during its conversations with Ohio Presbyterian Retirement Services (OPRS), a LeadingAge member in Columbus, OH.
• Medication Management Technologies PROVIDER CASE STUDIES 2015 : A set of 4 new case studies provides real-life examples of how providers implemented medication management technologies. One document in the collection summarizes the lessons learned from all the case studies.

Most Recommended

August 27, 2024, leaders of color network focuses on mentorship, august 14, 2024, cast releases “large language models in aging services” resource, august 20, 2024, leadingage advocacy: three things you need to know, august 15, 2024, nursing home staffing mandates: what you need to know, recently added.

September 11, 2024

Colleagues on the Move, September 11, 2024

September 10, 2024

Pilot Uses Vibration Sensors to Keep Older Adults Independent

Aging Services Grows its Next Generation of Leaders

September 06, 2024

Sorry, there was a problem.

Download the free Kindle app and start reading Kindle books instantly on your smartphone, tablet, or computer - no Kindle device required .

Read instantly on your browser with Kindle for Web.

Using your mobile phone camera - scan the code below and download the Kindle app.

Image Unavailable

• To view this video download Flash Player

Follow the author

Clinical Case Studies in Home Health Care 1st Edition

Home health care is an important aspect of community health and a growing area of healthcare services. Clinical Case Studies in Home Health Care uses a case-based approach to provide home healthcare professionals, educators, and students with a useful tool for thoughtful, holistic care. The book begins with a thorough and accessible introduction to the principles of home health care, including a discussion of supporting theoretical frameworks and information on managing complexities, transitioning patients to home care, and preparation for the home visit.  Subsequent sections are comprised entirely of case studies organized by body system. Though cases are diverse in content, each is presented in a consistent manner, incorporating relevant data about the patient and caregivers and the approach to patient care and promoting a logical approach to patient presentation.  Cases also include helpful tips about reimbursement practices, cultural competence, community resources, and rehabilitation needs.

• ISBN-10 0813811864
• ISBN-13 978-0813811864
• Edition 1st
• Publisher Wiley-Blackwell
• Publication date August 30, 2011
• Language English
• Dimensions 6.7 x 0.8 x 9.5 inches
• Print length 504 pages
• See all details

Editorial Reviews

From the inside flap.

The book begins with a thorough and accessible introduction to the principles of home health care, including a discussion of supporting theoretical frameworks and information on managing complexities, transitioning patients to home care, and preparation for the home visit. Subsequent sections are comprised entirely of case studies organized by body system.

Though cases are diverse in content, each is presented in a consistent manner, promoting a logical approach to understanding a patient's presentation, relevant data about the patient and caregivers, and managing patient care. Cases also include helpful tips about reimbursement practices, cultural competence, community resources, and rehabilitation needs.

Key features:

• Interdisciplinary care plans provided in each case
• Relevant, accessible information on preparing for and making the home visit
• Intriguing cases illustrating a range of patient needs and complexities of care
• Cases written by leading experts in the field

From the Back Cover

About the author, product details.

• Publisher ‏ : ‎ Wiley-Blackwell; 1st edition (August 30, 2011)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 504 pages
• ISBN-10 ‏ : ‎ 0813811864
• ISBN-13 ‏ : ‎ 978-0813811864
• Item Weight ‏ : ‎ 2.1 pounds
• Dimensions ‏ : ‎ 6.7 x 0.8 x 9.5 inches
• #115 in Nursing Home Care (Books)
• #184 in Home & Community Nursing Care
• #945 in Nursing Home & Community Health

About the author

Leslie neal-boylan.

Discover more of the author’s books, see similar authors, read author blogs and more

Customer reviews

• 5 star 4 star 3 star 2 star 1 star 5 star 0% 0% 0% 0% 0% 0%
• 5 star 4 star 3 star 2 star 1 star 4 star 0% 0% 0% 0% 0% 0%
• 5 star 4 star 3 star 2 star 1 star 3 star 0% 0% 0% 0% 0% 0%
• 5 star 4 star 3 star 2 star 1 star 2 star 0% 0% 0% 0% 0% 0%
• 5 star 4 star 3 star 2 star 1 star 1 star 0% 0% 0% 0% 0% 0%

Customer Reviews, including Product Star Ratings help customers to learn more about the product and decide whether it is the right product for them.

To calculate the overall star rating and percentage breakdown by star, we don’t use a simple average. Instead, our system considers things like how recent a review is and if the reviewer bought the item on Amazon. It also analyzed reviews to verify trustworthiness.

No customer reviews

• About Amazon
• Investor Relations
• Amazon Devices
• Amazon Science
• Sell products on Amazon
• Sell on Amazon Business
• Sell apps on Amazon
• Become an Affiliate
• Advertise Your Products
• Self-Publish with Us
• Host an Amazon Hub
• › See More Make Money with Us
• Amazon Business Card
• Shop with Points
• Reload Your Balance
• Amazon Currency Converter
• Amazon and COVID-19
• Your Account
• Your Orders
• Shipping Rates & Policies
• Returns & Replacements
• Manage Your Content and Devices

• Conditions of Use
• Privacy Notice
• Consumer Health Data Privacy Disclosure
• Your Ads Privacy Choices

5 Obstacles to Home-Based Health Care, and How to Overcome Them

by Pooja Chandrashekar , Sashi Moodley and Sachin H. Jain

Summary .   

One of the most promising opportunities to improve care and lower costs is the move of care delivery to the home. An increasing number of new and established organizations are launching and scaling models to move primary, acute, and palliative care to the home. For frail and vulnerable patients, home-based care can forestall the need for more expensive care in hospitals and other institutional settings. As an example, early results from Independence at Home, a five-year Medicare demonstration to test the effectiveness of home-based primary care, showed that all participating programs reduced emergency department visits, hospitalizations, and 30-day readmissions for homebound patients, saving an average of $2,700 per beneficiary per year and increasing patient and caregiver satisfaction. There are tremendous opportunities to improve care through these home-based care models, but there are significant risks and challenges to their broader adoption.

One of the most promising opportunities to improve care and lower costs is the move of care delivery to the home. An increasing number of new and established organizations are launching and scaling models to move primary, acute, and palliative care to the home. For frail and vulnerable patients, home-based care can forestall the need for more expensive care in hospitals and other institutional settings. As an example, early results from Independence at Home , a five-year Medicare demonstration to test the effectiveness of home-based primary care, showed that all participating programs reduced emergency department visits, hospitalizations, and 30-day readmissions for homebound patients, saving an average of $2,700 per beneficiary per year and increasing patient and caregiver satisfaction.

Partner Center

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Integr Care
• v.22(1); Jan-Mar 2022

The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team

Wei ting chen.

1 Advanced Practice Nurse, Division for Central Health, Tan Tock Seng Hospital, SG

2 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

3 National University Health System, SG

Yeow Leng Chow

To examine the roles of transitional care nurses in an integrated healthcare system and how the integrated healthcare system influences their evolving roles.

Background:

Transitional care teams have been introduced to enable the seamless transfer of patients from acute-care to the home settings. A qualitative case study of the transitional care team was conducted to understand the changing roles of these nurses in an integrated Regional Health System (RHS) in Singapore.

A hospital transitional team of an integrated RHS was studied. Purposive sampling was used. Non-participant observations and follow-up interviews were conducted with four nurses. Data were triangulated with the interviews of two managers and three healthcare professionals, and the analysis of documents. Within-case thematic analysis was carried out.

Three themes were identified: ‘Coming together to meet the needs of all’; ‘Standing strong amidst the stormy waves’; and ‘Searching for the right formula in handling complexity’. These themes have explained on the atypical roles taken on by nurses in their attempts to close the gaps and meet the patients’ needs. Various factors influencing the evolving roles were revealed.

Conclusion:

The roles of nurses have ‘emerged differently’ from their traditional counterparts. Various nursing roles have been undertaken to facilitate care integration. The findings emphasised the important balance between formal structural practices and informal processes in facilitating and supporting the nurses in their role development.

Introduction

Health systems are facing challenges as the ageing population increases. From 2014 to 2017, the proportion of the Singaporean population aged 65 and above rose from 11.2% to 13.0% [ 1 , 2 ]. It has been projected that about 18.7% of its population would be aged 65 and above in 2030 [ 3 ]. The elderly were found to have more chronic conditions, with 80.6% of the age-group more than 65 years reporting one or more chronic diseases compared to 54.8% for that between 45 and 64 years [ 4 ]. With the increased health and social care needs of the elderly in Singapore, the healthcare system and policies have been evolving to embrace the principles of integrated care [ 5 ]. Singapore’s reforms started in 2000 when the government reorganised all polyclinics and restructured hospitals under two healthcare clusters–the National Healthcare Group (NHG) and Singapore Health Services (SingHealth)–to provide integrated care for patients [ 6 ]. From 2008 to 2009, six integrated regional health systems (RHSs) have been formed ( Figure 1 ). Each RHS aimed to promote the integration of care services received by patients in public hospitals, primary care providers or intermediate and long-term care providers within a designated geographical area [ 6 , 7 ]. Further restructuring of the RHSs occurred in 2017, where three large RHSs were formed ( Figure 1 ). While such re-clustering efforts aimed to promote greater integration of care, evidence on its benefits is still lacking [ 5 ].

Re-clustering of six integrated regional health systems (RHSs) to three larger integrated RHSs in 2017 [ 8 , 9 ].

With the need to provide holistic and coordinated care, nursing teams have evolved from a traditional flattened structure of nurses to multi-skilled and multi-professional teams [ 10 ]. The elderly often require coordination of care among multiple healthcare and social-care providers [ 11 ] and transitional care from the hospital to home [ 12 ]. This has also accentuated the role of nurses in care coordination and management [ 13 , 14 ]. Similar nursing developments have taken place in Singapore ( Figure 2 ). The introduction of Hospital-to-Home (H2H) programme has driven the development of transitional care or RHS community nurses. These registered nurses (RN) were based in acute care hospitals and promote the safe and timely transfer of patients between care settings by taking on activities at hospital discharge and post-discharge care. This decreases preventable adverse events during care transition, such as medication errors and falls [ 12 ].

Development of Singapore’s healthcare system and home and community nursing [ 15 ].

A literature review has been conducted to understand the changing roles of transitional care and community nurses in integrated healthcare systems. Common activities and practices performed by home and community nurses have been identified in previous studies [ 16 , 17 , 18 ]. They are direct patient care, patients’ monitoring, educational actions, psychosocial care and administrative work. There is also a shift away from the reactive nursing delivery system to models of care that focus on preventive home visits for older people, nurse-led post-discharge services and the specialisation of nursing work [ 19 , 20 , 21 ].

Transitional care programmes have been studied to identify the main interventions involved, duration of care and their effectiveness. In a recent scoping review, key professionals involved in transitional care teams were often nurses, with some of them receiving additional training in transitional care or speciality training [ 22 ]. Common interventions were discharge planning, medication management, structured needs assessment, patient education, chronic disease self-management, post-discharge guidance, caregiver support, care coordination and case management [ 12 , 23 , 24 , 25 , 26 , 27 ]. Delivery of transitional care varied in duration and frequencies of telephonic and/or home visitation mode [ 22 , 28 ].

Despite the programmes have demonstrated their usefulness and cost-effectiveness [ 23 , 29 ], the changing roles assumed by nurses were little explored. The programmes often focused on specific disease conditions or patient profiles [ 29 , 30 ] such that roles of the nurses could be seen as an extension of work settings from hospital to community. A recent study has demonstrated the interrelated influence of moderating factors on the implementation fidelity of the transitional care program [ 25 ]. Gaps in the literature could be seen in the overall change in the roles of nurses in the hospital-to-home interface and as an overall integrated system approach. Such understanding will be crucial in determining whether certain roles were assumed considering the changing contextual system factors and developments of other professional roles in this care system.

As integrated healthcare systems are increasingly formed, studies have shown their impact on the roles of nurses [ 31 , 32 , 33 , 34 ]. Coordination and partnership across settings and delegation and supervision of unlicensed personnel were reported [ 33 ]. There were also a high number of non-patient-related activities such as meetings, referrals and administrative tasks [ 31 ]. Although all of these studies have afforded some evidence on the influences of the integrated care system on the evolution of the nursing roles, the actual changes and development of these roles have not been well elucidated. A study to understand the changing roles of nurses is warranted. In particular, the drivers for the development of community and home nursing have remained less explored. This study aimed to examine the roles of transitional care nurses in an integrated RHS and the influence of the development of RHS on their evolving roles. The research questions were the following:

• What are the transitional care nursing roles in an integrated RHS?
• What are the various influencing factors in the integrated RHS on their roles?
• How does the development of the integrated RHS affect the change in the roles of transitional care nurses?

Study design

A qualitative case study research design was used to examine the influence of different contexts and social interactions on the nursing roles, offering insights into the complex interrelationships between the components [ 35 , 36 ].

Theoretical framework

The role theory and complex adaptive system (CAS) theory were used to guide the study [ 37 , 38 ]. A role can be defined as ‘the set of prescriptions defining what the behaviour of a position member should be’ [ 39 ] (p29). Three aspects of role can be defined, with reference to the person segment (role of a nurse), behaviour segment (nursing roles) and person–behaviour segment (patterns of behaviour characteristics of transitional care nurses). This role theory emphasised the importance of observation as the optimal method to gather the behaviours of the transitional care nurses. The construct of the observation charts and interview schedules have aimed to uncover the various roles taken on by these nurses. Previous researchers have also emphasised the dynamic properties of roles and various influences on the roles of nurses within a social system [ 37 , 40 , 41 ]. Drawing reference from two existing CAS conceptual frameworks in healthcare [ 42 , 43 ] and findings from a separate study in the first author’s thesis [ 15 ], the conceptual framework for this study is proposed. This framework ( Figure 3 ) was based on the understanding that although nursing services are governed by systems of working within individual organisations, relationships were maintained between the organisations in the overarching integrated healthcare system. Besides emphasising the use of a qualitative case study research using multiple cases, this CAS framework guided the data analyses such that the within-case analysis preceded cross-case comparisons. The findings of the other three cases and the final analysis were reported separately in the first author’s thesis [ 15 ].

A refined conceptual framework that recognises the importance of relationships and interactions between different staff within each organisation and between different organisations [ 42 , 43 ].

Setting and sample

There were six integrated RHSs in Singapore before the mergers into three larger RHSs in January 2017. Despite the mergers, the operations in the six sub-systems have not changed drastically compared with their pre-merger times during data collection from April to September 2017. The sub-system of one of the three large RHSs in central Singapore was selected as the main research setting, hereafter referred to as ‘central RHS’. An instrumental case study was used to achieve the research objectives [ 35 ]. The transitional care team from the central RHS was the case of interest, named herein as ‘Case D’. This team formed a diverse case, offering a different insight to the roles of nurses providing care in a home environment [ 44 ]. Nurses in specially developed programmes to serve certain unique patient profiles, such as mental health and home ventilation, were excluded in this case.

Case D was managed under the main 1,500-bed tertiary hospital that anchored the central RHS. The hospital’s home-based care services had started with three silo programmes to serve post-discharge patients of different profiles: Aged Care Transition (ACTION), Virtual Hospital and Post-Acute Care at Home. The first programme aimed to provide case management service for patients with health and social care needs; the second programme targeted patients who were frequently admitted for chronic health conditions; and the third served to provide intensive medical and nursing care for clients with complex health care needs. The data collection was conducted after the merger of these three programmes into one transitional care team, allowing rich information to be collected. This team was led by nurses and supported by a multi-disciplinary team of doctors, pharmacists and allied health therapists in service provision. This service has also been financed by the H2H funding under the Ministry of Health since 2017. These RNs received in-house orientation and induction programme before they were merged into one department. They reviewed patients at their homes independently and work within escalation protocols for medical support through joint home visits and case discussions.

Purposive sampling was used to select participants. The inclusion criteria for the nurses were the following: (1) age of 21 years and above, (2) experience working as a nurse in transitional care services for more than 2 years and (3) provision of patient care for at least 24 hours a week to patients within the central RHS. The nurses were recruited for observations and follow-up interviews. Managers and other healthcare professionals (e.g. doctors, therapists and/or ancillary staff) were invited for interviews to elicit their perspectives on nurses’ work. Managers were included if they held key administrative positions in overseeing the department that governs nurses. The inclusion criteria for other healthcare professionals were the following: (1) age of 21 years and above, (2) working with a nurse participant and (3) provision of professional services under the organisation. Relevant documents, such as policies and forms that described the roles and practices of nurses in the last five years, were also examined.

Ethical consideration

Ethical approval for the study was obtained from the Institutional Review Board of the RHS (Ref. No.: 2016/01418). The potential participants had first been identified by the nursing manager based on the inclusion and exclusion criteria. The study was explained to the prospective participants, and written informed consent was obtained by the first author. Anonymity and confidentiality were assured through the use of codes to identify the participants. Verbal consent to observe the nurses’ work was obtained from patients or caregivers prior entry to their homes.

Data collection

Three data collection methods were used: non-participant observations of nurses by the first author, a registered nurse working in a tertiary hospital and doing her PhD project; individual interviews of nurses, managers and healthcare professionals; and a documentary analysis. Data collection continued to the point of data saturation, which was when the data set was completed and the research questions were answered [ 45 ]. The participants’ demographics were collected using self-completed demographic sheets.

Non-participant observations of the nurses during their regular working hours were undertaken for at least 24 hours a week. The first author asked them to provide care to patients as usual so that the data collected could genuinely reflect their practices. The first author followed each participant and observed their practices consecutively in a week. Two observation charts to document nurse-patient encounters during home visits and the nurses’ daily schedules were used to elicit the direct or non-direct care interventions and nursing work. Following the observations, the same nurses were interviewed individually based on a semi-structured interview guide to understand the ‘how’ and ‘why’ of the roles performed. Separate semi-structured interview guides were used for managers and healthcare professionals. All interviews were audio-recorded. Each interview lasted approximately 30–120 min. The interview guides were developed from the research questions and had been pilot-tested on a separate home hospice team, of which the findings were not used in this study. Lastly, documentary data were transcribed onto the data extraction form, which was constructed to capture relevant information on the work and roles of nurses [ 46 ].

Data analysis

A simple descriptive analysis using Microsoft Excel 2013 was conducted on the quantitative data from the participants’ demographic sheets and daily observational information. Audio recordings of the interviews were transcribed verbatim, and handwritten observation notes were typed into electronic text. A thematic analysis was then undertaken for the qualitative data using the six-phase data analytical method [ 47 ], incorporated with techniques of data condensation, data display and conclusion drawing [ 48 ]. QSR Nvivo 10 was used to organise the data.

First, data were collected by the first author to allow familiarity of the data [ 47 ]. Next, the first and third authors independently generated the initial codes before checking for agreement [ 48 ]. During the third step in searching for themes, different codes were sorted into potential units of analysis to discern pattern codes [ 47 , 48 ]. In the fourth step, three authors refined the themes by examining the levels of the coded data extracts to ensure coherence in its patterns and consider individual themes in relation to the data set as a whole [ 47 ]. The themes were defined in step five before concluding with a written report in step six. Pattern matching and explanation building were employed in the within-case analysis [ 49 ].

Methodological rigour

The four criteria of credibility, transferability, dependability and conformability were used to ensure the trustworthiness of the study [ 50 ]. Triangulation of the data collection methods and data sources was undertaken to enhance the credibility of the study [ 51 , 52 ]. Prolonged engagement was crucial to reduce the observer effect on the participants’ behaviours [ 53 ]. The authors undertook independent data analyses before coming together to ensure consistency in the coding and identification of themes [ 51 ]. The first author kept a research diary to enable the comprehension of the thoughts that led to the findings [ 51 ]. The study research design and findings are described in detail in the first author’s thesis [ 15 ] to allow for the transferability of the findings [ 54 ].

Demographic data of the participants and observation information

A total of four nurses were selected based on the inclusion and exclusion criteria, and they covered different geographical regions served by the central RHS. Two managers and three healthcare professionals who worked closely with these four nurses were interviewed. Table 1 presents the demographics of the participants. The nurse participants were observed over a total of 147 h ours over 17 days. Eleven home visits were made, with a mean duration of 54.55 min utes per home visit. A total of 11 relevant internal documents were reviewed here. These documents were mainly workflows, service manuals and induction materials.

Demographics of the participants.

Note : ‡ , range is not reported as the small numbers may reveal the identity of the participants; *, data not presented to ensure anonymity of the small number of participants.

Themes and sub-themes of Case D: RHS hospital transitional care team

The themes and sub-themes are presented in Table 2 . The nurses’ roles arose because of the need to come together in the integrated healthcare system ‘to meet the needs of all’. Case D was at the centre of all change forces, and the nurses’ roles were developing to be ‘strong amidst the stormy waves’. The nurses’ roles were still evolving and ‘searching for the right formula to handle the complexity’ in the integrated healthcare system.

Themes and sub-themes of Case D.

Theme 1: coming together to meet the needs of all

This theme describes the atypical roles undertaken by nurses in Case D (Sub-theme 1) and their attempts to close gaps and meet patients’ needs (Sub-theme 2).

Sub-theme 1: rising out of the norm

The observation of Case D nurses has demonstrated that the care delivered was beyond the traditional home visits, displaying the sub-theme of ‘out of the norm’. The nurses typically made only one visit for each patient as the first visit was considered free of charge for them. Therefore, during one single home visit, the nurses were observed to make a comprehensive health assessment, which included physical aspects, cognition, environmental safety, emotional well-being and social support system. As part of their role in care management, the nurses would promote adherence to chronic disease care plans by educating the patients and their caregivers. Ensuring medication adherence and reminding them of their appointments were significant components of their work. Coordination of care then followed to ensure that various health or social services were in place. Patients’ care management was executed mainly through telephone consultations.

Delivery of nursing care was not limited to direct contact with patients or caregivers at home visits or over the phone. The nurses were instrumental in discussing the patients with the multi-disciplinary team. A formal daily case discussion and weekly multi-disciplinary rounds (MDR) were held for each of the four sub-teams. Observations of the nurses also revealed that informal discussions with their multi-disciplinary team were common in the office.

‘The nurse went to speak to the occupational therapist in the office regarding a home visit for the patient. The nurse arranged the timing for the visit and updated her about the case. The nurse also updated her regarding another case.’ [Observation–Nurse03]

Proactive preventive care was observed as one of the nursing roles undertaken. The nurses received a national risk stratification list of hospitalised patients who might need services post-discharge. Each sub-team had a lead nurse to screen through the list and enrol patients with complex medical and social needs. As the service was developing, the nurses also participated in strategic development projects within the department as well as with other community providers.

Sub-theme 2: closing the gaps

There were unique features of the roles of the nurses, of which ‘closing the gaps’ was the most prominent observation. They made sure that the patients transited smoothly through various settings. Forming a safety net included addressing any new health concerns, providing health information and caregiver teaching and escalating rapidly to the medical team when these patients turned unstable. Although closing the gaps was the primary reason for the development of Case D, the nurses’ roles also addressed the current fragmentation of the integrated RHS.

‘Because if we cannot cross that bridge right, then we try other bridge that can support. If there aren’t any bridge that can support. Then it will be due to a limitation in the service, which is something geographically or politically or service limitation wise, we cannot do anything about it. We should just try our best to help the patients.’ [Interview–Manager02]

Closing the gaps has also meant that the nurses have moved away from the traditional manner of care delivery. Instead of solely functioning within a certain care setting, these nurses have worked in different settings such as inpatient wards, community settings and homes or via teleconsultation. The care network was expanded by their attendance at regular networking sessions and case discussions with the community providers and polyclinics (primary care). Although it was observed that the nurses spent much time on the telephone, these increased contacts have attempted to plug the gaps in the integrated RHS in which some patients had fallen through.

Theme 2: standing strong amidst the stormy waves

This theme has described how the nurses established their new roles in the face of various challenges, including the intense push for changes at the system and policy levels (Sub-theme 1), shaken foundation of the organisation (Sub-theme 2), remote influences of families (Sub-theme 3) and need to provide care to the most vulnerable patients (Sub-theme 4).

Sub-theme 1: moving along with the storm of change

The merger from the three programmes into one service was the most significant turning point for the nurses. This change was fuelled by the changing healthcare needs of the population. The participants echoed this, who explained that the patients were older and sicker and thus needed more care after hospitalisation. National programmes were introduced to expand the existing community healthcare services. Although the shift was welcomed, the nurses verbalised that the change in the funding structure has changed the care delivery. Programmes were nurse-led as the doctors’ visits were expensive. The free-of-charge nurse’s first visit was very intense to identify and address the patients’ biopsychosocial needs. One nurse also discussed her discomfort that her role was much determined by the cost of visits.

The governmental policies and funding on other primary and community services have exerted strong impacts on the nurses’ role. As the community services were run by non-for-profit organisations, different organisational sizes also meant different standards and capacities of the services. The disparate service capacities have resulted in some nurses holding on longer to their patients before handing them over to a suitable provider. Understanding the strengths and weaknesses of social services and working with them to improve their service scope has become part of their roles.

‘The networking is with the community partners most of the time… … that helped us to come to a consensus that this is the part that you will do and this is the part that I will do. We can come together and synergise, and benefit the patients.’ [Interview–Manager01]

Sub-theme 2: shaking a solid foundation

The expansion of the hospital outside of an institution setting has shaken its fundamental operating philosophy. The hospital was constantly setting new workflows, and regular briefing meetings were held. At times, there were uncertainties and confusion over the new and changing workflows by the team. Although the organisation has involved the nurses in the development of new workflows and processes, this also translated into heavier involvement in projects and meetings. The fast-paced changes have left nurses feeling overwhelmed.

‘I think it is not from them [managers], it is from the top management that will sometimes shake the team a little bit. How come it is last minute? How come we are the last team to know? That kind of feel. It will be good that the management can prepare us in advance on what is going to happen.’ [Interview–Manager02]

There was a shift in the model of care towards the nurse-led and team-based approach. One therapist shared that the doctors and therapists became consultative figures rather than directive ones. The shift in care delivery towards a team-based approach was evident. The managers, also known as the team leaders, have stood firm and resolute. They provided stability within the team by being the clinical support and by looking into nursing development to keep pace with rapid and constant changes. Standing firm amidst all of the changes and supporting the nurses in their roles were significant to maintain the cohesion of the team. They guided the nurses despite the lack of clarity.

‘I just have to make the boat works. If not, the whole boat will collapse. I cannot demonstrate that I am shaking. I just have to keep it going.’ [Interview–Manager02]

Sub-theme 3: maintaining a distant relationship

The relationship between the patients’ caregivers or families has exerted a lesser impact than other influences. Their main determining factor in establishing this relationship was often driven by the costs of the service. Even the enrolment and follow-up home visits were much decided by the family or caregivers. Regular updates and advice to family members and caregivers through telephone consults were commonly observed. The participants shared that these family members or caregivers have access to more health information via the internet. Communication via WhatsApp, text messages and emails were common. Because of the distant relationship, the nurses sometimes had little control of how the family members or caregivers managed the patients’ care.

‘The nurse made a phone call to arrange a home visit as the son reported that the patient passed less urine. The nurse was concerned of urinary retention and was planning to do a bladder scan. However the son refused the home visit.’ [Observation–Nurse04]

Sub-theme 4: sustaining a lifeline in the storm

The sub-theme ‘a lifeline in the storm’ describes the complex and challenging patients who depended on the nurses to prevent them from falling through gaps and weaknesses when the system has not integrated sufficiently to provide the care required by these patients. This particular group of patients often had extreme social circumstances or demonstrated non-adherence to lifestyle modifications or medications, leading to frequent disease exacerbations and hospital admissions. The patients’ multiple medical conditions sometimes limited the use of standard care plans. The patients had complex biopsychosocial needs such that several community services had to be in place. The nurses undertook the role as the single point of contact.

‘One point of contact. By doing so, patients… by being one point of contact…… they don’t need to remember so many nurses’ names. And what we are dealing with are elderly, who tends to be more forgetful.’ [Interview–Nurse02]

To meet the needs of these complex patients, the nurses first built a rapport with the patients. The nurses made contact with these patients in the wards before they were discharged and addressed their concerns when they encountered problems at home. One nurse described herself as ‘being a phone call away’. Thereafter, they would empower the patients in managing their own health. In a short transitional care period, they have ensured that patients were stable before handing over to a long-term care provider.

Theme 3: searching for the right formula in handling complexity

Case D has faced a number of complex changes as the RHS developed (Sub-theme 1) and working within a team and with several teams (Sub-theme 2). Their emerging roles in providing care differed from the norm (Sub-theme 3). Their evolving roles were still fraught with uncertainty, thus giving rise to the overarching theme of ‘searching for the right formula in handling complexity’.

Sub-theme 1: facing complexity at its prime

‘Complexity at its prime’ describes the pubescent stage of the changes in healthcare after the re-clustering in January 2017. The lack of awareness of other community services and their service capabilities was common. This was further hampered by the lack of system links between them, such that the nurses sometimes did not know the services received by the patients. The medical information documented by the community providers was not available on the National Electronic Health Records. Thus, the onus fell back on the nurses to communicate with the community providers to gather information. However, the constant and dynamic change was only the beginning as more upcoming changes were announced during the data collection period.

It is evident that the boundaries of work between different organisations and the rules in each organisation within the RHS have begun to change, leading to further complexity. It was observed that it was unclear whether certain nursing services were still within the scope. Protocols and workflows were continuously developed or modified. As the boundaries between the different organisations became blurred within the integrated system, there were duplications and gaps of services at times. The adaptability of the nurses came in useful when rules were unclear. In addition, the nurses were observed to display self-organising abilities and interacting within their own sub-teams and with other community providers. However, during such self-organisation and adaptation, one significant observation was that nurses unable to adapt effectively also departed from the system.

‘Those [Nurses] who have eventually left. I would not say that because they cannot make it. It is because I think that there is something that they think it is not something for them.’ [Interview Nurse02]

Sub-theme 2: teaming with teams

The nurses have formed a team that worked with several teams, thus giving rise to the sub-theme ‘team of teams’. Besides seeing the patients at home, they would assess the patients in the wards or clinics and hold case discussions with hospital teams or primary care teams. The nurses were recognised as the single source of contact and were supported by other healthcare professionals. Their role as a catalyst to other teams was also observed. In the community, they frequently collaborated with other homecare nurses and primary care and community providers. For ways to connect with them, other than the face-to-face physical presence in the wards or clinics, formal methods included holding joint MDR or teleconsultations. For more complex patients, joint home visits were made. The nurses usually followed up by speaking to the staff to discuss the patients after these formal communications. The various ways of communicating with several teams emphasised the role of nurses as good communicators.

‘My efforts might be limited by one self. Let’s say I gather a team of community partners. Together with community partners, working with them, to let them know that there is a shared common patient goal, then they help with whichever means of expertise. [Interview–Nurse03]

Sub-theme 3: emerging differently

As the hospital developed its community services in tandem with the integrated healthcare system, new roles were emerging. Because of the focus on integration and collaboration, the ways through which the nurses conducted their usual assessment have changed. Possible enrolment into the service was no longer only referred but was identified by a national risk stratification tool. These patients had to be assessed proactively to look for any unidentified needs and refer appropriately to the various community services.

‘As the patients’ conditions get more complex, the complex care does not allow the nurses to be so hospital-based, clinic-based. Rather be more proactive. Proactive to go in and be more engaging with the patients……. To elicit the behavioural changes in getting well.’ [Interview–Nurse03]

The drive towards integrated care has meant that the nurses have to coordinate with both the specialists and community partners. Working in such a grey zone has meant that their caseloads were always shared. In this multi-prolonged integrative work, the physical presence and contacts of the nurses could be observed at different parts of the integrated RHS. The observations had shown that their roles were required to cover the current gaps in the integrated RHS when other providers were unable to provide the services on time.

The research aimed to understand the changing roles of transitional care nurses in the integrated healthcare system. Key insights were gained on their roles, the systems in which they worked and the evolution of their roles as the integrated RHS developed.

Diverse nursing roles have been reported in the literature as new community programmes and initiatives were implemented to facilitate the transition of care between settings [ 12 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 33 ]. The health assessment, telephonic support, coordination and chronic disease management roles were similarly performed by nurses in Case D. Proactive recruitment was also in place to identify at-risk patients using predictive tools and early institution of preventive measures. The literature has also witnessed this increasing shift of roles from passive and reactive to proactive care [ 20 , 21 , 33 ]. Emphasis was also placed on discharge planning and coordinating with other professionals to prepare patients and caregivers for their post-discharge care [ 12 ]. More studies should be conducted on the importance of this anticipatory and integrative role by transitional care nurses to ensure other care partners to take over patients’ care when they bridge from hospital to community.

The findings have shown that the nurses in Case D have extended from clinically-focused roles and holistic direct patient care activities to other new roles in networking, project planning and representation in workgroup and committees. A ‘rising out of the norm’ may be the new working philosophy to place nurses as key players in developing integrated care. The nurses’ roles in Case D were unique when they were ‘closing the gaps’ through their provision of interim nursing interventions, using different forms of care delivery and working in different care settings. Nurses often bridged the gaps and worked between boundaries of health and social care [ 55 ]. In addition, Case D nurses have taken on the system roles in working with care partners to close the gaps through the development of collaborative partnerships and were beyond the usually described direct patient-nurse care in literature [ 12 , 23 , 24 , 25 , 26 , 27 ].

The findings have highlighted the impact of the restructuring of the healthcare system towards community care on the roles of nurses. Studies have similarly outlined the possible socio-political influences on nurses’ roles [ 56 , 57 ]. Findings have shown that nurses played a role not only in their organisations but also in the integrated RHS by partaking in collaborative meetings and developing services and workflows with other community partners. It was evident that these new and expanded roles of the transitional care nurses have been introduced as a result of the change in the funding system for various programmes. Although such increased funding has been welcomed to drive the rapid shift to community care, Schofield et al. (2011) have cautioned that community programmes were often suspended when competing demands for funds emerged [ 58 ]. Confusion created by the lack of well-developed program direction and protocols was similarly observed in other national transitional care programme [ 25 ]. Such policy and system changes have to be managed carefully so as not to place nurses in an uncertain state of change.

The presence of nursing managers and leaders was significant in fostering the growth and development of the roles of nurses in the integrated care system. A qualitative study has shown that leadership in community nursing was crucial in how policies are delivered and how leaders have translated the policies into action plans for frontline community nurses to deliver care [ 59 ]. In this study, the team leaders concurrently managed the senior management upstream and nurses in their teams downstream. The effect of the patterns of the patients’ family and caregivers on the roles of nurses is noteworthy. Similar to other Asian studies, family members were heavily involved in medical decision-making [ 60 ], and the hired foreign domestic workers and themselves were the direct care providers in home settings [ 61 ]. Although cost was often stated not as a barrier for patients to receive care [ 25 ], negotiations with the family to provide services have fallen on the nurses who have to balance between professional obligations and the family’s financial concerns.

The development of the integrated RHS on nursing roles and possible mechanisms of change were examined through the lens of complexity science and the role theory. The changes in the roles were largely complex, even though some form of structure and order was present. CAS theorists have highlighted that the organisational structures and processes have facilitated informal exchanges and interactions [ 62 , 63 , 64 ]. This research has demonstrated that the nurses have expanded linkages throughout the integrated RHS with a high amount and level of interactions undertaken. Although it may appear chaotic, there were actually ‘order within chaos’ as the nurses self-organised their work towards integrated care [ 65 ].

Adaptable and self-organising attributes of the nurses have been observed to ‘emerge differently’ in this new complex integrated care system. The roles of the nurses in various programmes in Case D were merged as one, and new roles were introduced. It was observed that establishing new nursing roles was also a dynamic process as the integrated healthcare system develops. Although it is tempting to reduce complexity and ensure certainty by managing persons and creating structures [ 66 ], the findings have suggested that broad frameworks and healthcare policies should be provided to allow local adaptability yet prevent wide variations in the roles of nurses [ 43 , 67 ]. In addition, the processes should only be formalised when necessary: this will avoid having several prohibitive workflows and formal guidelines that add to administrative work but serve little clinical purpose.

The strengths of this study were that this research took place when the RHS underwent organisational changes. It is also noteworthy that this study has afforded valuable insights into nurses who provided care at home in an Asian context. The findings have also informed the importance of transitional nursing interventions in integrated care systems, and these roles should be further emphasised in the national community nursing scope of practice and development. This study also revealed the significance of organisational structures and policies in influencing the roles of transitional care nurses. Adequate support in terms of educational preparation and continued expansion of their roles should be undertaken.

Although the limitation of generalisation due to the small number of nurses is present, a longer observation period of over a week per nurse has been undertaken. Although it is recognised that the findings reported here might be limited to a single case study, the first author has conducted three similar case studies to provide the cross-case comparison in her final thesis and further modified the CAS conceptual framework ( Figure 4 ). More studies are recommended using the framework, given the complexity of healthcare services and systems. Lastly, it is recommended that future studies on nursing roles should include observation as a data collection method instead of solely depending on interview methods as this method allows accurate capturing of multiple roles.

Proposed conceptual framework of the changing homecare nursing roles in an integrated regional health system (RHS).

The study has demonstrated the shift in the roles of transitional care nurses as the healthcare system grows increasingly complex and the replacement of linear thinking models with complexity science. The evolvement of the roles of nurses will be continuous and dynamic as different influencing factors come together and interact at varying strengths. The findings have contributed to developing the conceptual framework, which will enhance understanding the shift of nurses roles as the integrated care system develops. Further studies on the evolvement of nursing roles as the integrated RHS develops are strongly recommended to provide insights to future policy designs and nursing profession advancement.

Marlène Karam, inf., Ph.D. Professeure adjointe, Faculté des sciences infirmières, Université de Montréal, Canada.

Elodie Montaigne, Registered Nurse, MSc, PhD student in Community Health, Laval University, VITAM Research Center on Sustainable Health Qc, Canada and Visiting Lecturer, University of Rennes 1, France.

Competing Interests

The authors have no competing interests to declare.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US

Affiliations.

• 1 Froedtert Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA. Electronic address: [email protected].
• 2 Department of Economics, St. Ambrose University, McMullen Hall 124A 518 W. Locust St.Davenport, IA 52803, USA. Electronic address: [email protected].
• 3 University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109-5482, USA. Electronic address: [email protected].
• 4 Abt Associates, 5001 S Miami Blvd #210, Durham, NC 27703, USA. Electronic address: [email protected].
• 5 Marcella Niehoff School of Nursing, Loyola University Chicago, 2160 S. 1st Ave., Maywood, Illinois, 60153, USA. Electronic address: [email protected].
• 6 University of Maryland School of Nursing, 655 W. Lombard St., Baltimore, MD, 21201, USA.
• 7 University of South Carolina College of Nursing, 1601 Greene Street, Room 405, Columbia, SC, 29208, USA. Electronic address: [email protected].
• 8 Marquette University College of Nursing, PO Box 1881, Milwaukee, WI, 53201-1881, USA. Electronic address: [email protected].
• 9 Marquette University College of Nursing, PO Box 1881, Milwaukee, WI, 53201-1881, USA. Electronic address: [email protected].
• 10 Marquette University College of Nursing, PO Box 1881, Milwaukee, WI, 53201-1881, USA. Electronic address: [email protected].
• PMID: 33957500
• DOI: 10.1016/j.ijnurstu.2021.103946

Background: Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed.

Objective: To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization.

Research design: Secondary analysis of a multi-site dataset from a study of discharge readiness assessment and post-discharge return to hospital, comparing matched samples of patients referred and not referred for home health care at the time of hospital discharge.

Setting: Acute care, Magnet-designated hospitals in the United States PARTICIPANTS: The available sample (n = 18,555) included hospitalized patients discharged from medical-surgical units who were referred (n = 3,579) and not referred (n = 14,976) to home health care. The matched sample included 2767 pairs of home health care and non- home health care patients matched on patient and hospitalization characteristics using exact and Mahalanobis distance matching.

Methods: Unadjusted t-tests and adjusted multinomial logit regression analyses to compare the occurrence of readmissions and Emergency Department/Observation visits within 30 and 60-days post-discharge.

Results: No statistically significant differences in readmissions or Emergency Department /Observation visits between home health care and non-home health care patients were observed.

Conclusions: Home health care referral was not associated with lower rates of return to hospital within 30 and 60 days in this US sample matched on patient and clinical condition characteristics. This result raises the question of why home health care services did not produce evidence of lower post-discharge return to hospital rates. Focused attention by home health care programs on strategies to reduce readmissions is needed.

Keywords: Effectiveness; Emergency Department visits; Home health care; Readmission; Utilization.

Copyright © 2021. Published by Elsevier Ltd.

PubMed Disclaimer

Conflict of interest statement

Declaration of Competing Interest None

Similar articles

• Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial. Weiss ME, Yakusheva O, Bobay KL, Costa L, Hughes RG, Nuccio S, Hamilton M, Bahr S, Siclovan D, Bang J; READI Site Investigators. Weiss ME, et al. JAMA Netw Open. 2019 Jan 4;2(1):e187387. doi: 10.1001/jamanetworkopen.2018.7387. JAMA Netw Open. 2019. PMID: 30681712 Free PMC article. Clinical Trial.
• Cohort design to assess the association between post-hospital primary care physician follow-up visits and hospital readmissions. Kojima N, Bolano M, Sorensen A, Villaflores C, Croymans D, Glazier EM, Sarkisian C. Kojima N, et al. Medicine (Baltimore). 2022 Nov 18;101(46):e31830. doi: 10.1097/MD.0000000000031830. Medicine (Baltimore). 2022. PMID: 36401424 Free PMC article.
• A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care. Robert B, Sun AH, Sinden D, Spruin S, Hsu AT. Robert B, et al. J Am Med Dir Assoc. 2021 Mar;22(3):544-550.e2. doi: 10.1016/j.jamda.2020.07.020. Epub 2020 Sep 14. J Am Med Dir Assoc. 2021. PMID: 32943339
• Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review. Braet A, Weltens C, Sermeus W. Braet A, et al. JBI Database System Rev Implement Rep. 2016 Feb;14(2):106-73. doi: 10.11124/jbisrir-2016-2381. JBI Database System Rev Implement Rep. 2016. PMID: 27536797 Review.
• Effect of Early Follow-Up After Hospital Discharge on Outcomes in Patients With Heart Failure or Chronic Obstructive Pulmonary Disease: A Systematic Review. Health Quality Ontario. Health Quality Ontario. Ont Health Technol Assess Ser. 2017 May 25;17(8):1-37. eCollection 2017. Ont Health Technol Assess Ser. 2017. PMID: 28638496 Free PMC article. Review.
• Home care practice behavior and its influencing factors of primary care providers: a multicenter cross-sectional study in Sichuan Province, China. Zhou L, Liu S, Li H. Zhou L, et al. BMC Nurs. 2024 May 2;23(1):303. doi: 10.1186/s12912-024-01948-3. BMC Nurs. 2024. PMID: 38698388 Free PMC article.
• Natural Language Processing Applied to Clinical Documentation in Post-acute Care Settings: A Scoping Review. Scharp D, Hobensack M, Davoudi A, Topaz M. Scharp D, et al. J Am Med Dir Assoc. 2024 Jan;25(1):69-83. doi: 10.1016/j.jamda.2023.09.006. Epub 2023 Oct 11. J Am Med Dir Assoc. 2024. PMID: 37838000 Review.
• Machine learning applied to electronic health record data in home healthcare: A scoping review. Hobensack M, Song J, Scharp D, Bowles KH, Topaz M. Hobensack M, et al. Int J Med Inform. 2023 Feb;170:104978. doi: 10.1016/j.ijmedinf.2022.104978. Epub 2022 Dec 30. Int J Med Inform. 2023. PMID: 36592572 Free PMC article. Review.
• Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care. Sterling MR, Lau J, Rajan M, Safford MM, Akinyelure OP, Kern LM. Sterling MR, et al. J Am Geriatr Soc. 2023 Mar;71(3):810-820. doi: 10.1111/jgs.18135. Epub 2022 Dec 5. J Am Geriatr Soc. 2023. PMID: 36468538 Free PMC article.
• Discharge destination and readmissions among patients with head and neck cancer. Tucker J, Hollenbeak CS, Goyal N. Tucker J, et al. Laryngoscope Investig Otolaryngol. 2022 Aug 18;7(5):1407-1429. doi: 10.1002/lio2.890. eCollection 2022 Oct. Laryngoscope Investig Otolaryngol. 2022. PMID: 36262465 Free PMC article.
• Search in MeSH

LinkOut - more resources

Full text sources.

• Elsevier Science

Other Literature Sources

• scite Smart Citations
• MedlinePlus Health Information
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Login    |    1(877) 307-8573    |    Contact Us

Discover Recruit

Activated Insights Recruit enables you to automate outreach and engagement in your hiring process allowing senior living and home-based care providers to connect, qualify, and interview top caregivers faster than humanly possible.

• Discover Training
• Training for Home Care
• Training for Home Health
• Training for Hospice
• Training for Assisted Living
• Training for Independent Living
• Training for Skilled Nursing Facilities
• NAB Training
• Course Catalog
• State Compliance
• Specialty Learning Paths
• Options for Individual Care Professionals
• Instructor-Led Training Modules
• Barbara Karnes Series

Discover Retain

Activated Insights Retain is the ultimate offering for reducing employee turnover rates in home-based care and senior living, especially during the first 100 days when the risk is at its peak.

• EXPERIENCE MANAGEMENT
• Discover Experience Management
• Client Experience
• Patient Experience
• Resident Experience
• Employee Experience
• RECOGNITION
• Discover Recognition
• Reputation Management
• Great Place To Work
• U.S. News Best Senior Living
• Best of Home Care Awards
• Who We Help
• Speakers Bureau
• Testimonials

Case Studies

• Latest News

Featured Resources

Ep.19: Keeping Your Care Staff: Simple Strategies to Retain Care Staff for 5+ Years

Empowering Supervisors to Support Care Professionals in End-of-Life Care

Using Person-Centered Care to Support Older Adults in the LGBTQ+ Community

Learn from other agency’s success.

From No-Shows to Reschedules: How Automated Recruitment Grew Klipsch Senior Care, a Home Instead Franchise, Interview Show Rate by 40%

For Klipsch Senior Care, a Home Instead franchise, candidates were no-shows for in one out of every five interviews—until Recruit’s automated reengagement and nurturing drip campaigns.

How A Long Term Companion Used Activated Insights to Hire 51.5% More Employees and Build an Employer Brand That Resulted in an Indeed Click Through Rate Over 10x the Site Average

Caring for an aging parent or loved one can feel overwhelming. At A Long Term Companion, our compassionate, professional caregivers have been providing one-on-one support to our clients for over a decade.

How BrightStar Care Tinley Park Uses Activated Insights Experience Management to Retain 85% of Caregivers For Their First Six Months

In an industry where the median turnover rate has exceeded 60% for over five years now, any agency with sub-30% turnover has a story to tell.

How Angels On Call Used Activated Insights to Build a Reputation that Increased Caregiver Applicants 26% Year-Over-Year

Increasing caregiver applicants is no small feat. See how one agency managed to do it amongst a caregiver shortage.

How Arosa Boston Managed Their Employment Brand to Hire 62% of New Caregivers Through Google Reviews

See how online reviews help this agency stand out amongst competitors.

How Third-Party Surveys Helped Visiting Angels of Carlisle Achieve Their Top Growth Quarter in Company History

A skeptic became an advocate, and his agency is prospering.

How Norwood Seniors Network Keeps Their Annual Caregiver Turnover Under 30%

LIFETIME Care At Home Secures Referral Partnerships Using Satisfaction Data

Referral sources, especially in healthcare, look for consistency and quality. Here's how one agency owner uses satisfaction data to speak their language in a way that his competition isn't.

LIFETIME Care At Home Uses Client/Caregiver Satisfaction to Motivate Office Staff to Do Their Best Work

Motivating staff to do their best can be difficult. Here's one agency owner rallies his staff to get them all rowing in the same direction.

Request a Live Demo

See our integrations in action on a zero-pressure Zoom call.

© 2024 Activated Insights, LLC | Terms of Service | Privacy Policy

© 2024 Activated Insights | Terms of Service | Privacy Policy

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

A Case Study in Home Health Disease Management

HUFFMAN, MELINDA RN, MSN, CCNS

Melinda Huffman, RN, MSN, CCNS, is Principal Consultant, OUTCOMELogics, Inc., Winches-ter, TN.

Address for correspondence: [email protected] (e-mail).

Editor’s note: This is the second in a 3-part disease management series that will conclude in the November issue. The definitions in “Case Study Terms” are provided so readers can quickly clarify points and apply them to their own practice.

Full Text Access for Subscribers:

Individual subscribers.

Institutional Users

Not a subscriber.

You can read the full text of this article if you:

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Client teaching guides for home health care, preventing and controlling infections in home care and hospice</em>', '', 'home healthcare now', 'january 2014', '32', '1' , 'p 45-47');" onmouseout="javascript:tooltip_mouseout()" class="ejp-uc__article-title-link">bag technique: preventing and controlling infections in home care and hospice, best practices for home care “bag technique” and the use of surface barriers, nurse leadership in home healthcare, becoming an expert home health nurse.

Case Study: Fitness app

Jovana Čereković

Welcome back! It’s time for yet another case study from yours truly.

All jokes aside, this time I got to create an app that’s all about one of my biggest passions: fitness! I’m beyond excited to show you how it all came together. Let’s jump in and check it out!

Introduction

Let me quickly give you a little background story. I’ve been involved in sports for as long as I can remember — gymnastics, football, basketball, and even ballet. Yes, you heard that right: basketball and ballet! I was definitely a kid with a wide range of interests. But in the end, dancing stole my heart.

As I grew up, the dance competitions faded away and it was time for me to get started with working out on my own. Imagine my surprise when I discovered that creating my own workouts was way harder than I thought. I struggled to stay motivated and keep things interesting. How could I even call it a workout if I wasn’t breaking a sweat or feeling like I was doing anything right?

So, this app was basically inspired by those college days when I wished I had a magic app to create workout plans, keep me motivated, track my diet, and dish out tips without me getting lost in endless internet rabbit holes. I wanted an all-in-one solution so I didn’t have to reinvent the wheel every time I wanted to workout.

Research and inspiration

I’ve been doing my UX/UI design course for a couple of months now. And I like to believe I’ve learned a lot about UX/UI and also about me during the past few months. For example, I used to think I was a pretty shy person when I’m not comfortable around people — well, that went out the window pretty quickly after I started this course. Wanna know the first this I did now for my research? I shamelessly interrogated my entire fitness community on what they’d want in an app and how it could keep them motivated. Did somebody say shy? More like exceptionally nosy!

And of course, the next step was to check out the competition and see what features other apps had. I wanted to find out how I could make mine even better and more engaging for the users.

The problem

So, here’s the deal: One of the big problems with fitness apps is getting users to actually use them. It’s easy to download an app, but staying motivated and engaged? That’s the tricky part. Imagine setting a goal to work out every day, but instead, you end up binge-watching random videos on TikTok. The challenge is figuring out how to keep users from becoming ‘one-day warriors’ and turning their workout plans into a reality. How do we keep them motivated and coming back for more, instead of letting the app gather virtual dust?

The solution

Here is my solution. In the app there is a fun, mood-sensitive emoji that reacts to whether you’ve worked out or not — think of it as your personal fitness cheerleader with a personality. After three consecutive workouts, you start collecting fire sprites, adding a playful reward system to keep you motivated.

There is also a community section to connect with fellow fitness enthusiasts, a ‘My Plan’ area where you can organize your own workouts, and in-app exercises to keep things convenient. Plus, there is a meal plan section that lets you track your diet or follow premade in-app plans. To keep things exciting, I added the section with challenges, achievements, and the option to challenge friends — because nothing says ‘motivation’ like a little friendly competition!

User persona

Meet Alex Carter, a 28-year-old marketing specialist living in Los Angeles. With a packed schedule and a passion for fitness, Alex juggles a busy work life while trying to stay healthy and active. He values efficiency and personal growth, seeking a streamlined fitness app that fits seamlessly into his routine. Alex loves tech gadgets and social media, so he’s looking for an app with customizable workouts, progress tracking, and a vibrant design. He’s motivated by community engagement and gamification elements that keep him inspired and accountable.

For this app I’ve gone for a sleek, modern vibe using Helvetica Neue to keep things clean and contemporary. The bold red color represents passion and energy, driving users to push their limits and stay committed. The deep grey color provides a strong, grounding backdrop that conveys reliability and focus. Finally, the light gray for a modern and minimalist touch. Together, these colors create a powerful, engaging visual experience that fuels your drive to achieve your best.

Sketching and wireframes

When it came to sketching and wireframing for FitFusion, I focused on creating a user-friendly and intuitive layout. This initial stage was all about visualizing how users would interact with the app and refining the flow to make sure every feature supports the goal of leveling up the users workout game.

Now, let’s take a closer look at the full design.

When you open the app, you’ll be invited to sign up or sign in. If you’re a new user, you’ll complete a short questionnaire to help the app get to know you better. This includes four quick questions about your metrics, gender, and fitness goals.

Once you’ve successfully logged in, you’ll land on the app’s homepage, where all the magic happens. Here, you’ll be welcomed by FitFusion’s very own fitness buddy. Alongside our mood-swinging sidekick, you’ll also find your daily workout tracker and a rundown of all the active challenges you’re tackling.

As I mentioned before, our little sidekick can have some serious mood swings, so to avoid any drama, let’s start by tackling his emotional ups and downs first, before moving on to the rest of the app.

Let’s imagine you’re a super busy bee but manage to stick to your workout goal of 5 days a week. Each time you crush a workout, our sidekick will cheer you on with a motivational message.

And guess what? He’s not just watching from the sidelines — he’s hitting the gym too! You’ll notice his little biceps getting bigger every time you complete a workout. It’s like he’s your personal cheerleader and workout buddy rolled into one.

And now, for the grand reveal: after powering through 3 workouts in a row, you’ll be introduced to another, though somewhat temperamental, but totally valuable friend — our very own Fitness Fire Sprite. And yep, he’s got biceps that could give the cast of Geordie Shore a run for their money

Below, you can see how our little fitness buddies react to each completed workout throughout the week. At the end of your workout week, they’ll join you in celebrating your dedication and hard work!

You might have noticed that our little Fire Sprite has a ‘Rookie’ badge above his head. That’s your current level. Stick with your workouts for a whole month, and he’ll upgrade you to ‘Hero in Training.’ But we’re not stopping there — since working out should become a lifestyle, he’ll keep pushing you. After 3 months, you’ll earn the long awaited ‘Champ’ title. And if you’re still crushing it after 6 months, you’ll officially be a ‘Legend.’ Keep going, and watch your fitness journey turn into a legendary saga.

Remember that moodiness I mentioned earlier? It really kicks in if you skip your workouts and instead spend hours scrolling TikTok. Let’s say it’s Wednesday and you’ve missed your workout — no biggie, our fitness buddy’s not here to judge. He gets a bit bored, sure, but he’s a chill dude and will patiently wait for you to get back on track by Friday.

But if Friday rolls around and you’ve still skipped your workout, we’ve got a situation. Our Fire Sprite is starting to worry because after 3 missed workouts, he’s at risk of flaming out! Meanwhile, our little buddy’s eyes are welling up with tears, and they’re both losing muscle mass! The drama is real! Why would you do this to them? Get back in the game and save them from their tragic fate.

By Saturday, our Fire Sprite is feeling utterly defeated (*cue the sad violin*), resigned to his fate and waiting for his final moments. Meanwhile, our little fitness buddy is holding on to the hope that you’ll swoop in like Joker rescuing Harley Quinn, saving the day and bringing everything back to life. There’s still time to rescue them from their fitness crisis and bring back the muscle and the motivation, if you just do your workout…

Wow, I really got into the storytelling there — I almost felt like we were filming a reality TV show instead of discussing app features. Alright, let’s hit pause on our little fitness buddies and shift gears to focus on the other cool features of the app.

In the navbar you can also see a “Community” section. because, let’s face it, staying motivated is way easier when you’re not doing it alone. In this section, you’ve got three key areas.

First up is the Feed. Here, you’ll start by sharing how you’re feeling each day — are you pumped for a workout or just craving a nap? Based on your mood, you’ll see how many others are in the same boat. Plus, you can check out posts and achievements from other users, like or comment on their updates, and of course, share your own epic wins or hilarious fails!

The second and third areas of the community section are Challenges and the Blog. In the Challenges area, you’ll find your hard-earned medals from completed challenges, plus a variety of weekly, trending, and seasonal challenges. Whether you’re up for ‘Beat Your Best’ or a friendly face-off with your friends, you can dive into existing challenges or create your own, be it personal or with pals. It’s all about keeping things fun and competitive.

And in the Blog section you’ll discover tips, tricks, and everything you need to know about fitness and health. It’s your go-to spot for all the info you need to level up your knowledge and stay on top of your game

Now, let’s turn our attention to the ‘My Plan’ section in the navbar. This part is divided into two key areas: the Workout Plan and the Meal Plan. Let’s kick things off with the Workout Plan section, where you can organize and craft your personalized workout routine to match your goals.

In the Workout Plan section, you’ll get a full weekly spread from Monday to Sunday. Each day, you can add workouts directly from the app, or if you prefer, you can log a walk, bike ride, or any other activity as part of your workout. In the top right corner, you’ll see the estimated calories burned for each workout day, and there’s a handy little check button to mark off your completed workouts. Feel free to tweak your plan as you go — swap out upper body and leg days or add more workouts to keep things fresh and exciting.

In the Meals section, you can track every meal you have throughout the day and see detailed stats on calories, carbs, protein, and fats. You’ll also get personalized calorie recommendations for each meal based on your goals. If you prefer you can also choose from a variety of pre-designed meal plans available in the app.

Next section in the navbar is the In-App Workouts section. Here, you’ll find everything you need so you can ditch the endless internet searches for a decent workout plan. If you want to create your own, you’ve got access to a full range of workouts categorized by type and filtered to match your needs. Each workout comes with a detailed summary of exercises, and when you hit the ‘Start Workout’ button, you’ll get a video guide showing you how to do each exercise, complete with a timer for each move. It’s all designed to make your workout as smooth and effective as possible.

Finally, let’s wrap up with the Profile section. This is where you can check out all your stats, from the number of steps you’ve taken to the calories you’ve burned. Connect your smartwatch or any other fitness device to keep tabs on your progress. You can also upload progress photos to track how far you’ve come. Plus, in the options section, you can set and adjust all of your in-app goals to keep your fitness journey on track.

Final design

And that’s a wrap on my FitFusion case study! I’ve walked you through everything from our mood-swinging fitness buddies to the challenges that’ll keep you engaged. This app isn’t just about sweating it out; it’s about having fun while you do it. Whether you’re aiming to win over our Fire Sprite or just avoid another round of guilt trips from your digital sidekick, FitFusion’s got you covered. So, if you’re ready to trade TikTok marathons for real fitness wins, let’s dive in and crush those goals together! I would love to hear what you think about my solution for a fitness app.

Behance: https://www.behance.net/jovanacerekovic LinkedIn: https://www.linkedin.com/in/jovana-%C4%8Derekovi%C4%87-08b1bb30b/ Email: [email protected]

Written by Jovana Čereković

Text to speech

• History & Society
• Science & Tech
• Biographies
• Animals & Nature
• Geography & Travel
• Arts & Culture
• Games & Quizzes
• On This Day
• One Good Fact
• New Articles
• Lifestyles & Social Issues
• Philosophy & Religion
• Politics, Law & Government
• World History
• Health & Medicine
• Browse Biographies
• Birds, Reptiles & Other Vertebrates
• Bugs, Mollusks & Other Invertebrates
• Environment
• Fossils & Geologic Time
• Entertainment & Pop Culture
• Sports & Recreation
• Visual Arts
• Demystified
• Image Galleries
• Infographics
• Top Questions
• Britannica Kids
• Saving Earth
• Space Next 50
• Student Center

Rostov-on-Don

Our editors will review what you’ve submitted and determine whether to revise the article.

• Lonely Planet - Rostov-on-Don, Russia
• Fact Monster - World - Rostov-na-Donu, Russia

Recent News

Rostov-on-Don , city and administrative centre of Rostov oblast (province), southwestern Russia . It lies along the lower Don River , 30 miles (50 km) above the latter’s mouth on the Sea of Azov .

The city was founded in 1749 as the customs post of Temernika, when the river mouth was still in Turkish hands. It then became a flourishing trade centre. Between 1761 and 1763 the fortress of St. Dmitry of Rostov was built there, and a town developed around it, near the Armenian settlement of Nakhichevan-na-Donu, which later merged with Rostov. In 1797 town status was granted, and in 1806 it was named Rostov-on-Don. Because of its key position as a transport centre and port, the town grew steadily with the 19th-century Russian colonization and development of the north Caucasus region and conquest of the Transcaucasia .

These functions remain of great importance. The Don River route to the interior was improved by the opening of the Volga-Don Shipping Canal in 1952, linking the town to the entire Volga basin; a dredged channel gives access to the sea. Rostov lies on road, rail, and oil and natural-gas pipeline connections between central European Russia and the Caucasus region. This nodal location and the nearness of the great Donets Coal Basin have led to major industrial development, especially in engineering. Two huge plants make Rostov the largest producer of agricultural machinery in Russia. Other engineering products include ball bearings, electrical and heating equipment, wire, self-propelled barges, road-construction equipment, and industrial machinery. There are ship and locomotive repair yards and a range of consumer-goods industries. Rostov State University was founded in 1917, and there are numerous other institutions of higher education and scientific-research. Pop. (2002) 1,068,267; (2006 est.) 1,054,865.

• Election 2024
• Entertainment
• Newsletters
• Photography
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Election results
• Google trends
• AP & Elections
• Paralympic Games
• College football
• Auto Racing
• Movie reviews
• Book reviews
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Russian mercenary chief says his forces are rebelling, some left Ukraine and entered city in Russia

FILE - In this handout photo taken from video released by Prigozhin Press Service on Friday, March 3, 2023, Yevgeny Prigozhin, the owner of the Wagner Group military company, addresses Ukrainian President Volodymyr Zelenskyy asking him to withdraw the remaining Ukrainian forces from Bakhmut to save their lives, at an unspecified location in Ukraine. Prigozhin’s criticism of the top military brass is in stark contrast with more than two decades of rigidly controlled rule by President Vladimir Putin without any sign of infighting among his top lieutenants. (Prigozhin Press Service via AP, File)

FILE - The top Russian military commander in Ukraine, Gen. Sergei Surovikin, left, and Russian Defense Minister Sergei Shoigu, center, attend the meeting with Russian President Vladimir Putin during his visit to the joint staff of troops involved in Russia’s military operation in Ukraine, at an unknown location, Saturday, Dec. 17, 2022. While denouncing most senior military leaders, Prigozhin, the maverick millionaire head of the private military contractor Wagner, spoke approvingly about Gen. Sergei Surovikin, who led Russian forces in Ukraine for several months in the fall before Russian President Vladimir Putin appointed the chief of the military’s General Staff, Gen. Valery Gerasimov, to oversee the operations. (Gavriil Grigorov, Sputnik, Kremlin Pool Photo via AP, File)

In this grab taken from video and released by Prigozhin Press Service on Friday, June 23, 2023, Yevgeny Prigozhin, the outspoken millionaire head of the private military contractor Wagner, speaks during his interview at an unspecified location. Prigozhin, the millionaire owner of the Wagner Group military contractor, assailed the Russian military top brass, accusing it of downplaying the threat posed by the Ukrainian counteroffensive. (Prigozhin Press Service via AP, File)

A view of the Russian Defense Ministry building with anti-aircraft artillery systems atop the roof in Moscow, Saturday, June 24, 2023. (AP Photo)

FILE - A Russian serviceman guards an area of the Zaporizhzhia Nuclear Power Station in territory under Russian military control, southeastern Ukraine, on May 1, 2022. Ukrainian President Volodymyr Zelenskyy called on other countries to heed warnings that Russia may be planning to attack the power plant to cause a radiation disaster. Members of his government briefed international representatives Thursday June 22, 2023 on the possible threat. (AP Photo, File)

• Copy Link copied

The owner of the Wagner private military contractor made his most direct challenge to the Kremlin yet, calling for an armed rebellion aimed at ousting Russia’s defense minister. The security services reacted immediately by calling for the arrest of Yevgeny Prigozhin .

In a sign of how seriously the Kremlin was taking the threat, security was heightened in Moscow and in Rostov-on-Don, which is home to the Russian military headquarters for the southern region and also oversees the fighting in Ukraine.

While the outcome of the confrontation was still unclear, it appeared likely to further hinder Moscow’s war effort as Kyiv’s forces were probing Russian defenses in the initial stages of a counteroffensive. The dispute, especially if Prigozhin were to succeed, also could have repercussions for President Vladimir Putin and his ability to maintain a united front.

Prigozhin claimed early Saturday that his forces had crossed into Russia from Ukraine and had reached Rostov, saying they faced no resistance from young conscripts at checkpoints and that his forces “aren’t fighting against children.”

“But we will destroy anyone who stands in our way,” he said in one of a series of angry video and audio recordings posted on social media beginning late Friday. “We are moving forward and will go until the end.”

He claimed that the chief of the General Staff, Gen. Valery Gerasimov, scrambled warplanes to strike Wagner’s convoys, which were driving alongside ordinary vehicles. Prigozhin also said his forces shot down a Russian military helicopter that fired on a civilian convoy, but there was no independent confirmation.

And despite Prigozhin’s statements that Wagner convoys had entered Rostov-on-Don, there was no confirmation of that yet on Russian social networks. Video posted online showed armored vehicles, including tanks, stationed on the streets and troops moving into position, but it was unclear whether they were under Wagner or military command. Earlier, heavy trucks were seen blocking highways leading into the city and long convoys of National Guard trucks were seen on a road.

The governor of the Voronezh region, just to the north, told residents that a column of military vehicles was moving along the main highway and advised them to stay off the road.

Prigozhin said Wagner field camps in Ukraine were struck by rockets, helicopter gunships and artillery fire on orders from Gerasimov following a meeting with Defense Minister Sergei Shoigu, at which they decided to destroy Wagner.

The Wagner forces have played a crucial role in Russia’s war in Ukraine, succeeding in taking the city where the bloodiest and longest battles have taken place, Bakhmut. But Prigozhin has increasingly criticized Russia’s military brass , accusing it of incompetence and of starving his troops of weapons and ammunition.

Prigozhin, who said he had 25,000 troops under his command, said his troops would punish Shoigu in an armed rebellion and urged the army not to offer resistance: “This is not a military coup, but a march of justice.”

The National Anti-Terrorism Committee, which is part of the Federal Security Services, or FSB, charged him with calling for an armed rebellion, punishable by up to 20 years in prison.

The FSB urged Wagner’s contract soldiers to arrest Prigozhin and refuse to follow his “criminal and treacherous orders.” It called his statements a “stab in the back to Russian troops” and said they amounted to fomenting armed conflict.

Putin was informed about the situation and “all the necessary measures were being taken,” Kremlin spokesman Dmitry Peskov said.

Heavy military trucks and armored vehicles were seen in several parts of central Moscow early Saturday, and soldiers toting assault rifles were deployed outside the main building of the Defense Ministry. The area around the presidential administration near Red Square was blocked, snarling traffic.

But even with the heightened military presence, downtown bars and restaurants were filled with customers. At one club near the headquarters of the FSB, people were dancing in the street near the entrance.

Moscow’s mayor announced Saturday morning that counterterrorism measures were underway, including increased control of roads and possible restrictions on mass gatherings.

Prigozhin, whose feud with the Defense Ministry dates back years, had refused to comply with a requirement that military contractors sign contracts with the ministry before July 1. In a statement late Friday, he said he was ready to find a compromise but “they have treacherously cheated us.”

“Today they carried out a rocket strike on our rear camps, and a huge number of our comrades got killed,” he said. The Defense Ministry denied attacking the Wagner camps.

Prigozhin claimed that Shoigu went to the Russian military headquarters in Rostov-on-Don personally to direct the strike and then “cowardly” fled.

“The evil embodied by the country’s military leadership must be stopped,” he shouted.

Col. Gen. Sergei Surovikin, the deputy commander of the Russian group of forces fighting in Ukraine, urged the Wagner forces to stop any move against the army, saying it would play into the hands of Russia’s enemies, who are “waiting to see the exacerbation of our domestic political situation.”

Tatiana Stanovaya, a political analyst, predicted this would be the end of Prigozhin.

“Now that the state has actively engaged, there’s no turning back,” she tweeted. “The termination of Prigozhin and Wagner is imminent. The only possibility now is absolute obliteration, with the degree of resistance from the Wagner group being the only variable. Surovikin was dispatched to convince them to surrender. Confrontation seems totally futile.”

Lt. Gen. Vladimir Alexeyev, a top military officer, denounced Prigozhin’s move as “madness” that threatens civil war.

“It’s a stab in the back to the country and the president. ... Such a provocation could only be staged by enemies of Russia,” he said.

The Defense Ministry said in a statement that Ukraine was concentrating troops for an attack around Bakhmut to take advantage of “Prigozhin’s provocation.” It said Russian artillery and warplanes were firing on Ukrainian forces as they prepared an offensive.

In Washington, the Institute for the Study of War, said it appeared that “Prigozhin fully intends for Wagner to move against MoD leadership and forcibly remove them from power, more likely against the Southern Military District command in Rostov-on-Don but possibly also against Moscow.”

It added that despite Putin’s support for Prigozhin, he would be highly unlikely to accept any armed rebellion: “The violent overthrow of Putin loyalists like Shoigu and Gerasimov would cause irreparable damage to the stability of Putin’s perceived hold on power.”

At the White House, National Security Council Adam Hodge said: “We are monitoring the situation and will be consulting with allies and partners on these developments.”

Michael Kofman, director of Russia Studies at the CAN research group in Arlington, Virginia, tweeted that Prigozhin’s actions struck him as “a desperate act, though much depends on whether Prigozhin is alone, or if others that matter join him. I’m skeptical this ends well for him or Wagner.”

In Kyiv a Russian missile attack killed at least two people and injured eight Saturday when falling debris caused a fire on several floors of a 24-story apartment building in a central district, Serhii Popko, the head of the city’s military administration, posted on Telegram.

He said more than 20 missiles were detected and destroyed. Video from the scene showed a blaze in the upper floors of the building and the parking lot strewn with ash and debris.

In other developments in the war, Ukrainian President Volodymyr Zelenskyy called on other countries to heed warnings that Russia may be planning to attack an occupied nuclear power plant to cause a radiation disaster.

Members of his government briefed international representatives on the possible threat to the Zaporizhzhia Nuclear Power Plant, whose six reactors have been shut down for months. Zelenskyy said he expected other nations to “give appropriate signals and exert pressure” on Moscow.

The Kremlin’s spokesman has denied the threat to the plant is coming from Russian forces.

The potential for a life-threatening release of radiation has been a concern since Russian troops invaded Ukraine last year and seized the plant, Europe’s largest nuclear power station. The head of the U.N.’s atomic energy agency spent months trying to negotiate the establishment of a safety perimeter to protect the facility as nearby areas came under repeated shelling, but he has been unsuccessful.

The International Atomic Energy Agency noted Thursday that “the military situation has become increasingly tense” amid a Ukrainian counteroffensive that began this month in Zaporizhzhia province, where the namesake plant is located, and in an adjacent part of Donetsk province.