Dr. Melissa O'Connor’s Focus on Vulnerable Older Adults Leads to Clinical Decision Support Tool for Safe Discharge from Home Health Services

In July, Melissa O’Connor, PhD, MBA, RN, FGSA, FAAN, M. Louise Fitzpatrick Endowed Professor and director of the Gerontology Interest Group at  Villanova University’s M. Louise Fitzpatrick College of Nursing, completed the three-year Betty Irene Moore Fellowship for Nurse Leaders and Innovators. She was one of 10 nurse scientists accepted to the inaugural cohort in July 2020.

During the experience, Dr. O’Connor, a fierce advocate for advancing the care of vulnerable older adults living in the community, was focused on the health outcomes of these older adults receiving home health care. She developed and tested evidence-based interventions in home health to ensure vulnerable older adults receive the care they need to improve outcomes. Her project, Home Health Safely Discharge Decision Support (HEADS-UP), is focused on creating a clinical decision support system to determine readiness for discharge to support home health clinicians as they make the critical decision to discharge vulnerable older adults from services.

Why is this significant? The “baby boomer” generation will arrive at age 65 by 2034, the first time in United States history that older adults will outnumber children 17 years or under. Such demographic shifts are occurring worldwide and will require innovative, cost-effective, evidence-based, and interprofessional approaches to meet the unprecedented demands of this growing population.

In terms of her findings, Dr. O’Connor notes, “When provided with organized clinical information and ample time to accurately identify the needs of older adults, expert clinicians refer older adults for additional care significantly more often than real-world home health clinicians.” She says that racial disparities exist in home health discharge decision making, though a clinical decision support tool embedded in the electronic health record would alleviate bias based on race.

Dr. O’Connor’s work during the Fellowship is the first step in developing a home health discharge readiness clinical decision support tool.

“The development of an empirically-based clinical decision support tool will ensure that patients receive the home health care they need to prepare them to independently care for their multiple, complex, chronic conditions,” explains Dr. O’Connor. She continues, “Clinical decision support that identifies older adults who require more care versus those ready to be discharged has the potential to enhance decision making for nearly 10 million home health episodes per year to ensure that vulnerable older adults receive the care they need to prevent poor outcomes.”

Dr. O’Connor will be presenting her work at peer-reviewed, national and international conferences as well as publication in a referred journal.

The fellowship program, funded by a five-year, $37.5 million grant from the Gordon and Betty Moore Foundation, recognizes early- to mid-career nursing scholars and innovators with a high potential to accelerate leadership in nursing research, practice, education, policy and entrepreneurship. Dr. O’Connor received $450,000 to conduct an innovative project or study with the potential to address a gap in knowledge, meet a vital need, alter care delivery or design a new solution to advance health.

In addition to the project, the fellowship program features a hybrid online and classroom curriculum designed and taught in partnership with the UC Davis Graduate School of Management to enhance leadership and innovation capacity, strengthen strategic thinking and collaborative skills, expand professional networks, develop entrepreneurial skills, and propel innovative ideas to fruition. A mentor selected by the fellow and an additional mentor provided by the national program office round out the educational experience.