National University Health System (NUHS) Transitional Care Program

Frail elderly patients require a longer time to recuperate after hospitalization, and are often discharged home from the hospital with little support despite their needs fpr complex care. They are particularly vulnerable to hazards of hospitalization and fragmented care if not appropriately managed. A geriatrician-led transitional care program called NUH-to-Home (NUH2H) was started in March 2014 to provide high-quality person-centered interdisciplinary care for older adults who were discharged from the National University Hospital (NUH) Singapore. It aims to enhance the quality and safety of post-discharge care at home, leading to an eventual reduction in readmissions and prolonged hospital stay. In the first year of implementation, there was a 67%. 68% and 75% reduction in readmissions, emergency room visits and length of hospital stay respectively.

Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised controlled trial

Stroke rehabilitation involves care issues concerning the physical, psychosocial and spiritual aspects. Hospital-based rehabilitation has its limitations because many of the care issues only emerge when patients return home. Transitional care models supporting patients after discharge from the hospital have proved to be effective among chronically ill patients, but limited studies were conducted among stroke survivors. This study was a randomised controlled trial conducted to test the effectiveness of a transitional care programme (TCP) which was a nurse-led 4-week programme designed based on the assessment-intervention-evaluation Omaha System framework. Between August 2010 and October 2011, 108 stroke patients who were discharged home, able to communicate, and had slight to moderate neurological deficits and disability were randomised into control (n = 54) and intervention groups (n = 54). Data on the patient-related and clinical outcomes were collected at baseline, 4 weeks when the TCP was completed and 8 weeks after discharge from hospital. Repeated measures analysis of variance with intention-to-treat strategy was used to examine the outcomes. There were significant between-group differences in quality of life, the primary outcome measure of this study, in both physical (F(1, 104) = 10.15, P = 0.002) and mental (F(1, 104) = 8.41, P = 0.005) domains, but only the physical domain achieved a significant time × intervention interaction effect (F(1, 103) = 7.73, P = 0.006). The intervention group had better spiritual-religion-personal measures, higher satisfaction, higher Modified Barthel Index scores and lower depression scores when compared with the control group. They also had lower hospital readmission and use of emergency room rates, but only the use of emergency room had significant difference when compared to control. This study is original in testing a transitional model among stroke patients discharged from hospital. The TCP shares common features that have been proved to be effective when applied to chronically ill patients, and the duration of 4 weeks seems to be adequate to bring about immediate effects.

"When Things Are Really Complicated, We Call the Social Worker": Post-Hip-Fracture Care Transitions for Older People

Social workers play a key role in the delivery of interdisciplinary health care. However, in the past decade, concerns have been raised about social work's sustainability and contributions in a changing health care sector. These changes come at a time when older patients are more complex and vulnerable than ever before. In this article, using a strengths-based approach, the authors examine the key contributions made by social workers working with older patients with hip fracture as they strive to achieve successful care transitions. Twenty-five interviews with health care professionals (HCPs) were conducted and then analyzed using an analytical coding framework. Although social workers are vital, they are often underused and overlooked in the care of hip fracture patients. The authors sketch the important contributions that social workers make to care transitions after hip fracture, specifically informational continuity; patient-HCP relational continuity; conflict resolution; mediation among family, patient, and HCP (for example, doctors and nurses); collaboration with family caregivers and community supports; and relocation counseling.

Providing effective and preferred care closer to home: a realist review of intermediate care

Intermediate care is one of the number of service delivery models intended to integrate care and provide enhanced health and social care services closer to home, especially to reduce reliance on acute care hospital beds. In order for health and social care practitioners, service managers and commissioners to make informed decisions, it is vital to understand how to implement the admission avoidance and early supported discharge components of intermediate care within the context of local care systems. This paper reports the findings of a theory-driven (realist) review conducted in 2011-2012. A broad range of evidence contained in 193 sources was used to construct a conceptual framework for intermediate care. This framework forms the basis for exploring factors at service user, professional and organisational levels that should be considered when designing and delivering intermediate care services within a particular local context. Our synthesis found that involving service users and their carers in collaborative decision-making about the objectives of care and the place of care is central to achieving the aims of intermediate care. This pivotal involvement of the service user relies on practitioners, service managers and commissioners being aware of the impact that organisational structures at the local level can have on enabling or inhibiting collaborative decision-making and care co-ordination. Through all interactions with service users and their care networks, health and social care professionals should establish the meaning which alternative care environments have for different service users. Doing so means decisions about the best place of care will be better informed and gives service users choice. This in turn is likely to support psychological and social stability, and the attainment of functional goals. At an organisational level, integrated working can facilitate the delivery of intermediate care, but there is not a straightforward relationship between integrated organisational processes and integrated professional practice.

Transition Planning for the College Bound Adolescent with a Mental Health Disorder

Health promotion, disease prevention and anticipatory guidance are the hallmarks of nursing practice, particularly in pediatrics. While there is a wealth of information on anticipatory guidance for the pediatric patient at different ages and developmental stages, there is a paucity of information on anticipatory guidance for the adolescent and emerging adult in transitioning to manage their own health care. While an established need for anticipatory guidance and a transition plan from pediatric to adult health care is apparent for youth routinely followed for significant medical, intellectual, or developmental conditions, a group particularly vulnerable to destabilization of their health as they transition to self-directed adult health care management is composed of youth with mental health disorders. The risk for destabilization increases as they move away from social supports to the university setting. This article reviews available literature on anticipatory guidance for the college bound adolescent with a mental health disorder and makes recommendations for transition planning including examining the college and community services that would support mental health as well as personal choices regarding lifestyle habits while attending the university. Recommendations are made for nurses to be the leaders in filling this anticipatory guidance gap in preparing youth with mental health disorders for a successful transition to and through college life.

Integrating an EMR-based Transition Planning Tool for CYSHCN at a Children's Hospital: A Quality Improvement Project to Increase Provider Use and Satisfaction

An electronic medical record (EMR)-based transition planning tool (TPT) designed to facilitate transition from pediatric to adult-based health care for youth (16-25 years) with special health care needs was introduced at a large children's hospital. Activities to increase provider use were implemented in five plan-do-study-act cycles. Overall, 22 of 25 (88%) consenting providers in four pediatric subspecialty services used the TPT during 303 patient encounters, with nurses and case-managers the top users and physicians the least likely users. Use was highest with intensive technical assistance and following the introduction of an upgraded tool. Provider satisfaction with the TPT and self-reported transition planning activities notably increased across the PDSA cycles.

A Systematic Review of Transitional Care for Emerging Adults with Diabetes

The prevalence of diabetes and prediabetes in adolescents is increasing. A systematic review of 31 research articles focusing on transitional care for adolescents or emerging adults with diabetes or prediabetes was completed. Studies focused on those with type 1 diabetes, not type 2 diabetes or prediabetes, and were primarily descriptive. Major findings and conclusions include differences in pediatric versus adult care delivery and the importance of structured transitional programs using established recommendations of leading national organizations. Implications include future research on program development, implementation, and evaluation that is inclusive of adolescents and emerging adults, regardless of diabetes type, or prediabetes.

Innovative approach to patient-centered care coordination in primary care practices

OBJECTIVES

Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients.

STUDY DESIGN

Matched case-control differences-in-differences.

METHODS

Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity.

RESULTS

CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001).

CONCLUSIONS

Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery

Transition care is increasingly common for older people, yet little is known about the subjective experience of the transition care 'journey' from the perspective of clients themselves. This study examines how older people cope with frailty within the context of a dedicated transition care programme and discusses implications for improving service delivery. Qualitative in-depth interviews were carried out during 2011 in the homes of 20 older people who had recently been discharged from a transition care programme operating in Adelaide, South Australia (average age 80 years, 65% female). Thematic analysis identified three key themes: 'a new definition of recovery', 'complexities of control' and 'the disempowering system'. Despite describing many positive aspects of the programme, including meeting personal milestones and a renewed sense of independence, participants recognised that they were unlikely to regain their previous level of functioning. For some, this was exacerbated by lacking control over the transition care process while adapting to their new level of frailty. Overall, this research highlighted that benefits associated with transition care can be undermined by fragmentation in service delivery, loss of control and uncertainties around future support.

A multidisciplinary intervention for reducing readmissions among older adults in a patient-centered medical home

OBJECTIVES

To evaluate the effectiveness of a multidisciplinary practice model consisting of medical providers, clinical pharmacists, and social workers on reducing 30-day all-cause readmissions.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study included adults 60 years or older discharged from a large academic medical center. Patients were grouped as either receiving the primary care-based transitional care program (intervention group) or usual care (control group) after an index hospitalization. Only 1 index hospitalization was included per patient. All-cause 30-day readmission rates between propensity score matched study groups were analyzed by intention-to-treat, per protocol, and as-treated methods. Secondary outcomes included time to readmission, subgroup analysis, process measures, and cost avoidance influence of covariates on chance of readmission measured by logistic regression.

RESULTS

Over 27 months, 19,169 unique patients had 18,668 index hospitalizations and 572 interventions scheduled after discharge. Among matched subjects, 30-day readmission rates were not significantly different between those scheduled for the intervention and those never scheduled (21% vs 17.3%, respectively; P = .133). However, when those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P < .001). Likewise, time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015) and potential cost avoidance was observed only when the intervention was completed.

CONCLUSIONS

A community-based multidisciplinary transitional care program may reduce hospital readmissions among older adults.

Palliative Care in Your Nursing Home: Program Development and Innovation in Transitional Care

Each year in the United States, 31% of elders who die do so in hospitals, accounting for over half a million deaths often involving expensive and unnecessary treatments (Zhao & Encinosa, 2010 ). Re-hospitalizations of frail elders with end-stage illnesses are a concern for the hospitals that have discharged them and for the facilities in which they live. In 2011, Schervier Nursing Care Center, a 364-bed skilled nursing and rehabilitation facility in the Bronx, NY, looked at its re-hospitalization rates. It was discovered that a large percentage of the residents being sent to the hospital were from the long-term and subacute populations with end-stage diseases that were no longer responding to treatment. This article describes the development of two innovative programs whose goals were to increase the number of residents receiving palliative care, increase the number of completed advance directives, reduce re-hospitalizations, and increase hospital referrals to the nursing home for palliative care. The key components of both programs and their outcomes are described. The development and implementation of these programs were the author's capstone project for the Zelda Foster Social Work Leadership Fellowship in Palliative and End-of-Life Care.

Assistive technologies along supply chains in health care and in the social services sector

Health care systems in Austria and Slovenia are currently facing challenges due to scarce resources and demographic change which can be seen especially along the supply chains. The main objective of this paper is to present an option to improve the use of assistive technologies. An extensive literature research for the theoretic part as well as a qualitative survey for the empiric part focusing on short-term care were carried out. Results show that there is a lack of information and training on assistive technologies. As a consequence, their full potential cannot be exploited. Therefore a guideline for nursing consultations was developed. To conclude, both the literature research and the qualitative survey show that assistive technologies have high potentials to improve the supply chains in the health care and social services sector, but there is a lot of information and training on them needed.

A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial

OBJECTIVES

Medicare penalizes hospitals with 30-day readmissions above their expected rates. Hospitals have responded by implementing transitional care interventions; however, there is limited evidence to inform the development of a successful intervention.

STUDY DESIGN

Parallel-group, stratified, randomized controlled trial.

METHODS

A total of 512 patients hospitalized at 2 community hospitals, with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), were randomly assigned to the intervention (n = 253) or usual care (n = 259). The intervention encompassed a 90-day hospital-based transitional care program. The primary end points were 30- and 90-day all-cause readmissions. Secondary measures included all-cause emergency department (ED) visits and mortality.

RESULTS

On average, study participants were 67 years of age, 57% female, and 70% insured by Medicare. There was no statistical difference between treatment groups on 30-day readmission incidence rates (difference, 0.040; 95% CI, -0.047 to 0.127; P = .36), or 90-day readmission incidence rates (difference of 0.035; 95% CI -0.122 to 0.192; P = .66). Groups also did not differ in ED visit incidence rates at 30 or 90 days. The mortality rate among patients with CHF showed no difference between groups (risk ratio = 0.90; 95% CI, 0.40-2.05). However, for COPD, mortality at 90 days was lower in the intervention group than in the usual care group (risk ratio = 0.28; 95% CI, 0.10-0.83).

CONCLUSIONS

Stand-alone community hospitals may be unable to prevent readmissions despite the use of comprehensive, evidence-based intervention components that are within their control. Better collaboration between hospitals and community-based providers is needed to ensure continuity of care for discharged patients.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT01855022.

Caregiver presence and patient completion of a transitional care intervention

OBJECTIVES

To evaluate the association between family caregiver presence and patient completion of the Care Transitions Intervention (CTI), a patient activation model that provides transitional care coaching for 30 days following hospital discharge.

STUDY DESIGN

A convenience sample of 2747 fee-for-service Medicare patients recruited for the CTI during inpatient medical hospitalizations at 6 hospitals in Rhode Island between January 1, 2009 and June 31, 2011.

METHODS

As part of an effectiveness trial of the CTI, Transitions Coaches recruited patients prior to hospital discharge. When a family caregiver was present during recruitment, the patient and family caregiver were coached together or the family caregiver was coached independently.

RESULTS

We hypothesized that CTI participation would be equivalent for the 2265 coached patients without a family caregiver present at recruitment, versus the 482 patients with a family caregiver. After adjusting for significant covariates, patients with family caregivers were more than 5 times as likely to complete the intervention as patients without family caregivers (AOR = 5.48; 95% CI = 4.22-7.12). Men with family caregivers were nearly 8 times as likely to complete the intervention as men without family caregivers (AOR = 7.94; 95% CI = 5.26-11.98).

CONCLUSIONS

The inclusion of a family caregiver is associated with a greater rate of completing the CTI for post discharge coaching, particularly among men; the inclusion of a family caregiver is a feasible modification to the CTI program.

The role of team climate in improving the quality of chronic care delivery: a longitudinal study among professionals working with chronically ill adolescents in transitional care programmes

OBJECTIVES

This study aimed to (1) evaluate the effectiveness of implementing transition programmes in improving the quality of chronic care delivery and (2) identify the predictive role of (changes in) team climate on the quality of chronic care delivery over time.

SETTINGS

This longitudinal study was undertaken with professionals working in hospitals and rehabilitation units that participated in the transition programme 'On Your Own Feet Ahead!' in the Netherlands.

PARTICIPANTSS

A total of 145/180 respondents (80.6%) filled in the questionnaire at the beginning of the programme (T1), and 101/173 respondents (58.4%) did so 1 year later at the end of the programme (T2). A total of 90 (52%) respondents filled in the questionnaire at both time points. Two-tailed, paired t tests were used to investigate improvements over time and multilevel analyses to investigate the predictive role of (changes in) team climate on the quality of chronic care delivery.

INTERVENTIONS

Transition programme.

PRIMARY OUTCOME MEASURES

Quality of chronic care delivery measured with the Assessment of Chronic Illness Care Short version (ACIC-S).

RESULTS

The overall ACIC-S score at T1 was 5.90, indicating basic or intermediate support for chronic care delivery. The mean ACIC-S score at T2 significantly improved to 6.70, indicating advanced support for chronic care. After adjusting for the quality of chronic care delivery at T1 and significant respondents' characteristics, multilevel regression analyses showed that team climate at T1 (p<0.01) and changes in team climate (p<0.001) predicted the quality of chronic care delivery at T2.

CONCLUSIONS

The implementation of transition programmes requires a supportive and stimulating team climate to enhance the quality of chronic care delivery to chronically ill adolescents.