Transitional care

Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population

PURPOSE

The utility of a transitions-of-care (TOC) pharmacist intervention focused on improving the quality and safety of the medication process for high-risk cardiovascular patients was evaluated.

METHODS

A quality-improvement initiative was developed for patients with heart failure or acute coronary syndrome followed longitudinally at a hospital's outpatient cardiovascular clinic. The TOC pharmacist intervention occurred either before a patient's outpatient cardiovascular clinic appointment or during a hospitalization. The major outcome analyzed was the number of unplanned hospital readmissions within 30 days. Additional endpoints evaluated included the time to healthcare utilization, number of medication discrepancies identified, percentage of therapeutic recommendations accepted by a provider, number of medication access issues resolved, patient cost savings, patient satisfaction, and mean time spent on an intervention by the pharmacist per patient encounter.

RESULTS

A total of 118 patients received the TOC pharmacist intervention. A total of 516 medication discrepancies were identified and corrected, with 55.6% of discrepancies involving cardiovascular medications. A total of 244 recommendations for therapeutic optimization were provided, with an 81% provider acceptance rate and a 100% patient satisfaction rate. Fifty-five patients were provided with medication cost savings, and medication-access issues were resolved for 8 patients. A TOC pharmacist spent means of 98 and 73 minutes on patient education and coordination of care during inpatient and ambulatory encounters, respectively. The 30-day hospital readmission rate for patients with heart failure was reduced by 20%.

CONCLUSION

A TOC pharmacist intervention improved the quality and safety of care across both inpatient and ambulatory settings for high-risk cardiovascular patients at our institution.

Nurse perceptions of family nursing during acute hospitalizations of older adult patients

AIMS

The purpose of this study was to describe nurses' critical appraisal of their family nursing practice and experience of interaction and reciprocity in the nurse-family relationship.

BACKGROUND

Nursing practice that is inclusive of family during hospitalizations of older adults with chronic illnesses benefits patients and families, as well as nurses. There is, however, a limited amount of research that has focused on nurses' perceptions of caring for older adult patients and their families who are managing chronic illness.

DESIGN

The Calgary Family Intervention Model guided this descriptive mixed-methods study.

METHODS

Registered nurses working on four medical-surgical units completed the Family Nursing Practice Scale (n = 60), which includes a quantitative scale and three open-ended questions.

RESULTS

The results showed positive perceptions from nurse participants overall with significant variation across study units in nurses' perceptions of interactions in the nurse-family relationship. Additionally qualitative results revealed several themes concerning the advantages and disadvantages of working with families, in addition to how nurses are currently including families in their practice.

CONCLUSIONS

This study provides details concerning the advantages and disadvantages of working with families and how nurses currently strive to include families in their nursing practice. Although nurses in this study did espouse the importance of family nursing practice, they did point out a number of disadvantages. It is essential to understand the problems that can arise when working with families so that nurses are better able to manage these issues.

The Australian Aged Care and Its Implications for the Korean Aging Crisis

The Australian aged care system has evolved for >50 years to support frail older adults and allow them to make informed decisions about their care. Hospitals provide streamlined geriatric services from visits at the Emergency Department to discharges from acute and subacute geriatric care units. Moreover, nonhospital aged care services, including Transition Care Program, Commonwealth Home Support Program, Home Care Packages Program, and Residential Care (nursing home) are provided under the auspices of the Australian Government. These various specialized hospital and nonhospital services are integrated and coordinated by the multidisciplinary assessment team called ACAT (Aged Care Assessment Team). Korea does not have a similar amount of time to prepare a well-organized aged care system because of a rapidly increasing older population. The Korean government and aged care experts should exert vigorous efforts to improve the last journeys of the Korean older population.

Dynamic changes in the appropriateness of urinary catheter use among hospitalized older patients in the emergency department

Objectives

To investigate incidence, rationales, related factors and outcomes for changing from appropriate catheter placement to inappropriate use among hospitalized older patients in the emergency department.

Methods

A secondary analysis was adopted from a longitudinal study that was designed to follow the lifecycle of the urinary catheter among hospitalized older patients. Patients aged 65 and older with a urinary catheter that had been placed in the emergency department were included. Demographic factors, present health conditions, conditional factors of catheter placement, and rationales for daily urinary catheter use were collected from the original data. Inappropriate urinary catheter days were evaluated as an outcome.

Results

Appropriate urinary catheters were placed in the emergency department in 117 of the 156 patients (75%). Of these patients, 77 patients (65.8%) experienced a change from appropriate placement to inappropriate use, with a mean duration of 2.88±1.56 days. The common rationales were post-operation for hip fracture (36.3%) and no longer needing to monitor urine output (27.2%). A hierarchical regression model shows that a change from appropriate catheter placement to inappropriate use was associated with a diagnosis of urinary tract infection (OR = 0.15; 95% CI = 0.03–0.77; p = 0.02) and no record of the indication for catheter placement (OR = 4.76; 95% CI = 1.20–18.90; p = 0.02), and all variables together explained 35.9% of the variance. In addition, a change from appropriate placement to inappropriate use was further associated with prolonging inappropriate catheter-days (β = 5.34; 95% CI: 3.72–6.97; p <0.001).

Conclusions

The study highlights a considerable percentage of change from appropriate placement to inappropriate use. Efforts to construct reminder intervention, to improve the record of catheter placement and continued attention to catheter use are necessary to reduce inappropriate urinary catheter use.

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Transitional care incorporates actions to ensure the coordination and continuity of care between provider settings (ie, hospitals, nursing homes, home health care, patients’ home, and physician offices) occurs to meet the patient’s goals relative to their disease management. The evolution of transitional care over the past decade has facilitated the emergence of several transitional care models. However, there is a dearth of understanding related to the collaboration between nurse transition coaches and home care nurses when implementing transitional care model activities to achieve desired patient outcomes in the home health care setting. This case study describes the enactment of a specific transitional care model’s conceptual framework to derive an in-depth understanding of the collaborations between nurse transition coaches and home health nurses in the unique context of home health care. The case is a specific patient-centered Care Transitions Intervention (CTI) model with 4 embedded subunits: (1) the experiences and actions of the nurse transitions coach, (2) the experiences and actions of the home health nurse, (3) document and artifacts review, and (4) the experiences and observations of key leadership stakeholders involved in transitional care activities in one home health care organization located in Michigan.

A cross-sectional study of predictors of pain control during the transition from the surgical intensive care unit to surgical ward

BACKGROUND

The transition of patients from the intensive care unit (ICU) to the ward is a complicated process and patients may be at risk of increased levels of pain.

OBJECTIVES

The primary objective was to identify predictors of pain during the transition from the surgical ICU to the surgical ward. The secondary objective was to describe the patient pain experience during this transition.

METHODS

This was a cross-sectional study conducted at an academic medical centre in the United States. Patients who were discharged from the ICU were interviewed regarding their pain during transition from ICU to the ward using the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R). The primary outcome measures were the total score of this validated instrument (0-180 points) and score of the pain severity and sleep interference subscale (0-50 points). Predictors of pain control during this 24-h transition period were identified using linear regression analysis.

RESULTS

A total of 50 patients were included. After transition from the ICU, the median score on the APS-POQ-R was 45 (Q1 29 to Q3 74), and the median score on the pain severity and sleep interference subscale was 23 (Q1 15 to Q3 30). After adjusting for sex in a multivariate model, mean pain score in the preceding 24 h of ICU stay explained 31% of the variation in total APS-POQ-R score and 39% of variation in the pain severity and sleep interference subscale. Age, sex, race, type of surgery, number of surgeries, and opioid dose in the 24-h period before transfer were not significantly associated with either outcome measure. The worst pain experienced by patients during transfer was severe (i.e. score ≥7 on 0 to 10 scale) in 90% (n = 45) of patients. For 70% (n = 35) of patients, severe pain persisted for more than 50% of the time during the transition period.

CONCLUSION

Pain scores in the last 24 h of ICU stay is a predictor of total APS-POQ-R score and pain severity and sleep interference subscale score.

Implementation Requirements for Patient Discharge Planning in Health System: A qualitative study in Iran

BACKGROUND

Effective discharge planning plays a vital role in care continuity and integrated care. Identifying and providing infrastructures for discharge planning can reduce avoidable hospital readmissions and finally lead to improvement of quality of care. The current study aimed to identify the requirements of discharge planning from the perspective of professionals in the health system of Iran.

METHODS

For the purposes of this qualitative study, semi-structured interviews and sessions of focus group discussions with experts in the field were conducted. The data were analyzed using a thematic and framework analyses method. The study population was 51 participants including health policy makers, hospital and health managers, faculty members, nurses, practitioners, community medicine specialists and other professionals of the Ministry of Health andMedical Education (MOHME).

RESULTS

According to the control knobs (health reforms levels), recruitments of effective hospital discharge planning were divided into four areas, behavior (ofpolicy makers, service providers, recipients services), organization, payment and financing and regulation (themes), in which there were 3, 7, 2 and 3 sub-themes respectively. Based on the findings of the interviews, they were categorized into the following main themes: behavior (policy makers, providers and patients), organizational change, financing and payment system and rules and regulations.

CONCLUSIONS

According to the results of the present study, it appears to be essential for health managers and policy makers to pay attention to essential requirements of effective discharge planning.

Care coordination: Identifying and connecting the most appropriate care to the patients

Although nurses are increasingly expected to fulfill the role of care coordinator, the knowledge and skills required to be an effective care coordinator are not well understood. The purpose of this study was to describe the knowledge and skills required in care coordination practice using an interpretive phenomenological approach. Fifteen care coordinators from 10 programs were interviewed over a 6-month period. Semi-structured face-to-face interviews were audio recorded, transcribed, and analyzed using interpretive phenomenology. The central theme of care coordination practice was bridging the patient and the healthcare systems. To bridge, care coordinators needed to have knowledge of the patient and healthcare system as well as the skills to identify and negotiate treatments appropriate for the patient. The most salient finding and new to this literature was that care coordinators who used their medical knowledge about available treatment options to discern and negotiate for the most appropriate care to the patient made differences in patient outcomes. Nurses with medical and healthcare system knowledge, combined with the skills to navigate and negotiate with others in an increasingly complex healthcare system, are well situated to be care coordinators and generate optimal outcomes. Further investigations of critical care coordinator competencies are needed to support nurses currently enacting the role of care coordinator and to prepare future nurses to fulfill the role.

Specialty-care access for community health clinic patients: processes and barriers

Introduction

Community health clinics/centers (CHCs) comprise the US’s core health-safety net and provide primary care to anyone who walks through their doors. However, access to specialty care for CHC patients is a big challenge.

Materials and methods

In this descriptive qualitative study, semistructured interviews of 37 referral coordinators of CHCs were used to describe their perspectives on processes and barriers to patients’ access to specialty care. Analysis of data was done using content analysis.

Results

The process of coordinating care referrals for CHC patients is complex and begins with a provider’s order for consultation and ends when the referring provider receives the specialist’s note. Poverty, specialist and referral coordinator shortages, lack of insurance, insurance acceptability by providers, transport and clinic-location factors, lack of clinic–hospital affiliations, and poor communication between primary and specialty providers constitute critical barriers to specialty-care access for patients.

Conclusion

Understanding the complexities of specialty-care coordination processes and access helps determine the need for comprehensive and uninterrupted access to quality health care for vulnerable populations. Guaranteed access to primary care at CHCs has not translated into improved access to specialty care. It is critical that effective policies be pursued to address the barriers and minimize interruptions in care, and to ensure continuity of care for all patients needing specialty care.

Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review

BACKGROUND

The effectiveness of educational interventions for osteoarthritic patients undergoing total joint arthroplasty remains inconclusive. It is essential to understand the educational needs of these patients from their perspectives.

AIM

The aim of this study was to systematically summarize and synthesize osteoarthritic patients' expectations and experiences in undergoing total joint arthroplasty to identify their educational needs.

DESIGN

An integrative review was conducted.

METHODS

Twenty studies (13 qualitative and 7 quantitative), published between 2006 and 2016, were independently appraised by 2 reviewers using the Critical Appraisal Skills Programme checklist for qualitative studies and the Joanna Briggs Institute Critical Appraisal Tools for quantitative studies. Data were analysed using thematic analysis, and the findings were synthesized in a narrative summary.

RESULTS

Six themes describing patients' preoperative and post-operative educational needs were identified: (1) preoperative anxiety, (2) unrealistic expectations of recovery, (3) post-operative pain, (4) regaining functional abilities, (5) physical and psychological sense of loss, and (6) lack of continuity of care.

CONCLUSION

This review is the first to capture the osteoarthritic patients' educational needs from their perspectives. The biopsychosocial model can address the multidimensionality (biological, psychological, and social) of patients' educational needs. A robust infrastructure supporting interprofessional collaborative practice and continuity of care should be adopted to enhance current educational efforts.

Care Gaps in the Electronic Discharge Medication Reconciliation Process at an Acute Care Facility

Background

Many patients experience adverse events at the time of discharge from hospital, and most of these events are medication-related. To improve patient safety, Health PEI (the health authority for Prince Edward Island) has made medication reconciliation a priority. The Queen Elizabeth Hospital in Charlottetown is one of the few Canadian hospitals with an electronic discharge process. A discharge report has been developed to provide pertinent information to patients at discharge, including a final medication list to be shared with the community pharmacy at the patient's discretion.

Objective

To identify care gaps related to the transfer of information for the medication reconciliation part of the electronic discharge process at the Queen Elizabeth Hospital.

Methods

The study was conducted on 4 nursing units offering medical and surgical services. Data for the 8-week prospective study (June to August 2016) were collected using a study-specific discharge evaluation checklist and hospital-to-community pharmacy feedback form. All inpatients 65 years of age or older with a hospital stay longer than 4 days who were receiving more than 5 medications on discharge were eligible to participate.

Results

During the study period, data were compiled for the 72 of 154 eligible patients who provided consent. Of these, 69 (96%) had a change in medications. Follow-up showed that 12 (17%) of the 72 discharge reports had reached the patient's community pharmacy; of these, 5 had been sent from a community care or long-term care facility. Fifty-four patients were discharged home, of whom 50 presented to the community pharmacy after discharge, 37 (74%) of these on the day of discharge.

Conclusions

Most community pharmacies did not receive a discharge report from the patient or from the patient's community care or long-term care facility. This represented the largest care gap in the electronic discharge medication reconciliation process at the study hospital.

In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study

BACKGROUND

An increasing number of transitions due to substitution of care of more complex patients urges insight in and improvement of transitional medication safety. While lack of documentation of prescription changes and/or lack of information exchange between settings likely cause adverse drug events, frequency of occurrence of these causes is not clear. Therefore, we aimed at determining the frequency of in-hospital patients’ prescription changes that are not or incorrectly documented in their primary care provider’s (PCP) medical record.

METHODS

A medical record review study was performed in a database linking patients’ medical records of hospital and PCP. A random sample (n = 600) was drawn from all 1399 patients who were registered at a participating primary care practice as well as the gastroenterology or cardiology department in 2013 of the University Medical Center Utrecht, the Netherlands. Outcomes were the number of in-hospital prescription changes that was not or incorrectly documented in the medical record of the PCP, and timeliness of documentation.

RESULTS

Records of 390 patients included one or more primary-secondary care transitions; in total we identified 1511 transitions. During these transitions, 408 in-hospital prescription changes were made, of which 31% was not or incorrectly documented in the medical record of the PCP within the next 3 months. In case changes were documented, the median number of days between hospital visit and documentation was 3 (IQR 0–18).

CONCLUSIONS

One third of in-hospital prescription changes was not or incorrectly documented in the PCP’s record, which likely puts patients at risk of adverse drug events after hospital visits. Such flawed reliability of a routine care process is unacceptable and warrants improvement and close monitoring.

Enhancing Care Transitions for Older People through Interprofessional Simulation: A Mixed Method Evaluation

INTRODUCTION

The educational needs of the health and social care workforce for delivering effective integrated care are important. This paper reports on the development, pilot and evaluation of an interprofessional simulation course, which aimed to support integrated care models for care transitions for older people from hospital to home.

THEORY AND METHODS

The course development was informed by a literature review and a scoping exercise with the health and social care workforce. The course ran six times and was attended by health and social care professionals from hospital and community (n = 49). The evaluation aimed to elicit staff perceptions of their learning about care transfers of older people and to explore application of learning into practice and perceived outcomes. The study used a sequential mixed method design with questionnaires completed pre (n = 44) and post (n = 47) course and interviews (n = 9) 2-5 months later.

RESULTS

Participants evaluated interprofessional simulation as a successful strategy. Post-course, participants identified learning points and at the interviews, similar themes with examples of application in practice were: Understanding individual needs and empathy; Communicating with patients and families; Interprofessional working; Working across settings to achieve effective care transitions.

CONCLUSIONS AND DISCUSSION

An interprofessional simulation course successfully brought together health and social care professionals across settings to develop integrated care skills and improve care transitions for older people with complex needs from hospital to home.

Patient Perspectives on Transitions of Surgical Care: Examining the Complexities and Interdependencies of Care

This study examined a thematic network aimed at identifying experiences that influence patients' outcomes (e.g., patients' satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantly influenced by two cascades identified as patients' medical histories and home circumstances. Patients who reported previous medical or surgical histories also experienced less distress during the discharge process, whereas patients with no prior experiences reported more concerns and greater anxiety. Patient dissatisfactions and challenges were due in large part to the contrasts between hospital and home experiences. Our hybrid approach may inform patient-centered guidelines aimed at improving transitions of care among patients undergoing major surgery.

The Experience of Transitional Care for Non-Medically Complex Older Adults and Their Family Caregivers

Transitional care research has mainly focused on the experiences of older adults with complex medical conditions. To date, few publications examine the experience of transitional care for non-medically complex older adults. In this article, we draw on and thematically analyze interview and audio-diary data collected at three hospitals in Eastern England, and we explore the experience of transitional care of 18 older adults and family caregivers. Participants reported mixed experiences when describing their care transitions, which indicated variations in care quality. To achieve independence and overcome the difficulties with care transitions, participants used a range of interrogative techniques, such as questioning and information seeking. We contend that the existing transitional care interventions are inappropriate to address the care needs of non-medically complex older adults and family caregivers. Implications for frontline health care staff and health services researchers are discussed.

A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond

BACKGROUND

In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%.

PURPOSE OF RESEARCH

To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs.

PRIMARY PRACTICE SETTING

Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay.

METHODOLOGY AND SAMPLE

The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits.

RESULTS

Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in this program compared with the 90 days prior to participation. This produced an estimated net savings of $3,823,673 in medical center costs. In addition, registered nurse case managers (RN CMs) noted improved patient compliance and satisfaction with care and the licensed clinical social worker noted reduced caregiver burden.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The results of this program demonstrate how using an interdisciplinary approach to develop patient-centered transition plans of care through intensive case management interventions improves resource utilization with substantial financial savings. This program represents a feasible option for other VAMCs as well as civilian hospitals seeking to provide cost-effective transitional care to patients upon discharge and prevent untimely readmissions. With an RN CM at the hub of patient care, this program successfully demonstrates the value of smooth care transitions.

Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities

INTRODUCTION

Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission.

METHODS

Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions.

RESULTS

The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement.

DISCUSSION

Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

PURPOSE

To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers.

DESIGN

Pre-post quasi-experimental trial.

SETTING

General medical units of four US Department of Veterans Affairs hospitals.

SUBJECTS

898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively).

INTERVENTION

The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback.

MEASURES

The primary outcome was self-reported 7-day point prevalence abstinence at six months.

ANALYSIS

Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression.

RESULTS

Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI₉₅)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI₉₅=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001).

CONCLUSIONS

Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Health Care Utilization Among Elderly Medicare Beneficiaries With Coexisting Dementia and Cancer

Objective: The goal of this research is to delineate health care utilization among elderly Medicare beneficiaries with coexisting dementia and cancer compared with those with dementia alone, cancer alone, or neither condition. Method: The study cohort included 96,124 elderly patients aged 65 years and older who resided in the Mid-South region of the United States and were enrolled in Medicare during 2009. Multivariate regression analyses were used to examine health care utilizations while adjusting for sociodemographic characteristics. Results: Those with coexisting dementia and cancer diagnoses had higher rates of hospitalizations, hospital readmissions within 30 days, intensive care unit use, and emergency department visits compared with those with dementia only, cancer only, and those with neither condition. Patients with coexisting dementia and cancer also had a higher number of primary care visits and specialist visits. Conclusion: There is a greater need for developing tailored care plans for elderly with these two degenerative health conditions to address their unique health care needs and to reduce financial burden on the patients and the health care system.

A Missed Opportunity to Improve Patient Satisfaction? Patient Perceptions of Inpatient Communication With Their Primary Care Physician

Improving patient satisfaction is a major focus of hospitals. Patient satisfaction could be driven by patient perception of hospital team communication with their primary care physician (PCP). A retrospective mixed methods approach was used to characterize the relationship between patient satisfaction and patient perception of hospital team-PCP communication. Data were obtained through general medicine inpatient and postdischarge interviews, oversampling "vulnerable elders," and a faxed PCP survey. Among 1044 patients and their PCPs, 22.3% of PCPs were not aware of their patient's hospitalization. Among PCPs who reported that communication did not occur, half (49.2%) of their patients thought communication had occurred, implying a lack of patient awareness of discontinuity of care and possibly impeding safety. Patients who perceived that communication occurred were more satisfied with care (70.0% vs 53.1%, P < .001). Therefore, hospitals could potentially improve patient safety and satisfaction by seizing a missed opportunity to improve patient awareness of communication.

Do Villages Promote Aging in Place? Results of a Longitudinal Study

Villages are a new, grassroots, consumer-directed model that aims to promote aging in place and prevent unwanted relocations for older adults. In exchange for a yearly membership fee, Villages provide seniors with opportunities for social engagement (social events and classes), civic engagement (member-to-member volunteer opportunities), and an array of support services. In total, 222 Village members were surveyed at intake and 12-month follow-up to examine changes in their confidence aging in place, social connectedness, and health. The strongest positive results were in the domain of confidence, including significantly greater confidence aging in place, perceived social support, and less intention to relocate after 1 year in the Village. As most seniors were in good health and well connected at the time they joined the Village, there were not improvements in health or social connectedness. Authors discuss the importance of longer term, longitudinal studies to examine the effectiveness of Villages in preventing institutionalization over time.

Effects of a continuum of care intervention on frail elders’ self-rated health, experiences of security/safety and symptoms: A randomised controlled trial

We aimed to evaluate effects of the intervention on self-rated health, experiences of security/safety and symptoms. A non-blinded controlled trial was performed with participants randomised to either the intervention group or a control group, with follow-ups at 3, 6 and 12 months. The intervention involved collaboration between a nurse with geriatric competence at the emergency department, the hospital wards and a multi-professional team for care and rehabilitation of older adults, with a case manager from the municipality as the hub. Older people who sought care at the emergency department at Sahlgrenska University Hospital/Mölndal and who were discharged to their own homes in the Mölndal municipality were asked to participate. Inclusion criteria were age 80 years and older, or 65 to 79 years with at least one chronic disease and dependency in at least one activity of daily living. Analyses were conducted on the basis of the intention-to-treat principle. Outcome measures were self-rated health, experiences of security/safety and symptoms. These were analysed using Svensson’s method. Of 161 participants, 76 were allocated to the control group and 85 to the intervention group. Positive effects of the intervention were observed for frail older adult’s symptoms and self-rated health.

Pilot study on identification of incidents in healthcare transitions and concordance between medical records and patient interview data

OBJECTIVE

To investigate whether transitional incidents can be identified from the medical records of the general practitioners and the hospital and to assess the concordance of transitional incidents between medical records and patient interviews.

DESIGN

A pilot study.

SETTING

The study was conducted in 2 regions in the Netherlands: a rural and an urban region.

PARTICIPANTS

A purposeful sample of patients who experienced a transitional incident or are at high risk of experiencing transitional incidents.

MAIN OUTCOME MEASURES

Transitional incidents were identified from both the interviews with patients and medical records and concordance was assessed. We also classified the transitional incidents according to type, severity, estimated cause and preventability.

RESULTS

We identified 28 transitional incidents within 78 transitions of which 3 could not be found in the medical records and another 5 could have been missed without the patient as information source. To summarise, 8 (29%) incidents could have been missed using solely medical records, and 7 (25%) using the patients' information exclusively. Concordance in transitional incidents between patient interviews and medical records was 64% (18/28). The majority of the transitional incidents were unsafe situations; however, 43% (12/28) of the incidents reached the patient and 18% (5/28) caused temporary patient harm. Over half of the incidents were potentially preventable.

CONCLUSIONS

This pilot study suggests that the majority of transitional incidents can be identified from medical records of the general practitioner and hospital. With this information, we aim to develop a measurement tool for transitional incidents in the medical record of general practitioner and hospital.

Integrated care transitions: emergency to primary health care

Purpose

– The purpose of this paper is to focus on the Integrated Care Transitions Project between the emergency department (ED) of a university hospital and primary health care (PHC) services in a large city in Southern Brazil was the focus of this study. Care transitions occurred through telephone contact for patients discharged from the ED to PHC.

Design/methodology/approach

– This descriptive, exploratory qualitative research collected data via semi-structured interviews (n=14) including interns of health disciplines, advisors for interns, nurses, and physicians from the ED and PHC Family Unit. A thematic analysis of the data were conducted.

Findings

– ED providers felt they gained increased knowledge of the care networks available for patients in the community. Connection between the providers in ED and PHC facilitated confidence in the services provided in the community and increased continuity of care for patients’ needs. The PHC providers recognized integration promoted communication and better care planning for patients discharged from ED. Integrated care made the work in the PHC easier and benefited the users.

Research limitations/implications

– The study evaluated a program available in one hospital. Generalizability may be limited as services in the ED were provided by professional residents and their advisors, not employees of the hospital.

Practical implications

– Shared information by different health services leads to better care for patients and greater job satisfaction for providers.

Originality/value

– Care transitions are not well-managed in health care; there is limited research focusing on care transitions from ED to community. For providers and patients, this program assisted in building capacity and networks for transitions in care.

Ethnographic process evaluation of a quality improvement project to improve transitions of care for older people

OBJECTIVES

Quality improvement projects to address transitions of care across care boundaries are increasingly common but meet with mixed success for reasons that are poorly understood. We aimed to characterise challenges in a project to improve transitions for older people between hospital and care homes.

DESIGN

Independent process evaluation, using ethnographic observations and interviews, of a quality improvement project.

SETTING AND PARTICIPANTS

An English hospital and two residential care homes for older people.

DATA

32 hours of non-participant observations and 12 semistructured interviews with project members, hospital and care home staff.

RESULTS

A hospital-based improvement team sought to reduce unplanned readmissions from residential care homes using interventions including a community-based geriatric team that could be accessed directly by care homes and a communication tool intended to facilitate transfer of information between homes and hospital. Only very modest (if any) impacts of these interventions on readmission rates could be detected. The process evaluation identified multiple challenges in implementing interventions and securing improvement. Many of these arose because of lack of consensus on the nature of the problem and the proper solutions: while the hospital team was keen to reduce readmissions and saw the problems as lying in poor communication and lack of community-based support for care homes, the care home staff had different priorities. Care home staff were unconvinced that the improvement interventions were aligned with their needs or addressed their concerns, resulting in compromised implementation.

CONCLUSIONS

Process evaluations have a valuable role in quality improvement. Our study suggests that a key task for quality improvement projects aimed at transitions of care is that of developing a shared view of the problem to be addressed. A more participatory approach could help to surface assumptions, interpretations and interests and could facilitate the coproduction of solutions. This finding is likely to have broader applicability.

Transition journey from hospital to home in patients with cancer and their caregivers: a qualitative study

BACKGROUND

The National Cancer Institute Singapore initiated the NUH2 Home program in January 2014, referred to as "Caring Across the Cancer Continuum," a nurse-led cancer transitional care service (CTCS) that provides home care to patients with cancer and their caregivers. The study aimed to explore the transition experiences of patients with cancer and their caregivers.

METHOD

Using a purposive sampling, 12 patients with cancer and 12 caregivers were recruited. Audiotape interviews were conducted until data saturation was achieved. Each interview was transcribed verbatim, and thematic analyses were performed to extract significant themes and subthemes.

RESULTS

Four themes emerged from the data including (1) ongoing concerns, (2) needing timely help, (3) resuming control and normality of life, and (4) appreciating the transition care. The transition journey of patients and caregivers provided them with an ability to regain control and normality in their lives, be reassured and confident in being able to care for themselves and manage the physiological and psychological strains associated with the multiple vicissitudes associated with having cancer and its treatment while at home.

CONCLUSION

Our study addressed the nature, patterns, conditions, and responses to transition care. Our findings provided relevant contextual knowledge to further improve the transition care service based on the recommendations of the patients with cancer and their caregivers who first experienced the new service.

Transitioning Care Across Various Health Care Organizations

Health care is continuously undergoing evolutionary changes. These changes have been very dramatic for the end users. Instead of simple physician office visits and lengthy hospital stays, we are now faced with short hospital stays, office visits to different specialty providers, and an array of choices around them. With the present highway of choices between illness and wellness, it is important for transitions between these two to be affordable, advantageous to patients, and uncomplicated. This article discusses the choices patients and health care providers must make as the number of care options increase along with the risks and benefits.

Being back home after intermediate care: the experience of older people

Older people may face many challenges and experience insecurity after discharge from hospital to home. To bridge the potential gap between general hospital and home, the concept of intermediate care (IC) was developed in the year 2000. IC aims to safeguard older people from being discharged to their home before they have sufficiently recovered. However, knowledge within this area is sparse, and the experience of older people in particular is yet to be explored. The aim of this study was to explore older people's experiences of being back home after a stay in an IC unit. Data were drawn from 12 interviews. Transcripts were analysed using a phenomenological approach. The essential meaning of being back home after a stay in an IC unit was characterised by uncertainty. Four constituents emerged: experiencing a state of shock about coming home, dependence on informal helpers, feeling a sense of isolation, and fearing loss of functional ability permanently.

Aging population

Our aging population is rapidly growing and accounts for 46% of critical care patients and 60% of medical-surgical patients in the hospital. These acutely ill patients are challenging to frontline nurses because they frequently have multiple chronic conditions. This article provides a tool kit of resources and clinical skills to develop safe, quality, and accountable care plans for positive patient outcomes; it presents several resources to assist in individualized care, the complexity of care, and the issues of transitions of care. This article empowers frontline nurses to develop gerontological skills and meet the unique needs of our aging population.

Organizing integrated care for older persons: strategies in Sweden during the past decade

PURPOSE

The purpose of this paper is to describe and analyse ways of organizing integrated care for older persons in Sweden during the past decade.

DESIGN/METHODOLOGY/APPROACH

The data consist of 62 cases of development work, described in official reports. A meta-analysis of cases was performed, including content analysis of each case. A theoretical framework comprising different forms of integration (co-ordination, contracting, co-operation and collaboration) was applied.

FINDINGS

Co-operation was common and collaboration, including multiprofessional teamwork, was rare in the cases. Contracting can be questioned as being a form of integration, and the introduction of consumer choice models appeared problematic in inter-organization integration. Goals stated in the cases concerned steering and designing care, rather than outcome specifications for older persons. Explicit goals to improve integration in itself could imply that the organizations adapt to strong normative expectations in society. Trends over the decade comprised development of local health care systems, introduction of consumer choice models and contracting out.

RESEARCH LIMITATIONS/IMPLICATIONS

Most cases were projects, but others comprised evaluations of regular organization of integrated care. These evaluations were often written normatively, but constituted the conditions for practice and were important study contributions.

PRACTICAL IMPLICATIONS

Guiding clinical practice to be aware of importance of setting follow-up goals.

SOCIAL IMPLICATIONS

Awareness of the risk that special funds may impede sustainable strategies development.

ORIGINALITY/VALUE

A theoretical framework of forms of integration was applied to several different strategies, which had been carried out mostly in practice. The study contributes to understanding of how different strategies have been developed and applied to organize integrated care, and highlights some relationships between integration theory and practice.

Striving to maintain a dignified life for the patient in transition: next of kin's experiences during the transition process of an older person in transition from hospital to home

Next of kin represent significant resources in the care for older patients. The aim of this study was to describe and illuminate the meaning of the next of kin's experiences during the transition of an older person with continuing care needs from hospital to home. The study has a phenomenological hermeneutic design. Individual, narrative interviews were conducted, and the data analysis was conducted in accordance with Lindseth and Norberg's phenomenological hermeneutic method. Two themes and four subthemes were identified and formulated. The first theme: "Balancing vulnerability and strength," encompassed the subthemes "enduring emotional stress" and "striving to maintain security and continuity." The second theme: "Coping with an altered everyday life," encompassed "dealing with changes" and "being in readiness." Our findings suggest that the next of kin in striving to maintain continuity and safety in the older person's transition process are both vulnerable individuals and significant agents. Thus, it is urgent that health care providers accommodate both their vulnerability and their abilities to act, and thereby make them feel valued as respected agents and human beings in the transition process.

Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: evidence from a systematic review

PURPOSE

Cardiovascular diseases are the leading cause of death and disability worldwide. Among these diseases, heart failure (HF) and acute myocardial infarction (AMI) are the most common causes of hospitalization. Therefore, readmission for HF and AMI is receiving increasing attention. Several socioeconomic factors could affect readmissions in this target group, and thus, a systematic review was conducted to identify the effect of socioeconomic factors on the risk for readmission in people aged 65 years and older with HF or AMI.

METHODS

The search was carried out by querying an electronic database and hand searching. Studies with an association between the risk for readmission and at least one socioeconomic factor in patients aged 65 years or older who are affected by HF or AMI were included. A quality assessment was conducted independently by two reviewers. The agreement was quantified by Cohen's Kappa statistic. The outcomes of studies were categorized in the short-term and the long-term, according to the follow-up period of readmission. A positive association was reported if an increase in the risk for readmission among disadvantaged patients was found. A cumulative effect of socioeconomic factors was computed by considering the association for each study and the number of available studies.

RESULTS

A total of eleven articles were included in the review. They were mainly published in the United States. All the articles analyzed patients who were hospitalized for HF, and four of them also analyzed patients with AMI. Seven studies (63.6%) were found for the short-term outcome, and four studies (36.4%) were found for the long-term outcome. For the short-term outcome, race/ethnicity and marital status showed a positive cumulative effect on the risk for readmission. Regarding the educational level of a patient, no effect was found.

CONCLUSION

Among the socioeconomic factors, mainly race/ethnicity and marital status affect the risk for readmission in elderly people with HF or AMI. Multidisciplinary hospital-based quality initiatives, disease management, and care transition programs are a priority for health care systems to achieve better coordination.

Transitional care strategies from hospital to home: a review for the neurohospitalist

Hospitals are challenged with reevaluating their hospital's transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a "bridging" strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.

Patient-centered, evidence-based, and cost-conscious cancer care across the continuum: Translating the Institute of Medicine report into clinical practice

In 2013, the Institute of Medicine (IOM) concluded that cancer care in the United States is in crisis. Patients and their families are not receiving the information that they need to make informed decisions about their cancer care. Many patients do not have access to palliative care and too few are referred to hospice at the appropriate point in their disease trajectory. Simultaneously, there is a growing demand for cancer care with increases in new cancer diagnoses and the number of patients surviving cancer. Furthermore, there is a workforce shortage to care for this growing and elderly population. The IOM's report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, outlined recommendations to improve the quality of cancer care. This article provides an overview of the IOM report and highlights the recommendations that are most relevant to practicing clinicians who care for patients with cancer across the continuum. The implementation of the recommendations in clinical practice will require better patient-clinician communication, improved care coordination, targeted clinician training, effective dissemination of evidence-based guidelines and strategies for eliminating waste, and continuous quality assessment and improvement efforts.

Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives

BACKGROUND

Community pharmacists play a vital part in reconciling medications for patients transitioning from hospital to community care, yet their roles have not been fully examined in the extant literature.

OBJECTIVES

The objectives of this study were to: 1) examine the barriers and facilitators community pharmacists face when reconciling medications for recently discharged patients; and 2) identify pharmacists' preferred content and modes of information transfer regarding updated medication information for recently discharged patients.

METHODS

Community pharmacists were purposively and conveniently sampled from the Wisconsin (U.S. state) pharmacist-based research network, Pharmacy Practice Enhancement and Action Research Link (PEARL Rx). Community pharmacists were interviewed face-to-face, and transcriptions from audio recordings were analyzed using directed content analysis. The Theory of Planned Behavior (TPB) guided the development of questions for the semi-structured interviews.

RESULTS

Interviewed community pharmacists (N = 10) described the medication reconciliation process to be difficult and time-consuming for recently discharged patients. In the context of the TPB, more barriers than facilitators of reconciling medications were revealed. Themes were categorized as organizational and individual-level themes. Major organizational-level factors affecting the medication reconciliation process included: pharmacy resources, discharge communication, and hospital resources. Major individual-level factors affecting the medication reconciliation process included: pharmacists' perceived responsibility, relationships, patient perception of pharmacist, and patient characteristics. Interviewed pharmacists consistently responded that several pieces of information items would be helpful when reconciling medications for recently discharged patients, including the hospital medication discharge list and stop-orders for discontinued medications.

CONCLUSIONS

The TPB was useful for identifying barriers and facilitators of medication reconciliation for recently discharged patients from community pharmacists' perspectives. The elucidation of these specific facilitators and barriers suggest promising avenues for future research interventions to improve exchange of medication information between the community pharmacy, hospitals, and patients.

A pilot randomized control trial: testing a transitional care model for acute psychiatric conditions

OBJECTIVE

People with multiple and persistent mental and physical health problems have high rates of transition failures when transferring from a hospital level of care to home. The transitional care model (TCM) is evidence-based and demonstrated to improve posthospital outcomes for elderly with physical health conditions, but it has not been studied in the population with serious mental illness.

METHOD

Using a randomized controlled design, 40 inpatients from two general hospital psychiatric units were recruited and randomly assigned to an intervention group (n = 20) that received the TCM intervention that was delivered by a psychiatric nurse practitioner for 90 days posthospitalization, or a control group (n = 20) that received usual care. Outcomes were as follows: service utilization, health-related quality of life, and continuity of care.

RESULTS

The intervention group showed higher medical and psychiatric rehospitalization than the control group (p = .054). Emergency room use was lower for intervention group but not statistically significant. Continuity of care with primary care appointments were significantly higher for the intervention group (p = .023). The intervention group's general health improved but was not statistically significant compared with controls.

CONCLUSIONS

A transitional care intervention is recommended; however, the model needs to be modified from a single nurse to a multidisciplinary team with expertise from a psychiatric nurse practitioner, a social worker, and a peer support specialist. A team approach can best manage the complex physical/mental health conditions and complicated social needs of the population with serious mental illness.

The indispensable intermediaries: a qualitative study of informal caregivers' struggle to achieve influence at and after hospital discharge

BACKGROUND

The care policy and organization of the care sector is shifting to accommodate projected demographic changes and to ensure a sustainable model of health care provision in the future. Adult children and spouses are often the first to assume care giving responsibilities for older adults when declining function results in increased care needs. By introducing policies tailored to enabling family members to combine gainful employment with providing care for older relatives, the sustainability of the future care for older individuals in Norway is more explicitly placed on the family and informal caregivers than previously. Care recipients and informal caregivers are expected to take an active consumer role and participate in the care decision-making process. This paper aims to describe the informal caregivers' experiences of influencing decision-making at and after hospital discharge for home-bound older relatives.

METHODS

This paper reports findings from a follow-up study with an exploratory qualitative design. Qualitative telephone interviews were conducted with 19 informal caregivers of older individuals discharged from hospital in Norway. An inductive thematic content analysis was undertaken.

RESULTS

Informal caregivers take on comprehensive all-consuming roles as intermediaries between the care recipient and the health care services. In essence, the informal caregivers take the role of the active participant on behalf of their older relative. They describe extensive efforts struggling to establish dialogues with the "gatekeepers" of the health care services. Achieving the goal of the best possible care for the care recipient seem to depend on the informal caregivers having the resources to choose appropriate strategies for gaining influence over decisions.

CONCLUSIONS

The care recipients' extensive frailty and increasing dependence on their families coupled with the complexity of health care services contribute to the perception of the informal caregivers' indispensable role as intermediaries. These findings accentuate the need to further discuss how frail older individuals and their informal caregivers can be supported and enabled to participate in decision-making regarding care arrangements that meet the care recipient's needs.

The importance of health information technology in care coordination and transitional care

Care coordination and transitional care services are strategically important for achieving the priorities of better care, better health, and reduced costs embodied in the National Strategy for Quality Improvement in Health Care (National Quality Strategy [NQS]). Some of the most vulnerable times in a person’s care occur with changes in condition as well as movement within and between settings of care. The American Academy of Nursing (AAN) believes it is essential to facilitate the coordination of care and transitions by using health information technology (HIT) to collect, share, and analyze data that communicate patient-centered information among patients, families, and care providers across communities. HIT makes information accessible, actionable, timely, customizable, and portable. Rapid access to information also creates efficiencies in care by eliminating redundancies and illuminating health history and prior care. The adoption of electronic health records (EHRs) and information systems can enable care coordination to be more effective but only when a number of essential elements are addressed to reflect the team-based nature of care coordination as well as a focus on the individual’s needs and preferences. To that end, the AAN offers a set of recommendations to guide the development of the infrastructure, standards, content, and measures for electronically enabled care coordination and transitions in care as well as research needed to build the evidence base to assess outcomes of the associated interventions.

Risk of death following kidney allograft failure: a systematic review and meta-analysis of cohort studies

BACKGROUND

People with kidney allograft failure represent an increasing fraction of all those starting dialysis therapy. We sought to summarize prognosis following kidney allograft failure and identify potentially beneficial interventions or modifiable risk factors.

METHODS

We searched MEDLINE and EMBASE (inception to 1 October 2013) and article reference lists without language restriction and selected cohort studies of all-cause mortality and fatal infection-related and cardiovascular events in people starting dialysis following kidney allograft failure. Two reviewers independently extracted data on study design, participant characteristics, dialysis modality, transplant nephrectomy, immunosuppression strategy, transplant-naive comparators and risk of bias. Discrepancies were resolved with a third reviewer.

RESULTS

Forty studies comprising 249 716 participants met the inclusion criteria. The first year of dialysis therapy was associated with the highest mortality. By random effects meta-analysis, annual risk of death, from years 1 to 4, was 0.12 [95% confidence interval (95% CI): 0.09-0.15], 0.06 (95% CI: 0.05-0.07), 0.05 (95% CI: 0.04-0.06) and 0.05 (95% CI: 0.04-0.06), respectively. We found high heterogeneity in each meta-analysis, which remained unexplained by prespecified subgroup analyses. We could not find sufficient information to summarize the risk for fatal infection-related and cardiovascular events, or to test the role of transplant nephrectomy or different immunosuppressive strategies. Risk of bias was high, especially participation bias.

CONCLUSION

Mortality is higher during the first year of dialysis treatment following kidney allograft failure than in subsequent years. Insufficient data are available to assess factors or interventions potentially impacting prognosis following kidney allograft failure. In a culture promoting transplantation, clinical research of different models of care in this growing high-risk population should be a research priority.

Quality in transitional care of the elderly: Key challenges and relevant improvement measures

Introduction

Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures.

Methodology

Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers.

Results

Six main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment).

Conclusion

Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.