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Mitsutake S, Lystad RP, Long JC, Braithwaite J, Ishizaki T, Close J, Mitchell R. Group-based trajectories of potentially preventable hospitalisations among older adults after a hip fracture. Osteoporos Int 2024:10.1007/s00198-024-07203-4. [PMID: 39080036 DOI: 10.1007/s00198-024-07203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/20/2024] [Indexed: 08/17/2024]
Abstract
Key predictors of three trajectory group membership of potentially preventable hospitalisations were age, the number of comorbidities, the presence of chronic obstructive pulmonary disease and congestive heart failure, and frailty risk at the occurrence of hip fracture. These predictors of their trajectory group could be used in targeting prevention strategies. PURPOSE Although older adults with hip fracture have a higher risk of multiple readmissions after index hospitalisation, little is known about potentially preventable hospitalisations (PPH) after discharge. This study examined group-based trajectories of PPH during a five-year period after a hip fracture among older adults and identified factors predictive of their trajectory group membership. METHODS This retrospective cohort study was conducted using linked hospitalisation and mortality data in New South Wales, Australia, between 2013 and 2021. Patients aged ≥ 65 years who were admitted after a hip fracture and discharged between 2014 and 2016 were identified. Group-based trajectory models were derived based on the number of subsequent PPH following the index hospitalisation. Multinominal logistic regression examined factors predictive of trajectory group membership. RESULTS Three PPH trajectory groups were revealed among 17,591 patients: no PPH (89.5%), low PPH (10.0%), and high PPH (0.4%). Key predictors of PPH trajectory group membership were age, number of comorbidities, dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), frailty risk, place of incident, surgery, rehabilitation, and length of hospital stay. The high PPH had a higher proportion of patients with ≥ 2 comorbidities (OR: 1.86, 95% confidence interval (CI): 1.04-3.32) and COPD (OR: 2.97, 95%CIs: 1.76-5.04) than the low PPH, and the low and high PPHs were more likely to have CHF and high frailty risk as well as ≥ 2 comorbidities and COPD than the no PPH. CONCLUSIONS Identifying trajectories of PPH after a hip fracture and factors predictive of trajectory group membership could be used to target strategies to reduce multiple readmissions.
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Affiliation(s)
- Seigo Mitsutake
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan.
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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Wolfson S, Patel D, Toto E, Khlevner J, Santucci NR. "An urgent need for transition of care programs for adolescents and young adults with neurogastroenterology and motility disorders". J Pediatr Gastroenterol Nutr 2024; 79:1-5. [PMID: 38623964 PMCID: PMC11216879 DOI: 10.1002/jpn3.12217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/26/2024] [Accepted: 03/02/2024] [Indexed: 04/17/2024]
Abstract
Transition of Care for Adolescents and Young Adults (AYA) with Neurogastroenterology & Motility (NGM) Disorders.
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Affiliation(s)
- Sharon Wolfson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dhiren Patel
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Erin Toto
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Vagelos College of Physicians and Surgeons/New York Presbyterian Morgan Stanley Children’s Hospital, New York, New York, USA
| | - Neha R. Santucci
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Villarreal-Granda P, Recio-Platero A, Martín-Bayo Y, Durantez-Fernández C, Cárdaba-García RM, Pérez-Pérez L, Madrigal M, Muñoz-del Caz A, Olea E, Bahillo Ruiz E, Jiménez-Navascués L, Velasco-Gonzalez V. Models Used by Nurse Case Managers in Different Autonomous Communities in Spain: A Scoping Review. Healthcare (Basel) 2024; 12:749. [PMID: 38610172 PMCID: PMC11011987 DOI: 10.3390/healthcare12070749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: The role of the nurse case manager is unknown to the population. The main objective is to analyze the existing differences within the national territory in order to make known the situation in Spain with a view to the recognition of its functions and the creation of the professional profile in an equal manner. (2) Methods: A scoping review was conducted in order to achieve the main aim. Selected articles were subjected to a critical reading, and the levels of evidence and grades of recommendation of the Joanna Briggs Institute were verified. The search field was limited to the last ten years. (3) Results: Case management models are heterogeneous in different autonomous communities in Spain. Case nurse management is qualified for high-complexity patients, follow up on chronic patients, and coordinate health assistance. (4) Conclusions: It concludes that nursing's role is crucial in the field of case management, being required in the follow-up of chronic patients of high complexity. Despite the proven health benefits, efficacy, and efficiency of case management, there are many heterogeneous models that coexist in Spain. This involves a restriction in the development of a nursing career because of the lack of a definition of its functions and competences.
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Affiliation(s)
- Paula Villarreal-Granda
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
| | - Amada Recio-Platero
- Unidad de Insuficiencia Cardiaca y Terapias Avanzadas, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Yara Martín-Bayo
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
| | - Carlos Durantez-Fernández
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
| | - Rosa M. Cárdaba-García
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
| | - Lucía Pérez-Pérez
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
- Primary Care Management Valladolid West (SACYL), 47012 Valladolid, Spain
| | - Miguel Madrigal
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
| | - Alba Muñoz-del Caz
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
- University Clinical Hospital of Valladolid, 47003 Valladolid, Spain
| | - Elena Olea
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Instituto de Biomedicina y Genética Molecular (IBGM), Consejo Superior de Investigaciones Científicas, Universidad de Valladolid (UVa-CSIC), 47005 Valladolid, Spain
| | - Esther Bahillo Ruiz
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
- Nursing Department, Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain
| | - Lourdes Jiménez-Navascués
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
- Nursing Department, Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain
| | - Veronica Velasco-Gonzalez
- Nursing Department, Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (P.V.-G.); (R.M.C.-G.); (L.P.-P.); (M.M.); (A.M.-d.C.); (E.O.); (V.V.-G.)
- Nursing Care Research (GICE), Faculty of Nursing, University of Valladolid, 47005 Valladolid, Spain; (E.B.R.); (L.J.-N.)
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Kinard T, Brennan-Cook J, Johnson S, Long A, Yeatts J, Halpern D. Effective Care Transitions: Reducing Readmissions to Improve Patient Care and Outcomes. Prof Case Manag 2024; 29:54-62. [PMID: 38015801 DOI: 10.1097/ncm.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
PURPOSE/OBJECTIVES Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services. PRIMARY PRACTICE SETTING A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization. FINDINGS/CONCLUSIONS An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up.
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Affiliation(s)
- Tara Kinard
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Jill Brennan-Cook
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Sara Johnson
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - Andrea Long
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - John Yeatts
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
| | - David Halpern
- Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions
- Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities
- Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives
- Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office
- John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization
- David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care
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Michaelis C, Hundt E, Lombardi W, Howie Esquivel J. Transitions in care: Piloting a neurocritical care clinic with nurse practitioners and physician associates. J Am Assoc Nurse Pract 2024; 36:153-159. [PMID: 37751220 DOI: 10.1097/jxx.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/25/2023] [Indexed: 09/27/2023]
Abstract
ABSTRACT The transition period from hospital to home is a vulnerable time for rehospitalization and adverse events for patients. Follow-up clinic visits within 7-14 days of discharge is an effective strategy for reducing hospital readmissions. Neurocritical care patients have a unique set of needs to safely transition to home. We evaluated the feasibility of a Neuroscience Rapid Follow-Up Clinic with nurse practitioners (NPs) and physician associates (PAs) to meet transitional care gaps in neurocritical care patients and prevent rehospitalization. Clinic procedures and documentation templates were customized for the pilot clinic. Five NPs and one PA underwent a brief training course for the ambulatory care setting. Eligible patients were tracked throughout the hospitalization and the team made follow-up appointments. The pilot clinic took place from October 2022 to January 2023. Nine patients were seen in the clinic approximately 8 days after discharge. The clinic attendance rate was 90%. Among the clinic attendees, 66% received referrals to a primary care provider or other services, one third received medication changes or refills and all received patient-specific education. There were no rehospitalizations among the clinic patients. Implementation of this pilot clinic was possible with the current departmental resources. This innovative model of care has the potential to reduce hospital readmissions.
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Affiliation(s)
| | - Elizabeth Hundt
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - William Lombardi
- UVA Center for Advanced PracticeUVA Center for Advanced Practice, University of Virginia Medical Center, Charlottesville, Virginia
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Saragih ID, Everard G, Saragih IS, Lee BO. The beneficial effects of transitional care for patients with stroke: A meta-analysis. J Adv Nurs 2024; 80:789-806. [PMID: 37727124 DOI: 10.1111/jan.15850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/21/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Transitional care interventions have emerged as a promising method of ensuring treatment continuity and health care coordination when patients are discharged from hospital to home. However, few studies have investigated the frequency and duration of interventions and the effects of interventions on physical function. Therefore, this study aimed to determine the efficacy of transitional care for patients with stroke. METHODS Six databases and the grey literature were searched to obtain relevant articles from October 1, 2022 to March 10, 2023. The primary outcomes studied were motor performance, walking speed, activities of daily living (ADLs) and caregiver burden following hospital-to-home transitional care. The quality of the studies was assessed with Cochrane risk of bias version 2. The quality and sensitivity of the evidence were assessed to ensure rigour of the findings. Meta-analyses were performed using stata 17.0. RESULTS A total of 2966 patients were identified from 23 studies. Transitional care improved post-stroke motor performance, walking speed and ADLs, and reduced caregiver burden. CONCLUSION The findings suggest that provision of transitional care model implementation in patients with stroke is important because it reduces disability in stroke patients and helps to decrease caregivers' burden. IMPACT The findings of the study emphasize the importance of transitional care programmes for stroke patients after they are discharged from the hospital and returned to their homes. To meet the needs of patients, all levels of health professionals including nurses should be aware of the discharge process and care plan.
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Affiliation(s)
| | - Gauthier Everard
- Centre Interdisciplinaire de recherche en réadaptation et intégration sociale, Université Laval, Québec, QC, Canada
- Pole d'Hépato-Gastro-Entérologie, Institut de Recherche Expérimentale et Clinique, UCLouvain, Bruxelles, Belgium
| | - Ice Septriani Saragih
- Department of Medical Surgical Nursing, STIkes Santa Elisabeth Medan, Medan, Indonesia
| | - Bih-O Lee
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Innovative Research on Aging Society (CIRAS), National Chung Cheng University, Chiayi, Taiwan
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Joo JY. Fragmented care and chronic illness patient outcomes: A systematic review. Nurs Open 2023; 10:3460-3473. [PMID: 36622952 PMCID: PMC10170908 DOI: 10.1002/nop2.1607] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023] Open
Abstract
AIM This systematic review examined recent studies on fragmented care of patients with chronic illnesses in the United States to examine the association between fragmented care and patient outcomes. DESIGN Systematic review. METHODS Studies published from January 1, 2012, to June 1, 2022, were selected from four electronic databases (PubMed, CINAHL, PsycINFO, and Web of Science), following the Cochrane protocols and PRISMA statements. Based on inclusion and exclusion criteria, ten studies that examined associations published between 2015 and 2021 were selected. A methodological assessment was conducted with the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The studies selected for this systematic review were rated as having fair methodological rigor. The protocol of this review was registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42021285379). Because of the heterogeneity of the selected studies' data, a systematic narrative synthesis of the extracted data was conducted. RESULTS Three common measures for fragmented care and outcomes were synthesized. A synthesis of the studies found significant association between fragmented care and adverse outcomes of chronic illnesses (emergency department visits, utilization of diagnostic tests, and healthcare costs). Despite the heterogeneity of significant findings between fragmented care and patient outcomes, the relationship between these outcomes and fragmented care was significant. This systematic review provides clear evidence of the association between care fragmentation and its adverse effects on individuals with chronic illnesses. However, mixed relationship findings were also reported. CONCLUSION Given the demands of overcoming fragmented care in healthcare settings in the United States, nurse managers, healthcare leaders, and policymakers should utilize this evidence to reduce fragmented care strategies. It is recommended that nurse researchers and other healthcare practitioners conduct further studies to understand the contexts and mechanisms of fragmented care and develop theoretical frameworks for care fragmentation and chronic illness outcomes.
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Affiliation(s)
- Jee Young Joo
- College of Nursing, Gachon University, Incheon, South Korea
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Cui M, Hua J, Shi X, Yang W, Geng Z, Qian X, Geng G. Factors associated with instrumental support in transitional care among older people with chronic disease: a cross-sectional study. BMC Nurs 2022; 21:230. [PMID: 35996136 PMCID: PMC9394025 DOI: 10.1186/s12912-022-01014-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Instrumental support, which is defined as practical, tangible, and informational assistance extended to patients, is crucial for older people in transition. However, little is known about instrumental support in transitional care. Thus, the aim of this study was to evaluate the instrumental support of older people in transitional care. Methods This cross-sectional study was conducted using the Questionnaire of Instrumental Support in Transitional Care (QISCT) to collect data from 747 older people in China from September to November 2020. Survey items consisted of a sociodemographic characteristics questionnaire and the QISCT. Multiple regression analyses were conducted to examine the association between independent variables and the QISCT scores. Results The total score of the QISCT was 39.43 (± 9.11), and there was a significant gap between the anticipated support and received support. The satisfaction of instrumental support was low. Multiple regression analyses showed that educational level, the number of intimate relationships, monthly family income, monthly costs of transitional care, diabetes, and chronic obstructive pulmonary disease were associated with instrumental support in transitional care. Conclusions To cope with the burden caused by chronic disease, the government and transitional care teams should establish a demand-oriented transitional care service model and pay more attention to helping older people obtain adequate and satisfactory instrumental support.
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Affiliation(s)
- Min Cui
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Jianing Hua
- Affiliated Hospital of Jiangnan University, 1800 Lihu Avenue, Wuxi, Jiangsu Province, China
| | - Xiaoliu Shi
- Affiliated Hospital of Nantong University, 20 Xisi Road, Chongchuan District, Nantong, Jiangsu Province, China
| | - Wenwen Yang
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Zihan Geng
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China
| | - Xiangyun Qian
- Affiliated Nantong Hospital 3 of Nantong University, No. 60 Qingnian Zhong road, Chongchuan District, Nantong, 226001, Jiangsu, China.
| | - Guiling Geng
- School of Medical, Nantong University, No19, Qixiu Road, Chong Chuan District, Nantong, Jiangsu Province, 226001, China.
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