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Jung D, Jarrín OF, Choi JHS, Knox S, Emerson KG, Chen Z. The Role of Neighborhood Socioeconomic Status in Institutionalization of Home Health Care Patients With and Without Alzheimer's Disease and Related Dementias. J Am Med Dir Assoc 2024; 25:105170. [PMID: 39067862 DOI: 10.1016/j.jamda.2024.105170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES To assess whether neighborhood socioeconomic status (SES) moderates the association between Alzheimer's disease and related dementias (ADRD) and successful discharge to the community. In addition, to explore whether the role of neighborhood SES on successful discharge for patients with ADRD varies by the severity of ADRD. DESIGN This is a retrospective cohort study. SETTING AND PARTICIPANTS Medicare Fee-for-service beneficiaries, aged 65 or older, who received home health care in 2019. METHODS We used linear probability regression models with successful discharge to the community as the main outcome, and neighborhood SES and ADRD as independent variables. Also, we modified the Functional Assessment Staging Tool (FAST) to measure ADRD severity. RESULTS Our study results show ADRD and residing in neighborhoods with lower socioeconomic conditions were independently associated with lower probabilities of successful discharge to the community. We also found that the differences in probabilities of remaining at home between patients with and without ADRD were larger among those in neighborhoods with lower SES (ADRD∗less disadvantaged neighborhood, coeff: -0.01, P < .001; ADRD∗more disadvantaged neighborhood, coeff: -0.02, P < .001; ADRD∗most disadvantaged neighborhood, coeff: 0.032, P < .001). Among patients with ADRD, patients with the most advanced ADRD were less likely to remain in their homes and community when living in neighborhoods with lower SES. CONCLUSIONS AND IMPLICATIONS Our study results show that when patients with ADRD receiving home health care live in neighborhoods with lower SES, they face further challenges to remaining in their homes and community. Public health officials and community planners should consider using area-level interventions to improve care and health outcomes for patients with ADRD. Also, further research aimed at identifying the specific factors and resources influencing lower care quality and poorer health outcomes in socioeconomically disadvantaged neighborhoods, particularly for patients with ADRD, can provide valuable insights for the development and implementation of targeted interventions.
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Affiliation(s)
- Daniel Jung
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA.
| | - Olga F Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA; Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Jeong Ha Steph Choi
- Department of Psychology, College of Arts & Sciences, Georgia State University, Atlanta, GA, USA
| | - Sara Knox
- Department of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Kerstin Gerst Emerson
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA; Institute of Gerontology, University of Georgia, Athens, GA, USA
| | - Zhuo Chen
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
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Fadeyi O, Saghari S, Esmaeili A, Hami A. Assessment of Patient Satisfaction With Inpatient Services Provided at an Acute Care Facility: A Quality Improvement Project. Cureus 2024; 16:e55511. [PMID: 38440202 PMCID: PMC10911950 DOI: 10.7759/cureus.55511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 03/06/2024] Open
Abstract
Hospitals across the United States use patient satisfaction surveys to assess the quality of inpatient and outpatient services provided to patients when they interact with the healthcare system. Results from this survey are used as input to identify weaknesses in the system with the intention of providing appropriate intervention. Here, we report the results of the quality improvement project completed in an acute healthcare facility. Patient satisfaction was evaluated based on indices established by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Responses from 400 patients admitted into the hospital between July 2022 and June 2023 were obtained using a pre-designed questionnaire prepared by HCAHPS on behalf of Prime Healthcare Services. Indices of assessment include doctor-patient interaction, nurse-patient interaction, hospital responsiveness to patient needs, hospital environment, communication about medicine, discharge information, transition of care, overall assessment, and willingness to recommend. The best hospital performance was seen in the dissemination of discharge information, while the worst performance was noted in the transition of care and communication about medicine. Appropriate recommendations were made to improve on these weak areas.
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Affiliation(s)
- Olaniyi Fadeyi
- Internal Medicine, West Anaheim Medical Center, Anaheim, USA
| | - Saviz Saghari
- Internal Medicine, West Anaheim Medical Center, Anaheim, USA
| | - Ali Esmaeili
- Internal Medicine, West Anaheim Medical Center, Anaheim, USA
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Turbow SD, Ali MK, Culler SD, Rask KJ, Perkins MM, Clevenger CK, Vaughan CP. Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults. JAMA Netw Open 2023; 6:e2313592. [PMID: 37191959 PMCID: PMC10189568 DOI: 10.1001/jamanetworkopen.2023.13592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
Importance When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals. Objective To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries. Design, Setting, and Participants This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022. Exposures Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals. Main Outcomes and Measures The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions. Results The cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available. Conclusions and Relevance In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.
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Affiliation(s)
- Sara D. Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mohammed K. Ali
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Steven D. Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Molly M. Perkins
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Camille P. Vaughan
- Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, Georgia
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Skudlik S, Hirt J, Döringer T, Thalhammer R, Lüftl K, Prodinger B, Müller M. Challenges and care strategies associated with the admission to nursing homes in Germany: a scoping review. BMC Nurs 2023; 22:5. [PMID: 36600231 DOI: 10.1186/s12912-022-01139-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/06/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The admission to a nursing home is a critical life-event for affected persons as well as their families. Admission related processes are lacking adequate participation of older people and their families. To improve transitions to nursing homes, context- and country-specific knowledge about the current practice is needed. Hence, our aim was to summarize available evidence on challenges and care strategies associated with the admission to nursing homes in Germany. METHODS We conducted a scoping review and searched eight major international and German-specific electronic databases for journal articles and grey literature published in German or English language since 1995. Further inclusion criteria were focus on challenges or care strategies in the context of nursing home admissions of older persons and comprehensive and replicable information on methods and results. Posters, only-abstract publications and articles dealing with mixed populations including younger adults were excluded. Challenges and care strategies were identified and analysed by structured content analysis using the TRANSCIT model. RESULTS Twelve studies of 1,384 records were finally included. Among those, seven were qualitative studies, three quantitative observational studies and two mixed methods studies. As major challenges neglected participation of older people, psychosocial burden among family caregivers, inadequate professional cooperation and a lack of shared decision-making and evidence-based practice were identified. Identified care strategies included strengthening shared decision-making and evidence-based practice, improvement in professional cooperation, introduction of specialized transitional care staff and enabling participation for older people. CONCLUSION Although the process of nursing home admission is considered challenging and tends to neglect the needs of older people, little research is available for the German health care system. The perspective of the older people seems to be underrepresented, as most of the studies focused on caregivers and health professionals. Reported care strategies addressed important challenges, however, these were not developed and evaluated in a comprehensive and systematic way. Future research is needed to examine perspectives of all the involved groups to gain a comprehensive picture of the needs and challenges. Interventions based on existing care strategies should be systematically developed and evaluated to provide the basis of adequate support for older persons and their informal caregivers.
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Affiliation(s)
- Stefanie Skudlik
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany.
| | - Julian Hirt
- International Graduate Academy, Medical Faculty, Institute for Health and Nursing Science, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute for Applied Nursing Science, Department of Health, Eastern Switzerland University of Applied Sciences (Formerly FHS St. Gallen), St. Gallen, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias Döringer
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
- Faculty of Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
| | - Regina Thalhammer
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
| | - Katharina Lüftl
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
- Faculty of Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
| | - Birgit Prodinger
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
- Faculty of Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
| | - Martin Müller
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Rosenheim, Germany
- Department for Primary Care and Health Services Research, Medical Faculty, Nursing Science and Interprofessional Care, Heidelberg University, Heidelberg, Germany
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Post-Hospital Availability of Instrumental Support May Influence Patients' Readiness for Discharge. Prof Case Manag 2022; 27:194-202. [PMID: 35617535 DOI: 10.1097/ncm.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF STUDY Evaluate the relationship between unplanned acute care utilization after discharge from an index hospital admission and registered nurse and patient perceptions of available instrumental support the patient would have after discharge. PRIMARY PRACTICE SETTING Three hospitals in a large regional hospital system in the southeastern United States. METHODOLOGY AND SAMPLE Retrospective, secondary quantitative analysis of 13,361 patient records (mean age 58.4 years; 51% female) from index hospitalizations evaluating patient and nurse responses to 2 questions that specifically address instrumental support on both the patient and nurse versions of the Readiness for Hospital Discharge Survey (RHDS) and subsequent unexpected care received (emergency department [ED] visit, observation stay, hospital readmission) in the acute care setting within 60 days of discharge. Logistic regression was used to evaluate the relationship between RHDS scores and unplanned care received. RESULTS Patients who required hospital-based acute care within 60 days after discharge had lower average RN-RHDS scores than those who did not require hospital-based acute care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Including a nursing assessment of potential postdischarge expected instrumental support may be helpful in identifying patients who are at a higher risk of experiencing postdischarge acute care utilization. Monitoring ED visits and observation stays in addition to readmissions will facilitate capturing significantly more points of care received after discharge and provide additional information regarding postdischarge care utilization.
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Carter AJE, Harrison M, Kryworuchko J, Kekwaletswe T, Wong ST, Goldstein J, Warner G. Essential Elements to Implementing a Paramedic Palliative Model of Care: An Application of the Consolidated Framework for Implementation Research. J Palliat Med 2022; 25:1345-1354. [PMID: 35727113 DOI: 10.1089/jpm.2021.0459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Comfort care without transport to hospital was not traditionally a paramedic practice. The novel Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to manage and share goals of care, and palliative care training. This study determined essential elements for implementation, scale, and spread of this Program. Methods: Deliberative dialogs, a qualitative method, were held with diverse stakeholders/experts in one province with the Program (Nova Scotia, March 2018) and one without (British Columbia, July 2018). The Consolidated Framework for Implementation Research (CFIR) informed the discussion guide and was used in a framework analysis. Four team members analyzed the data independently; themes were derived by consensus with the broader research team. Results: CFIR constructs framed several key elements. Inter-sectoral communication is critical but challenged by privacy concerns and the siloed structure of the health system. Locally adapted training is an essential characteristic of the intervention; cost is a factor. A shift in mindset away from traditional paramedic roles is required; this can be facilitated by paramedic champions and a positive implementation climate. Early engagement of diverse stakeholders and planning for sustainability is key. Conclusion: This framework analysis using CFIR constructs can guide successful scale and spread of the program. The constructs of Outer setting: Cosmopolitanism; Characteristics of the intervention: Adaptability; Inner Setting: Implementation climate; and Processes: Engagement, and Planning, emerged as essential.
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Affiliation(s)
- Alix J E Carter
- Emergency Health Services Nova Scotia, Halifax, Nova Scotia, Canada.,Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michelle Harrison
- Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health Halifax, Nova Scotia, Canada
| | - Jennifer Kryworuchko
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada.,School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tjingaita Kekwaletswe
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sabrina T Wong
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada.,School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judah Goldstein
- Emergency Health Services Nova Scotia, Halifax, Nova Scotia, Canada.,Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Grace Warner
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
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Hardcastle VG. The critical role of care coordinators for persons with substance use disorder in rural settings: a case study. SOCIAL WORK IN HEALTH CARE 2021; 60:561-580. [PMID: 34629020 DOI: 10.1080/00981389.2021.1986456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 06/07/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
Many rural regions lack the basic fundamentals in healthcare for Opioid Use Disorder. We present a case of a dual-diagnosed, impoverished, adult female court-ordered to inpatient treatment in rural Kentucky. A care coordinator linked her to regional and community resources to address her health, environmental, and psychosocial needs, as well as provided needed transportation, coaching, and emotional support. As a result, she overcame the substantial barriers that each component of the care continuum presents in severely underserved areas. This case study highlights the critical role care coordination plays in reentry, its differences from urban areas, and its alignment with social work's core values.
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Affiliation(s)
- Valerie Gray Hardcastle
- Institute for Health Innovation, Northern Kentucky University, Highland Heights, Kentucky, U.S.A
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Groenvynck L, Fakha A, de Boer B, Hamers JPH, van Achterberg T, van Rossum E, Verbeek H. Interventions to Improve the Transition from Home to a Nursing Home: A Scoping Review. THE GERONTOLOGIST 2021; 62:e369-e383. [PMID: 33704485 PMCID: PMC9372886 DOI: 10.1093/geront/gnab036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives The transition from home to a nursing home is a stressful event for both older persons and informal caregivers. Currently, this transition process is often fragmented, which can create a vicious cycle of health care-related events. Knowledge of existing care interventions can prevent or break this cycle. This project aims to summarize existing interventions for improving transitional care, identifying their effectiveness and key components. Research Design and Methods A scoping review was performed within the European TRANS-SENIOR consortium. The databases PubMed, EMBASE (Excerpta Medica Database), PsycINFO, Medline, and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they described interventions designed to improve the transition from home to a nursing home. Results 17 studies were identified, describing 13 interventions. The majority of these interventions focused on nursing home adjustment with 1 study including the entire transition pathway. The study identified 8 multicomponent and 5 single-component interventions. From the multicomponent interventions, 7 main components were identified: education, relationships/communication, improving emotional well-being, personalized care, continuity of care, support provision, and ad hoc counseling. The study outcomes were heterogeneous, making them difficult to compare. The study outcomes varied, with studies often reporting nonsignificant changes for the main outcome measures. Discussion and Implications There is a mismatch between the theory on optimal transitional care and current transitional care interventions, as they often lack a comprehensive approach. This research is the first step toward a uniform definition of optimal transitional care and a tool to improve/develop (future) transitional care initiatives on the pathway from home to a nursing home.
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Affiliation(s)
- Lindsay Groenvynck
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Amal Fakha
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Bram de Boer
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Jan P H Hamers
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Theo van Achterberg
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Erik van Rossum
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands.,Academy of Nursing, Research Center on Community Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
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Cations M, Lang C, Crotty M, Wesselingh S, Whitehead C, Inacio MC. Factors associated with success in transition care services among older people in Australia. BMC Geriatr 2020; 20:496. [PMID: 33228558 PMCID: PMC7686713 DOI: 10.1186/s12877-020-01914-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/17/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The Australian Transition Care Program (TCP) is a national intermediate care service aiming to optimise functional independence and delay entry to permanent care for older people leaving hospital. The aim of this study was to describe the outcomes of TCP and identify demographic and clinical factors associated with TCP 'success', to assist with clinical judgements about suitable candidates for the program. METHOD We conducted a descriptive cohort study of all older Australians accessing TCP for the first time between 2007 and 2015. Logistic regression models assessed demographic and clinical factors associated with change in performance on a modified Barthel Index from TCP entry to discharge and on discharge to community. Fine-Gray regression models estimated factors associated with transition to permanent care within 6 months of TCP discharge, with death as a competing event. RESULTS Functional independence improved from entry to discharge for 46,712 (38.4%) of 124,301 TCP users. Improvement was more common with younger age, less frailty, shorter hospital stay prior to TCP, and among women, those without a carer, living outside a major city, and without dementia. People who received TCP in a residential setting were far less likely to record improved functional impairment and more likely to be discharged to permanent care than those in a community setting. Discharge to community was more common with younger age and among women and those without dementia. Nearly 12% of community TCP and 63% of residential TCP users had transitioned to permanent care 6 months after discharge. Entry to permanent care was more common with older age, higher levels of frailty, and among those with dementia. CONCLUSIONS More than half of TCP users are discharged to home and remain at home after 6 months. However, residential-based TCP may have limited efficacy. Age, frailty, carer status, and dementia are key factors to consider when assessing program suitability. Future studies comparing users to a suitably matched control group will be very helpful for confirming whether the TCP program is meeting its aims.
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Affiliation(s)
- Monica Cations
- South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA, 5001, Australia.
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Catherine Lang
- South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA, 5001, Australia
| | - Maria Crotty
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Steven Wesselingh
- South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA, 5001, Australia
| | - Craig Whitehead
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Maria C Inacio
- South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA, 5001, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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10
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Maenhout A, Cornelis E, Van de Velde D, Desmet V, Gorus E, Van Malderen L, Vanbosseghem R, De Vriendt P. The relationship between quality of life in a nursing home and personal, organizational, activity-related factors and social satisfaction: a cross-sectional study with multiple linear regression analyses. Aging Ment Health 2020; 24:649-658. [PMID: 30724580 DOI: 10.1080/13607863.2019.1571014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: This study aimed to investigate quality of life in nursing home residents and the relationship with personal, organizational, activity-related factors and social satisfaction.Methods: In a cross-sectional survey study in 73 nursing homes in Flanders, Belgium, 171 cognitively healthy residents were randomly recruited (mean age 85.40 years [±5.88]; 27% men, 73% women). Quality of life, as the dependent/response variable, was measured using anamnestic comparative self-assessment (range -5 to +5). Multiple linear regression (forward stepwise selection) was used (1) to investigate which factors were significantly related to nursing home residents' quality of life and (2) to model the relationship between the variables by fitting a linear equation to the observed data.Results: Nursing home residents reported a quality of life score of 2.12 (±2.16). Mood, self-perceived health status, social satisfaction and educational level were withheld as significant predictors of the anamnestic comparative self-assessment score (p < 0.001), explaining 38.1% of the variance in quality of life.Conclusions: Results suggest that a higher quality of life in nursing homes can be pursued by strategies to prevent depression and to improve nursing home residents' subjective perception of health (e.g. offering good care) and social network. It is recommended that nursing homes prepare for future generations, who will be more educated.
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Affiliation(s)
- Annelies Maenhout
- Research Group Zorginnovatie, Artevelde University College Ghent, Ghent, Belgium
| | - Elise Cornelis
- Research Group Zorginnovatie, Artevelde University College Ghent, Ghent, Belgium.,Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium.,Department of Geriatrics, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dominique Van de Velde
- Research Group Zorginnovatie, Artevelde University College Ghent, Ghent, Belgium.,Department of Occupational Therapy, Faculty of Medicine and Health Sciences Rehabilitation Sciences and Physiotherapy, University Ghent, Ghent, Belgium
| | - Valerie Desmet
- Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium
| | - Ellen Gorus
- Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium.,Department of Geriatrics, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Gerontology (GERO), Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Van Malderen
- Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium.,Department of Gerontology (GERO), Vrije Universiteit Brussel, Brussels, Belgium
| | - Ruben Vanbosseghem
- Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium
| | - Patricia De Vriendt
- Research Group Zorginnovatie, Artevelde University College Ghent, Ghent, Belgium.,Frailty in Ageing Research Group (FRIA), Vrije Universiteit Brussel, Brussels, Belgium.,Department of Gerontology (GERO), Vrije Universiteit Brussel, Brussels, Belgium
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Breaking Down Silos: Consensus-Based Recommendations for Improved Content, Structure, and Accessibility of Advance Directives in Emergency and Out-of-Hospital Settings. J Palliat Med 2020; 23:379-388. [DOI: 10.1089/jpm.2019.0087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Brooke BS, Beckstrom J, Slager SL, Weir CR, Del Fiol G. Discordance in Information Exchange Between Providers During Care Transitions for Surgical Patients. J Surg Res 2019; 244:174-180. [PMID: 31299433 DOI: 10.1016/j.jss.2019.06.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/26/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The exchange of health information between primary care providers (PCPs) and surgeons is critical during transitions of care for older patients with multiple comorbidities; however, it is unknown to what extent this process occurs. This study was designed to characterize the extent to which factors associated with older patient's recovery, such as functional status, cognitive status, social status, and emotional factors, are shared among PCPs and surgical providers during care transitions. MATERIALS AND METHODS We prospectively identified 15 patients aged over 60 y with ≥3 comorbidities referred for general and vascular surgery procedures at a Veterans Administrative and academic medical center. Semistructured Critical Decision Method interviews were conducted with patients along with their surgical providers and referring PCPs. Thematic content analysis was performed independently by five reviewers on the cognitive processes associated with functional status, cognitive status, social status, and emotional factors. Interrater reliability between providers and patients was assessed using Cohen's kappa. RESULTS Forty-seven Critical Decision Method interviews were conducted, which included 20 paired interviews between a PCP and a surgeon and 16 paired interviews that involved a patient and a provider. The majority of patients reported experiencing poor information exchange between their PCP and surgeon (58%) and feeling they were primarily responsible for communicating their own health information during care transitions (67%). In paired interviews between PCPs and surgeons, there was nearly perfect agreement for the shared knowledge of cognitive (kappa: 0.83) and emotional (kappa 1) factors. In contrast, there was only minimal agreement for shared knowledge of functional status (kappa 0.38) and social status (kappa: 0.34). CONCLUSIONS Information exchange between PCPs and surgical providers is often discordant during transitions of surgical care for medically complex older patients, particularly when it pertains to communicating their functional or social status.
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Affiliation(s)
- Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah; Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Julie Beckstrom
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stacey L Slager
- Pharmacotherapy Outcomes Research Center, University of Utah School of Pharmacy, Salt Lake City, Utah
| | - Charlene R Weir
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
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Carlin C, David G. Reduced Health Care Utilization among Elderly Patients with Informal Caregivers. Perm J 2019; 23:18-173. [PMID: 31314726 DOI: 10.7812/tpp/18-173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Prior literature has focused on the impact of informal caregiving (presence of a family member in the home or nearby) on caregiver employment, but little research has analyzed the impact of informal caregiving on health care utilization patterns. OBJECTIVE To study the effect of informal caregivers on postacute care and recovery of Medicare patients. DESIGN We used cross-sectional Health Plan administrative data to measure differences in health care utilization for Medicare patients who did and did not have coresident adult caregivers available. We identified coresident caregivers as those residing at the same postal address as discharged patients. Analysis was a combination of Poisson and logit models. MAIN OUTCOME MEASURES Length of hospitalization, type of hospitalization (ambulatory-care sensitive vs not), likelihood of discharge to postacute care (skilled nursing facility or home health), and likelihood of hospital readmission and postdischarge Emergency Department visits. RESULTS Patients with caregivers were discharged after shorter hospital lengths of stay and were less likely to require postacute emergency care, home health services, or discharge to skilled nursing facilities. Savings were smaller when caregivers were younger, in poor health, or female. We extrapolated the reduced utilization associated with a coresidential caregiver to estimate Medicare savings of $514 million in 2015. CONCLUSION By calculating the impact of informal caregiving on patterns of health care utilization, we support the need to integrate the availability of caregivers into discharge planning. Future quantification of differences by caregiver characteristics is important.
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Affiliation(s)
- Caroline Carlin
- Medica Research Institute, Minneapolis, MN.,Department of Family Medicine and Community Health, University of Minnesota, Minneapolis
| | - Guy David
- Health Care Management Department, Wharton School, University of Pennsylvania, PA
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Spooner AJ, Booth N, Downer TR, Gordon L, Hudson AP, Bradford NK, O’Donnell C, Geary A, Henderson R, Franks C, Conway A, Yates P, Chan RJ. Advanced practice profiles and work activities of nurse navigators: An early-stage evaluation. Collegian 2019. [DOI: 10.1016/j.colegn.2018.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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De Vriendt P, Cornelis E, Vanbosseghem R, Desmet V, Van de Velde D. Enabling meaningful activities and quality of life in long-term care facilities: The stepwise development of a participatory client-centred approach in Flanders. Br J Occup Ther 2018. [DOI: 10.1177/0308022618775880] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Meaningful activities of daily living promote the quality of life of residents of long-term care facilities. This project aimed to develop an approach to enable meaningful activities of daily living and to guide long-term care facilities in a creative and innovative attitude towards residents' meaningful activities of daily living. Method The approach was developed in six steps: (1) in-depth-interviews with 14 residents; (2) a survey with 171 residents; (3) a systematic map and synthesis review on interventions enriching meaningful activities of daily living; (4) qualitative analysis of 24 ‘good examples’ and, to support future implementation, (5) focus groups with staff ( n = 69). Results determined the components of the new approach which was (6) pilot-tested in one long-term care facility. Quantitative and qualitative data were gathered concerning benefits for the residents and feasibility for the staff. Results A client- and activity-oriented approach was developed, characterised by an active participatory attitude of residents and staff and a systematic iterative process. Significant positive effects were found for the number of activities, the satisfaction with the leisure offered, the social network, medication use, but not for quality of life. The approach appeared to be feasible. Conclusion This approach stimulates residents' meaningful activities of daily living and social life. Further investigation is needed to evaluate its outcome and implementation potentials.
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Affiliation(s)
- Patricia De Vriendt
- Professor, Research Group Innovation in Health Care and Department of Occupational Therapy, Artevelde University College, Gent, Belgium; Faculty of Medicine and Pharmacy, Department of Gerontology and Frailty in Ageing (FRIA) Research Group, Vrije Universiteit Brussel, Brussels, Belgium; Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy, Department of Occupational Therapy, Ghent University, Gent, Belgium
| | - Elise Cornelis
- Occupational Therapist, University Hospital Brussels, Belgium; PhD Candidate Gerontology, Faculty of Medicine and Pharmacy, Department of Gerontology and Frailty in Ageing (FRIA) Research Group, Vrije Universiteit Brussel, Brussels, Belgium; Lecturer and Researcher, Department of Occupational Therapy, Artevelde University College, Gent, Belgium
| | - Ruben Vanbosseghem
- Lecturer and Researcher, Department of Nursing, Artevelde University College, Research Group Innovation in Health Care, Gent, Belgium
| | - Valerie Desmet
- Occupational Therapist, Lecturer and Researcher, Department of Occupational Therapy, Artevelde University College, Gent, Belgium
| | - Dominique Van de Velde
- Professor Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy, Department of Occupational Therapy, Ghent University, Gent, Belgium; Department of Occupational Therapy, Artevelde University College, Gent, Belgium
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Smith AD, Treschuk J. Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2018. [DOI: 10.1177/1084822318765737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Outcomes of transcatheter aortic valve replacement using a minimalist approach. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:192-195. [DOI: 10.1016/j.carrev.2017.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/02/2017] [Accepted: 08/04/2017] [Indexed: 11/23/2022]
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Abstract
In the United States, home health care (HHC) is a rapidly growing industry and home infusion therapy is a rapidly growing market. HHC can present substantial occupational safety and health (OSH) risks. This article summarizes major OSH risks relevant to home infusion therapy by illustrating them through real-life scenarios collected systematically using qualitative research methods by the National Institute for Occupational Safety and Health-funded research projects at the University of Massachusetts Lowell. The need for home infusion therapy will continue to grow in the future, and safety interventions to prevent or minimize OSH risks are essential.
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Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients' and health care professionals' decision making. Palliat Med 2017; 31:617-624. [PMID: 28618896 PMCID: PMC5476192 DOI: 10.1177/0269216316673476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increasing importance is being placed on the coordination of services at the end of life. AIM To describe decision-making processes that influence transitions in care when approaching the end of life. DESIGN Qualitative study using field observations and longitudinal semi-structured interviews. SETTING/PARTICIPANTS Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. FINDINGS Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions. CONCLUSION While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.
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Affiliation(s)
- Maureen A Coombs
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Roses Parker
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
| | - Kay de Vries
- School of Health Sciences, University of Brighton, Brighton, UK
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Welch JL, Meek J, Bartlett Ellis RJ, Ambuehl R, Decker BS. PATTERNS OF HEALTHCARE ENCOUNTERS EXPERIENCED BY PATIENTS WITH CHRONIC KIDNEY DISEASE. J Ren Care 2017; 43:209-218. [PMID: 28371226 DOI: 10.1111/jorc.12200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patterns of healthcare encounters by patients in each stage of chronic kidney disease (CKD) have not been fully described. OBJECTIVE This study describes patterns of healthcare resource use by patients with CKD. DESIGN A retrospective descriptive design was used. PARTICIPANTS Patients with Stages 1-5 CKD were identified in five existing de-identified healthcare insurance claims databases in the United States using codes from the International Classification of Diseases (ICD-9-CM). MEASUREMENTS The databases contained more than 23,660,000 claims records from over 11 million subscribers who were continuously enrolled in a single 2014 health plan. All CKD patients' 2014 claims were extracted, yielding 1,987 unique people with 110,594 healthcare encounters. RESULTS Healthcare resources are used to manage the causes of CKD and its multiple effects on health, and thus the number of healthcare encounters among people with more advanced disease was, as expected, relatively higher. There were more hospitalisations, emergency department visits and specialist encounters in this group. Surprisingly, however, even people in earlier stages of kidney disease experienced a median of 14-17 healthcare encounters during a single calendar year. CONCLUSIONS Understanding patterns of healthcare encounters provides important information about the transition experiences of patients with CKD. Exploring ways to reduce the risks associated with transitions in care may prevent problems with home medication management, frequent emergency department visits and potentially avoidable hospitalisations.
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Affiliation(s)
- Janet L Welch
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Julie Meek
- Indiana University School of Nursing, Hendersonville, North Carolina, USA
| | | | | | - Brian S Decker
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Nasarwanji M, Werner NE, Carl K, Hohl D, Leff B, Gurses AP, Arbaje AI. Identifying Challenges Associated With the Care Transition Workflow From Hospital to Skilled Home Health Care: Perspectives of Home Health Care Agency Providers. Home Health Care Serv Q 2017; 34:185-203. [PMID: 26495858 DOI: 10.1080/01621424.2015.1092908] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.
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Affiliation(s)
- Mahiyar Nasarwanji
- a Armstrong Institute for Patient Safety and Quality , Johns Hopkins University , Baltimore , Maryland , USA
| | - Nicole E Werner
- b Department of Industrial and Systems Engineering , University of Wisconsin-Madison , Madison , Wisconsin , USA
| | - Kimberly Carl
- c Johns Hopkins Home Care Group , Baltimore , Maryland , USA
| | - Dawn Hohl
- c Johns Hopkins Home Care Group , Baltimore , Maryland , USA
| | - Bruce Leff
- d Division of Geriatric Medicine and Gerontology, Department of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,e Department of Community and Public Health , Johns Hopkins School of Nursing , Baltimore , Maryland , USA.,f Department of Health Policy and Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Ayse P Gurses
- a Armstrong Institute for Patient Safety and Quality , Johns Hopkins University , Baltimore , Maryland , USA.,f Department of Health Policy and Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,g Department of Anesthesiology and Critical Care , Johns Hopkins University , Baltimore , Maryland , USA
| | - Alicia I Arbaje
- a Armstrong Institute for Patient Safety and Quality , Johns Hopkins University , Baltimore , Maryland , USA.,d Division of Geriatric Medicine and Gerontology, Department of Medicine , Johns Hopkins University , Baltimore , Maryland , USA.,h Department of Clinical Investigation , Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
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22
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Keller G, Merchant A, Common C, Laizner AM. Patient experiences of in-hospital preparations for follow-up care at home. J Clin Nurs 2017; 26:1485-1494. [DOI: 10.1111/jocn.13427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Gretchen Keller
- Ingram School of Nursing; McGill University; Montreal QC Canada
| | | | - Carol Common
- McGill University Health Centre; Montreal QC Canada
| | - Andrea M Laizner
- Ingram School of Nursing; McGill University; Montreal QC Canada
- MUHC Research Institute; Montreal QC Canada
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Ferrah N, Ibrahim JE, Kipsaina C, Bugeja L. Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process. J Aging Health 2017; 30:584-604. [PMID: 28553803 DOI: 10.1177/0898264316686575] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors.
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Affiliation(s)
| | | | | | - Lyndal Bugeja
- Monash University, Victoria, Australia
- Coroners Court of Victoria, Australia
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Lindegaard Pedersen J, Pedersen PU, Damsgaard EM. Nutritional Follow-Up after Discharge Prevents Readmission to Hospital - A Randomized Clinical Trial. J Nutr Health Aging 2017; 21:75-82. [PMID: 27999853 DOI: 10.1007/s12603-016-0745-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To compare the effects of two individualized nutritional follow-up intervention strategies (home visit or telephone consultation) with no follow-up, with regard to acute readmissions to hospital at two points in time, 30 and 90 days after discharge from hospital. DESIGN Randomized clinical trial with two intervention groups and one control group, and monitoring on readmission at 30 and 90 days after discharge. SETTING Intervention in the participants' homes after discharge from hospital. PARTICIPANTS Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: Upon discharge, the patients were stratified according to nutritional status (MNA), and assigned to one of three groups: 'home visit', 'telephone', or 'control' group. INTERVENTION Individualized nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patient's homes, or over the telephone. All patients received a diet plan on discharge. The control group received standard care, but no follow-up after discharge. MEASUREMENTS Information on readmissions to hospital and mortality at 30 and 90 days after discharge was obtained from electronic patient records. Intention-to-treat (ITT) and per-protocol (PP) analyses were carried out. RESULTS Two-hundred and eight participants were randomized, 73 to home visits, 68 to the telephone consultation group, and 67 to the control group. The mean age of the participants was 86.1 years. Home visit participants had a lower risk of readmission to hospital compared to control participants at 30 days after discharge (HR=0.4; 95% CI: 0.2-0.9, p=0.03) and 90 days after discharge (HR=0.4; 95% CI: 0.2-0.8, p<0.01). No significant difference was detected between the telephone consultation group and the control group, at either 30 days (HR=0.6, 95% CI: 0.3-1.3, p=0.18) or 90 days after discharge (HR=0.7, 95% CI: 0.4-1.3, p=0.23). The PP analysis revealed that the risk of readmission was significantly lower in the home visit group compared to the control group and the telephone consultation group compared to the control group, and this was evident at 30 days as well as at 90 days after discharge. CONCLUSION An individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention.
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Affiliation(s)
- J Lindegaard Pedersen
- Jette Lindegaard Pedersen, Clinical research nurse, Aarhus University Hospital, Geriatrics, P.P. Oerumsgade 11, Aarhus, 8000, Denmark, 0045 40256721,
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Brody AA, Gibson B, Tresner-Kirsch D, Kramer H, Thraen I, Coarr ME, Rupper R. High Prevalence of Medication Discrepancies Between Home Health Referrals and Centers for Medicare and Medicaid Services Home Health Certification and Plan of Care and Their Potential to Affect Safety of Vulnerable Elderly Adults. J Am Geriatr Soc 2016; 64:e166-e170. [PMID: 27673753 DOI: 10.1111/jgs.14457] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe the prevalence of discrepancies between medication lists that referring providers and home healthcare (HH) nurses create. DESIGN The active medication list from the hospital at time of HH initiation was compared with the HH agency's plan of care medication list. An electronic algorithm was developed to compare the two lists for discrepancies. SETTING Single large hospital and HH agency in the western United States. PARTICIPANTS Individuals referred for HH from the hospital in 2012 (N = 770, 96.3% male, median age 71). MEASUREMENTS Prevalence was calculated for discrepancies, including medications missing from one list or the other and differences in dose, frequency, or route for medications contained on both lists. RESULTS Participants had multiple medical problems (median 16 active problems) and were taking a median of 15 medications (range 1-93). Every participant had at least one discrepancy; 90.1% of HH lists were missing at least one medication that the referring provider had prescribed, 92.1% of HH lists contained medications not on the referring provider's list, 89.8% contained medication naming errors. 71.0% contained dosing discrepancies, and 76.3% contained frequency discrepancies. CONCLUSION Discrepancies between HH and referring provider lists are common. Future work is needed to address possible safety and care coordination implications of discrepancies in this highly complex population.
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Affiliation(s)
- Abraham A Brody
- Geriatric Research Education and Clinical Center, James J. Peters Bronx Veterans Affairs Medical Center, Bronx, New York.,Hartford Institute for Geriatric Nursing, College of Nursing, New York University, New York, New York
| | - Bryan Gibson
- Informatics Decision-Enhancement and Analytic Sciences, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - David Tresner-Kirsch
- MITRE Corporation, Bedford, Massachusetts.,Brandeis University, Waltham, Massachusetts
| | - Heidi Kramer
- Informatics Decision-Enhancement and Analytic Sciences, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Iona Thraen
- Geriatric Research Education and Clinical Center, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah.,College of Social Work, University of Utah, Salt Lake City, Utah
| | | | - Randall Rupper
- Geriatric Research Education and Clinical Center, George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah.,Department of Geriatrics, University of Utah, Salt Lake City, Utah
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Sefcik JS, Nock RH, Flores EJ, Chase JAD, Bradway C, Potashnik S, Bowles KH. Patient Preferences for Information on Post-Acute Care Services. Res Gerontol Nurs 2016; 9:175-82. [PMID: 26815304 PMCID: PMC4955661 DOI: 10.3928/19404921-20160120-01] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/04/2015] [Indexed: 11/20/2022]
Abstract
The purpose of the current study was to explore what hospitalized patients would like to know about post-acute care (PAC) services to ultimately help them make an informed decision when offered PAC options. Thirty hospitalized adults 55 and older in a Northeastern U.S. academic medical center participated in a qualitative descriptive study with conventional content analysis as the analytical technique. Three themes emerged: (a) receiving practical information about the services, (b) understanding "how it relates to me," and (c) having opportunities to understand PAC options. Study findings inform clinicians what information should be included when discussing PAC options with older adults. Improving the quality of discharge planning discussions may better inform patient decision making and, as a result, increase the numbers of patients who accept a plan of care that supports recovery, meets their needs, and results in improved quality of life and fewer readmissions. [Res Gerontol Nurs. 2016; 9(4):175-182.].
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Affiliation(s)
- Justine S. Sefcik
- F31NR015693, University of Pennsylvania School of Nursing, Philadelphia, PA,
| | - Rebecca H. Nock
- T32NR009356, Center for Integrative Science in Aging and, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,
| | - Emilia J. Flores
- Center for Integrative Science in Aging and, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA,
| | - Jo-Ana D. Chase
- University of Missouri Sinclair School of Nursing, S343 Sinclair School of Nursing, Columbia, MO, 65211
- T32NR009356, University of Pennsylvania School of Nursing, Philadelphia, PA,
| | - Christine Bradway
- CISA/Dept of Biobehavioral Health Sciences University of Pennsylvania School of Nursing Philadelphia, PA
| | - Sheryl Potashnik
- Decision Support: Optimizing Post-Acute Referrals and Effect on Patient Outcomes, University of Pennsylvania School of Nursing, Philadelphia, PA,
| | - Kathryn H. Bowles
- University of Pennsylvania School of Nursing, Vice President for Research and Director of the Center for Home Care Policy and Research, Visiting Nurse Service of New York, Claire M. Fagin School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104
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Lauck SB, Wood DA, Baumbusch J, Kwon JY, Stub D, Achtem L, Blanke P, Boone RH, Cheung A, Dvir D, Gibson JA, Lee B, Leipsic J, Moss R, Perlman G, Polderman J, Ramanathan K, Ye J, Webb JG. Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway. Circ Cardiovasc Qual Outcomes 2016; 9:312-21. [DOI: 10.1161/circoutcomes.115.002541] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 03/12/2016] [Indexed: 11/16/2022]
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Chen L, Sit JWH, Shen X. Quasi-experimental evaluation of a home care model for patients with stroke in China. Disabil Rehabil 2016; 38:2271-6. [DOI: 10.3109/09638288.2015.1123305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Desai AD, Popalisky J, Simon TD, Mangione-Smith RM. The effectiveness of family-centered transition processes from hospital settings to home: a review of the literature. Hosp Pediatr 2015; 5:219-31. [PMID: 25832977 DOI: 10.1542/hpeds.2014-0097] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization. METHODS We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes≤30 days after discharge, and US studies. Transition processes, principal outcome measures (patient health outcomes and health care utilization), and assessment time-frames were extracted for each study. RESULTS The search yielded 3458 articles, and 16 clinical trials met final inclusion criteria. Four studies evaluated pediatric ED-to-home transitions and indicated family-tailored discharge education was associated with better patient health outcomes. Remaining trials evaluating adult hospital-to-home transitions indicated a transition needs assessment or provision of an individualized transition record was associated with better patient health outcomes and reductions in health care utilization. The effectiveness of postdischarge telephone follow-up and/or home visits on health care utilization showed mixed results. CONCLUSIONS Patient-tailored discharge education is associated with improved patient health outcomes in pediatric ED patients. Effective transition processes identified in the adult literature may inform future quality improvement research regarding pediatric hospital-to-home transitions.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
| | - Jean Popalisky
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
| | - Rita M Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and Seattle Children's Research Institute, Seattle, Washington
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Kornhaber R, Wiechula R, McLean L. The effectiveness of collaborative models of care that facilitate rehabilitation from a traumatic injury: a systematic review. ACTA ACUST UNITED AC 2015. [DOI: 10.11124/01938924-201513080-00016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Developing a rural transitional care community case management program using clinical nurse specialists. CLIN NURSE SPEC 2015; 28:147-55. [PMID: 24714432 DOI: 10.1097/nur.0000000000000044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority. BACKGROUND As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed. RATIONALE Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions. DESCRIPTION After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients. OUTCOMES The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care. CONCLUSION Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems. IMPLICATIONS The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.
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Reidt SL, Larson TA, Hadsall RS, Uden DL, Blade MA, Branstad R. Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits. ACTA ACUST UNITED AC 2015; 32:146-52. [PMID: 24584311 DOI: 10.1097/nhh.0000000000000024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Medication regimens can be complicated during the transition from hospital to home for a variety of reasons. The primary purpose of this retrospective study was to measure the impact of integrating a pharmacist into a model of care at a Medicare-certified home healthcare agency for clients recently discharged from the hospital. The secondary purpose was to describe the medication-related problems among clients receiving services from the model of care involving a pharmacist. Integrating a pharmacist within the model of care demonstrated a positive clinical impact on clients.
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Affiliation(s)
- Shannon L Reidt
- Shannon L. Reidt, PharmD, MPH, BCPS, is an Assistant Professor at University of Minnesota College of Pharmacy, Minneapolis, Minnesota. Tom A. Larson, PharmD, is a Professor at University of Minnesota College of Pharmacy Minneapolis, Minnesota. Ronald S. Hadsall, PhD, is a Professor at University of Minnesota College of Pharmacy Minneapolis, Minnesota. Donald L. Uden, PharmD, is a Professor at University of Minnesota College of Pharmacy, Minneapolis, Minnesota. Mary Ann Blade, RN, is the former CEO, Minnesota Visiting Nurse Agency, Minneapolis, Minnesota. Rachel Branstad, PharmD, is a Pharmacy Practice Resident, Hennepin County Medical Center, Minneapolis, Minnesota
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Hvalvik S, Reierson IÅ. 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. Int J Qual Stud Health Well-being 2015; 10:26554. [PMID: 25746043 PMCID: PMC4352170 DOI: 10.3402/qhw.v10.26554] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Sigrun Hvalvik
- Faculty of Health and Social Studies, Telemark University College, 3901 Porsgrunn, Norway
- Centre for Caring Research-Southern Norway, Telemark University College, 3901 Porsgrunn, Norway and University of Agder, 4898 Grimstad, Norway;
| | - Inger Å Reierson
- Faculty of Health and Social Studies, Telemark University College, 3901 Porsgrunn, Norway
- Centre for Caring Research-Southern Norway, Telemark University College, 3901 Porsgrunn, Norway and University of Agder, 4898 Grimstad, Norway
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Impact of discharge planning decision support on time to readmission among older adult medical patients. Prof Case Manag 2015; 19:29-38. [PMID: 24300427 DOI: 10.1097/01.pcama.0000438971.79801.7a] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE STUDY Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission. PRIMARY PRACTICE SETTING Four medical units at one urban, university medical center. METHODOLOGY AND SAMPLE A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental). RESULTS After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.
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Barber RD, Coulourides Kogan A, Riffenburgh A, Enguidanos S. A role for social workers in improving care setting transitions: a case study. SOCIAL WORK IN HEALTH CARE 2015; 54:177-92. [PMID: 25760487 PMCID: PMC5479582 DOI: 10.1080/00981389.2015.1005273] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
High 30-day readmission rates are a major burden to the American medical system. Much attention is on transitional care to decrease financial costs and improve patient outcomes. Social workers may be uniquely qualified to improve care transitions and have not previously been used in this role. We present a case study of an older, dually eligible Latina woman who received a social work-driven transition intervention that included in-home and telephone contacts. The patient was not readmitted during the six-month study period, mitigated her high pain levels, and engaged in social outings once again. These findings suggest the value of a social worker in a transitional care role.
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Affiliation(s)
- Ruth D Barber
- a Davis School of Gerontology, University of Southern California , Los Angeles , California , USA
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Roots A, MacDonald M. Outcomes associated with nurse practitioners in collaborative practice with general practitioners in rural settings in Canada: a mixed methods study. HUMAN RESOURCES FOR HEALTH 2014; 12:69. [PMID: 25495058 PMCID: PMC4292823 DOI: 10.1186/1478-4491-12-69] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 12/01/2014] [Indexed: 06/01/2023]
Abstract
BACKGROUND The formalized nurse practitioner (NP) role in British Columbia is relatively new with most roles implemented in primary care. The majority of primary care is delivered by physicians using the fee-for-service model. There is a shortage of general practitioners associated with the difficulties of recruitment and retention, particularly in rural and remote locations. The uptake of the primary care NP role has been slow due to challenges in understanding the extent of its contributions. This study aims to identify the outcomes associated with the NP role in collaborative primary care practice. METHODS Three case studies where NPs were embedded into rural fee-for-service practices were undertaken to determine the outcomes at the practitioner, practice, community, and health services levels. Interviews, documents, and before and after data, were analyzed to identify changes in practise, access, and acute care service utilization. RESULTS The results showed that NPs affected how care was delivered, particularly through the additional time afforded each patient visit, development of a team approach with interprofessional collaboration, and a change in style of practise from solo to group practise, which resulted in improved physician job satisfaction. Patient access to the practice improved with increased availability of appointments and practice staff experienced improved workplace relationships and satisfaction. At the community level, access to primary care improved for harder-to-serve populations and new linkages developed between the practice and their community. Acute care services experienced a statistically significant decrease in emergency use and admissions to hospital (P = 0.000). The presence of the NP improved their physician colleagues' desire to remain in their current work environment. CONCLUSIONS This study identified the diversity of needs that can be addressed by the NP role. Namely, the importance of time to enhance patient care and its associated benefits, especially in the fee-for-service model; the value of the NP's role in the community; the acceptance of the clinical competence of NPs by their physician colleagues; the outcomes generated at the practice level in terms of organizational effectiveness and service provision; and substantiated the impact of the role in improving primary care access and reducing acute care utilization.
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Affiliation(s)
- Alison Roots
- />School of Health and Human Sciences, Southern Cross University, PO Box 157, Lismore, NSW 2480 Australia
| | - Marjorie MacDonald
- />School of Nursing, University of Victoria, HSD A402, STN CSC, PO Box 1700, Victoria, BC V8W 2Y2 Canada
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Daiello LA, Gardner R, Epstein-Lubow G, Butterfield K, Gravenstein S. Association of dementia with early rehospitalization among Medicare beneficiaries. Arch Gerontol Geriatr 2014; 59:162-8. [PMID: 24661400 DOI: 10.1016/j.archger.2014.02.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 02/25/2014] [Accepted: 02/28/2014] [Indexed: 01/22/2023]
Abstract
Preventable hospital readmissions have been recognized as indicators of hospital quality, a source of increased healthcare expenditures, and a burden for patients, families, and caregivers. Despite growth of initiatives targeting risk factors associated with potentially avoidable hospital readmissions, the impact of dementia on the likelihood of rehospitalization is poorly characterized. Therefore, the primary objective of this retrospective cohort study was to investigate whether dementia was an independent predictor of 30-day readmissions. Administrative claims data for all admissions to Rhode Island hospitals in 2009 was utilized to identify hospitalizations of Medicare fee-for-service beneficiaries with a diagnosis of Alzheimer's Disease or other dementias. Demographics, measures of comorbid disease burden, and other potential confounders were extracted from the data and the odds of 30-day readmission to any United States hospital was calculated from conditional logistic regression models. From a sample of 25,839 hospitalizations, there were 3908 index admissions of Medicare beneficiaries who fulfilled the study criteria for a dementia diagnosis. Nearly 20% of admissions (n=5133) were followed by a readmission within thirty days. Hospitalizations of beneficiaries with a dementia diagnosis were more likely to be followed by a readmission within thirty days (adjusted odds ratio (AOR) 1.18; 95% CI, 1.08, 1.29), compared to hospitalizations of those of without dementia. Controlling for discharge site of care did not attenuate the association (AOR 1.21; 95% CI, 1.10, 1.33).
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Affiliation(s)
- Lori A Daiello
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA; Alzheimer's Disease and Memory Disorders Center, Rhode Island Hospital, Providence, RI, USA.
| | - Rebekah Gardner
- Healthcentric Advisors, Providence, RI, USA; Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Gary Epstein-Lubow
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA; Butler Hospital, Geriatric Psychiatry, Providence, RI, USA
| | | | - Stefan Gravenstein
- Healthcentric Advisors, Providence, RI, USA; Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Hanratty B, Lowson E, Grande G, Payne S, Addington-Hall J, Valtorta N, Seymour J. Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02170] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe end of life may be a time of high service utilisation for older adults. Transitions between care settings occur frequently, but may produce little improvement in symptom control or quality of life for patients. Ensuring that patients experience co-ordinated care, and moves occur because of individual needs rather than system imperatives, is crucial to patients’ well-being and to containing health-care costs.ObjectiveThe aim of this study was to understand the experiences, influences and consequences of transitions between settings for older adults at the end of life. Three conditions were the focus of study, chosen to represent differing disease trajectories.SettingEngland.ParticipantsThirty patients aged over 75 years, in their last year of life, diagnosed with heart failure, lung cancer and stroke; 118 caregivers of decedents aged 66–98 years, who had died with heart failure, lung cancer, stroke, chronic obstructive pulmonary disease or selected other cancers; and 43 providers and commissioners of services in primary care, hospital, hospice, social care and ambulance services.Design and methodsThis was a mixed-methods study, composed of four parts: (1) in-depth interviews with older adults; (2) qualitative interviews and structured questionnaire with bereaved carers of older adult decedents; (3) telephone interviews with care commissioners and providers using case scenarios derived from the interviews with carers; and (4) analysis of linked Hospital Episode Statistics (HES) and mortality data relating to hospital admissions for heart failure and lung cancer in England 2001–10.ResultsTransitions between care settings in the last year of life were a common component of end-of-life care across all the data sets that made up this study, and many moves were made shortly before death. Patients’ and carers’ experiences of transitions were of a disjointed system in which organisational processes were prioritised over individual needs. In many cases, the family carer was the co-ordinator and provider of care at home, excluded from participation in institutional care but lacking the information and support to extend their role with confidence. The general practitioner (GP) was a valued, central figure in end-of-life care across settings, though other disciplines were critical of GPs’ expertise and adherence to guidelines. Out-of-hours services and care homes were identified by many as contributors to unnecessary transitions. Good relationships and communication between professionals in different settings and sectors was recognised by families as one of the most important influences on transitions but this was rarely acknowledged by staff.ConclusionsDevelopment of a shared understanding of professional and carer roles in end-of-life transitions may be one of the most effective ways of improving patients’ experiences. Patients and carers manage many aspects of end-of-life care for themselves. Identifying ways to extend their skills and strengthen their voices, particularly in hospital settings, would be welcomed and may reduce unnecessary end-of-life transitions. Why the experiences of carers appear to have changed little, despite the implementation of a range of relevant policies, is an important question that has not been answered. Recommendations for future research include the relationship between policy interventions and the experiences of end-of-life carers; identification of ways to harmonise understanding of the carers’ role and strengthen their voice, particularly in hospital settings; identification of ways to reduce the influence of interprofessional tensions in end-of-life care; and development of interventions to enhance patients’ experiences across transitions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Barbara Hanratty
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Elizabeth Lowson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Gunn Grande
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Sheila Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | | | - Nicole Valtorta
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Jane Seymour
- School of Health Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham, UK
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Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study. Int J Integr Care 2014; 14:e012. [PMID: 24868195 PMCID: PMC4027933 DOI: 10.5334/ijic.1525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 02/04/2014] [Accepted: 02/07/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient's health status and individual needs. The objective of this study was to identify and describe the process and content of the patient information exchange between nurses in home care and hospital during hospitalization of older home-living patients. Methods A multiple case study design was used. Using observations, qualitative interviews and document reviews, the total patient information exchange during each patient's episode of hospitalization (n = 9), from day of admission to return home, was captured. Results Information exchange mainly occurred at discharge, including a discharge note sent from hospital to home care, and telephone reports from hospital nurse to home care nurse, and meetings between hospital nurse and patient coordinator from the municipal purchaser unit. No information was provided from the home care nurses to the hospital nurses at admission. Incompleteness in the content of both written and verbal information was found. Information regarding physical care was more frequently reported than other caring dimensions. Descriptions of the patients’ subjective experiences were almost absent and occurred only in the verbal communication. Conclusions The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange.
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Reid RC, Cummings GE, Cooper SL, Abel SL, Bissell LJ, Estabrooks CA, Rowe BH, Wagg A, Norton PG, Ertel M, Cummings GG. The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool. BMC Health Serv Res 2013; 13:515. [PMID: 24330805 PMCID: PMC3867622 DOI: 10.1186/1472-6963-13-515] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 12/09/2013] [Indexed: 11/13/2022] Open
Abstract
Background OPTIC is a mixed method Partnership for Health System Improvement (http://www.cihr-irsc.gc.ca/e/34348.html) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3). Methods The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing. Results Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings. Conclusions While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Greta G Cummings
- Faculty of Nursing, University of Alberta, 5-110 Edmonton Clinical Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9, Canada.
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Dale B, Hvalvik S. Administration of care to older patients in transition from hospital to home care services: home nursing leaders' experiences. J Multidiscip Healthc 2013; 6:379-89. [PMID: 24124378 PMCID: PMC3794989 DOI: 10.2147/jmdh.s51947] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Older persons in transition between hospital and home care services are in a particularly vulnerable situation and risk unfortunate consequences caused by organizational inefficiency. The purpose of the study reported here was to elucidate how home nursing leaders experience the administration of care to older people in transition from hospital to their own homes. METHODS A qualitative study design was used. Ten home nursing leaders in two municipalities in southern Norway participated in individual interviews. The interview texts were audio taped, transcribed verbatim and analyzed by use of a phenomenological-hermeneutic approach. RESULTS Three main themes and seven subthemes were deduced from the data. The first main theme was that the home nursing leaders felt challenged by the organization of home care services. Two subthemes were identified related to this. The first was that the leaders lacked involvement in the transitional process, and the second was that they were challenged by administration of care being decided at another level in the municipality. The second main theme found was that the leaders felt that they were acting in a shifting and unsettled context. Related to this, they had to adjust internal resources to external demands and expectations, and experienced lack of communication with significant others. The third main theme identified was that the leaders endeavored to deliver care in accordance with professional values. The two related subthemes were, first, that they provided for appropriate internal systems and routines, and, second, that they prioritized available professional competence, and made an effort to promote a professional culture. CONCLUSION To meet the complex needs of the patients in a professional way, the home nursing leaders needed to be flexible and pragmatic in their administration of care. This involved utilizing available professional competence appropriately. The coordination and communication between the different organizational levels and units were pointed out as major factors requiring improvement.
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Affiliation(s)
- Bjørg Dale
- Centre for Caring Research - Southern Norway, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
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Long T, Genao I, Horwitz LI. Reasons for readmission in an underserved high-risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open 2013; 3:e003212. [PMID: 24056478 PMCID: PMC3780332 DOI: 10.1136/bmjopen-2013-003212] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients. DESIGN We created an instrument with 27 open-ended questions based on current interventions. SETTING Yale-New Haven Hospital. PATIENTS Patients at the Yale Adult Primary Care Center (PCC). MEASUREMENTS We conducted semi-structured qualitative interviews of patients who had four or more admissions in the previous 6 months and were currently readmitted to the hospital. RESULTS We completed 17 interviews and identified themes relating to risk of readmission. We found that patients went directly to the emergency department (ED) when they experienced a change in health status without contacting their primary provider. Reasons for this included poor telephone or urgent care access and the belief that the PCC could not treat acute illness. Many patients could not name their primary provider. Conversely, every patient except one reported being able to obtain medications without undue financial burden, and every patient reported receiving adequate home care services. CONCLUSIONS These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships. Formal transitional care services are unlikely to be adequate in reducing readmissions without also addressing primary care access and continuity.
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Affiliation(s)
- Theodore Long
- Internal Medicine Residency Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- The Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA
| | - Inginia Genao
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Leora I Horwitz
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
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Ruggiano N, Brown EL, Hristidis V, Page TF. Adding Home Health Care to the Discussion on Health Information Technology Policy. Home Health Care Serv Q 2013; 32:149-62. [DOI: 10.1080/01621424.2013.813884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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"Just another fish in the pond": the transitional care experience of a hip fracture patient. Int J Integr Care 2013; 13:e023. [PMID: 23882170 PMCID: PMC3718274 DOI: 10.5334/ijic.1103] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 04/19/2013] [Accepted: 04/21/2013] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care. METHODS This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings. RESULTS FOUR KEY THEMES WERE IDENTIFIED OVER THE PATIENTS CARE TRAJECTORY: 'Missing Crucial Coversations'-Patient and family caregivers did not feel involved or informed about decisions in care; 'Who's Who'-Confusion about the role of health care providers; 'Ready or Not'-Not knowing what to expect or what is expected; and, 'Playing by the Rules'-Health system policies and procedures hinder individualized care. CONCLUSION Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.
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Mittler JN, O'Hora JL, Harvey JB, Press MJ, Volpp KG, Scanlon DP. Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions. Popul Health Manag 2013; 16:255-60. [PMID: 23437868 DOI: 10.1089/pop.2012.0087] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Efforts are under way nationally to reduce avoidable hospital readmissions by changing payments to hospitals, but it is unclear how well or how quickly these policy changes will produce widespread reductions in hospital readmissions. To examine some of the challenges to implementing such approaches, the authors analyzed the early experiences of 3 statewide programs to reduce preventable readmissions that began in 2009. Based on interviews with program participants in 2011, the authors identified 3 key obstacles to progress: the difficulty of developing collaborative relationships across care settings, gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations. These findings underscore the uncertainty of success of current readmissions policies and suggest that immediate improvement in readmission rates through a change in reimbursement may be unlikely unless these other obstacles are addressed expeditiously. In particular, cultivation of productive collaboration across care settings will be critical because these kinds of relationships are not well established or naturally occurring in most communities.
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Affiliation(s)
- Jessica N Mittler
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania 16803, USA.
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Deitelzweig SB. Transitions of care in anticoagulation management for patients with atrial fibrillation. Hosp Pract (1995) 2013; 40:20-7. [PMID: 23299032 DOI: 10.3810/hp.2012.10.999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Thromboprophylaxis with oral anticoagulants (OACs) is an important but underused element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.
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Affiliation(s)
- Steven B Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA.
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McLeod J, Stolee P, Walker J, Heckman G. Measuring care transition quality for older patients with musculoskeletal disorders. Musculoskeletal Care 2013; 12:13-21. [PMID: 23300145 DOI: 10.1002/msc.1043] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim of the current study was to examine the ability of a performance measurement scale, the Care Transitions Measure (CTM) adequately to assess the quality of care transitions among a complex population of older musculoskeletal (MSK) rehabilitation patients. METHODS Fifteen older (aged 60+) patients with MSK disorders were recruited from two inpatient rehabilitation units. A telephone interview was conducted three to four weeks post-discharge; this included the CTM and global questions used for construct validation. To assess inter-rater reliability, the CTM was re-administered to ten subjects in a second interview six to ten days later. Participant comments were recorded in an effort to gauge how respondents understood and interpreted items. RESULTS The CTM demonstrated acceptable inter-rater reliability for the overall score (intraclass correlation coefficient = 0.77; p = 0.03), in spite of only fair agreement for specific items. The internal consistency was high (Cronbach's alpha = 0.94). The construct validity was supported; however, qualitative data suggest that additional items should be considered for inclusion, and the need for revisions to the wording of the response options and some items. CONCLUSIONS Although the CTM proved to be reliable for an MSK population, there is a need for modifications to improve the construct validity and utility of the CTM. Recommendations for scale improvement are made. The results of the present study support efforts to improve the outcomes of care transitions, care planning and the overall quality of life for older rehabilitation patients.
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Affiliation(s)
- Jordache McLeod
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Enderlin CA, McLeskey N, Rooker JL, Steinhauser C, D'Avolio D, Gusewelle R, Ennen KA. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs 2012; 34:47-52. [PMID: 23122908 DOI: 10.1016/j.gerinurse.2012.08.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 08/16/2012] [Accepted: 08/20/2012] [Indexed: 11/26/2022]
Abstract
Older adults are at high risk for gaps in care as they move between health care providers and settings during the course of illness, such as following hospital discharge. These gaps in care may result in unnecessary re-hospitalization and even death. Nurses can assist older adults to achieve successful transitions of care by taking a systematic approach and individualizing care to meet patient and family health literacy, cognitive, and sensory needs. This article reviews trends in transitions of care, models, partnerships, and health literacy. Models described include the Transitional Care Model, Care Transitions Program, Project BOOST (Better Outcomes for Older adults through Safe Transitions), Project RED (Re-engineered Discharge), Chronic Care Model, and INTERACT(II) (Interventions to Reduce Acute Care Transfers). Approaches to transitions of care are discussed, and resources for geriatric nurses are provided.
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Affiliation(s)
- Carol A Enderlin
- College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham, Slot #529, Little Rock, AR 72205, USA.
| | - Nanci McLeskey
- Gerontology, University of Utah, College of Nursing, 10 South 2000 East, Salt Lake City, UT 84112, USA
| | - Janet L Rooker
- College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham, Slot #529, Little Rock, AR 72205, USA
| | - Colleen Steinhauser
- Nebraska Methodist College of Nursing and Allied Health, 720 North 87th Street, Omaha, NE 61884, USA
| | - Deborah D'Avolio
- Northeastern University, Bouve College of Health Sciences, School of Nursing, 106 C, 360 Huntington Avenue, Boston, MA 02115, USA
| | - Riesa Gusewelle
- United Health Care, House Calls Program, Little Rock, AR, USA
| | - Kathleen A Ennen
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA
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