Care co-ordination improves quality-of-care at South Auckland Health

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

CONTEXT

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.

OBJECTIVE

In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.

DATA SOURCES

We searched 7 bibliographic databases and 5 pediatric journals.

STUDY SELECTION

Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.

DATA EXTRACTION

Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.

RESULTS

Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.

LIMITATIONS

Variability limited findings and reduced generalizability.

CONCLUSIONS

In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Implementation and Evaluation of a Unit-Based Discharge Coordinator to Improve the Patient Discharge Experience

Hospitals are currently focusing on quality measure initiatives such as patient safety, satisfaction scores, and patient length of stay. Inefficient and ineffective discharge planning is often directly associated with long hospital stays and poor patient satisfaction with the overall discharge process. The purpose of this quality improvement initiative is to describe and address the implementation and evaluation of a unit-based discharge coordinator role on a general medicine pediatric unit at a tertiary care children's hospital. Improved outcomes, including an increase in patient satisfaction with the discharge process, decreased length of stay, and a decrease in patient safety net reports are demonstrated through implementation. A unit-based discharge coordinator can play an important part in enhancing the overall discharge experience for the patient and families by providing an effective and efficient approach to discharge, providing the patients and families with a feeling of preparedness.

Identifying keys to success in reducing readmissions using the ideal transitions in care framework

BACKGROUND

Systematic attempts to identify best practices for reducing hospital readmissions have been limited without a comprehensive framework for categorizing prior interventions. Our research aim was to categorize prior interventions to reduce hospital readmissions using the ten domains of the Ideal Transition of Care (ITC) framework, to evaluate which domains have been targeted in prior interventions and then examine the effect intervening on these domains had on reducing readmissions.

METHODS

Review of literature and secondary analysis of outcomes based on categorization of English-language reports published between January 1975 and October 2013 into the ITC framework.

RESULTS

66 articles were included. Prior interventions addressed an average of 3.5 of 10 domains; 41% demonstrated statistically significant reductions in readmissions. The most common domains addressed focused on monitoring patients after discharge, patient education, and care coordination. Domains targeting improved communication with outpatient providers, provision of advanced care planning, and ensuring medication safety were rarely included. Increasing the number of domains included in a given intervention significantly increased success in reducing readmissions, even when adjusting for quality, duration, and size (OR per domain, 1.5, 95% CI 1.1 - 2.0). The individual domains most associated with reducing readmissions were Monitoring and Managing Symptoms after Discharge (OR 8.5, 1.8 - 41.1), Enlisting Help of Social and Community Supports (OR 4.0, 1.3 - 12.6), and Educating Patients to Promote Self-Management (OR 3.3, 1.1 - 10.0).

CONCLUSIONS

Interventions to reduce hospital readmissions are frequently unsuccessful; most target few domains within the ITC framework. The ITC may provide a useful framework to consider when developing readmission interventions.

Who does what? How staff in England and Denmark perceive roles in the coordination of children's inpatient care: a comparison of questionnaire survey data

AIMS AND OBJECTIVES

To explore and compare staff perceptions of their own and others roles in the coordination of care for children in hospital in Denmark and England.

BACKGROUND

The provision of well-coordinated care is a declared aim of health care providers; however, there is no universally held model for achieving this. Staff have developed ways of coordinating care in response to local conditions creating diversity and inconsistency in practice.

DESIGN

Survey.

METHODS

A structured self-administered questionnaire was used to gather perceptions of clinical staff (n = 85) about who should perform a range of specific care coordination activities. The study sites were two Danish and two English hospitals that provided local and regional children's services. Data were coded and analysis assisted by using Excel spreadsheets.

RESULTS

In both countries care coordination was perceived to involve many different staff groups. Of these, nurses and doctors were named most frequently as being responsible for coordination activities. There was consensus between countries about who should perform half the activities listed. Where there was not consensus, this was due to more frequent naming of administrative staff in the English sites and more frequent naming of nurses in the Danish sites. Overall, greater clarity about who should perform specific activities was recorded by the Danish staff.

CONCLUSIONS

Staff in England and Denmark hold many shared perceptions in relation to the performance of care coordination activities and their own roles in relation to these. However, the lack of clarity about who should perform specific tasks revealed by the English respondents indicates a greater potential here for omission or duplication of care coordination activities.

RELEVANCE TO CLINICAL PRACTICE

Clarification of who should perform specific activities may contribute to improved coordination of care by reducing the opportunity for duplication or omission in the process of care.

Rules and resources: a structuration approach to understanding the coordination of children's inpatient health care

AIM

This paper presents findings from a multi-method study exploring the process of care coordination in children's inpatient health care.

BACKGROUND

Existing work on care coordination is typified by "black-box" type studies that measure inputs to and outcomes of care coordination roles and practices, without addressing the process of coordination.

METHOD

Using questionnaires, interviews and observation to collect data in multiple sites in the United Kingdom and Denmark between 1999 and 2005, the study gathered the perceptions of staff and compared these with observed practice. Giddens' structuration theory was used to provide an analytical and explanatory framework.

FINDINGS

Current care coordination practice is diverse and inconsistent. It involves a wide range of clinical and non-clinical staff, many of whom perceive a lack of clarity about who should perform specific coordination activities. Staff draw upon a wide range of different material and non-material resources in coordinating care, the use of which is governed by largely tacit and informal rules.

CONCLUSIONS

Care coordination can be usefully conceptualized as a "structurated" process--one that is continually produced and reproduced by staff using rules and resources to "instantiate" or bring about care coordination through action. Potentially negative implications of this are manifested in diversity and inconsistency in care coordination practice. However, positive aspects such as the opportunity this provides to tailor care to the needs of the individual patient can be realized.

Discharge Planning Process

Discharge planning is an integral but ill-defined process in most acute care settings. The time available to a healthcare team to adequately prepare patients for discharge has virtually evaporated with decreasing lengths of hospital stay. A research utilization (RU) team at a tertiary care teaching institution reviewed the literature from 1990 to 2002 in search of a research-based practice regarding staff nurses' roles in the discharge process. Review of the literature revealed varied discharge planning processes using staff nurses, advanced practice nurses, or case managers specifically prepared to implement the discharge planning process. Insufficient evidence was found to support a change from the current staff nurse practice.

Interprofessional care co-ordinators: the benefits and tensions associated with a new role in UK acute health care

While more flexible models of service delivery are being introduced in UK health and social care, little is known about the impact of new roles, particularly support worker roles, on the work of existing practitioners. This action research study aimed to explore the impact of one such new role, that of interprofessional care co-ordinators (IPCCs). The general (internal) medical service of a UK hospital uses IPCCs to provide support to the interprofessional team and, in doing so, promote efficiency of acute bed use. Using a range of methods, mainly qualitative, this action research study sought to explore the characteristics and impact of the role on interprofessional team working. While the role's flexibility, autonomy and informality contributed to success in meeting its intended objectives, these characteristics also caused some tensions with interprofessional colleagues. These benefits and tensions mirror wider issues associated with the current modernisation agenda in UK health care.

The association between care co-ordination and emergency department use in older managed care enrollees

Objective

To investigate the association between care co-ordination and use of the Emergency Department (ED) in older managed care enrollees.

Design

Nested case-control with 103 cases (used the ED) and 194 controls (did not use the ED).

Patients and methods

Older patients with multiple chronic illnesses enrolled in a care management programme of a large group-model health maintenance organisation with more than 50,000 members over the age of 64. Better care co-ordination was defined as timely follow-up after a change in treatment; fewer decision-makers involved with the care plan; and a higher patient-perceived rating of overall care co-ordination. Logistic regression was used to assess the relationship between ED use (the outcome variable) and measures of care co-ordination (the predictor variables).

Results

Self-reported care co-ordination was not significantly different between cases and controls for any of the four classifications of inappropriate ED use. Similarly, no differences were found in the number of different physicians or medication prescribers involved in the patients' care. Four-week follow-up after potentially high-risk events for subsequent ED use, including changes in chronic disease medications, missed encounters, and same day encounters, did not differ between subjects with inappropriate ED use and controls.

Conclusion

Existing measures of care co-ordination were not associated with inappropriate ED use in this study of older adults with complex care needs. The absence of an association may, in part, be attributable to the paucity of validated measures to assess care co-ordination, as well as the methodological complexity inherent in studying this topic. Future research should focus on the development of new measures and on approaches that better isolate the role of care co-ordination from other potential variables that influence utilisation.

National Service Framework for Older People: stroke coordinators

The National Service Framework (NSF) for Older People aims to develop integrated stroke services with specialized treatment, carer involvement, secondary prevention and rehabilitation. There is an emphasis upon the role of stroke coordinators. The aim of this study was to examine the relationships between stroke coordinators and other agencies involved in stroke care, and to describe stroke coordinators' current roles. Interviews with 11 stroke coordinators across the West Midlands region took place and were evaluated using a grounded theory approach. The roles of stroke coordinators and the perceived levels of integration among stroke services varied between localities. In a few areas, a number of 'adhesive' factors helped bond the coordinator role to successful integration, while in most areas the absence of all or some of these factors made the role less effective. To meet the demands of the NSF, a stroke coordinator's role needs to be a high profile, corporate function, requiring a higher level of autonomy, accountability and responsibility, and demanding creativity and innovation from post holders.