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Morley C, Jose K, Hall SE, Shaw K, McGowan D, Wyss M, Winzenberg T. Evidence-informed, experience-based co-design: a novel framework integrating research evidence and lived experience in priority-setting and co-design of health services. BMJ Open 2024; 14:e084620. [PMID: 39122385 DOI: 10.1136/bmjopen-2024-084620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024] Open
Abstract
OBJECTIVE To describe a new co-design framework termed Evidence-informed, Experience-based Co-design (E2CD). BACKGROUND Involving consumers and clinicians in planning, designing and implementing services results in the end-product being more likely to meet the needs of end-users and increases the likelihood of their uptake and sustainability. Different forms and definitions of co-design have been described in the literature and have had varying levels of success in health service redesign. However, many fall short of including people with lived experience in all aspects of the process, particularly in setting priorities for service (re)design. In addition, health services need to deliver evidence-based care as well as care that meets the needs of users, yet few ways of integrating research evidence into co-design processes are described. This paper describes a new framework to approach co-design which addresses these issues. We believe that it offers a roadmap to address some of healthcare's most wicked problems and potentially improve outcomes for some of the most vulnerable people in our society. We use improving services for people with high healthcare service utilisation as a working example of the Framework's application. CONCLUSION Evidence-informed experience-based co-design has the potential to be used as a framework for co-design that integrates research evidence with lived experience and provides people with lived experience a central role in decision-making about prioritising and designing services to meet their needs.
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Affiliation(s)
- Claire Morley
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kim Jose
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Sonj E Hall
- Bellberry Ltd, Eastwood, South Australia, Australia
| | - Kelly Shaw
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- KPHealth, Hobart, Tasmania, Australia
| | - Deirdre McGowan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Martina Wyss
- Primary Health Tasmania, Launceston, Tasmania, Australia
| | - Tania Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13182. [PMID: 38726466 PMCID: PMC11079440 DOI: 10.1002/emp2.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Rachel M. Skains
- University of Alabama at BirminghamBirminghamAlabamaUSA
- Geriatric Research, Education, and Clinical CenterBirmingham VA Medical CenterBirminghamAlabamaUSA
| | | | - Nadine Qadoura
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Shan W. Liu
- Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E, Kashuba S, Clement F. Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review. Int J Emerg Med 2024; 17:16. [PMID: 38302890 PMCID: PMC10835906 DOI: 10.1186/s12245-024-00584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. METHODS A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. RESULTS Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. CONCLUSION Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.
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Affiliation(s)
- Ally Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Benedicta Asante
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maha Khan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nkiruka Eze
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Sherri Kashuba
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
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Gettel CJ, Hastings SN, Biese KJ, Goldberg EM. Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population. Clin Geriatr Med 2023; 39:659-672. [PMID: 37798071 PMCID: PMC10716862 DOI: 10.1016/j.cger.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519, USA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT 06519, USA.
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC 27710, USA; Geriatric Research, Education, Clinical Center, Durham VA Health Care System, Durham, NC, USA; Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Biese
- Department of Emergency Medicine, University of North Carolina, 170 Manning Drive, CB #7594, Chapel Hill, NC 27599, USA; Department of Medicine, Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, 13001 East 17th Place, CB #C290, Aurora, CO 80045, USA
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Marston C, Morgan DD, Philip J, Agar M. Supporting Carers as Patients Move between Hospital and Home: A Systematic Review of Interventions to Support These Transitions in Care. J Palliat Med 2023; 26:270-298. [PMID: 36251853 DOI: 10.1089/jpm.2022.0221] [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] [Indexed: 02/03/2023] Open
Abstract
Background: Hospital-to-home transitions become more frequent and complex as people approach end of life. Although carers are critical to enabling these transitions, they report high levels of unmet need. A review of the interventions to assist these care transitions, along with understanding those intervention components and mechanisms that support carers of people with advanced illness, is required to inform an optimal care model for palliative care practice. Aim: To describe the characteristics and reporting quality of intervention studies aimed at improving hospital-to-home transitions for carers of people with advanced illness. Design: This is a systematic review with a narrative synthesis. (international prospective register of systematic reviews [PROSPERO] ID: CRD42020192088). Data Sources: MEDLINE, EMCare, and PsychINFO databases were searched (2000-2021) for prospective studies reporting on interventions that (1) aimed to improve hospital-to-home transitions and (2) targeted carers of people with advanced illness. The Template for Intervention Description and Replication (TIDieR) checklist and constructs of the Care Transition Framework were used to assess the reporting quality of intervention design, delivery, and outcomes. Results: In total, 37 articles were analyzed that included a range of study designs, interventions, and outcomes. Health care utilization (n = 29) and clinical patient-related (n = 21) measures were the most reported outcome. Theoretical discussion was minimal (n = 5) with most studies using efficacy data from past research to justify intervention choice. Conclusion: Carers are critical partners in hospital-to-home transitions at end of life; yet they are largely under-represented in intervention design, delivery, and outcomes. Improving the reporting quality of carer-focused care transition interventions will inform future study design and support translation into practice and policy.
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Affiliation(s)
- Celia Marston
- Department of Occupational Therapy, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Deidre D Morgan
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Jennifer Philip
- Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Palliative Care Service, St. Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Palliative Care Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Meera Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Seidenfeld J, Ramos K, Bruening RA, Sperber NR, Stechuchak KM, Hastings SN. Patient experiences of a care transition intervention for Veterans to reduce emergency department visits. Acad Emerg Med 2023; 30:388-397. [PMID: 36630213 DOI: 10.1111/acem.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/19/2022] [Accepted: 01/08/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Care transition interventions (CTIs) are used to improve outcomes after an emergency department (ED) visit. A recent randomized controlled trial of a Veterans Health Administration (VHA) CTI titled Discharge Information and Support for Patients receiving Outpatient care in the ED (DISPO ED) demonstrated no difference in repeat ED visits. However, changes in health care utilization are not the only measures of a CTI worth evaluation, and there is interest in using patient-centered outcomes to assess CTIs as well. To inform future CTI design and outcome measure selection, the study aims were to understand how patients experienced the CTI and what elements they valued. METHODS This was a qualitative study of participants randomized to the intervention arm of the DISPO ED trial using semistructured interviews. The interview guide included questions about clinical health and other issues addressed by the study nurse, the most and least helpful aspects of the intervention, and impacts of the intervention on their perceptions of self-management. Interviews were analyzed using directed content analysis. RESULTS Our sample comprised 24 participants, with average age of 61 years, 58% male, and 50% Black or African American. We identified six major themes related to (1) experiences during the intervention and (2) elements they valued. Patients reported clinical health coaching recommendations covering a wide range of topics as well as care coordination actions such as appointment scheduling. Valuable elements of the intervention highlighted personal characteristics of the study nurse that promoted a sense of interpersonal connection and empathy in their interactions. CONCLUSIONS Intervention users described assistance with care coordination as well as clinical concerns. We identified aspects that were highly valued by the participants, such as interpersonal support and empathy from the interventionist. These findings suggest the need for more comprehensive nonutilization outcome measures for CTIs to capture the patient's perspective.
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Affiliation(s)
- Justine Seidenfeld
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA.,Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine Ramos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca A Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, North Carolina, USA.,Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
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Hall AG, Davlyatov GK, Orewa GN, Mehta TS, Feldman SS. Multiple Electronic Health Record-Based Measures of Social Determinants of Health to Predict Return to the Emergency Department Following Discharge. Popul Health Manag 2022; 25:771-780. [PMID: 36315199 DOI: 10.1089/pop.2022.0088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Health care systems continue to struggle with preventing 30-day readmissions to their institutions. Social determinants of health (SDOH) are important predictors of repeat visits to the hospital. In many health systems, SDOH data are limited to those variables that are most relevant to care delivery or payment (eg, race, gender, insurance status). Despite calls for integrating a more robust set of measures (eg, measures of health behaviors and living conditions) into the electronic health record (EHR), these data often have missing values necessitating the use of imputation to build a comprehensive picture of patients who are likely to return to the health system. Using logistic regression analyses and imputation of missing data from 2017 to 2018, this study uses measures found in the EHR (eg, tobacco use, living situation, problems at home, education) to assess those SDOH that might predict a return to the emergency department within 30 days of discharge from a health system. In both imputed and raw data, the total number of recorded health conditions was the most important predictor and collectively SDOH variables made a relatively small contributions in determining the likelihood of a return to the hospital. Although SDOH variables might be important in the design of programs aimed at preventing readmissions, they may not be useful in readmission predictive models.
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Affiliation(s)
- Allyson G Hall
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ganisher K Davlyatov
- Department of Health Administration and Policy, University of Oklahoma Health Sciences Center, Norman, Oklahoma, USA
| | - Gregory N Orewa
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tapan S Mehta
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Gettel CJ, Serina PT, Uzamere I, Hernandez-Bigos K, Venkatesh AK, Rising KL, Goldberg EM, Feder SL, Cohen AB, Hwang U. Emergency department-to-community care transition barriers: A qualitative study of older adults. J Am Geriatr Soc 2022; 70:3152-3162. [PMID: 35779278 PMCID: PMC9669106 DOI: 10.1111/jgs.17950] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/15/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions. METHODS We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. RESULTS Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. CONCLUSIONS Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Peter T. Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ivie Uzamere
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kizzy Hernandez-Bigos
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Kristin L. Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, PA, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Shelli L. Feder
- Yale University School of Nursing, Orange, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Andrew B. Cohen
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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Shah MN, Jacobsohn GC, Jones CMC, Green RK, Caprio TV, Cochran AL, Cushman JT, Lohmeier M, Kind AJ. Care transitions intervention reduces ED revisits in cognitively impaired patients. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12261. [PMID: 35310533 PMCID: PMC8919246 DOI: 10.1002/trc2.12261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/13/2021] [Accepted: 01/11/2022] [Indexed: 01/25/2023]
Abstract
Introduction About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population. Methods We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression. Results Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects. Discussion Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.
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Affiliation(s)
- Manish N. Shah
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of Medicine (Geriatrics and Gerontology)University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Gwen C. Jacobsohn
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Courtney MC Jones
- Department of Emergency MedicineUniversity of Rochester Medical CenterRochesterNew YorkUSA
- Department of Public Health SciencesUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Rebecca K. Green
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Thomas V. Caprio
- Department of Medicine, Division of GeriatricsUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Amy L. Cochran
- Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Department of MathematicsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Jeremy T. Cushman
- Department of Emergency MedicineUniversity of Rochester Medical CenterRochesterNew YorkUSA
- Department of Public Health SciencesUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Amy J.H. Kind
- Department of Medicine (Geriatrics and Gerontology)University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- William S. Middleton VA Geriatrics Research Education and Clinical Center (GRECC)MadisonWisconsinUSA
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11
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Jacobsohn GC, Jones CMC, Green RK, Cochran AL, Caprio TV, Cushman JT, Kind AJH, Lohmeier M, Mi R, Shah MN. Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial. Acad Emerg Med 2022; 29:51-63. [PMID: 34310796 PMCID: PMC8766871 DOI: 10.1111/acem.14357] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.
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Affiliation(s)
- Gwen C Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Rebecca K Green
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Amy L Cochran
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Thomas V Caprio
- Division of Geriatrics, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center, Madison, Wisconsin, USA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Ranran Mi
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
- Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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12
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Brock J, Jencks SF, Hayes RK. Future Directions in Research to Improve Care Transitions From Hospital Discharge. Med Care 2021; 59:S401-S404. [PMID: 34228023 PMCID: PMC8263143 DOI: 10.1097/mlr.0000000000001590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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13
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Gesell SB, Prvu Bettger J, Lawrence RH, Li J, Hoffman J, Lutz BJ, Grudzen C, Johnson AM, Krishnan JA, Hsu LL, Zwart D, Williams MV, Schnipper JL. Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio. Med Care 2021; 59:S344-S354. [PMID: 34228016 PMCID: PMC8263141 DOI: 10.1097/mlr.0000000000001591] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. OBJECTIVE The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. RESEARCH DESIGN Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. RESULTS Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. CONCLUSION These lessons can help guide future pragmatic studies of care transitions.
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Affiliation(s)
- Sabina B. Gesell
- Department of Social Sciences and Health Policy
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem
| | - Janet Prvu Bettger
- Duke University School of Medicine, Duke Roybal Center on Aging, Durham, NC
| | - Raymona H. Lawrence
- Department Health Policy and Community Health, Jiann Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA
| | - Jing Li
- Department of Internal Medicine, Center for Health Services Research (CHSR), University of Kentucky, Lexington, KY
| | - Jeanne Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA
| | - Barbara J. Lutz
- School of Nursing, University of North Carolina-Wilmington, Wilmington, NC
| | - Corita Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
| | - Anna M. Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jerry A. Krishnan
- Institute for Healthcare Delivery Design, Office of the Vice Chancellor for Health Affairs
| | - Lewis L. Hsu
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Dorien Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mark V. Williams
- Department of Internal Medicine, Center for Health Services Research, University of Kentucky HealthCare, Lexington, KY
| | - Jeffrey L. Schnipper
- Brigham Health Hospital Medicine Unit and Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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