An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges

Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy

INTRODUCTION

Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement.

MATERIAL AND METHODS

Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time.

RESULTS

1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed.

DISCUSSION AND CONCLUSIONS

Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).

Development of the EVIBEC Learning Outcomes Framework to support the delivery of evidence-based practice curricula in health care professional programmes: a codesign approach

BACKGROUND

All healthcare professional education programmes must adopt a systematic approach towards ensuring graduates achieve the competencies required to be an evidence-based practitioner. While a list of competencies for evidence-based practice exist, health care educators continue to struggle with effectively integrating the necessary competencies into existing curricula. The purpose of this project was to develop an open access cross-discipline, learning outcomes framework to support educators in integrating the teaching, learning and assessment required to ensure all graduates of health care professional programmes can achieve the necessary evidence-based practice competencies.

METHODS

An interdisciplinary team of health care professional educators and a librarian completed a review of the health professions literature on the teaching and assessment of evidence-based practice. The literature, coupled with the teams' collective experiences in evidence-based education and research, were used to identify relevant teaching, learning and evidence-based competency frameworks to inform the project design. The guide and toolkit for experience-based co-design developed by the National Health Service Institute for Innovation and Improvement was adopted for this study ( Institute for Innovation and Improvement: Experience Based Design: Guide & Tools In. Leeds: NHS; 2009.). A four-step approach involving three online participatory co-design workshops and a national validation workshop was designed. Students (n = 33), faculty (n = 12), and clinical educators (n = 15) participated in formulating and mapping learning outcomes to evidence-based competencies.

RESULTS

Through a rigorous, systematic co-design process the Evidenced-based Education Collaborative (EVIBEC) Learning Outcomes Framework was developed. This framework consists of a series of student-centred learning outcomes, aligned to evidence-based practice competencies, classified according to the 5 As of EBP and mapped to the cognitive levels of Bloom's taxonomy. Associated learning activities for each step of EBP are suggested.

CONCLUSIONS

A consensus-based, student-centred learning outcomes framework aligned to a contemporary set of EBP core competencies has been developed. The freely accessible EVIBEC framework may support entry level health care professional EBP education, by informing EBP curriculum development and offering the potential for interdisciplinary approaches to and sharing of valuable teaching and learning resources. Co-design proved an effective method in creating and refining this framework.

Recruitment of patients, carers and members of the public to advisory boards, groups and panels in public and patient involved health research: a scoping review

OBJECTIVES

The objectives of this scoping review are to: (1) identify the distribution of and context of the recruitment strategies used, (2) explore the facilitators, benefits, barriers and ethical issues of the identified recruitment strategies, (3) distinguish the varying terminology for involvement (ie, panels, boards, individual) and (4) determine if the individual recruitment strategies used were to address issues of representation or bias.

DESIGN

A scoping review.

SETTING

This scoping review follows the framework by Peters et al. Seven electronic databases were explored including Scopus, Medline, PubMed, Web of Science, CINAHL, Cochrane Library and PsycINFO (conducted July 2021). The search strategy was codeveloped among the research team, PPI research experts and a faculty librarian. Two independent reviewers screened articles by title and abstract and then at full text based on predetermined criteria.

PRIMARY AND SECONDARY OUTCOME MEASURES

Explore recruitment strategies used, facilitators, benefits, barriers and ethical issues of the identified recruitment strategies. Identify terminology for involvement. Explore recruitment strategies used to address issues of representation or bias.

RESULTS

The final sample was from 51 sources. A large portion of the extracted empirical literature had a clinical focus (37%, n=13) but was not a randomised control trial. The most common recruitment strategies used were human networks (78%, n=40), such as word of mouth, foundation affiliation, existing networks, clinics or personal contacts. Within the reviewed literature, there was a lack of discussion pertaining to facilitators, benefits, barriers and ethical considerations of recruitment strategies was apparent. Finally, 41% (n=21) of studies employed or proposed recruitment strategies or considerations to address issues of representation or bias.

CONCLUSION

We conclude with four key recommendations that researchers can use to better understand appropriate routes to meaningfully involve patients, carers and members of the public to cocreate the evidence informing their care.

Transitional care programs in Canada for older adults transitioning from hospital to home: protocol for a systematic review of text and opinion

OBJECTIVE

The objective of this systematic review is to identify what transitional care programs exist across Canada, including the characteristics and outcomes of these programs.

INTRODUCTION

There is growing evidence of the benefits of transitional care programs to support older adults moving from hospital to home. However, there is limited literature identifying the types of transitional care programs that exist internationally and little evidence available within Canada.

INCLUSION CRITERIA

Sources of gray literature published from 2016 that focus on older adults receiving services from transitional care programs to move from hospital to home in Canada will be considered for inclusion. Sources of gray literature will be excluded if interventions are targeted at adults younger than 65 years, Indigenous adults younger than 55 years, or if the primary discharge destination is not an independent community dwelling. Interventions designed for older adults waiting in hospital for long-term care placement will also be excluded from this review.

METHODS

An initial limited search of Canadian national gray literature resources will be undertaken, followed by an advanced Google search of Canadian resources and news media reports. Lastly, an advanced search of Google for all 10 provinces and 3 territories will be undertaken to target examples of local transitional care programs that may not be found through a national search, such as local pilot projects, health region-specific programs, and provincial organizations. All identified sources will be retrieved and full text review of selected citations assessed in detail by 2 independent reviewers. Data about the characteristics and outcomes of transitional care programs and results will be extracted and synthesized, with a meta-aggregation approach for grading according to JBI ConQual method.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298821.

Discharge Delay: How Can We Help Ourselves, Patients, and Families

PURPOSE/OBJECTIVES

Discharge delays are frustrating to patients, staff, and families. Case managers need a better understanding of what type of patient may experience a discharge delay so they can better prepare patients and families or avoid the discharge delay before it happens.

PRIMARY PRACTICE SETTINGS

Hospital.

FINDINGS/CONCLUSIONS

Discharge delays are exasperating to all involved, as they take up precious time and resources of case managers and make patients and families feel like there is an unclear plan. There are actions a case manager can take to lessen the burden of a discharge delay. Actions such as having a rapid discharge plan once the home environment is deemed inappropriate and making sure families and patients are communicated with frequently about their plan of care can decrease or avoid a discharge delay.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case managers need to know how to identify a patient who might experience a delay in their discharge early, so they can assist the patient and family to ease their stress by explaining limitations and realistic timelines. By identifying a patient who will be experiencing a delay in their discharge due to postacute lack of staffing, care managers can alert families that finding other options for discharge might be more satisfactory. By screening a patient and identifying their needs early, a discharge delay can be shortened or avoided.

Waiting for home: The experience of delayed discharge for people with dementia

INTRODUCTION

Individuals who remain in hospital once their health has stabilised experience delayed discharge. This often occurs for people with dementia when care needs exceed what can be managed at home. There is little research that takes into account the experience and needs of these patients. This Interpretive Description (ID) study, theoretically grounded in personhood and social citizenship perspectives, focused on the perspectives of people with dementia experiencing delayed discharge to address this gap in research and to better understand how nursing care can be improved for them.

METHODS

Twenty-one individuals participated in this study: eight patient participants experiencing delayed discharge and living with dementia, six family members, and seven nurses. Data collection methods primarily included participant observations, totalling 100 h of observations. Fourteen semi-structured interviews were also conducted with family members and nurses and with one patient participant. Informal conversations were undertaken with patient participants who did not take part in interviews.

RESULTS

Thematic analysis resulted in three main themes, encapsulating the patients' experiences: (1) Living and Waiting; (2) Distress and Behaviours; and (3) Looking Beyond the Designation. Findings are discussed in the context of the passive nature of delayed discharge care, the need for person-centred care, and prevailing discourses around the behavioural symptoms of dementia.

CONCLUSION

Implications for nursing practice include the need to acknowledge and foster the abilities of people with dementia. The behaviour narrative and labelling prevalent in hospitals must also be challenged. Lastly, nurses need to recognise the significant transition that is the delayed discharge experience, especially for people with dementia. This study advocates for person-centred and inclusive nursing care, where ongoing needs are recognised and addressed, particularly for people with dementia experiencing delayed discharge, who are waiting for home.

Co-designing implementation strategies to promote remote physical activity programs in frail older community-dwellers

Background

The "AGIL Barcelona (AGILBcn)" community-based integrated care program is a multicomponent healthy aging intervention for frail older adults. In this context, the present study aimed to identify implementation strategies to optimize the accessibility, acceptability, and adaptability of mobile health (mhealth) interventions to enhance physical activity in frail older adults, and to prioritize action points according to their importance and feasibility, through a co-design process.

Material and methods

A mixed methods approach was used. In the qualitative phase, a method adapted from the World Café was applied in 6 virtual groups to identify strategies to facilitate the virtual physical activity program. In the quantitative phase, prioritization and feasibility of the strategies was analyzed through surveys. Strategies were ranked based on priority vs. feasibility, revealing if strategies should either be: implemented first; if possible; taken into account for future consideration; or directly disregarded. The convenience sample included older adults (n = 7), community professionals (n = 9) and health professionals (n = 13). Qualitative data were analyzed by summative content analysis and quantitative data by nonparametric descriptive analyses.

Results

A total of 27 strategies were identified and grouped into four categories: general strategies for reducing barriers; specific strategies for facilitating the use of a digital application; specific strategies for facilitating participation in virtual exercise groups; and specific strategies for facilitating external support. According to the ranking of strategies, the first ones to be implemented included: digital literacy, digital capability assessment, family technology support, weekly telephone follow-up by professionals, personalizing exercises, and virtual exercises in small groups.

Conclusion

The active participation of all stakeholders enabled us to identify potential strategies for implementing person-oriented technology in physical activity programs and for engaging older adults.

A qualitative study exploring hospital-based team dynamics in discharge planning for patients experiencing delayed care transitions in Ontario, Canada

BACKGROUND

In attempt to improve continuity of patient care and reduce length of stay, hospitals have placed an increased focus on reducing delayed discharges through discharge planning. Several benefits and challenges to team-based approaches for discharge planning have been identified. Despite this, professional hierarchies and power dynamics are common challenges experienced by healthcare providers who are trying to work as a team when dealing with delayed discharges. The objective of this study was to explore what was working well with formal care team-based discharge processes, as well as challenges experienced, in order to outline how teams can function to better support transitions for patients experiencing a delayed discharge.  METHODS: We conducted a descriptive qualitative study with hospital-based healthcare providers, managers and organizational leaders who had experience with delayed discharges. Participants were recruited from two diverse health regions in Ontario, Canada. In-depth, semi-structured interviews were conducted in-person, by telephone or teleconference between December 2019 and October 2020. All interviews were recorded and transcribed. A codebook was developed by the research team and applied to all transcripts. Data were analyzed inductively, as well as deductively through directed content analysis.

RESULTS

We organized our findings into three main categories - (1) collaboration with physicians makes a difference; (2) leadership should meaningfully engage with frontline providers and (3) partnerships across sectors are critical. Regular physician engagement, as equal members of the team, was recommended to improve consistent communication, relationship building between providers, accessibility, and in-person communication. Participants highlighted the need for a dedicated senior leader who ensured members of the team were treated as equals and advocated for the team. Improved partnerships across sectors included the enhanced integration of community-based providers into discharge planning by placing more focus on collaborative practice, combined discharge planning meetings, and having embedded and physically accessible care coordinators in the hospital.

CONCLUSIONS

Team-based approaches for delayed discharge can offer benefits. However, to optimize how teams function in supporting these processes, it is important to consistently collaborate with physicians, ensure senior leadership engage with and seek feedback from frontline providers through co-design, and actively integrate the community sector in discharge planning.

Dismissal disagreement and discharge delays: Associations of patient-clinician plan of care agreement with discharge outcomes

BACKGROUND

Many hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.

OBJECTIVE

To measure the correlation between patient-clinician care agreement and discharge outcomes.

DESIGN

A prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).

SETTING AND PARTICIPANTS

Internal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019-March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.

MAIN OUTCOME AND MEASURES

Patient-clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30-day readmission was measured. Then, associations between patient-clinician agreement, delayed discharge, and 30-day readmissions were analyzed using multivariable logistic regression.

RESULTS

Of the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient-clinician agreement scores were not significantly correlated with discharge outcomes. Patient-clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home-goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).

CONCLUSIONS

Patients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.

Programmes to support transitions in community care for children with complex care needs: a scoping review

OBJECTIVE

This scoping review aimed to map the range of programmes in the literature to support children and youth with complex care needs and their families during transitions in care in the community.

DESIGN

A scoping review of the literature.

CONTEXT

This review included programmes that supported the transition in care to home and between settings in the community.

DATA SOURCES

We implemented our strategy to search five databases: (1) PubMed; (2) CINAHL; (3) ERIC; (4) PyscINFO and (5) Social Work Abstracts. The search was last implemented on 29 April 2021.

STUDY SELECTION

Our search results were imported into Covidence Systematic Review Software. First, two reviewers assessed titles and abstracts against our eligibility criteria. Relevant articles were then retrieved in full and reviewed by two reviewers for inclusion. Disagreements were resolved by a third reviewer.

DATA EXTRACTION

Relevant data were extracted related to population, concept, context, methods and key findings pertinent to our review objective.

RESULTS

A total of 2482 records were identified. After our two-stage screening process, a total of 27 articles were included for analysis. Articles ranged in the type of transitions being supported and target population. The most common transition reported was the hospital-to-home transition. Intervention components primarily consisted of care coordination using a teams-based approach. The most reported barriers and enablers to implementing these transition care programmes were related to physical opportunities.

LIMITATIONS

Included articles were limited to English and French.

CONCLUSIONS

This review identified important gaps within the literature, as well as areas for future consideration to ensure the effective development and implementation of programmes to support children and youth with complex care needs during transitions in care.

Impact of COVID-19 Measures on Discharge Planning and Continuity of Integrated Care in the Community for Older Patients in Singapore

Introduction:

The COVID-19 pandemic affects the process of care transition for patients with underlying chronic conditions. This study aims to explore the impact of the pandemic measures on discharge planning and continuum of care for vulnerable older patients from multi-stakeholder perspectives.

Methods:

We conducted focus group discussions and individual interviews with healthcare workers, community partners, government officials and family caregivers in Singapore. All interviews were audio-recorded, transcribed verbatim and thematically analysed.

Results:

A total of 53 individuals participated in the study. Discharge planning and care continuity in the community were affected primarily by the limited step-down care options and remote assessment of discharge needs. Participants felt a need to revisit the decision of ‘essential’ community services through engagement of all stakeholders to enhance care community.

To improve better care transition, participants suggested the need for clearer communication of guidelines, improved intersectoral collaboration, shared responsibility of patient care through community engagement and employment of novel models of care.

Conclusion:

The pandemic measures generated challenges of safe discharge of patients and care continuity in the community. Findings shed light on the need to proactively assess care pathways and catalyse novel models to improve care transition beyond the pandemic.

Methods to Generate Innovative Research Ideas and Improve Patient and Public Involvement in Modern Epidemiological Research: Review, Patient Viewpoint, and Guidelines for Implementation of a Digital Cohort Study

Background

Patient and public involvement (PPI) in research aims to increase the quality and relevance of research by incorporating the perspective of those ultimately affected by the research. Despite these potential benefits, PPI is rarely included in epidemiology protocols.

Objective

The aim of this study is to provide an overview of methods used for PPI and offer practical recommendations for its efficient implementation in epidemiological research.

Methods

We conducted a review on PPI methods. We mirrored it with a patient advocate’s viewpoint about PPI. We then identified key steps to optimize PPI in epidemiological research based on our review and the viewpoint of the patient advocate, taking into account the identification of barriers to, and facilitators of, PPI. From these, we provided practical recommendations to launch a patient-centered cohort study. We used the implementation of a new digital cohort study as an exemplary use case.

Results

We analyzed data from 97 studies, of which 58 (60%) were performed in the United Kingdom. The most common methods were workshops (47/97, 48%); surveys (33/97, 34%); meetings, events, or conferences (28/97, 29%); focus groups (25/97, 26%); interviews (23/97, 24%); consensus techniques (8/97, 8%); James Lind Alliance consensus technique (7/97, 7%); social media analysis (6/97, 6%); and experience-based co-design (3/97, 3%). The viewpoint of a patient advocate showed a strong interest in participating in research. The most usual PPI modalities were research ideas (60/97, 62%), co-design (42/97, 43%), defining priorities (31/97, 32%), and participation in data analysis (25/97, 26%). We identified 9 general recommendations and 32 key PPI-related steps that can serve as guidelines to increase the relevance of epidemiological studies.

Conclusions

PPI is a project within a project that contributes to improving knowledge and increasing the relevance of research. PPI methods are mainly used for idea generation. On the basis of our review and case study, we recommend that PPI be included at an early stage and throughout the research cycle and that methods be combined for generation of new ideas. For e-cohorts, the use of digital tools is essential to scale up PPI. We encourage investigators to rely on our practical recommendations to extend PPI in future epidemiological studies.

Developing a patient safety guide for primary care: A co-design approach involving patients, carers and clinicians

BACKGROUND

Patients and carers should be actively involved in patient safety and empowered to use person-centred approaches where they are asked to both identify safety concerns and partner in preventing them.

OBJECTIVES

The aim of this study was to co-design a patient safety guide for primary care (PSG-PC) to support patients and carers to address key patient safety questions and identify key points where they can make their care safer. The objectives were to i) identify when and how patients and carers can be involved in primary care patient safety, and ii) identify the relevant information to include in the PSG-PC.

DESIGN

An experience-based co-design approach.

SETTING AND PARTICIPANTS

We conducted three workshops with patients, carers, community pharmacists and general practitioners to develop and refine the PSG-PC.

RESULTS

Participants identified both explicit and implicit issues of primary care patient safety especially relating to technical and relational components of involving patients and carers. The importance of communication, understanding roles and responsibilities, and developing partnerships between patients and health-care providers were considered essential for actively involving patients in patient safety. Co-developing the PSG-PC provided insight to improve care to develop the PSG-PC.

DISCUSSION

The PSG-PC is the first guide to be developed for primary care, co-designed with patients, carers, general practitioners and pharmacists. The PSG-PC will support patients and carers to partner with health-care professionals to improve patient safety addressing international and national priorities to continuously improve patient safety.

Caregiving for older adults with hip fractures: Exploring the perspectives of caregivers, providers and decision-makers in Ontario, Canada

INTRODUCTION

Caregivers play an important role in providing physical, emotional and social support to individuals with hip fracture. This study sought to explore perceptions of caregiving for older adults with hip fractures by comparing experiences of caregivers, providers and decision-makers.

METHODS

Semi-structured interviews were conducted both in-person and by telephone with caregivers, providers and decision-makers (n=32) from one rural and one urban hospital selected from two health regions in Ontario, Canada. Interviews were audio-recorded and transcribed verbatim. The data were coded descriptively and interpretively, and compared within and across participants types.

RESULTS

Three main themes reflected tensions between caregivers and providers/decision-makers. Firstly, differing expectations of caregiver roles were identified. Several caregivers wanted more participation in the decision-making process but often felt excluded, while others expressed feeling stressed due to the expectations placed on them. Conversely, providers and decision-makers often described caregivers needing to strike a balance between providing supportive care while avoiding becoming too involved. Secondly, different expectations of what the healthcare system and providers could provide, with tensions particularly around timing of discharge were noted. Finally, there were differing perceptions of information needs. Providers spoke about the importance of providing education to caregivers and perceived themselves to be providing appropriate education. However, caregivers often described poor communication and not having a clear understanding of next steps and the care plan.

CONCLUSION

Managing and tailoring expectations, improving communication (e.g., content, timing) and the consistency of information shared with caregivers from different providers could facilitate more positive caregiving experiences and interactions.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges

Objective

To engage with patients, caregivers and care providers to co‐design components of an intervention that aims to improve delayed hospital discharge experiences.

Design

This is a qualitative study, which entailed working groups and co‐design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention.

Setting and Participants

Our team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7‐member Patient and Caregiver Advisory Council participated in all stages of the research.

Results

Key challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on‐going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on‐going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho‐social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on‐going engagement.

Discussion and Conclusions

Our findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.