Posthospital care transitions: patterns, complications, and risk identification

Locum Tenens and Pediatric Surgery: A Position Statement and Practice Guidelines From the American Pediatric Surgical Association (APSA)

The American Pediatric Surgical Association (APSA) Practice Committee endorsed by the Board of Governors presents a Position Statement on the role of locum tenens in the practice of pediatric surgery. The Practice Committee also presents a set of guidelines for locum tenens practice. These recommendations highlight safe practice and quality care that protects the patient as well as the pediatric surgeon by offering best practice standards, defining optimal resources and establishing parameters by which hospitals and locum tenens agencies should abide. These guidelines are intended to foster discussion and contract negotiation as well as inform decision making for a) pediatric surgeons considering locum tenens opportunities, b) host organizations (hospitals and practices) seeking the coverage of a pediatric surgeon, and c) locum tenens companies vetting both surgeons and hospitals for appropriateness of such coverage. This Position Statement and foundational set of guidelines align with APSA's Vision (all children receive the highest quality surgical care) and Mission (to provide the best surgical care to our patients and families by supporting an inclusive community through education, discovery and advocacy).

Dual-Eligible Nursing Home Residents: Enrollment Growth In Managed Care Plans That Coordinate Care, 2013-20

Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5 percent of residents per month in 2013 to 16.9 percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.

Continuum: A Postdischarge Supportive Care Intervention for Hospitalized Patients With Advanced Cancer

CONTEXT

Patients with advanced cancer are at increased risk for multiple hospitalizations and often have considerable needs postdischarge. Interventions to address patients' needs after transitioning home are lacking.

OBJECTIVES

We sought to demonstrate the feasibility and acceptability of a postdischarge intervention for this population.

METHODS

We conducted a single-arm pilot trial (n = 54) of a postdischarge intervention, consisting of a video visit with an oncology nurse practitioner (NP) within three days of discharge to address symptoms, medications, hospitalization-related issues, and care coordination. We enrolled English-speaking adults with advanced breast, gastrointestinal, genitourinary, or thoracic cancers experiencing an unplanned hospitalization and preparing for discharge home. The intervention was deemed feasible if ≥70% of approached patients enrolled and ≥70% of enrolled patients completed the intervention within three days of discharge. Two weeks after discharge, patients rated the ease and usefulness of the video technology on a 0-10 scale (higher scores indicate greater ease of use). NPs completed postintervention surveys to assess protocol adherence.

RESULTS

We enrolled 54 of 75 approached patients (77.3%). Of enrolled patients (median age = 65.0 years), 83.3% participated in the intervention within three days of discharge. The median ease of participating in the intervention was 9.0 (IQR: 6.0-10.0) and the median usefulness of the intervention was 7.0 (IQR: 4.5-8.0). The majority of visits focused on symptom management (85.7%), followed by posthospital medical issues (69.0%).

CONCLUSION

An oncology NP-delivered intervention immediately after hospital discharge is a feasible and acceptable approach to providing postdischarge care for hospitalized patients with advanced cancer.

Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates.

DATA SOURCES

Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used.

STUDY SELECTION

Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis.

MAIN OUTCOMES AND MEASURES

Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period.

RESULTS

We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications.

DISCUSSION

Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients.

PROSPERO REGISTRATION NUMBER

CRD42022302871.

Exploring home rehabilitation therapists' experiences of supporting older persons to physical exercise after acute hospitalization: a qualitative interview study

PURPOSE

After hospitalization, older persons may face a decline in physical function and daily independence. In-hospital exercise interventions can mitigate this decline, and continued support from primary healthcare post-discharge may enhance sustainability. This study aimed to explore home rehabilitation therapists' experiences of supporting physical exercise after acute hospitalization, including exercise programs initiated during hospital stay.

METHODS

This qualitative study was conducted alongside a randomized-controlled trial to investigate prerequisites for a transitional care intervention. Twelve interviews were conducted with physiotherapists, occupational therapists, and managers across seven rehabilitation therapy services in Stockholm, Sweden. Data were analyzed using reflexive thematic analysis.

RESULTS

The analysis generated the theme Striving for individualized support for physical exercise, although limited resources and a fragmented home care risk to direct support away from those who need it the most. It was based on four subthemes: The starting point is always the patient's current needs, goals, and prerequisites, Continuing the exercise initiated during hospitalization by adapting it to the patient's situation at home, Work premises not tailored to patients with complex care needs, and A home care organization that lacks coordination and unified purpose.

CONCLUSIONS

Interventions supporting older persons to physical exercise after acute hospitalization need to be tailored to the individual, support motivation, and be adapted to the patient's home situation. Challenges may arise when care recourses lack alignment with the patients' needs, and when the collaboration among care providers is limited. The findings contribute valuable insights for future studies incorporating transitional care interventions in similar context.

Long-Term Impact of COVID-19 Related Disruption of National Health Service Elective Services on Emergency Major Lower Limb Amputations

BACKGROUND

The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs).

METHODS

Patients' data for emergency MLLA for critical limb-threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018-March 2020) and the pandemic group (April 2020-March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]).

RESULTS

A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n = 26).

CONCLUSIONS

NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Prioritizing mobility factors for assessment during the transition of older adults from hospital to home: a cross-sectional survey of physiotherapists in Southeastern Nigeria

BACKGROUND

Assessing all factors influencing older adults' mobility during the hospital-to-home transition is not feasible given the complex and time-sensitive nature of hospital discharge processes.

OBJECTIVE

To describe the mobility factors that Nigerian physiotherapists prioritize to be assessed during hospital-to-home transition of older adults and explore the differences in the prioritization of mobility factors across the physiotherapists' demographics and practice variables.

METHODS

This cross-sectional study included 121 physiotherapists who completed an online questionnaire, ranking 74 mobility factors using a nine-point Likert scale. A factor was prioritized if ≥ 70% of physiotherapists rated the factor as "Critical" (scores ≥7) and ≤ 15% of physiotherapists rated a factor as "Not Important" (scores ≤3). We assessed the differences in the prioritization of mobility factors across the physiotherapists' demographics/practice variables using Mann Whitney U and Kruskal-Wallis tests.

FINDINGS

Forty-three of 74 factors were prioritized: four cognitive, two environmental, one financial, four personal, eighteen physical, seven psychological, and seven social factors. Males and those with self-reported expertise in each mobility determinants more frequently rated factors as critical.

CONCLUSION

Prioritizing many mobility factors underscores the complex nature of mobility, suggesting that an interdisciplinary approach to addressing these factors may enhance post-hospital discharge mobility outcomes.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE

To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare were used.

STUDY DESIGN

Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

CONCLUSIONS

HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Factors associated with readmission in chronic kidney disease: Systematic review and meta-analysis

BACKGROUND

Risk factors associated with all-cause hospital readmission are poorly characterised in patients with chronic kidney disease.

OBJECTIVE

A systematic review and meta-analysis were conducted to identify risk factors and protectors of hospital readmission in chronic kidney disease.

DESIGN, PARTICIPANTS & MEASUREMENTS

Studies involving adult patients were identified from four databases from inception to 31/03/2020. Random-effects meta-analyses were conducted to determine factors associated with all-cause 30-day hospital readmission in general chronic kidney disease, in dialysis and in kidney transplant recipient groups.

RESULTS

Eighty relevant studies (chronic kidney disease, n = 14 studies; dialysis, n = 34 studies; and transplant, n = 32 studies) were identified. Meta-analysis revealed that in both chronic kidney disease and transplant groups, increasing age in years and days spent at the hospital during the initial stay were associated with a higher risk of 30-day readmission. Other risk factors identified included increasing body mass index (kg/m2 ) in the transplant group, and functional impairment and discharge destination in the dialysis group. Within the chronic kidney disease ​​​​group, having an outpatient follow-up appointment with a nephrologist within 14 days of discharge was protective against readmission but this was not protective if provided by a primary care provider or a cardiologist.

CONCLUSION

Risk-reduction interventions that can be implemented include a nephrologist appointment within 14 days of hospital discharge, rehabilitation programme for functional improvement in the dialysis group and meal plans in the transplant group. Future risk analysis should focus on modifiable factors to ensure that strategies can be tested and implemented in those who are more at risk.

Development of a tool for assessing the performance of long-term care systems in relation to care transition: Transitional Care Assessment Tool in Long-Term Care (TCAT-LTC)

BACKGROUND

Improving the quality and safety of care transitions is a priority in many countries. Carrying out performance measurements play a significant role in improving quality of decisions undertaken by different actors involved in reforms. Therefore, the main objective of this paper is to present the development of an evaluation tool for assessing the performance of long-term care systems in relation to care transition, namely the Transitional Care Assessment Tool in Long-Term Care (TCAT-LTC). This study is performed as part of a larger European TRANS-SENIOR project.

METHODS

The development of the TCAT-LTC involved three steps. First, we developed a conceptual model based on Donabedian's quality framework and literature review. Second, we carried out a thorough process of item pool generation using deductive (systematic literature review) and deductive-inductive methods (in-depth interviews) with experts in the field of long-term care. Third, we conducted preliminary validation of the tool by asking experts in research and practice to provide an opinion on a tool and to assess content validity. Future fourth step will involve a tool's pilot with country experts from Germany, the Netherlands and Poland.

RESULTS

By applying methodological triangulation, we developed the TCAT-LTC, which consists of 2 themes, 12 categories and 63 items. Themes include organizational and financial aspects. Organizational aspects include categories such as communication, transfer of information, availability and coordination of resources, training and education of staff, education/support of the patient/informal caregiver, involvement of the patient/informal caregiver, telemedicine and e-Health, and social care. Financial aspects include categories such as primary care, hospital, and long-term care. We also present the instructions on the application of the TCAT-LTC.

CONCLUSIONS

In this paper, we presented the development of the TCAT-LTC evaluation tool for assessing the performance of long-term care systems in relation to care transition. The TCAT-LTC is the first tool to assess the performance of long-term care systems in relation to care transition. Assessments can be carried out at the national and international level and enable to monitor, evaluate, and compare performance of the long-term care systems in relation to care transition within and across countries.

Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home

OBJECTIVES

To adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home.

DESIGN

Quality improvement intervention.

SETTING AND PARTICIPANTS

Veterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility.

METHODS

We used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse-driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact.

RESULTS

Between October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity-review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge.

CONCLUSIONS AND IMPLICATIONS

We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

Pilot RCT examining feasibility and disability outcomes of a mobile health platform for strategy training in inpatient stroke rehabilitation (iADAPT)

BACKGROUND

Strategy training is an intervention that may reduce disability when delivered in inpatient rehabilitation following stroke. However, shorter lengths of stay and challenges with continuity of care following discharge results in difficulties in achieving adequate intervention dosage and carryover of training.

OBJECTIVE

We examined whether strategy training using a mobile health platform (iADAPT) is feasible during inpatient stroke rehabilitation and following discharge.

METHODS

In this RCT, participants were randomized to receive strategy training using either the iADAPT application (n = 16) or a workbook (n = 15). Participants in both groups received 7 in-person sessions during inpatient rehabilitation and 3 remote sessions following discharge. We calculated descriptive statistics to examine acceptance, attendance, and adherence, and within-group effect sizes on satisfaction and disability.

RESULTS

Participants in the iADAPT group attended fewer total intervention sessions (n = 5.5, workbook n = 9.0) but attempted a similar number of goals (n = 7.6, workbook n = 8.2). Both groups reported similar satisfaction with in-person intervention (Treatment Expectancy: iADAPT d = 0.60, workbook d = 0.47; Patient Provider Connection: iADAPT d = 0.18, workbook d = 0.31), but the mobile health group reported greater satisfaction with remote intervention (Treatment Expectancy: iADAPT d = -0.91, workbook d = -0.97; Patient Provider Connection: iADAPT d = 0.85, workbook d = -1.80). .

CONCLUSIONS

Considering these promising feasibility metrics and the benefits of mobile health, it is worth continuing to explore the efficacy of strategy training using a mobile health platform.

Development and validation of prediction models for the discharge destination of elderly patients with aspiration pneumonia

BACKGROUND

Discharge planning enhances the safe and timely transfer of inpatients between facilities. Predicting the discharge destination of inpatients with aspiration pneumonia is important for discharge planning. We aimed to develop and validate prediction models for the discharge destination of elderly patients with aspiration pneumonia.

METHODS

Using a nationwide inpatient database, we identified aspiration pneumonia cases for patients aged ≥65 years who had been admitted to hospital from their home or from a nursing home between April 2020 and March 2021. We divided the cases into derivation and validation cohorts according to the location of the admitting hospital. We developed two prediction models by dividing the cases based on the patient's place of residence prior to admission, one model to predict the home discharge of cases admitted from home and the other to predict the home or to a nursing home discharge of cases admitted from a nursing home. The models were internally validated with bootstrapping and internal-externally validated using a validation cohort. Nomograms that could be used easily in clinical practice were also created.

RESULTS

The derivation cohort included 19,746 cases admitted from home and 14,359 cases admitted from a nursing home. Of the former, 10,760 (54.5%) cases were discharged home; from the latter, 7,071 (49.2%) were discharged to either home or a nursing home. The validation cohort included 6,262 cases admitted from home and 6,352 cases admitted from a nursing home. In the internal-external validation, the C-statistics of the final model for the cases admitted from home and the cases admitted from a nursing home were 0.71 and 0.67, respectively.

CONCLUSIONS

We developed and validated new prediction models for the discharge of elderly patients with aspiration pneumonia either to home or to a nursing home. Our models and nomograms could facilitate the early implementation of discharge planning.

Readmissions after radical nephrectomy in a national cohort

OBJECTIVE

To analyze the factors and costs associated with 30-day readmissions for patients undergoing radical nephrectomy.

MATERIALS AND METHODS

We used the 2014 Nationwide Readmission Database to identify adults who underwent radical nephrectomy for renal cancer, stratified by surgical approach. We determined patient factors associated with readmission rates, diagnoses, and costs using multivariate logistic regression.

RESULTS

Among 19,523 individuals, the 30-day readmission rate was 7.7% (n = 1,506). On multivariate regression, odds of readmission were significantly increased with age ≥75 in those who underwent open nephrectomy (OR: 1.35; 95%CI: 1.03-1.78). Subjects with a Charlson comorbidity score ≥3 had significantly higher rates of readmission regardless of surgical approach (Open RN - OR: 1.85; 95%CI: 1.33-2.56; Lap RN - OR: 1.99; 95%CI 1.10-3.59; Robotic RN - OR: 2.18; 95%CI: 1.23-3.86). Common reasons for readmission were gastrointestinal, cardiovascular, urinary tract infections, and wound complications across all surgical approaches. The mean cost per readmission was as high as 126% ($20,357) of the mean index admission cost.

CONCLUSION

One in 13 adults undergoing radical nephrectomy is readmitted within 30 days of discharge. Associated readmission cost is up to 1.26 times the cost of index admission. Our findings may inform efforts aiming to reduce hospital readmissions and curtail healthcare costs.

Integration of patient experience factors improves readmission prediction

Many readmission prediction models have marginal accuracy and are based on clinical and demographic data that exclude patient response data. The objective of this study was to evaluate the accuracy of a 30-day hospital readmission prediction model that incorporates patient response data capturing the patient experience. This was a prospective cohort study of 30-day hospital readmissions. A logistic regression model to predict readmission risk was created using patient responses obtained during interviewer-administered questionnaires as well as demographic and clinical data. Participants (N = 846) were admitted to 2 inpatient adult medicine units at Massachusetts General Hospital from 2012 to 2016. The primary outcome was the accuracy (measured by receiver operating characteristic) of a 30-day readmission risk prediction model. Secondary analyses included a readmission-focused factor analysis of individual versus collective patient experience questions. Of 1754 eligible participants, 846 (48%) were enrolled and 201 (23.8%) had a 30-day readmission. Demographic factors had an accuracy of 0.56 (confidence interval [CI], 0.50-0.62), clinical disease factors had an accuracy of 0.59 (CI, 0.54-0.65), and the patient experience factors had an accuracy of 0.60 (CI, 0.56-0.64). Taken together, their combined accuracy of receiver operating characteristic = 0.78 (CI, 0.74-0.82) was significantly more accurate than these factors were individually. The individual accuracy of patient experience, demographic, and clinical data was relatively poor and consistent with other risk prediction models. The combination of the 3 types of data significantly improved the ability to predict 30-day readmissions. This study suggests that more accurate 30-day readmission risk prediction models can be generated by including information about the patient experience.

Risk Factors for Early Hospital Readmission in Geriatric Patients: A Systematic Review

The number of older patients is constantly growing, and early hospital readmissions in this population represent a major problem from a health, social and economic point of view. Furthermore, the early readmission rate is often used as an indicator of the quality of care. We performed a systematic review of the literature to better understand the risk factors of early readmission (30 and 90 days) in the geriatric population and to update the existing evidence on this subject. The search was carried out on the MEDLINE, EMBASE and PsycINFO databases. Three independent reviewers assessed the potential inclusion of the studies, and then each study was independently assessed by two reviewers using Joanna Briggs Institute critical appraisal tools; any discrepancies were resolved by the third reviewer. Studies that included inpatients in surgical wards were excluded. Twenty-nine studies were included in the review. Risk factors of early readmission can be classified into socio-economic factors, factors relating to the patient's health characteristics, factors related to the use of the healthcare system and clinical factors. Among these risk factors, those linked to patient frailty play an important role, in particular malnutrition, reduced mobility, risk of falls, fatigue and functional dependence. The early identification of patients at higher risk of early readmission may allow for targeted interventions in view of discharge.

Feasibility and usefulness of the going home toolkit, an mhealth app, during hospital discharge: patient and clinician perspectives

Feasibility and Usefulness of the Going Home Toolkit, an mHealth App, during Hospital Discharge: Patient and Clinician Perspectives. Objective Communication gaps during discharge planning contribute to post-discharge outcomes. mHealth Apps may allow health systems to provide resources to fill patients' needs. The study's purpose was to elicit feedback regarding The Going Home Toolkit (GHT), an App that aims to facilitate patient communication about discharge needs. Participants Twenty patients hospitalized within the past year, and seven case managers involved in discharge processes from an academic health sciences center. Methods Using tablets installed with the GHT prototype, remote engagement studio interviews were used to observe GHT use and perceptions about usefulness and feasibility. Results Patients successfully used the GHT to identify resources that they may not have known otherwise. Clinicians reported the GHT would support patient engagement during discharge. However, patients liked being able to search for resources, while clinicians focused on offering a list of information. This can be described as a pull vs. push approach to accessing resources. Participants recognized the GHT's unique focus on cognitive processes related to self-management vs. knowledge transfer. Conclusions The GHT represents a valuable tool for facilitating anticipatory planning and procurement of resources post-discharge. Future work should focus on refining the user interface and user experience of the app and creating seamless links to community resources.

Critical Age Theory: Institutional Abuse of Older People in Health Care

Theories of elder abuse focus on the characteristics of the victim, the perpetrator, and the context of abuse. Although all three factors play a role, we are biased to notice individual misbehavior as the primary and sole cause of abuse. We see individuals as responsible for abuse. By examining abuses across a spectrum of healthcare services, abuse is more likely to be due to the institutional culture that includes the use of medications, Assisted Living, Skilled Nursing Facilities/nursing homes, hospices, hospitals, and Medicare Advantage programs. This study highlights multiple and consistent institutional abuses that result in harm and death of older adults on a consistent basis. The results show that when profit is increased, standards of care are diminished, and abuse ensues. Assigning responsibility to the management of healthcare becomes a priority in reducing this level of abuse. However, there are biases that stop us from assigning blame to institutions. Individual healthcare workers adhere to work protocol and rationalize the negative outcomes as inevitable or due to the vulnerability and frailness of older people. This culture is socialized for new employees that develop a culture of diminishing the needs of the individual patient in favor of the priorities dictated by the management protocol. In addition, the public is focused on assigning blame to individuals. Once an individual is assigned blame then they do not look beyond that to understand the context of abuse. A context that is generated by healthcare facilities maximizing profit and denigrating patient care. Regulatory agencies such as the U.S. DHHS, CDC, State Public Health Agencies, State/City Elder Abuse units, and Ombudsmen Programs all collude, for multiple reasons, in diminishing institutional responsibility.

Development and Pilot Implementation of a Training Framework to Prepare and Integrate Pharmacy Students into a Multicentre Hospital Research Study

A unique approach was introduced to integrate pharmacy students into a multicentre patient-centred research project predicting medication related harm (MRH) post-discharge. A training framework was developed to prepare students for research participation and integration. The framework aligned research project tasks with the pharmacists’ national competency standards framework. The framework was piloted on four research placement students from two local universities during three hospital placements, from October 2020 to August 2021. Following their initial orientation and training, students collected data from 38 patients and were involved in patient screening processes, interviewing, data collection and analysis. Patients’ MRH risk scores correlated with re-admission rates with 16/38 (42%) of patients re-admitted within eight weeks following discharge. Their participation in the research enabled students to obtain skills in (1) literature searching, (2) maintaining patient confidentiality, (3) interviewing patients, (4) obtaining data from medical records, (5) communicating with patients and clinicians, and (6) the use of clinical information to predict MRH risk.

Familial caregiving following stroke: findings from the comprehensive post-acute stroke services (COMPASS) pragmatic cluster-randomized transitional care study

BACKGROUND

Stroke patients discharged home often require prolonged assistance from caregivers. Little is known about the real-world effectiveness of a comprehensive stroke transitional care intervention on relieving caregiver strain.

OBJECTIVES

To describe the effect of the COMPASS transitional care (COMPASS-TC) intervention on caregiver strain and characterize the types, duration, and intensity of caregiving.

METHODS

The cluster-randomized COMPASS pragmatic trial evaluated the effectiveness of COMPASS-TC versus usual care with patients with mild stroke and TIA at 40 hospitals in North Carolina, USA. Of 5882 patients enrolled, 4208 (71%) identified a familial caregiver. A follow-up Caregiver Questionnaire, including the Modified Caregiver Strain Index, was administered at approximately three months post-discharge. Demographics and frequency, duration, and intensity of caregiving were compared between groups.

RESULTS

1228 caregivers (29%) completed the questionnaire. Completion was positively associated with older patient age, white race, and spousal relationship. One-third of the caregivers provided ≥30 hours of care per week and 889 (79%) provided care ≥9 weeks. Average standardized caregiver strain was 21.9 (0-100), increasing with stroke severity and comorbidity burden. Women caregivers reported higher strain than men. Treatment allocation was not associated with caregiver strain.

CONCLUSIONS

This sample of mild stroke and TIA survivors received significant assistance from familial caregivers. However, caregiver strain was relatively low. Findings support the importance of familial caregiving in stroke, the continued disproportionate burden on women within the family, and the need for future research on caregiver support.

"Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers

BACKGROUND

The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes.

OBJECTIVE

To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions.

DESIGN/PARTICIPANTS/APPROACH

Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis.

KEY RESULTS

Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility.

CONCLUSIONS

Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.

Developing standardized patient assessment data elements for Medicare post-acute care assessments

BACKGROUND

To support interoperability and care planning across provider types, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the submission of standardized patient assessment data using the assessment instruments provided by the Centers for Medicare & Medicaid Services (CMS). CMS was tasked with developing standardized assessment data elements (SADEs) within clinical categories named in the IMPACT Act.

METHOD

We used environmental scans, subject matter expert, and stakeholder input to identify candidate SADEs; tested candidate data elements in alpha testing; revised SADEs and training protocols based on alpha analyses and stakeholder feedback; tested SADEs across post-acute care (PAC) settings in a national field test that included 3121 patients across 143 home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities in 14 markets across the United States; and analyzed data and stakeholder input from national testing. Field testing measured the time required for assessment, percent completion, and inter-rater reliability. We analyzed qualitative feedback from stakeholder focus groups and technical expert panels. We also obtained survey and focus group feedback from data collectors.

RESULTS

We developed a mixed-method, multi-stakeholder procedure to identify and gather input on SADE for cross-setting use. This process yielded feasible and reliable SADEs for PAC settings that assess pain, cognitive status, mood, and medication reconciliation. The success of this work depended on working iteratively with diverse stakeholders and providing qualitative as well as quantitative evidence.

CONCLUSIONS

The procedures applied in this project for developing and adopting SADEs for PAC, as well as the challenges and strategies to overcome challenges, should be considered in future item and quality measure development.

Better understanding care transitions of adults with complex health and social care needs: a study protocol

Background

Adults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers.

Methods/design

We will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged.

Discussion

This study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study’s findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07588-0.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities

OBJECTIVE

To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes.

DATA SOURCES

Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014.

STUDY DESIGN

We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions.

DATA EXTRACTION METHODS

We identified Medicare beneficiaries discharged from a hospital to IRF.

PRINCIPAL FINDINGS

In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals.

CONCLUSIONS

Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

Published models that predict hospital readmission: a critical appraisal

INTRODUCTION

The number of readmission risk prediction models available has increased rapidly, and these models are used extensively for health decision-making. Unfortunately, readmission models can be subject to flaws in their development and validation, as well as limitations in their clinical usefulness.

OBJECTIVE

To critically appraise readmission models in the published literature using Delphi-based recommendations for their development and validation.

METHODS

We used the modified Delphi process to create Critical Appraisal of Models that Predict Readmission (CAMPR), which lists expert recommendations focused on development and validation of readmission models. Guided by CAMPR, two researchers independently appraised published readmission models in two recent systematic reviews and concurrently extracted data to generate reference lists of eligibility criteria and risk factors.

RESULTS

We found that published models (n=81) followed 6.8 recommendations (45%) on average. Many models had weaknesses in their development, including failure to internally validate (12%), failure to account for readmission at other institutions (93%), failure to account for missing data (68%), failure to discuss data preprocessing (67%) and failure to state the model's eligibility criteria (33%).

CONCLUSIONS

The high prevalence of weaknesses in model development identified in the published literature is concerning, as these weaknesses are known to compromise predictive validity. CAMPR may support researchers, clinicians and administrators to identify and prevent future weaknesses in model development.

Functional Impairment, Symptom Burden, and Clinical Outcomes Among Hospitalized Patients With Advanced Cancer

BACKGROUND

National guidelines recommend regular measurement of functional status among patients with cancer, particularly those who are elderly or high-risk, but little is known about how functional status relates to clinical outcomes among hospitalized patients with advanced cancer. The goal of this study was to investigate how functional impairment is associated with symptom burden and healthcare utilization and clinical outcomes.

PATIENTS AND METHODS

We conducted a prospective observational study of patients with advanced cancer with unplanned hospitalizations at Massachusetts General Hospital from September 2014 through March 2016. Upon admission, nurses assessed patients' activities of daily living (ADLs; mobility, feeding, bathing, dressing, and grooming). Patients with any ADL impairment on admission were classified as having functional impairment. We used the revised Edmonton Symptom Assessment System (ESAS-r) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. Multivariable regression models were used to assess the relationships between functional impairment, hospital length of stay, and survival.

RESULTS

Among 971 patients, 390 (40.2%) had functional impairment. Those with functional impairment were older (mean age, 67.18 vs 60.81 years; P<.001) and had a higher physical symptom burden (mean ESAS physical score, 35.29 vs 30.85; P<.001) compared with those with no functional impairment. They were also more likely to report moderate-to-severe pain (74.9% vs 63.1%; P<.001) and symptoms of depression (38.3% vs 23.6%; P<.001) and anxiety (35.9% vs 22.4%; P<.001). Functional impairment was associated with longer hospital length of stay (β = 1.29; P<.001) and worse survival (hazard ratio, 1.73; P<.001).

CONCLUSIONS

Hospitalized patients with advanced cancer who had functional impairment experienced a significantly higher symptom burden and worse clinical outcomes compared with those without functional impairment. These findings provide evidence supporting the routine assessment of functional status on hospital admission and using this to inform discharge planning, discussions about prognosis, and the development of interventions addressing patients' symptoms and physical function.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives

BACKGROUND

Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions.

OBJECTIVE

We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions.

DESIGN

Semi-structured interviews with interdisciplinary hospital and SNF providers.

PARTICIPANTS

Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6).

APPROACH

Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs.

KEY RESULTS

Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge.

CONCLUSIONS

As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review

Background

Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge.

Methods

Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data.

Results

Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33–60.5] (n = 5 studies) and 50% [interquartile range 39–76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18–40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16–24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2–180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs.

Conclusions

This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified.

Electronic supplementary material

The online version of this article (10.1007/s40264-020-00918-3) contains supplementary material, which is available to authorized users.

Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility

BACKGROUND

Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2).

METHODS

This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments.

RESULTS

Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions.

CONCLUSION

SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.

Association between operational positive depression symptom screen scores on hospital admission and 30-day readmissions

BACKGROUND

Positive scores on inpatient depression symptom screens have been found to be associated with readmissions, yet most studies have used depression screens collected as part of research studies.

OBJECTIVE

We evaluated whether the relationship between depression severity and readmission persisted when depression screening data was obtained for operational purposes.

DESIGN

Retrospective analysis studying prospective use of PHQ data.

SETTING

Large academic medical center.

INTERVENTION

Ward nurses obtained depression screens from patients soon after admission. Patients who answered 'yes' to at least one Patient Health Questionnaire (PHQ)-2 question were screened using the PHQ-9.

MAIN OUTCOMES AND MEASURES

We examined the association between depression severity and 30-day readmissions using logistic regression, adjusting for known predictors of hospital readmission.

RESULTS

From July 2014-June 2016, 18,792 discharged adult medicine inpatients received an initial depression screen (PHQ-2) and 1105 patients (5.90%) had at least one positive response. Of this group, 3163 patients (6.32%) were readmitted within 30 days. 1128 patients received the PHQ-9. Compared to patients with no depression, patients with moderately-severe depression had 3.03 higher odds (95%CI, 1.44-6.38) and patients with severe depression had 1.63 higher odds (95%CI, 0.70-3.78) of being readmitted, after adjusting for known predictors of hospital admission. Adding PHQ-9 results did not significantly improve the predictive power of a readmissions model.

CONCLUSIONS

Our mixed results call into question whether PHQ data obtained for operational purposes may differ compared to data obtained for research purposes. Differences in training of screening staff or patient discomfort with discussing depression in the hospital could explain our findings.

Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives

BACKGROUND

Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.

OBJECTIVE

To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.

DESIGN

Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.

PARTICIPANTS

A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.

MAIN MEASURES

A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.

KEY RESULTS

The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.

CONCLUSIONS

Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.

Impacts of Post-Hospitalization Accessible Health Technology and Caregiver Support on 90-Day Acute Care Use and Self-Care Assistance: A Randomized Clinical Trial

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Implementation of a Pharmacist-Managed Transitions of Care Tool

Purpose

To improve, expand, and sustain a pharmacist-based transitions of care (TOC) program and to assess interventions targeting veterans at high risk for adverse outcomes.

Methods

A TOC program was developed and piloted at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC). Following success of the pilot project, targeted interventions were identified to improve and expand the program. Patients deemed high risk for readmission by an acute care pharmacist were identified and referred for continued postdischarge follow-up. The study population included patients discharged to the community with primary care established within the RLRVAMC system. Eligible patients were entered into a TOC database by the referring acute care pharmacist. A pharmacist in the primary care clinic reviewed then contacted the patient within 1 week of discharge. Appropriate documentation of each visit was completed in the electronic health record. Data collection included background information, time to follow-up, medication discrepancies, pharmacist interventions, emergency department visits, and hospital readmissions.

Results

A total of 139 patients were included, of which 99 patients were reached for pharmacist follow-up. There were 43 medication-related discrepancies among all patients. The most common discrepancy was taking the wrong dose of a prescribed medication. Additional counseling was provided to 75% of patients. The subset of patients who were reached by a pharmacist had decreased index (5.1% vs 15.0%; P = .049) and all-cause readmissions (8.1% vs 27.5%; P = .03) at 30 days compared with those who did not received pharmacist follow-up, respectively.

Conclusions

This study demonstrated that implementation and expansion of a pharmacist-based TOC process is effective in communicating high-risk patients and intervening on medication-related issues postdischarge.

Lower household income is associated with an increased risk of hospital readmission in patients with decompensated cirrhosis

BACKGROUND AND AIM

The impact of household income, a surrogate of socioeconomic status, on hospital readmission rates for patients with decompensated cirrhosis has not been well characterized.

METHODS

The Nationwide Readmission Database from 2012 to 2014 was used to study the association of lower median household income on 30-, 90-, and 180-day hospital readmission rates for patients with decompensated cirrhosis.

RESULTS

From the 42 679 001 hospital admissions contained in the sample, there were 82 598 patients with decompensated cirrhosis who survived a hospital admission in the first 6 months of the year. During a uniform 6-month follow-up period, 25 914 (31.4%), 39 928 (48.3%), and 47 496 (57.5%) patients were readmitted at 30, 90, and 180 days, respectively. After controlling for demographic and clinical confounders, patients residing in the three lowest income quartiles were significantly more likely to be readmitted at 30 days than those in the fourth quartile (first quartile, odds ratio [OR] 1.32 [95% confidence interval, CI, 1.17-1.47, P < 0.01]; second quartile, OR 1.25 [95% CI 1.13-1.38, P < 0.01]; and third quartile, OR 1.08 [95% CI 0.97-1.20, P = 0.07]). The association between lower socioeconomic status and the higher risk of readmissions persisted at 90 days (first quartile, OR 1.21 [95% CI 1.14-1.30, P < 0.01]) and 180 days (first quartile, OR 1.32 [95% CI 1.20-1.44, P < 0.01]).

CONCLUSION

Patients with decompensated cirrhosis residing in the lowest income quartile had a 32% higher odds of hospital readmissions at 30, 90, and 180 days compared with those in the highest income quartile.

Unreadiness for hospital discharge predicts readmission among cardiac patients: results from the national DenHeart survey

AIMS

Readiness for hospital discharge describes a patient's perception of feeling prepared to leave the hospital. In mixed patient populations, readiness for hospital discharge has shown to predict readmission and mortality in the short term. The objectives of a population of men and women with cardiac diseases, were to investigate: (i) whether readiness for hospital discharge predicts readmission and mortality within 1-year post-discharge, as well as (ii) the association between 'physical stability', 'adequate support', 'psychological ability', and 'adequate information and knowledge' and readiness for hospital discharge.

METHODS AND RESULTS

Data from the national cross-sectional survey DenHeart were used and included patients with cardiac diseases at hospital discharge. Readiness for hospital discharge was evaluated by one self-reported question, and attributes were illuminated by Short-Form-12, the Edmonton Symptom Assessment Scale and ancillary questions. Data were combined with national registries at baseline and at 1-year follow-up. Cox proportional-hazards model were used to regress readmission and mortality. The analysis included 13 114 patients (response rate: 52%). The majority responded that they felt ready for hospital discharge (95%). Feeling unready (n = 618) was a predictor of 1 year, all-cause readmission among women and men [hazard ratio (HR) = 1.43, 95% confidence interval (CI) 1.18-1.74; HR = 1.59, 95% CI 1.34-1.90]. No significant results were found on all-cause mortality. The four attributes were associated with unreadiness at hospital discharge.

CONCLUSION

Not feeling ready for hospital discharge was a predictor of increased readmission risk in women and men with cardiac disease during 1 year after hospital discharge. Four attributes were significantly impaired in patients feeling unready for hospital discharge.

Impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review

OBJECTIVES

To identify and synthesise available evidence on the impact of transitional care interventions with both predischarge and postdischarge elements on readmission rates in older medical patients.

DESIGN

A systematic review.

METHOD

Inclusion criteria were: medical patients ≥65 years or mean age in study population of ≥75 years; interventions were transitional care interventions between hospital and home with both predischarge and postdischarge components; outcome was hospital readmissions. Studies were excluded if they: included other patient groups than medical patients, included patients with only one diagnosis or patients with only psychiatric disorders. PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from January 2008 to August 2019. Study selection at title level was undertaken by one author; the remaining selection process, data extraction and methodological quality assessment were undertaken by two authors independently. A narrative synthesis was performed, and effect sizes were estimated.

RESULT

We identified 1951 records and included 11 studies: five randomised trials, four non-randomised controlled trials and two pre-post cohort studies. The 11 studies represent 15 different interventions and 29 outcome results measuring readmission rates within 7-182 days after discharge. Twenty-two of the 29 outcome results showed a drop in readmission rates in the intervention groups compared with the control groups. The most significant impact was seen when interventions were of high intensity, lasted at least 1 month and targeted patients at risk. The methodological quality of the included studies was generally poor.

CONCLUSION

Transitional care interventions reduce readmission rates among older medical patients although the impact varies at different times of outcome assessment. High-quality studies examining the impact of interventions are needed, preferably complimented by a process evaluation to refine and improve future interventions.

PROSPERO REGISTRATION NUMBER

CRD42019121795.

Crossing boundaries: Establishing a framework for researching quality and safety in care transitions

BACKGROUND

Despite the breadth and diversity of research and policies on care transitions, research studies often report similar components that affect the quality and safety of care, including communication across professional groups and care settings, transfer of information, coordination of resources or training of healthcare personnel. In this article, we aim to deepen our understanding of care transitions by proposing a heuristic research framework that takes into account the components and factors influencing the quality and safety of care transitions in diverse settings.

METHODOLOGY

Using a pragmatic qualitative narrative meta-synthesis of empirically grounded research studies (N = 13) involving 31 researchers from seven countries (Australia, Canada, Denmark, Germany, the Netherlands, Norway and the UK), we conducted a thematic analysis to identify the components analysed in the included studies. We then used these components to create a framework for researching care transitions.

RESULTS

Our narrative synthesis found that the quality and safety of care transitions are influenced by a range of patient-centred, communicative, collaborative, cultural, competency-based, accountability-based and spatial components. These components are encompassed within a broader set of dimensions that require careful consideration: (1) the conceptualising of the care transition notion, (2) the methodology for researching care transitions, (3) the role of patients and carers in care transitions, (4) the complexity surrounding care transitions, (5) the boundaries intertwined in care transitions and (6) care transition improvement interventions. These six dimensions constitute an analytical framework for planning and conducting research on care transitions in diverse settings.

CONCLUSION

The proposed six-dimensional framework for researching quality and safety in care transitions offers a roadmap for future practice and policy interventions and provides a starting point for planning and designing future research.

Development and internal validation of prognostic models to predict negative health outcomes in older patients with multimorbidity and polypharmacy in general practice

BACKGROUND

Polypharmacy interventions are resource-intensive and should be targeted to those at risk of negative health outcomes. Our aim was to develop and internally validate prognostic models to predict health-related quality of life (HRQoL) and the combined outcome of falls, hospitalisation, institutionalisation and nursing care needs, in older patients with multimorbidity and polypharmacy in general practices.

METHODS

Design: two independent data sets, one comprising health insurance claims data (n=592 456), the other data from the PRIoritising MUltimedication in Multimorbidity (PRIMUM) cluster randomised controlled trial (n=502). Population: ≥60 years, ≥5 drugs, ≥3 chronic diseases, excluding dementia. Outcomes: combined outcome of falls, hospitalisation, institutionalisation and nursing care needs (after 6, 9 and 24 months) (claims data); and HRQoL (after 6 and 9 months) (trial data). Predictor variables in both data sets: age, sex, morbidity-related variables (disease count), medication-related variables (European Union-Potentially Inappropriate Medication list (EU-PIM list)) and health service utilisation. Predictor variables exclusively in trial data: additional socio-demographics, morbidity-related variables (Cumulative Illness Rating Scale, depression), Medication Appropriateness Index (MAI), lifestyle, functional status and HRQoL (EuroQol EQ-5D-3L). Analysis: mixed regression models, combined with stepwise variable selection, 10-fold cross validation and sensitivity analyses.

RESULTS

Most important predictors of EQ-5D-3L at 6 months in best model (Nagelkerke's R² 0.507) were depressive symptoms (-2.73 (95% CI: -3.56 to -1.91)), MAI (-0.39 (95% CI: -0.7 to -0.08)), baseline EQ-5D-3L (0.55 (95% CI: 0.47 to 0.64)). Models based on claims data and those predicting long-term outcomes based on both data sets produced low R² values. In claims data-based model with highest explanatory power (R²=0.16), previous falls/fall-related injuries, previous hospitalisations, age, number of involved physicians and disease count were most important predictor variables.

CONCLUSIONS

Best trial data-based model predicted HRQoL after 6 months well and included parameters of well-being not found in claims. Performance of claims data-based models and models predicting long-term outcomes was relatively weak. For generalisability, future studies should refit models by considering parameters representing well-being and functional status.

Hospital to Community Transitions for Older Adults: An Update for the Practicing Clinician

Spurred by changes in both population demographics and health care reimbursement, health care providers are responding by using new models to more fully support the posthospital transition. This paper reviews common models for posthospital transition and also describes the Mayo Clinic model for care transition. Models are designed with the intent of managing the cost of health care by reducing 30-day hospital readmissions and improving management of chronic disease. Meta-analyses have proved helpful in identifying the most effective program elements designed to reduce 30-day hospital readmissions. These elements include a bundled and multidisciplinary approach to best meet the needs of patients. Successful care teams also emphasize self-empowerment for both patients and caregivers. There are 2 general types of practice. In 1 model, introduced by Mary Naylor, an advanced-practice provider cares for the patient for a set period of time, which includes home visits. In the second model, introduced by Eric Coleman, a transitions coach, who can be an RN, a social worker, or a trained volunteer, serves as the health care coach, while improving self-efficacy. Both models have been successful. At Mayo Clinic, the Mayo Clinic Care Transitions program has encompassed a 7-year experience, using the services of an advanced practice provider. In previous studies, this model demonstrated a 20.1% (95% confidence interval [CI], 15.8 to 24.1%) decrease in 30-day readmission in controls compared with 12.4% (95% CI, 8.9 to 15.7%) in the control group. Although this model was successful in reducing 30-day readmissions, there was no difference between groups at 180 days. In patients experiencing the highest deciles of cost (8th decile), enrollment in a care transitions program reduced their overall cost by $2700. This cost savings was statistically significant. Both patients and caregivers participating in the program appreciated the home visits and felt more comfortable communicating at home.

Physical Function in the Hospital Is Associated With Patient-Centered Outcomes in an Inpatient Rehabilitation Facility

OBJECTIVE

Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC "6-clicks" basic mobility short form in the hospital and outcomes in an IRF.

METHODS

This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression.

RESULTS

A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15-1.93), moderately high (aRR = 1.52; 95% CI = 1.16-2.01), or high (aRR = 1.37; 95% CI = 1.02-1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events.

CONCLUSION

Patients with moderate-but not very low or very high-PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion.

IMPACT

Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF.

Validation of the MEDSAIL Tool to Screen for Capacity for Safe and Independent Living Among Nursing Home Residents

OBJECTIVES

Capacity for safe and independent living (SAIL) refers to an individual's ability to solve problems associated with everyday life and perform activities necessary for living independently. Little guidance exists on the assessment of capacity for SAIL among nursing home residents. As a result, capacity for SAIL is not fully considered in the development of discharge plans to ensure safety and independence in the community. We reasoned that this problem could be addressed with the Making and Executing Decisions for Safe and Independent Living (MEDSAIL) tool, developed to screen for capacity for SAIL among community-dwelling older adults. In this report, we describe findings on the validity of the MEDSAIL when used with nursing home residents.

DESIGN

Prospective cross-sectional pilot study.

SETTING AND PARTICIPANTS

Twenty-four residents of a Veterans Health Affairs Community Living Center (CLC; nursing home); exclusion criteria were cognitive impairment too severe to complete the protocol, diagnosis of serious mental illness or developmental disability, inability to hear, or inability to communicate verbally.

METHODS

Participants completed 2 assessments: the MEDSAIL interview administered by a research assistant and the criterion standard capacity interview administered by a geriatric psychiatrist. We examined internal consistency, divergent validity, and criterion-based validity.

RESULTS

Five of 7 MEDSAIL scenarios approximated acceptable levels of internal consistency (α >0.70). MEDSAIL scores were highly positively correlated with criterion standard capacity determination (0.88, P = .001), and the Wilcoxon rank-sum test statistic for the 2 assessments was also statistically significant (P = .001).

CONCLUSIONS AND IMPLICATIONS

MEDSAIL has promise as a user-friendly brief screening tool for use by nursing home staff to understand resident capacity for SAIL. This information can be used in the development of discharge plans to keep the resident safe and independent in the community. In addition, tailoring the MEDSAIL scenarios specifically to the nursing home setting may further enhance the tool's validity and utility in this new application.

Patient Continuity of Care Questionnaire in a cardiac sample: A Confirmatory Factor Analysis

OBJECTIVE

Even though continuity is essential after discharge, there is a lack of reliable questionnaires to measure and assess patients' perceptions of continuity of care. The Patient Continuity of Care Questionnaire (PCCQ) addresses the period before and after discharge from hospital. However, previous studies show that the factor structure needs to be confirmed and validated in larger samples, and the aim of this study was to evaluate the psychometric properties of the PCCQ with focus on factor structure, internal consistency and stability.

DESIGN

A psychometric evaluation study. The questionnaire was translated into Swedish using a forward-backward technique and culturally adapted through cognitive interviews (n=12) and reviewed by researchers (n=8).

SETTING

Data were collected in four healthcare settings in two Swedish counties.

PARTICIPANTS

A consecutive sampling procedure included 725 patients discharged after hospitalisation due to angina, acute myocardial infarction, heart failure or atrial fibrillation.

MEASUREMENT

To evaluate the factor structure, confirmatory factor analyses based on polychoric correlations were performed (n=721). Internal consistency was evaluated by ordinal alpha. Test-retest reliability (n=289) was assessed with intraclass correlation coefficient (ICC).

RESULTS

The original six-factor structure was overall confirmed, but minor refinements were required to reach satisfactory model fit. The standardised factor loadings ranged between 0.68 and 0.94, and ordinal alpha ranged between 0.82 and 0.95. All subscales demonstrated satisfactory test-retest reliability (ICC=0.76-0.94).

CONCLUSION

The revised version of the PCCQ showed sound psychometric properties and is ready to be used to measure perceptions of continuity of care. High ordinal alpha in some subscales indicates that a shorter version of the questionnaire can be developed.

Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018

Purpose and Objectives

Emergency departments see a disproportionate share of low-income and uninsured patients. We developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data.

Intervention Approach

We leveraged an academic–community partnership to develop a social needs screening tool and referral process.

Evaluation Methods

In a 25-day feasibility trial incorporating rapid improvement cycles, emergency department staff screened 210 patients for social needs. Observational and interview notes were analyzed, and data were linked from patient screenings, the United Way of Salt Lake 2-1-1 consumer information system, and electronic health records.

Results

Domains uncovered during pilot testing included screening based on appearance or insurance; discomfort asking stigmatizing questions; and lack of clarity regarding the screening’s purpose. During the trial, 61% (n = 129) of patients reported 1 or more need, 52% (n = 67) of whom wanted follow-up. Of the 65 patients with complete data who wanted referrals, 49% (n = 32) were ultimately reached by 2-1-1, which provided an average of 4 community referrals (eg, pharmacy programs, utility assistance). Service usage 3 months before versus 3 months after emergency department index dates demonstrated that patients with social needs experienced a significant increase in emergency department use compared with those without needs (1.07 vs 1.36, P = .03), while patients with no needs experienced increases in primary care visits compared with those patients with unmet needs (0.24 vs 0.56, P = .03).

Implications for Public Health

We demonstrated the ability to systematically screen and refer for emergency department patients’ unmet social needs by using existing resources and to link screening results, service referral details, and health service data. However, our experiences demonstrate that widespread implementation efforts should thoughtfully address staff perceptions and patient communication challenges.

Entrustment decisions: Implications for curriculum development and assessment

With increased interest in the use of entrustable professional activities (EPAs) in undergraduate and postgraduate medical education, comes questions about their implications for curriculum development and assessment. This paper addresses some of those questions, discussed at a symposium of the 2017 conference of AMEE, by presenting the components of an EPA, describing their importance and application, identifying their implications for assessment, and pinpointing some of challenges they pose in undergraduate and postgraduate settings. It defines entrustment, describes the three levels of trust, and presents trainee and supervisor factors that influence it as well as perceived benefits, and risks. Two aspects of EPAs have implications for assessment: units of professional practice and decisions based on entrustment, which impact an assessment's blueprint, test methods, scores, and standards. In an undergraduate setting EPAs have great appeal, but work is needed to identify and develop a robust assessment system for core EPAs. At the postgraduate level, there is tension between the granularity of the competencies and the integrated nature of the EPAs. Even though work remains, EPAs offer an important step in the evolution of competency-based education.

An Analysis of 1-Year Charges for Head and Neck Cancer: Targets for Value-Based Interventions

OBJECTIVE

To identify the dominant clinical factors associated with increased 1-year charges in treating head and neck cancer.

STUDY DESIGN

Retrospective review.

SETTING

Single academic institution.

SUBJECTS AND METHODS

We retrospectively reviewed 1-year charges for 196 consecutive patients with head and neck cancer (HNC) who were treated exclusively at our institution. We analyzed charges by department as well as factors associated with increased charges per multivariable regression.

RESULTS

The mean age was 59.6 years (SD, 14.9). Most of the population was male (64%), white (70%), and commercially insured (46%). The most common primary sites were the oropharynx (25%; 76%, HPV positive), skin (19%), and thyroid (17%). Eighty-three percent of total charges were due to standard-of-care treatment for HNC: surgery ($16 million), radiation therapy ($22 million), or chemotherapy ($11 million). The median total charge per patient was $212,484 (interquartile range, $78,630-$475,823). Multivariable regression demonstrated that the following were associated with increased charges: nasopharynx subsite ($250,929 [95% CI, $93,290-$408,569]; effect size in US dollars, P = .002), advanced stage (American Joint Committee on Cancer, seventh edition; $80,331 [$22,726-$137,936], P = .007), therapeutic surgery ($281,893 [$117,371-$446,415], P = .001), chemotherapy ($183,331 [$125,497-$241,165], P < .001), radiation ($203,397 [$143,454-$263,341], P < .001), surgical complication requiring return to the operating room ($147,247 [$37,240-$257,254], P = .009), emergency department visits ($89,050 [$23,811-$154,289], P = .008), and admissions ($140,894 [$82,895-$198,893], P < .001; constant, -$233,927 [-$410,790 to -$57,064]). The top quartile accrued 55% of the total charges.

CONCLUSION

Radiation, followed by surgery and chemotherapy, were the most expensive components of HNC care. In this analysis, we identified the dominant clinical factors associated with increased charges.

Implementing a Warm Handoff Between Hospital and Skilled Nursing Facility Clinicians

OBJECTIVES

Care transitions between hospitals and skilled nursing facilities (SNFs) are associated with disruptions in patient care and high risk for adverse events. Communication between hospital-based and SNF-based clinicians is often suboptimal; there have been calls to foster direct, real-time communication between sending and receiving clinicians to enhance patient safety. This article described the implementation of a warm handoff between hospital and SNF physicians and advanced practice providers at the time of hospital discharge.

METHODS

Before patient transfer, hospital clinicians called SNF clinicians to provide information relevant to the continuation of safe patient care and offer SNF clinicians the opportunity to ask clarifying questions. The calls were documented in the hospital discharge summary.

RESULTS

A total of 2417 patient discharges were eligible for inclusion. Warm handoffs were documented at an increasing rate throughout implementation of the intervention, beginning with 15.78% (n = 3) in stage 1, then 20.27% (n = 75) in stage 2, and finally 46.89% (n = 951) in stage 3. The overall average rate of documentation was 42.57%. Participant feedback indicated that clinicians were most concerned about understanding the purpose of the warm handoff, managing their workload, and improving the efficiency of the process.

CONCLUSIONS

Use of a warm handoff showed promise in improving communication during hospital-SNF patient transfers. However, the implementation also highlighted specific barriers to the handoff related to organizational structures and clinician workload. Addressing these underlying issues will be critical in ensuring continued participation and support for efforts that foster direct communication among clinicians from different healthcare institutions.