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Kaskie B, Shehu E, Ohms K, Liebzeit D, Ashida S, Buck HG. Critical Elements of Care Coordination for Older Persons in Rural Communities: An Evaluation of the Iowa Return to Community Service Demonstration. J Appl Gerontol 2024; 43:678-687. [PMID: 38087499 DOI: 10.1177/07334648231218091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
We evaluated the Iowa Return to Community, a service demonstration designed to coordinate care and reduce preventable healthcare utilization among at-risk older persons living at home in rural communities. During 2021, 262 older persons elected to participate in the IRTC program. Individuals who participated were more likely to live in micropolitan areas (OR = 2.30, 95% CI 1.34-3.95) relative to metropolitan locations. Individuals who used recommended services were more likely to be men (OR 3.65, 95% CI 1.16-11.51) and more likely to live in rural (OR 17.48, 95% CI 1.37-223.68) and micropolitan areas (OR 3.17, 95% CI 1.00-10.05). However, prevention of health care use corresponded more with consistent and prolonged IRTC program engagement rather than volume of service use. The IRTC constitutes a population aging and rural health strategy to reduce unnecessary health care use while supporting individual preferences to remain at home.
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Affiliation(s)
- Brian Kaskie
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Erblin Shehu
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Kent Ohms
- Iowa Department on Aging, Des Moines, IA, USA
| | | | - Sato Ashida
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Harleah G Buck
- College of Nursing, University of Iowa, Iowa City, IA, USA
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Bruce C, Pinn-Kirkland T, Meyers A, Javaluyas E, Osborn J, Kelkar S, Bruchhaus L, McLaury K, Sauceda K, Carr K, Garcia C, Arabie LA, Williams T, Vozzella G, Nisar T, Schwartz RL, Sasangohar F. Investigating patient engagement associations between a postdischarge texting programme and patient experience, readmission and revisit rates outcomes. BMJ Open 2024; 14:e079775. [PMID: 38485169 PMCID: PMC10941103 DOI: 10.1136/bmjopen-2023-079775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES This study aimed (1) to examine the association between patient engagement with a bidirectional, semiautomated postdischarge texting programme and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey outcomes, readmissions and revisit rates in a large health system and (2) to describe operational and clinical flow considerations for implementing a postdischarge texting programme. SETTING The study involved 1 main academic hospital (beds: 2500+) and 6 community hospitals (beds: 190-400, averaging 300 beds per hospital) in Houston, Texas. METHODS Retrospective, observational cohort study between non-engaged patients (responded with 0-2 incoming text messages) and engaged patients (responded with 3+ incoming, patient-initiated text messages) between December 2022 and May 2023. We used the two-tailed t-test for continuous variables and χ2 test for categorical variables to compare the baseline characteristics between the two cohorts. For the binary outcomes, such as the revisit (1=yes, vs 0=no) and readmissions (1=yes vs 0=no), we constructed mixed effect logistic regression models with the random effects to account for repeated measurements from the hospitals. For the continuous outcome, such as the case mix index (CMI), a generalised linear quantile mixed effect model was built. All tests for significance were two tailed, using an alpha level of 0.05, and 95% CIs were provided. Significance tests were performed to evaluate the CMI and readmissions and revisit rates. RESULTS From 78 883 patients who were contacted over the course of this pilot implementation, 49 222 (62.4%) responded, with 39 442 (50%) responded with 3+ incoming text messages. The engaged cohort had higher HCAHPS scores in all domains compared with the non-engaged cohort. The engaged cohort used significantly fewer 30-day acute care resources, experiencing 29% fewer overall readmissions and 20% fewer revisit rates (23% less likely to revisit) and were 27% less likely to be readmitted. The results were statistically significant for all but two hospitals. CONCLUSIONS This study builds on the few postdischarge texting studies, and also builds on the patient engagement literature, finding that patient engagement with postdischarge texting can be associated with fewer acute care resources. To our knowledge, this is the only study that documented an association between a text-based postdischarge programme and HCAHPS scores, perhaps owing to the bidirectionality and ease with which patients could interact with nurses. Future research should explore the texting paradigms to evaluate their associated outcomes in a variety of postdischarge applications.
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Affiliation(s)
- Courtenay Bruce
- System Patient Experience, Houston Methodist, Houston, Texas, USA
| | - Theresa Pinn-Kirkland
- Houston Methodist Physicians Alliance for Quality, Houston Methodist, Houston, Texas, USA
| | - Adam Meyers
- Houston Methodist Physician Organization, Houston Methodist, Houston, Texas, USA
| | | | - John Osborn
- System Quality & Patient Safety, Houston Methodist, Houston, Texas, USA
| | - Sayali Kelkar
- System Quality & Patient Safety, Houston Methodist, Houston, Texas, USA
| | - Lindsey Bruchhaus
- Department of Guest Relations and Patient Experience, Houston Methodist The Woodlands, The Woodlands, Texas, USA
| | - Kristen McLaury
- Department of Guest Relations and Patient Experience, Houston Methodist The Woodlands, The Woodlands, Texas, USA
| | - Katherine Sauceda
- Department of Guest Relations and Patient Experience, Houston Methodist Sugar Land Hospital, Sugar Land, Texas, USA
| | - Karen Carr
- Department of Guest Relations and Patient Experience, Houston Methodist Sugar Land Hospital, Sugar Land, Texas, USA
| | - Claudia Garcia
- Department of Guest Relations and Patient Experience, Houston Methodist Baytown, Houston, Texas, USA
| | | | - Terrell Williams
- System Patient Experience, Houston Methodist, Houston, Texas, USA
| | - Gail Vozzella
- Department of Nursing, Houston Methodist, Houston, Texas, USA
| | - Tariq Nisar
- Center for Health Data Science & Analytics, Houston Methodist, Houston, Texas, USA
| | - Roberta L Schwartz
- Houston Methodist Academic Institute, Houston Methodist, Houston, Texas, USA
| | - Farzan Sasangohar
- Industrial and Systems Engineering, Texas A&M University System, College Station, Texas, USA
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Rahnama K, Dahri K, Legal M, Inglis C. Characterizing Current and Optimal Involvement of Hospital Pharmacists in the Discharge Process: A Survey of Pharmacists in British Columbia. Can J Hosp Pharm 2024; 77:e3433. [PMID: 38204508 PMCID: PMC10754396 DOI: 10.4212/cjhp.3433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/31/2023] [Indexed: 01/12/2024]
Abstract
Background Transitions of care represent a vulnerable time when patients are at increased risk of medication errors. Medication-related problems constitute one of the main contributors to hospital readmissions. Discharge interventions carried out by pharmacists have been shown to reduce hospital readmissions. Although clinical pharmacists in British Columbia are involved in discharges, their degree of involvement and the interventions they prioritize in practice have not been fully elucidated. Objectives To characterize the current involvement of BC hospital pharmacists at the time of discharge, to identify which discharge interventions they believe should be prioritized, and who they feel should be responsible for these interventions, as well as to identify strategies to optimize the discharge process. Methods A survey of BC hospital pharmacists was conducted in January and February 2022. The survey included questions about pharmacists' current involvement at the time of discharge, interventions required for a successful discharge, solutions for optimizing the patient discharge process, and participants' baseline characteristics. Results The survey response rate was 20% (101/500). Pharmacists reported performing all interventions for less than 60% of their patients. Interventions such as medication reconciliation on discharge, medication education, and ensuring adherence were considered very important for a successful discharge and were considered to be best performed by pharmacists. Solutions for optimizing the discharge process included improved staffing, weekend coverage, timely notification of discharge, and prescribing by pharmacists. Conclusions Despite the belief that most interventions listed in the survey are necessary for successful discharge, various barriers prevented pharmacists from providing them to all patients. Increased resources and expanded scope of practice for pharmacists could reduce hospital readmissions and enable broader implementation of discharge interventions.
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Affiliation(s)
- Kiana Rahnama
- , BSc, PharmD, ACPR, is with Lions Gate Hospital, North Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BScPharm, PharmD, ACPR, FCSHP, is with the Faculty of Pharmaceutical Sciences, The University of British Columbia, and Vancouver General Hospital, Lower Mainland Pharmacy Services, Vancouver, British Columbia
| | - Michael Legal
- , BScPharm, ACPR, PharmD, is with Lower Mainland Pharmacy Services, Vancouver, British Columbia
| | - Colleen Inglis
- , BSc, BScPharm, PharmD, is with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, and Island Health Comox Valley Health Services, Courtenay, British Columbia
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Landi S, Panella MM, Leardini C. Disentangling organizational levers and economic benefits in transitional care programs: a systematic review and configurational analysis. BMC Health Serv Res 2024; 24:46. [PMID: 38195545 PMCID: PMC10777542 DOI: 10.1186/s12913-023-10461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/08/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Promoting safe and efficient transitions of care is critical to reducing readmission rates and associated costs and improving the quality of patient care. A growing body of literature suggests that transitional care (TC) programs are effective in improving quality of life and reducing unplanned readmissions for several patient groups. TC programs are highly complex and multidimensional, requiring evidence on how specific practices and system characteristics influence their effectiveness in patient care, readmission reduction and costs. METHODS Using a systematic review and a configurational approach, the study examines the role played by system characteristics (size, ownership, professional skills, technology used), the organizational components implemented, analyzing their combinations, and the potential economic impact of TC programs. RESULTS The more organizational components are implemented, the greater the likelihood that a TC program will be successful in reducing readmission rates. Not all components have the same effect. The results show that certain components, 'post-discharge symptom monitoring and management' and 'discharge planning', are necessary but not sufficient to achieve the outcome. The results indicate the existence of two different combinations of components that can be considered sufficient for the reduction of readmissions. Furthermore, while system characteristics are underexplored, the study shows different ways of incorporating the skill mix of professionals and their mode of coordination in TC programs. Four organizational models emerge: the health-based monocentric, the social-based monocentric, the multidisciplinary team and the mono-specialist team. The economic impact of the programs is generally positive. Despite an increase in patient management costs, there is an overall reduction in all post-intervention costs, particularly those related to readmissions. CONCLUSIONS The results underline the importance of examining in depth the role of system characteristics and organizational factors in facilitating the creation of a successful TC program. The work gives preliminary insights into how to systematize organizational practices and different coordination modes for facilitating decision-makers' choices in TC implementation. While there is evidence that TC programs also have economic benefits, the quality of economic evaluations is relatively low and needs further study.
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Affiliation(s)
- Stefano Landi
- Department of Management, Università di Verona, Via Cantarane, 24, 37129, Verona, Italy.
| | - Maria Martina Panella
- IRCCS- Azienda ospedaliera universitaria Bologna, Policlinico di S.Orsola-Malpighi, Via Pietro Albertoni, 15, Bologna, Italy
| | - Chiara Leardini
- Department of Management, Università di Verona, Via Cantarane, 24, 37129, Verona, Italy
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Sison SDM, John J, Mac C, Ruopp M, Driver JA. Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home. J Am Med Dir Assoc 2023; 24:1334-1340. [PMID: 37302797 DOI: 10.1016/j.jamda.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/01/2023] [Accepted: 05/07/2023] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Stephanie Denise M Sison
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Joyanne John
- Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA, USA
| | - Chi Mac
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA, USA
| | - Marcus Ruopp
- Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA, USA.
| | - Jane A Driver
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA; Geriatrics and Extended Care, VA Boston Healthcare System, Boston, MA, USA
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Gallo LC, Fortmann AL, Clark TL, Roesch SC, Bravin JI, Spierling Bagsic SR, Sandoval H, Savin KL, Gilmer T, Talavera GA, Philis-Tsimikas A. Mi Puente (My Bridge) Care Transitions Program for Hispanic/Latino Adults with Multimorbidity: Results of a Randomized Controlled Trial. J Gen Intern Med 2023; 38:2098-2106. [PMID: 36697929 PMCID: PMC9876654 DOI: 10.1007/s11606-022-08006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Multimorbidity frequently co-occurs with behavioral health concerns and leads to increased healthcare costs and reduced quality and quantity of life. Unplanned readmissions are a primary driver of high healthcare costs. OBJECTIVE We tested the effectiveness of a culturally appropriate care transitions program for Latino adults with multiple cardiometabolic conditions and behavioral health concerns in reducing hospital utilization and improving patient-reported outcomes. DESIGN Randomized, controlled, single-blind parallel-groups. PARTICIPANTS Hispanic/Latino adults (N=536; 75% of those screened and eligible; M=62.3 years (SD=13.9); 48% women; 73% born in Mexico) with multiple chronic cardiometabolic conditions and at least one behavioral health concern (e.g., depression symptoms, alcohol misuse) hospitalized at a hospital that serves a large, mostly Hispanic/Latino, low-income population. INTERVENTIONS Usual care (UC) involved best-practice discharge processes (e.g., discharge instructions, assistance with appointments). Mi Puente ("My Bridge"; MP) was a culturally appropriate program of UC plus inpatient and telephone encounters with a behavioral health nurse and community mentor team who addressed participants' social, medical, and behavioral health needs. MAIN MEASURES The primary outcome was 30- and 180-day readmissions (inpatient, emergency, and observation visits). Patient-reported outcomes (quality of life, patient activation) and healthcare use were also examined. KEY RESULTS In intention-to-treat models, the MP group evidenced a higher rate of recurrent hospitalization (15.9%) versus UC (9.4%) (OR=1.91 (95% CI 1.09, 3.33)), and a greater number of recurrent hospitalizations (M=0.20 (SD=0.49) MP versus 0.12 (SD=0.45) UC; P=0.02) at 30 days. Similar trends were observed at 180 days. Both groups showed improved patient-reported outcomes, with no advantage in the Mi Puente group. Results were similar in per protocol analyses. CONCLUSIONS In this at-risk population, the MP group experienced increased hospital utilization and did not demonstrate an advantage in improved patient-reported outcomes, relative to UC. Possible reasons for these unexpected findings are discussed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02723019. Registered on 30 March 2016.
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Affiliation(s)
- Linda C Gallo
- Department of Psychology, San Diego State University, San Diego, CA, USA.
- South Bay Latino Research Center, San Diego State University, 780 Bay Blvd. Suite 200, Chula Vista, CA, 91910, USA.
| | - Addie L Fortmann
- Scripps Whittier Diabetes Institute, Scripps Health, San Diego, CA, USA
| | - Taylor L Clark
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Scott C Roesch
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Julia I Bravin
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | | | - Haley Sandoval
- Scripps Whittier Diabetes Institute, Scripps Health, San Diego, CA, USA
| | - Kimberly L Savin
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Todd Gilmer
- Family Medicine and Public Health, University of California, San Diego, San Diego, CA, USA
| | - Gregory A Talavera
- Department of Psychology, San Diego State University, San Diego, CA, USA
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Murray J, Baxter R, Lawton R, Hardicre N, Shannon R, Langley J, Partridge R, Moore S, O'Hara JK. Unpacking the Cinderella black box of complex intervention development through the Partners at Care Transitions (PACT) programme of research. Health Expect 2023. [PMID: 37186409 DOI: 10.1111/hex.13682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/19/2022] [Accepted: 11/15/2022] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Complex intervention development has been described as the 'Cinderella' black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste. METHODS We applied a new consensus-based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people. Through this process, we aimed to reflect on the framework's utility for intervention development and identify any important gaps within it to support its continued development. FINDINGS The framework was a useful tool for transparent reporting of the process of complex intervention development. We identified potential 'action' gaps in the framework including 'consolidation of evidence' and 'development of principles' that could bracket and steer decision-making in the process. CONCLUSIONS We consider that the level of transparency demonstrated in this report, aided through use of the framework, is essential in the quest for reducing research waste. PATIENT OR PUBLIC CONTRIBUTION We have involved our dedicated patient and public involvement group in all work packages of this programme of research. Specifically, they attended and contributed to co-design workshops and contributed to finalizing the intervention for the pilot evaluation. Staff also participated by attending co-design workshops, helping us to prioritize content ideas for the intervention and supporting the development of intervention components outside of the workshops.
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Affiliation(s)
- Jenni Murray
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, UK
| | - Ruth Baxter
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, UK
| | | | - Natasha Hardicre
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, UK
| | - Rosie Shannon
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, UK
- School of Psychology, University of Leeds, Leeds, UK
| | | | | | - Sally Moore
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford, West Yorkshire, UK
| | - Jane K O'Hara
- School of Healthcare, University of Leeds, Leeds, UK
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Vundi N, Clouser JM, Adu AK, Li J. Implementation and function of interdisciplinary rounds: An observational multisite hospital study from project ACHIEVE. J Hosp Med 2023; 18:224-233. [PMID: 36779326 DOI: 10.1002/jhm.13062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Interdisciplinary rounds (IDR) are increasingly employed by hospitals; however, there is no formal definition, structure, or framework. OBJECTIVE The purpose of this observational study was to document the heterogeneity of IDRs and assess the different characteristics associated with IDR functions. DESIGNS, SETTINGS, AND PARTICIPANTS Observation of IDR occurred at 27 hospitals that were purposively selected to ensure a mix of the following criteria: geographic region, provider type, for-profit status, population (e.g., urban, rural), and teaching status. Hospitals identified general medical floors covered by hospitalists for IDR observations. INTERVENTION The study team conducted hospital site visits to observe the implementation of IDR. A checklist was developed to record IDR structure and processes, content, and outcomes. Data from two content expert observers were reconciled, and a consensus was attained. MAIN OUTCOME AND MEASURES The study measures include two IDR functions: topics discussed during IDR (changes in medical treatment, responsibilities and shared understanding of goals and expectations, anticipation of discharge date and needs, anticipating follow-up care and service needs), and effective communication. RESULTS Hospitals varied significantly in IDR implementation. 51.9% included the "core" team (i.e., a physician, nurse, pharmacist, and case manager/social worker), though all included a case manager or social worker. Most (81.5%) occurred before noon. Content chiefly focused on medical care (74.1 to 92.6%) with patient responsibilities and preferences being less frequently discussed (25.9 to 40.7%). Bivariate analyses revealed that afternoon rounds were more likely to include dischargeȐrelated topics, such as patient/caregiver preferences (100% vs. 27.3%, p = .003) and follow-up needs (100% vs. 36.4%, p = .010).When IDR occurred at bedside, financial resources were more often assessed (100% vs. 34.8%, p = .015) and patient's ability to obtain medication was more often anticipated (75% vs. 21.7%, p = .031).
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Affiliation(s)
- Nikita Vundi
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Jessica M Clouser
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Akosua K Adu
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jing Li
- Department of Medicine, Washington University, St. Louis, Missouri, USA
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Nguyen AT, Wisniewski J, Leang DW, Keller MS, Rosen S, Shane R, Pevnick JM. Effect of the population health inpatient Medicare Advantage pharmacist intervention on hospital readmissions: A quasi-experimental controlled study. J Manag Care Spec Pharm 2023; 29:266-275. [PMID: 36840959 PMCID: PMC10387964 DOI: 10.18553/jmcp.2023.29.3.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.
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Affiliation(s)
- An T Nguyen
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jesse Wisniewski
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Donna W Leang
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sonja Rosen
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rita Shane
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joshua M Pevnick
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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Provider-To-Provider Communication About Care Transitions: Considering Different Health Technology Tools. J Healthc Qual 2023; 45:133-139. [PMID: 36848603 DOI: 10.1097/jhq.0000000000000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
ABSTRACT Transitions in patient care require exchanges of information between providers. This period of transition presents a range of challenges, and inadequate transitions can have serious consequences for patients. Our objective was to understand providers' perspectives about patient care transitions, especially around communication between providers and the role of health information technology in provider-to-provider communication. Semi-structured interviews were conducted. Deductive-dominant thematic analysis was used to allow categorization of data based on general themes derived from the interview guides, as well as identification of emergent themes. We characterized three main themes involving providers' perspectives about care transitions. Themes included communication challenges, communication preferences, and suggestions for improving the care transition processes. With respect to challenges around communication, providers highlighted four main concerns. These concerns included the existence of too many methods of communication, high volume of communication, challenges with involvement of multiple providers delivering longitudinal care, and difficulty communicating with providers outside the health system. Providers noted opportunities to improve transitions including improving standardization, enhancing the specialty to primary care transition process, and increasing communication back to the referring provider. Implementation and evaluation of these improvements could be considered by health systems to enhance care transitions.
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Ladhar S, Dahri K, Inglis C, Sambrielaz A, Raza H, Legal M. Insights into British Columbian Hospital Pharmacists Perspectives on the Discharge Process. Innov Pharm 2022; 13:10.24926/iip.v13i4.5093. [PMID: 37305597 PMCID: PMC10256297 DOI: 10.24926/iip.v13i4.5093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Background: Transitions of care represent a vulnerable time for patients where unintended therapeutic changes are common and inadequate communication of information frequently results in medication errors. Pharmacists have a large impact on the success of patients during these care transitions; however, their role and experiences are largely absent from the literature. Objectives: The purpose of this study was to gain a greater understanding of British Columbian hospital pharmacists' perceptions of the hospital discharge process and their role in it. Methods: A qualitative study utilizing focus groups and key informant interviews of British Columbian hospital pharmacists was conducted from April to May 2021. Questions asked during interviews were developed following a detailed literature search and included questions regarding the use of frequently studied interventions. Interview sessions were transcribed and then thematically analyzed using both NVivo software and manual coding. Results: Three focus groups with a total of 20 participants and one key informant interview were conducted. Six themes were identified through data analysis: (1) overall perspectives; (2) important roles of pharmacists in discharges; (3) patient education; (4) barriers to optimal discharges; (5) solutions to current barriers; and (6) prioritization. Conclusions and Relevance: Pharmacists play a vital role in patient discharges but due to limited resources and inadequate staffing models, they are often unable to be optimally involved. Understanding the thoughts and perceptions of pharmacists on the discharge process can help us better allocate limited resources to ensure patients receive optimal care.
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Affiliation(s)
- Simroop Ladhar
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
| | - Karen Dahri
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
- Lower Mainland Pharmacy Services, Lower Mainland, BC
| | - Colleen Inglis
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
- Island Health, Courtenay, BC
| | - Amanda Sambrielaz
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
| | - Haider Raza
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
| | - Michael Legal
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC
- Lower Mainland Pharmacy Services, Lower Mainland, BC
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Ackermann RT, Liss DT, French DD, Cooper AJ, Aikman C, Schaeffer C. Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge. J Gen Intern Med 2022; 37:3832-3838. [PMID: 35266127 PMCID: PMC9640508 DOI: 10.1007/s11606-022-07473-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/22/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures. OBJECTIVE To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016. INTERVENTIONS Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services. MAIN MEASUREMENTS Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year. KEY RESULTS Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant. CONCLUSIONS Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research. TRIAL REGISTRATION National Clinical Trials Registry (NCT03066492).
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Affiliation(s)
- Ronald T Ackermann
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA.
| | - David T Liss
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Dustin D French
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Veterans Affairs Health Services Research and Development Service, Chicago, IL, USA
| | - Andrew J Cooper
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Cassandra Aikman
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
| | - Christine Schaeffer
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 609, Chicago, IL, 60611, USA
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Williams PH, Gilmartin HM, Leonard C, McCarthy MS, Kelley L, Grunwald GK, Jones CD, Whittington MD. The Influence of the Rural Transitions Nurse Program for Veterans on Healthcare Utilization Costs. J Gen Intern Med 2022; 37:3529-3534. [PMID: 36042072 PMCID: PMC9585107 DOI: 10.1007/s11606-022-07401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 01/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The Veterans Affairs (VA) Healthcare System Rural Transitions Nurse Program (TNP) addresses barriers veterans face when transitioning from urban tertiary VA hospitals to home. Previous clinical evaluations of TNP have shown that enrolled veterans were more likely to follow up with their primary care provider within 14 days of discharge and experience a significant reduction in mortality within 30 days compared to propensity-score matched controls. OBJECTIVE Examine changes from pre- to post-hospitalization in total, inpatient, and outpatient 30-day healthcare utilization costs for TNP enrollees compared to controls. DESIGN Quantitative analyses modeling the changes in cost via multivariable linear mixed-effects models to determine the association between TNP enrollment and changes in these costs. PARTICIPANTS Veterans meeting TNP eligibility criteria who were discharged home following an inpatient hospitalization at one of the 11 implementation sites from April 2017 to September 2019. INTERVENTION The four-step TNP transitional care intervention. MAIN MEASURES Changes in 30-day total, inpatient, and outpatient healthcare utilization costs were calculated for TNP enrollees and controls. KEY RESULTS Among 3001 TNP enrollees and 6002 controls, no statistically significant difference in the change in total costs (p = 0.65, 95% CI: (- $675, $350)) was identified. However, on average, the increase in inpatient costs from pre- to post-hospitalization was approximately $549 less for TNP enrollees (p = 0.02, 95% CI: (- $856, - $246)). The average increase in outpatient costs from pre- to post-hospitalization was approximately $421 more for TNP enrollees compared to controls (p = 0.003, 95% CI: ($109, $671)). CONCLUSIONS Although we found no difference in change in total costs between veterans enrolled in TNP and controls, TNP was associated with a smaller increase in direct inpatient medical costs and a larger increase in direct outpatient medical costs. This suggests a shifting of costs from the inpatient to outpatient setting.
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Affiliation(s)
- Piper H. Williams
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Michaela S. McCarthy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
| | - Gary K. Grunwald
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Christine D. Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO USA
| | - Melanie D. Whittington
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO USA
- University of Kansas Medical Center, Kansas City, KS USA
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Shannon R, Baxter R, Hardicre N, Mills T, Murray J, Lawton R, O'Hara JK. A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home. Health Expect 2022; 25:2796-2806. [PMID: 36056639 DOI: 10.1111/hex.13560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/06/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention. METHODS This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims. RESULTS Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness. CONCLUSION The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing. PATIENT OR PUBLIC CONTRIBUTION This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.
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Affiliation(s)
- Rosie Shannon
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | - Ruth Baxter
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | - Natasha Hardicre
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | - Thomas Mills
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | - Jenni Murray
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Bradford, UK
| | | | - Jane K O'Hara
- School of Healthcare, University of Leeds, Baines Wing, Leeds, UK
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Spivack SB, DeWalt D, Oberlander J, Trogdon J, Shah N, Meara E, Weinberger M, Reiter K, Agravat D, Colla C, Lewis V. The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates. J Gen Intern Med 2022; 37:3005-3012. [PMID: 34258724 PMCID: PMC9485329 DOI: 10.1007/s11606-021-07005-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A great deal of research has focused on how hospitals influence readmission rates. While hospitals play a vital role in reducing readmissions, a significant portion of the work also falls to primary care practices. Despite this critical role of primary care, little empirical evidence has shown what primary care characteristics or activities are associated with reductions in hospital admissions. OBJECTIVE To examine the relationship between practices' readmission reduction activities and their readmission rates. DESIGN, SETTING, AND PARTICIPANTS A retrospective study of 1,788 practices who responded to the National Survey of Healthcare Organizations and Systems (fielded 2017-2018) and 415,663 hospital admissions for Medicare beneficiaries attributed to those practices from 2016 100% Medicare claims data. We constructed mixed-effects logistic regression models to estimate practice-level readmission rates and a linear regression model to evaluate the association between practices' readmission rates with their number of readmission reduction activities. INTERVENTIONS Standardized composite score, ranging from 0 to 1, representing the number of a practice's readmission reduction capabilities. The composite score was composed of 12 unique capabilities identified in the literature as being significantly associated with lower readmission rates (e.g., presence of care manager, medication reconciliation, shared-decision making, etc.). MAIN OUTCOMES AND MEASURES Practices' readmission rates for attributed Medicare beneficiaries. KEY RESULTS Routinely engaging in more readmission reduction activities was significantly associated (P < .05) with lower readmission rates. On average, practices experienced a 0.05 percentage point decrease in readmission rates for each additional activity. Average risk-standardized readmission rates for practices performing 10 or more of the 12 activities in our composite measure were a full percentage point lower than risk-standardized readmission rates for practices engaging in none of the activities. CONCLUSIONS Primary care practices that engaged in more readmission reduction activities had lower readmission rates. These findings add to the growing body of evidence suggesting that engaging in multiple activities, rather than any single activity, is associated with decreased readmissions.
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Affiliation(s)
- Steven B Spivack
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church St, New Haven, CT, 06510, USA.
| | - Darren DeWalt
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Jonathan Oberlander
- Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Justin Trogdon
- Department of Health Policy and Management, University of North Carolina Gillings School of Public Health, Chapel Hill, USA
| | - Nilay Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Ellen Meara
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Morris Weinberger
- Department of Health Policy and Management, University of North Carolina Gillings School of Public Health, Chapel Hill, USA
| | - Kristin Reiter
- Department of Health Policy and Management, University of North Carolina Gillings School of Public Health, Chapel Hill, USA
| | - Devang Agravat
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Carrie Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Valerie Lewis
- Department of Health Policy and Management, University of North Carolina Gillings School of Public Health, Chapel Hill, USA
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Follow-up Post-discharge and Readmission Disparities Among Medicare Fee-for-Service Beneficiaries, 2018. J Gen Intern Med 2022; 37:3020-3028. [PMID: 35355202 PMCID: PMC8966846 DOI: 10.1007/s11606-022-07488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous studies have identified disparities in readmissions among Medicare beneficiaries hospitalized for the Hospital Readmissions Reduction Program's (HRRP's) priority conditions. Evidence suggests timely follow-up is associated with reduced risk of readmission, but it is unknown whether timely follow-up reduces disparities in readmission. OBJECTIVE To assess whether follow-up within 7 days after discharge from a hospitalization reduces risk of readmission and mitigates identified readmission disparities. DESIGN A retrospective cohort study using Cox proportional hazards models to estimate the associations between sociodemographic characteristics (race and ethnicity, dual-eligibility status, rurality, and area social deprivation), follow-up, and readmission. Mediation analysis was used to examine if disparities in readmission were mitigated by follow-up. PARTICIPANTS We analyzed data from 749,402 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, or pneumonia, and discharged home between January 1 and December 1, 2018. MAIN MEASURE All-cause unplanned readmission within 30 days after discharge. KEY RESULTS Post-discharge follow-up within 7 days of discharge was associated with a substantially lower risk of readmission (HR: 0.52, 95% CI: 0.52-0.53). Across all four HRRP conditions, beneficiaries with dual eligibility and beneficiaries living in areas with high social deprivation had a higher risk of readmission. Non-Hispanic Black beneficiaries had higher risk of readmission after hospitalization for pneumonia relative to non-Hispanic Whites. Mediation analysis suggested that 7-day follow-up mediated 21.2% of the disparity in the risk of readmission between dually and non-dually eligible beneficiaries and 50.7% of the disparity in the risk of readmission between beneficiaries living in areas with the highest and lowest social deprivation. Analysis suggested that after hospitalization for pneumonia, 7-day follow-up mediated nearly all (97.5%) of the increased risk of readmission between non-Hispanic Black and non-Hispanic White beneficiaries. CONCLUSIONS Improving rates of follow-up could be a strategy to reduce readmissions for all beneficiaries and reduce disparities in readmission based on sociodemographic characteristics.
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Rosenstengle C, Kripalani S, Rahimi RS. Hepatic encephalopathy and strategies to prevent readmission from inadequate transitions of care. J Hosp Med 2022; 17 Suppl 1:S17-S23. [PMID: 35972038 DOI: 10.1002/jhm.12896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 11/06/2022]
Abstract
One of the most costly and frequent causes of hospital readmissions in the United States is hepatic encephalopathy in patients with underlying liver cirrhosis. In this narrative review, we cover current practices in inpatient management, transitions of care, and strategies to prevent hospital readmissions. Bundled approaches using a model such as the "Ideal Transitions of Care" appear to be more likely to prevent readmissions and assist patients as they transition to outpatient care. Numerous strategies have been evaluated to prevent readmissions in patients with hepatic encephalopathy, including technologic interventions, involvement of nonphysician team members, early follow-up strategies, and involvement of palliative care when appropriate.
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Affiliation(s)
- Craig Rosenstengle
- Division of Gastroenterology & Hepatology, Baylor University Medical Center, Dallas, Texas, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Chan EY, Wu LT, Ng EJY, Glass GF, Tan RHT. Applying the RE-AIM framework to evaluate a holistic caregiver-centric hospital-to-home programme: a feasibility study on Carer Matters. BMC Health Serv Res 2022; 22:933. [PMID: 35854296 PMCID: PMC9296119 DOI: 10.1186/s12913-022-08317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Prolonged caregiving of an older adult can cause family caregivers to be overwhelmed, potentially affecting the well-being of both the caregivers and their care-recipients. Carer Matters is a holistic hospital-to-home programme, centred on caregivers’ needs as their care-recipients transit from hospital to home. The programme was piloted to support caregivers through caregivers needs assessment, tailored resources, tele-support, training courses, and community support network. This study aimed to examine the feasibility of Carer Matters in a tertiary hospital in Singapore. Methods This feasibility study was conducted on the pilot implementation from January to December 2021, during the Covid-19 pandemic. It adopted the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study highlighted quantitative data collected from key process indicators, such as number of caregivers screened, assessed on their needs and provided with assistance. Additionally, qualitative data was collected from in-depth interviews with 51 stakeholders involved in the implementation to examine their perspectives and experiences. These included family caregivers, clinician caregiver support nurses, hospital leaders and community partners. Results During the pilot, 550 caregivers were enrolled. All caregivers received educational resources when they completed the needs assessment, while 69 of them who reported high burden were given tele-support and 252 attended our caregiver training courses. Despite initial recruitment challenges and obstacles to adoption, stakeholders interviewed found Carer Matters to be effective in providing caregivers with emotional support, knowledge and skills that improved their caregiving abilities, and reduced their sense of isolation and caregiving stress. Among caregivers, the training courses were effective with majority of caregivers agreeing that the courses addressed their needs (99%) and improved their knowledge of the relevant disease conditions (97%). Programme maintenance considered among stakeholders included strategies such as multipronged approach in recruiting caregivers and inviting caregiver advocates to share their experiences. Conclusion This feasibility study highlights that Carer Matters is a valuable component to the ecosystem of support for family caregivers and their care recipients. Carer Matters extends the current patient-centric care model to a more holistic post-discharge continuity of care for both caregivers and their care-recipients, improving and maintaining their overall well-being to better allow transition from hospital-to home. Trial registration Feasibility Study of Project Carer Matters for Family Caregivers of Persons with Dementia (NCT number: NCT05205135). Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08317-3.
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Affiliation(s)
- Ee Yuee Chan
- Nursing Research Unit, Tan Tock Seng Hospital, Singapore, Singapore. .,Alice Lee Centre of Nursing Studies, Yong Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Geriatric Education and Research Institute, Singapore, Singapore.
| | - Ling Ting Wu
- Nursing Research Unit, Tan Tock Seng Hospital, Singapore, Singapore
| | | | | | - Robyn Hwee Teng Tan
- Geriatric Education and Research Institute, Singapore, Singapore.,Singapore Social Service Research Centre, National University of Singapore, Singapore, Singapore
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Hladkowicz E, Dumitrascu F, Auais M, Beck A, Davis S, McIsaac DI, Miller J. Evaluations of postoperative transitions in care for older adults: a scoping review. BMC Geriatr 2022; 22:329. [PMID: 35428193 PMCID: PMC9013054 DOI: 10.1186/s12877-022-02989-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background Most people having major surgery are over the age of 65. The transition out of hospital is a vulnerable time for older adults, particularly after major surgery. Research on postoperative transitions in care is growing, but it is not clear how postoperative transitions are being evaluated. The objective of this scoping review was to synthesize processes and outcomes used to evaluate postoperative transitions in care for older adults. Methods We conducted a scoping review that included articles evaluating a postoperative transition in care among adults aged > 65 having major elective surgery. We searched Medline (Ovid), EMBASE (Ovid), CINHAL, and Cochrane Central Register of Controlled Trials (CENTRAL) from their respective inception dates to April 6, 2021. We also searched The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov from their respective inception dates to April 6, 2021. Screening and data extraction was completed by reviewers in duplicate. Data relevant to study design and objective, intervention description, and process or outcome evaluations were extracted. Process evaluations were categorized using the Ideal Transitions in Care Framework, and outcome evaluations were categorized using the Institute for Healthcare Improvement Triple Aim Framework. Results After screening titles and abstracts and full-text article review, we included 20 articles in our final synthesis. There was variability in the processes and outcomes used to evaluate postoperative transitions in care. The most common outcomes evaluated were health service utilization (n = 9), including readmission and Emergency Department visits, experiential outcomes (n = 9) and quality of life (n = 7). Process evaluations included evaluating the education provided to patients to promote self-management (n = 6), coordination of care among team members (n = 3) and outpatient follow-up (n = 3). Only two articles measured frailty, one article used theory to guide their evaluations and no articles engaged knowledge users. Conclusions There is inconsistency in how postoperative transitions in care were evaluated. There is a need to use theories and to engage key stakeholders involved in postoperative transitions in care, including older adults and their caregivers, to identify the most appropriate approaches for developing and evaluating interventions to meaningfully improve care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02989-6.
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Chen J, Wijesundara JG, Enyim GE, Lombardini LM, Gerber BS, Houston TK, Sadasivam RS. Understanding Patients' Intention to Use Digital Health Apps That Support Postdischarge Symptom Monitoring by Providers Among Patients With Acute Coronary Syndrome: Survey Study. JMIR Hum Factors 2022; 9:e34452. [PMID: 35254269 PMCID: PMC8938838 DOI: 10.2196/34452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background After hospital discharge, patients with acute coronary syndrome (ACS) often experience symptoms that prompt them to seek acute medical attention. Early evaluation of postdischarge symptoms by health care providers may reduce unnecessary acute care utilization. However, hospital-initiated follow-up encounters are insufficient for timely detection and assessment of symptoms. While digital health tools can help address this issue, little is known about the intention to use such tools in ACS patients. Objective This study aimed to assess ACS patients’ intention to use digital health apps that support postdischarge symptom monitoring by health care providers and identify patient-perceived facilitators and barriers to app use. Methods Using email invitations or phone calls, we recruited ACS patients discharged from a central Massachusetts health care system between December 2020 and April 2021, to participate in the study. Surveys were delivered online or via phone to individual participants. Demographics and access to technology were assessed. The intention to use a symptom monitoring app was assessed using 5-point Likert-type (from strongly agree to strongly disagree) items, such as “If this app were available to me, I would use it.” Responses were compared across demographic subgroups and survey delivery methods. Two open-ended questions assessed perceived facilitators and barriers to app use, with responses analyzed using qualitative content analysis. Results Among 100 respondents (response rate 8.1%), 45 (45%) completed the survey by phone. The respondents were on average 68 years old (SD 13 years), with 90% (90/100) White, 39% (39/100) women, and 88% (88/100) having access to the internet or a mobile phone. Most participants (65/100, 65%) agreed or strongly agreed that they would use the app, among which 53 (82%) would use the app as often as possible. The percentage of participants with the intention to use the app was 75% among those aged 65-74 years and dropped to 44% among those older than 75 years. The intention to use was higher in online survey respondents (vs phone survey respondents; odds ratio 3.07, 95% CI 1.20-7.88) after adjusting for age and access to technology. The analysis of open-ended questions identified the following 4 main facilitators (motivations): (1) easily reaching providers, (2) accessing or providing information, (3) quickly reaching providers, and (4) consulting providers for symptoms, and the following 4 main barriers: (1) privacy/security concerns, (2) uncomfortable using technology, (3) user-unfriendly app interface, and (4) preference for in-person/phone care. Conclusions There was a strong intention to use a symptom monitoring app postdischarge among ACS patients. However, this intent decreased in patients older than 75 years. The survey identified barriers related to technology use, privacy/security, and the care delivery mode. Further research is warranted to determine if such intent translates into app use, and better symptom management and health care quality.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States.,Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Jessica G Wijesundara
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Gabrielle E Enyim
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Lisa M Lombardini
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ben S Gerber
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Thomas K Houston
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Rajani S Sadasivam
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Gilmartin HM, Warsavage T, Hines A, Leonard C, Kelley L, Wills A, Gaskin D, Ujano-De Motta L, Connelly B, Plomondon ME, Yang F, Kaboli P, Burke RE, Jones CD. Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study. J Hosp Med 2022; 17:149-157. [PMID: 35504490 DOI: 10.1002/jhm.12802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.
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Affiliation(s)
- Heather M Gilmartin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Theodore Warsavage
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Anne Hines
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Chelsea Leonard
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lynette Kelley
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Ashlea Wills
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - David Gaskin
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Lexus Ujano-De Motta
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Brigid Connelly
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA
| | - Fan Yang
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Peter Kaboli
- Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Robert E Burke
- Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA
- Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine D Jones
- Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA
- Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Xie F, Liu N, Yan L, Ning Y, Lim KK, Gong C, Kwan YH, Ho AFW, Low LL, Chakraborty B, Ong MEH. Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions. EClinicalMedicine 2022; 45:101315. [PMID: 35284804 PMCID: PMC8904223 DOI: 10.1016/j.eclinm.2022.101315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/22/2022] [Accepted: 02/07/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Emergency readmission poses an additional burden on both patients and healthcare systems. Risk stratification is the first step of transitional care interventions targeted at reducing readmission. To accurately predict the short- and intermediate-term risks of readmission and provide information for further temporal risk stratification, we developed and validated an interpretable machine learning risk scoring system. METHODS In this retrospective study, all emergency admission episodes from January 1st 2009 to December 31st 2016 at a tertiary hospital in Singapore were assessed. The primary outcome was time to emergency readmission within 90 days post discharge. The Score for Emergency ReAdmission Prediction (SERAP) tool was derived via an interpretable machine learning-based system for time-to-event outcomes. SERAP is six-variable survival score, and takes the number of emergency admissions last year, age, history of malignancy, history of renal diseases, serum creatinine level, and serum albumin level during index admission into consideration. FINDINGS A total of 293,589 ED admission episodes were finally included in the whole cohort. Among them, 203,748 episodes were included in the training cohort, 50,937 episodes in the validation cohort, and 38,904 in the testing cohort. Readmission within 90 days was documented in 80,213 (27.3%) episodes, with a median time to emergency readmission of 22 days (Interquartile range: 8-47). For different time points, the readmission rates observed in the whole cohort were 6.7% at 7 days, 10.6% at 14 days, 13.6% at 21 days, 16.4% at 30 days, and 23.0% at 60 days. In the testing cohort, the SERAP achieved an integrated area under the curve of 0.737 (95% confidence interval: 0.730-0.743). For a specific 30-day readmission prediction, SERAP outperformed the LACE index (Length of stay, Acuity of admission, Charlson comorbidity index, and Emergency department visits in past six months) and the HOSPITAL score (Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months, and Length of stay). Besides 30-day readmission, SERAP can predict readmission rates at any time point during the 90-day period. INTERPRETATION Better performance in risk prediction was achieved by the SERAP than other existing scores, and accurate information about time to emergency readmission was generated for further temporal risk stratification and clinical decision-making. In the future, external validation studies are needed to evaluate the SERAP at different settings and assess their real-world performance. FUNDING This study was supported by the Singapore National Medical Research Council under the PULSES Center Grant, and Duke-NUS Medical School.
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Affiliation(s)
- Feng Xie
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore
- Institute of Data Science, National University of Singapore, Singapore
- Corresponding author at: Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.
| | - Linxuan Yan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Yilin Ning
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Ka Keat Lim
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Changlin Gong
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Heng Kwan
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Andrew Fu Wah Ho
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Lian Leng Low
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore
- Department of Post-Acute and Continuing Care, Outram Community Hospital, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Bibhas Chakraborty
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Department of Statistics and Data Science, National University of Singapore, Singapore
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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23
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Calderon AL, Lamb G. Why did you come back to the hospital? A qualitative analysis of 72-hour readmissions. Hosp Pract (1995) 2022; 50:55-60. [PMID: 34933654 DOI: 10.1080/21548331.2021.2022383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Readmissions occurring within a few days of discharge are more likely due to a problem from the patient's original admission and may be preventable by interventions in the hospital setting. As part of a quality improvement project intended to reduce readmissions within 72 hours of discharge our objective was to explore patient and physician perspectives of reasons for readmissions and to identify potential indicators of readmission during the index admission. METHODS A retrospective chart review of all readmissions within 72 hours between 2/1/2019 and 6/7/2019 in our healthcare system comprised of an academic medical center and 2 smaller community hospitals. As part of a hospital protocol, patients readmitted within 30 days were interviewed by a social worker regarding reasons for readmission and their perspective on what might have prevented it. These answers, physician notes relevant to the reason for readmission and the clinical course of the index admission were abstracted from patient charts. For the subset of patients identified by themselves or their physicians as potentially benefitting from a longer hospitalization, their index admission was reviewed for indicators of readmission. Reasons for readmission, potential preventive measures, and indicators of readmission were independently reviewed by two authors then grouped into common themes by consensus. RESULTS One hundred and thirty-one patients readmitted within 72 hours were identified. Most patients were readmitted for infection related, cardiac or pulmonary reasons. Extending the initial admission was the most common factor suggested by both patients and physicians to prevent readmission. Focusing on 70 patients who may have benefited from a longer admission, indicators included patients not returning to their baseline health status, inadequate management of a known issue, or new symptoms developing during the index admission. CONCLUSIONS Patients should be evaluated for indicators of readmission, which may help guide decisions to discharge patients and decrease rates of 72-hour readmissions.
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Affiliation(s)
| | - Geoffrey Lamb
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Development of an evidence-based reference framework for care coordination with a focus on the micro level of integrated care: A mixed method design study combining scoping review of reviews and nominal group technique. Health Policy 2022; 126:245-261. [DOI: 10.1016/j.healthpol.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/18/2022]
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Impact of multimorbidity and frailty on adverse outcomes among older delayed discharge patients: Implications for healthcare policy. Health Policy 2022; 126:197-206. [DOI: 10.1016/j.healthpol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/22/2022]
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Franchini M, Molinaro S, Caiolfa M, Salvatori M, Pieroni S. Facing the National Recovery and Resilience Plan: Sources of Data, Indicators, and Participatory Strategies in Healthcare and Social Fields. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910457. [PMID: 34639756 PMCID: PMC8507716 DOI: 10.3390/ijerph181910457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/27/2021] [Accepted: 10/01/2021] [Indexed: 01/24/2023]
Abstract
Innovation in governance and services should be the target of the Italian National Recovery and Resilience Plan. Monitoring processes, impacts, and outcomes requires a system of new indicators that are practical to collect. Secondary data sources, their availability, and their information potential should be evaluated, and primary sources should be implemented to supplement traditional disease surveillance. This work highlights the most relevant aspects for bridging the mismatching between complex community needs and current health/social supply and how those aspects could be faced. As a result, we propose a structured multi-phases process for setting the design and functionalities of a cooperative information system, built on the integration between secondary and primary data for informing policies about chronic low back pain (CLBP), a widely recognized determinant of disability and significant economic burden. In particular, we propose the Dress-KINESIS, a tool for improving community capacity development and participation that allows one to freely collect big health and social data and link it to existing secondary data. The system also may be able to monitor how the resources are distributed across different care sectors and suggest how to improve efficiency based on the patient’s CLBP risk stratification. Moreover, it is potentially customizable in other fields of health.
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Affiliation(s)
- Michela Franchini
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (S.M.); (M.S.); (S.P.)
- Correspondence:
| | - Sabrina Molinaro
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (S.M.); (M.S.); (S.P.)
| | | | - Massimiliano Salvatori
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (S.M.); (M.S.); (S.P.)
| | - Stefania Pieroni
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (S.M.); (M.S.); (S.P.)
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Fancher KG, Williams MV. Hospital Readmissions: New Pandemic, Same Old Problems? Jt Comm J Qual Patient Saf 2021; 47:684-685. [PMID: 34588154 PMCID: PMC8438816 DOI: 10.1016/j.jcjq.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Variability in skilled nursing facility screening and admission processes: Implications for value-based purchasing. Health Care Manage Rev 2021; 45:353-363. [PMID: 30418292 DOI: 10.1097/hmr.0000000000000225] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospitalized older adults are increasingly admitted to skilled nursing facilities (SNFs) for posthospital care. However, little is known about how SNFs screen and evaluate potential new admissions. In an era of increasing emphasis on postacute care outcomes, these processes may represent an important target for interventions to improve the value of SNF care. PURPOSE The aim of this study was to understand (a) how SNF clinicians evaluate hospitalized older adults and make decisions to admit patients to an SNF and (b) the limitations and benefits of current practices in the context of value-based payment reforms. METHODS We used semistructured interviews to understand the perspective of 18 clinicians at three unique SNFs-including physicians, nurses, therapists, and liaisons. All transcripts were analyzed using a general inductive theme-based approach. RESULTS We found that the screening and admission processes varied by SNF and that variability was influenced by three key external pressures: (a) inconsistent and inadequate transfer of medical documentation, (b) lack of understanding among hospital staff of SNF processes and capabilities, and (c) hospital payment models that encouraged hospitals to discharge patients rapidly. Responses to these pressures varied across SNFs. For example, screening and evaluation processes to respond to these pressures included gaining access to electronic medical records, providing inpatient physician consultations prior to SNF acceptance, and turning away more complex patients for those perceived to be more straightforward rehabilitation patients. CONCLUSIONS We found facility behavior was driven by internal and external factors with implications for equitable access to care in the era of value-based purchasing. PRACTICE IMPLICATIONS SNFs can most effectively respond to these pressures by increasing their agency within hospital-SNF relationships and prioritizing more careful patient screening to match patient needs and facility capabilities.
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Chen J, Wijesundara JG, Patterson A, Cutrona SL, Aiello S, McManus DD, McKee MD, Wang B, Houston TK. Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses' and patients' perspectives. BMC Health Serv Res 2021; 21:1021. [PMID: 34583702 PMCID: PMC8480104 DOI: 10.1186/s12913-021-07031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND After hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients' post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers. METHODS Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model. RESULTS Participants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI). CONCLUSIONS Strategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Jessica G Wijesundara
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Angela Patterson
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Sarah L Cutrona
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - M Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Thomas K Houston
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Taupin D, Anderson TS, Merchant EA, Kapoor A, Sokol-Hessner L, Yang JJ, Auerbach AD, Stevens JP, Herzig SJ. Preventability of 30-Day Hospital Revisits Following Admission with COVID-19 at an Academic Medical Center. Jt Comm J Qual Patient Saf 2021; 47:696-703. [PMID: 34548237 PMCID: PMC8383478 DOI: 10.1016/j.jcjq.2021.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic may have affected the preventability of 30-day hospital revisits, including readmissions and emergency department (ED) visits without admission. This study was conducted to examine the preventability of 30-day revisits for patients admitted with COVID-19 in order to inform the design of interventions that may decrease preventable revisits in the future. METHODS The study team retrospectively reviewed a cohort of adults admitted to an academic medical center with COVID-19 between March 21 and June 29, 2020, and discharged alive. Patients with a 30-day revisit following hospital discharge were identified. Two-physician review was used to determine revisit preventability, identify factors contributing to preventable revisits, assess potential preventive interventions, and establish the influence of pandemic-related conditions on the revisit. RESULTS Seventy-six of 576 COVID-19 hospitalizations resulted in a 30-day revisit (13.2%), including 21 ED visits without admission (3.6%) and 55 readmissions (9.5%). Of these 76 revisits, 20 (26.3%) were potentially preventable. The most frequently identified factors contributing to preventable revisits were related to the choice of postdischarge location and to patient/caregiver understanding of the discharge medication regimen, each occurring in 25.0% of cases. The most frequently cited potentially preventive intervention was "improved self-management plan at discharge," occurring in 65.0% of cases. Five of the 20 preventable revisits (25.0%) had contributing factors that were thought to be directly related to the COVID-19 pandemic. CONCLUSION Although only approximately one quarter of 30-day hospital revisits following admission with COVID-19 were potentially preventable, these results highlight opportunities for improvement to reduce revisits going forward.
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Tomlinson J, Marques I, Silcock J, Fylan B, Dyson J. Supporting medicines management for older people at care transitions - a theory-based analysis of a systematic review of 24 interventions. BMC Health Serv Res 2021; 21:890. [PMID: 34461892 PMCID: PMC8404335 DOI: 10.1186/s12913-021-06890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Older patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled. METHOD This study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed. RESULTS Common behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions. CONCLUSION This study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.
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Affiliation(s)
- Justine Tomlinson
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK.
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Iuri Marques
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Jonathan Silcock
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Beth Fylan
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Judith Dyson
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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Zwart DL, Schnipper JL, Vermond D, Bates DW. How Do Care Transitions Work?: Unraveling the Working Mechanisms of Care Transition Interventions. Med Care 2021; 59:S387-S397. [PMID: 34228021 PMCID: PMC8263132 DOI: 10.1097/mlr.0000000000001581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Failure of safe care transitions after hospital discharge results in unnecessary worsening of symptoms, extended period of illness or readmission to the hospital. OBJECTIVE The objective of this study was to add to the understanding of the working of care transition interventions between hospital and home through unraveling the contextual elements and mechanisms that may have played a role in the success of these interventions, and by developing a conceptual model of how these components relate to each other. RESEARCH DESIGN This was a qualitative study using in-person, semi-structured interviews, based on realist evaluation methods. SUBJECTS A total of 26 researchers, designers, administrators, and/or practitioners of both current "leading" care transitions interventions and of less successful care transition intervention studies or practices. MEASURES The contextual elements and working mechanisms of the different care transition intervention studies or practices. RESULTS Three main contextual factors (internal environment, external environment, and patient population) and 7 working mechanisms (simplifiying, verifiying, connecting, translating, coaching, monitoring, and anticipating) were found to be relevant to the outcome of care transition interventions. Context, Intervention, Mechanism, and Outcome (CIMO) configurations revealed that, in response to these contextual factors, care transition interventions triggered one or several of the mechanisms, in turn generating outcomes, including a safer care transition. CONCLUSION We developed a conceptual model which explains the working of care transition interventions within different contexts, and believe it can help support future successful implementation of care transition interventions.
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Affiliation(s)
- Dorien L.M. Zwart
- Harkness Fellowship Program in Health Care Policy and Practice, The Commonwealth Fund, New York, NY
- Harvard Medical School, Boston, MA
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston, MA
- Clinical Research, Hospital Medicine Unit, Brigham Health
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital
| | - Debbie Vermond
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - David W. Bates
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital
- Harvard T.H. Chan School of Public Health, Boston, MA
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Valverde PA, Ayele R, Leonard C, Cumbler E, Allyn R, Burke RE. Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives. J Gen Intern Med 2021; 36:2251-2258. [PMID: 33532965 PMCID: PMC8342702 DOI: 10.1007/s11606-020-06511-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Patricia A Valverde
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA. .,Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO, 80045, USA.
| | - Roman Ayele
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA.,Health Systems, Management and Policy Department, Colorado School of Public Health, Aurora, CO, USA
| | - Chelsea Leonard
- Denver-Seattle Center of Innovation at Eastern Colorado VA Healthcare System, Denver, CO, USA
| | - Ethan Cumbler
- Division of Hospital Medicine, Departments of Medicine and Surgery, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Rebecca Allyn
- Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Robert E Burke
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Trivedi SP, Kopp Z, Tang AJ, Mammen A, Pandya D, Horwitz LI, Schwartz MD. Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1043-1049. [PMID: 33332907 DOI: 10.1097/acm.0000000000003896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME). METHOD In 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident, and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and discharge communication practices residents reported they performed frequently (> 60% of time). The authors used content analysis to explore factors that motivated residents to change their discharge practices. RESULTS The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication (adjusted odds ratio 1.73; 95% confidence interval [CI], 1.07-2.81) or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.23). In open-ended comments, residents reported that experiencing adverse patient events at some point in the postdischarge continuum was a major impetus for practice change. CONCLUSIONS This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the postdischarge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented health care system.
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Affiliation(s)
- Shreya P Trivedi
- S.P. Trivedi is co-director, Innovations in Media and Education Delivery and clinical instructor, Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts. The author was, when the study occurred, a population health fellow, New York University Grossman School of Medicine, New York, New York
| | - Zoe Kopp
- Z. Kopp is a second-year resident in internal medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Alice J Tang
- A.J. Tang is assistant professor, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Albin Mammen
- A. Mammen is a third-year resident in internal medicine, Department of Medicine, Baylor College of Medicine, Baylor, Texas
| | - Dharmini Pandya
- D. Pandya is assistant professor, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Leora I Horwitz
- L.I. Horwitz is associate professor, Department of Population Health and Medicine, and director, Center for Healthcare Innovation and Delivery Science, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0003-1800-6040
| | - Mark D Schwartz
- M.D. Schwartz is professor, Department of Population Health, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0002-7123-0060
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Trivedi SP, Kopp Z, Williams PN, Hupp D, Gowen N, Horwitz LI, Schwartz MD. Who is Responsible for Discharge Education of Patients? A Multi-Institutional Survey of Internal Medicine Residents. J Gen Intern Med 2021; 36:1568-1575. [PMID: 33532957 PMCID: PMC8175511 DOI: 10.1007/s11606-020-06508-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, little is known about how perceptions of responsibility among the team impact discharge communication practices. OBJECTIVE Our study attempts to understand residents' perceptions of who is primarily responsible for discharge education, how these perceptions affect their own reported communication with patients, and how residents envision improving multidisciplinary communication around discharges. DESIGN A multi-institutional cross-sectional survey. PARTICIPANTS Internal medicine (IM) residents from seven US residency programs at academic medical centers were invited to participate between March and May 2019, via email of an electronic link to the survey. MAIN MEASURES Data collected included resident perception of who on the multidisciplinary team is primarily responsible for discharge communication, their own reported discharge communication practices, and open-ended comments on ways discharge multidisciplinary team communication could be improved. KEY RESULTS Of the 613 resident responses (63% response rate), 35% reported they were unsure which member of the multidisciplinary team is primarily responsible for discharge education. Residents who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51-7.30) and 3.01 (95% CI, 1.66-5.71) times the odds, respectively, of reporting doing discharge communication practices frequently compared to those who were not sure who was primarily responsible. To improve multidisciplinary discharge communication, residents called for the following among team members: (1) clarifying roles and responsibilities for communication with patients, (2) setting expectations for communication among multidisciplinary team members, and (3) redefining culture around discharges. CONCLUSIONS Residents report a lack of understanding of who is responsible for discharge education. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more frequent discharge communication.
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Affiliation(s)
- Shreya P Trivedi
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
- Department of Medicine, Beth Israel Deaconess Medical Center, 550 Brookline Avenue, Boston, MA, 02215, USA.
| | - Zoe Kopp
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Paul N Williams
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Derek Hupp
- Department of Medicine, University of Iowa, Iowa, IA, USA
| | - Nick Gowen
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Leora I Horwitz
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Mark D Schwartz
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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Hahn-Goldberg S, Huynh T, Chaput A, Krahn M, Rac V, Tomlinson G, Matelski J, Abrams H, Bell C, Madho C, Ferguson C, Turcotte A, Free C, Hogan S, Nicholas B, Oldershaw B, Okrainec K. Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation. BMC Health Serv Res 2021; 21:361. [PMID: 33865385 PMCID: PMC8052788 DOI: 10.1186/s12913-021-06374-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/09/2021] [Indexed: 12/04/2022] Open
Abstract
Background Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process. Methods Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations. Results Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant. Conclusions This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06374-8.
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Affiliation(s)
| | - Tai Huynh
- OpenLab, University Health Network, Toronto, Canada
| | - Audrey Chaput
- Caregiver Advisor, University Health Network, Toronto, Canada
| | - Murray Krahn
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Valeria Rac
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - John Matelski
- Biostatistics Research Unity, University Health Network, Toronto, Canada
| | | | - Chaim Bell
- Department of Medicine, Sinai Health System, Toronto, Canada
| | - Craig Madho
- OpenLab, University Health Network, Toronto, Canada
| | | | | | - Connie Free
- St. Josephs General Hospital Elliot Lake, Elliot Lake, Canada
| | | | - Bonnie Nicholas
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, Canada
| | | | - Karen Okrainec
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
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Duncan I, Fitzner K, Zhao E, Shtein Y. Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers. Popul Health Manag 2021; 24:722-726. [PMID: 33848438 DOI: 10.1089/pop.2021.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although the Centers for Medicare & Medicaid Services has focused on Medicare hospital readmissions for select diagnoses through the Hospital Readmissions Reduction program, there is no similar initiative for employers, who account for the majority of the 48% of private health care spending in the United States. Readmissions are costly and it is estimated that as many as half of these may be preventable. This study analyzes a national claims database to understand post-discharge transitions and their cost in the working population. Within an employer-sponsored, commercially-insured population, this study found that 4% of members are hospitalized annually and drive 37% of population health care cost. Of these members, 17% undergo additional admissions in the year following discharge and drive approximately 67% of the cost of the admitted population. This study found that the post-discharge site of care transitions has significant implications for the cumulative cost of care. More than a third of patients discharged home will transition to higher cost settings over the course of a year. Mental health and substance abuse diagnoses add significantly to admission/readmission rates and costs. Prior research indicates that post-discharge interventions that activate and engage patients in self-management are beneficial in mitigating overall cost and readmissions.
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Affiliation(s)
- Ian Duncan
- Statistics Department, University of California Santa Barbara, Santa Barbara, California, USA
| | - Karen Fitzner
- Santa Barbara Actuaries, Santa Barbara, California, USA
| | - Elaine Zhao
- Santa Barbara Actuaries, Santa Barbara, California, USA
| | - Yoni Shtein
- Laguna Health, San Francisco, California, USA
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Leonard C, Gilmartin H, McCreight M, Kelley L, Mayberry A, Burke RE. Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program. Implement Sci Commun 2021; 2:28. [PMID: 33685521 PMCID: PMC7938579 DOI: 10.1186/s43058-021-00127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites. METHODS The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years. FINDINGS Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns. CONCLUSIONS This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.
| | - Heather Gilmartin
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Lynette Kelley
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, 1700 N Wheeling Street, Aurora, CO, 80045, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, PA, USA.,Hospital Medicine Section, Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Interventions to Improve Hospital Admission and Discharge Management: An Umbrella Review of Systematic Reviews. Qual Manag Health Care 2021; 29:67-75. [PMID: 32224790 DOI: 10.1097/qmh.0000000000000244] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this umbrella review was to summarize the research evidence on programs to improve the transition between ambulatory and hospital care. METHODS The MEDLINE database and the Cochrane library were searched. Systematic reviews of randomized controlled trials published between January 2000 and September 2018 in English or German were included. Studies were eligible if an assessment or coordination intervention had been evaluated and if patients had been transferred between hospital (defined as internal medicine, surgery, or unspecified hospital setting) and home (defined as any permanent residence). Risk of bias was assessed using the AMSTAR criteria. Results are presented descriptively and in table format. RESULTS Thirty-nine systematic reviews comprising 492 different studies were included. More than half of these studies were conducted in the United States, the United Kingdom, Canada, and Australia. All studies evaluated strategies to improve discharge management (introduced after patients' arrival at the hospital); no study assessed strategies to improve admission management (initiated in primary care before patients' transition to hospital). The reviews included focused on a specific patient group, a specific intervention type, or a specific outcome. Overall, interventions focusing on elderly patients and high-intensity interventions seemed to be most effective. An overview of classifications of care transition strategies is provided. CONCLUSIONS Future research should focus on hospital admission management programs.
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Pugh J, Penney LS, Noël PH, Neller S, Mader M, Finley EP, Lanham HJ, Leykum L. Evidence based processes to prevent readmissions: more is better, a ten-site observational study. BMC Health Serv Res 2021; 21:189. [PMID: 33648491 PMCID: PMC7919066 DOI: 10.1186/s12913-021-06193-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background 30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). Methods Design: Mixed method, multi-stepped observational study. Data collection occurred 2014–2018 with data analyses completed in 2021. Setting: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. Participants: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. Exposure: Frequency of use of twenty recommended care transition processes, scored 0–3. Sites’ individual process scores and cumulative total scores were tested for correlation with RSRR. Outcome: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits. Results Total scores: Mean 38.3 (range 24–47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007). Conclusions Sites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.
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Affiliation(s)
- Jacqueline Pugh
- Department of Internal Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA. .,South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA.
| | - Lauren S Penney
- Department of Internal Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA.,South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA
| | - Polly H Noël
- South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA.,Department of Family and Community Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA
| | - Sean Neller
- Department of Internal Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA
| | - Michael Mader
- South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA
| | - Erin P Finley
- Department of Internal Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA.,South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA
| | - Holly J Lanham
- Department of Internal Medicine, University of Texas Health at San Antonio, Long School of Medicine, San Antonio, TX, USA.,South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA
| | - Luci Leykum
- South Texas Veterans Health Care System, Research Service, San Antonio, TX, USA.,Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin, TX, USA
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Reducing 30-Day Readmissions Through Nursing Science: An Application of Transitions Theory With Best Practice Guidelines. ANS Adv Nurs Sci 2021; 43:2-14. [PMID: 31299686 DOI: 10.1097/ans.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Transition Management Model was developed by and for nurse care coordinators at an Independent Health Network to reduce Medicare and Medicaid 30-day readmission rates. Preimplementation assessment revealed the need for a nursing science framework to effectively reduce 30-day readmissions. The model was developed through thoughtful integration of transitions theory with best practice guidelines set forth by Project BOOST. Initial results of the Transition Management Model produced a decline in readmission rates by 11%. The Transition Management Model initiative can serve as an exemplar for the integration of transitions theory to best practice guidelines to effectively reduce 30-day readmissions.
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Sauro K, Maini A, Machan M, Lorenzetti D, Chandarana S, Dort J. Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol. BMJ Open 2021; 11:e043374. [PMID: 33495258 PMCID: PMC7839915 DOI: 10.1136/bmjopen-2020-043374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer. METHODS AND ANALYSIS This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis. ETHICS AND DISSEMINATION Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.
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Affiliation(s)
- Khara Sauro
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Arjun Maini
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Machan
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diane Lorenzetti
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir Chandarana
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph Dort
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Vest JR, Unruh MA, Hilts KE, Sanner L, Jones J, Khokhar S, Jung HY. End user information needs for a SMART on FHIR-based automated transfer form to support the care of nursing home patients during emergency department visits. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:1239-1248. [PMID: 33936500 PMCID: PMC8075455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Nursing home (NH) patients are extensive users of emergency department (ED) services. Problematically, poor information sharing and incomplete access to information complicates the delivery of care in EDs for NH patients. Paper-based transfer forms can support information sharing, but have significant limitations. Standards-based automated transfer-forms that leverage health information exchange data may address the limitations of paper-based forms and better support care delivery. This study developed a prototype SMART on FHIR automated transfer form for NH patients using priority data elements identified through individual interviews, a review of existing transfer forms, a targeted survey of end users, and a design workshop. Analyses were grounded in the 5 Rights of clinical decision support framework. The most valuable data elements included: emergency contact/healthcare proxy, current medication list, reason for transfer to the ED, baseline neurological state, and relevant diagnoses / medical history. The working prototype was successfully deployed within an Amazon Web Service environment.
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Affiliation(s)
- Joshua R Vest
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Mark A Unruh
- Weill Cornell Medical College, New York, NY, USA
| | - Katy Ellis Hilts
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Lindsey Sanner
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Joshua Jones
- Regenstrief Institute, Inc., Indianapolis, IN, USA
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Capiau A, Foubert K, Van der Linden L, Walgraeve K, Hias J, Spinewine A, Sennesael AL, Petrovic M, Somers A. Medication Counselling in Older Patients Prior to Hospital Discharge: A Systematic Review. Drugs Aging 2020; 37:635-655. [PMID: 32643062 DOI: 10.1007/s40266-020-00780-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older patients are regularly exposed to multiple medication changes during a hospital stay and are more likely to experience problems understanding these changes. Medication counselling is often proposed as an important component of seamless care to ensure appropriate medication use after hospital discharge. OBJECTIVES The purpose of this systematic review was to describe the components of medication counselling in older patients (aged ≥ 65 years) prior to hospital discharge and to review the effectiveness of such counselling on reported clinical outcomes. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (PROSPERO CRD42019116036), a systematic search of MEDLINE, EMBASE and CINAHL was conducted. The QualSyst Assessment Tool was used to assess bias. The impact of medication counselling on different outcomes was described and stratified by intervention content. RESULTS Twenty-nine studies were included. Fifteen different components of medication counselling were identified. Discussing the dose and dosage of patients' medications (19/29; 65.5%), providing a paper-based medication list (19/29; 65.5%) and explaining the indications of the prescribed medications (17/29; 58.6%) were the most frequently encountered components during the counselling session. Twelve different clinical outcomes were investigated in the 29 studies. A positive effect of medication counselling on medication adherence and medication knowledge was found more frequently, compared to its impact on hard outcomes such as hospital readmissions and mortality. Yet, evidence remains inconclusive regarding clinical benefit, owing to study design heterogeneity and different intervention components. Statistically significant results were more frequently observed when counselling was provided as part of a comprehensive intervention before discharge. CONCLUSIONS Substantial heterogeneity between the included studies was found for the components of medication counselling and the reported outcomes. Study findings suggest that medication counselling should be part of multifaceted interventions, but the evidence concerning clinical outcomes remains inconclusive.
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Affiliation(s)
- Andreas Capiau
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium. .,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
| | - Katrien Foubert
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Lorenz Van der Linden
- Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Julie Hias
- Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université Catholique de Louvain, Brussels, Belgium.,Department of Pharmacy, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Anne-Laure Sennesael
- Department of Pharmacy, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium.,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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Glans M, Kragh Ekstam A, Jakobsson U, Bondesson Å, Midlöv P. Risk factors for hospital readmission in older adults within 30 days of discharge - a comparative retrospective study. BMC Geriatr 2020; 20:467. [PMID: 33176721 PMCID: PMC7659222 DOI: 10.1186/s12877-020-01867-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population. METHODS This comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student's t-test, χ2-test or Fishers' exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission. RESULTS The final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001). CONCLUSION Patients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.
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Affiliation(s)
- Maria Glans
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden. .,Department of Medications, Region Skåne Office for Hospitals in Northeastern Skåne, SE-291 85, Kristianstad, Sweden.
| | - Annika Kragh Ekstam
- Department of Orthopaedics, Region Skåne Office for Hospitals in Northeastern Skåne, SE-291 85, Kristianstad, Sweden
| | - Ulf Jakobsson
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden
| | - Åsa Bondesson
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, SE-291 85, Kristianstad, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, Clinical Research Center, Box 50332, 20213, Malmö, Sweden
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Practices to support relational coordination in care transitions: Observations from the VA rural Transitions Nurse Program. Health Care Manage Rev 2020; 47:109-114. [PMID: 33181554 DOI: 10.1097/hmr.0000000000000300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring safe transitions of care around hospital discharge requires effective relationships and communication between health care teams. Relational coordination (RC) is a process of communicating and relating for the purpose of task integration that predicts desirable outcomes for patients and providers. RC can be measured using a validated survey. PURPOSE The aim of the study was to demonstrate the application of RC practices within the rural Transitions Nurse Program (TNP), a nationwide transitions of care intervention for Veterans, and assess relationships and mechanisms for developing RC in teams. METHODOLOGY/APPROACH TNP implemented practices expected to support RC. These included creation of a transition nurse role, preimplementation site visits, process mapping to understand workflow, creation of standardized communication templates and protocols, and inclusion of teamwork and shared accountability in job descriptions and annual reviews. We used the RC Survey to measure RC for TNP health care teams. Associations between the months each site participated in TNP, number of Veterans enrolled, and adherence to the TNP intervention were assessed as possible mechanisms for developing high RC using Spearman (rs) correlations. RESULTS The RC Survey was completed by 44 providers from 11 Veterans Health Administration medical centers. RC scores were high across sites (mean = 4.19; 1-5 Likert scale) and were positively correlated with months participating in TNP (rs = .66) and number of enrollees (rs = .63), but not with adherence to the TNP intervention (rs = .12). PRACTICE IMPLICATIONS The impact of practices to support RC can be assessed using the RC Survey. Our findings suggest scale-up time is a likely mechanism to the development of high-quality relationships and communication within teams.
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Morkisch N, Upegui-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC, Freiberger E. Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatr 2020; 20:345. [PMID: 32917145 PMCID: PMC7488657 DOI: 10.1186/s12877-020-01747-w] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/31/2020] [Indexed: 01/19/2023] Open
Abstract
Background Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components’ role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes). Methods Randomized controlled trials (sample size ≥50 participants per group; intervention period ≥30 days), with geriatric patients were included. Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Central Register of Controlled Trials) were searched from January 1994 to December 2019 published in English or German. A qualitative synthesis of the findings as well as a systematic assessment of the interventions intensities was performed. Results Three articles met the inclusion criteria. One of the included trials applied all of the nine Transitional Care Model components described by Hirschman and colleagues and obtained a high-intensity level of intervention in the intensities assessment. This and another trial reported reductions in the readmission rate (p < 0.05), but the third trial did not report significant differences between the groups in the longer follow-up period (up to 12 months). Conclusions Our findings suggest that high intensity multicomponent and multidisciplinary interventions are likely to be effective reducing readmission rates in geriatric patients, without increasing cost. Components such as type of staffing, assessing and managing symptoms, educating and promoting self-management, maintaining relationships and fostering coordination seem to have an important role in reducing the readmission rate. Research is needed to perform further investigations addressing geriatric patients well above 65 years old, to further understand the importance of individual components of the TCM in this population.
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Affiliation(s)
| | - Luz D Upegui-Arango
- Bundesverband Geriatrie e.V, Berlin, Germany.,Institute of Medical Psychology and Medical Sociology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Maria I Cardona
- Institute of Biomedicine of Aging, Nuremberg, Friedrich-Alexander-University Erlangen-Nuremberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | | | - Martina Rimmele
- Institute of Biomedicine of Aging, Nuremberg, Friedrich-Alexander-University Erlangen-Nuremberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | - Cornel Christian Sieber
- Institute of Biomedicine of Aging, Nuremberg, Friedrich-Alexander-University Erlangen-Nuremberg, Kobergerstr. 60, 90408, Nuremberg, Germany.,Kantonspital Winterthur/Swiss, Winterthur, Switzerland
| | - Ellen Freiberger
- Institute of Biomedicine of Aging, Nuremberg, Friedrich-Alexander-University Erlangen-Nuremberg, Kobergerstr. 60, 90408, Nuremberg, Germany.
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Oikonomou E, Page B, Lawton R, Murray J, Higham H, Vincent C. Validation of the Partners at Care Transitions Measure (PACT-M): assessing the quality and safety of care transitions for older people in the UK. BMC Health Serv Res 2020; 20:608. [PMID: 32611336 PMCID: PMC7329420 DOI: 10.1186/s12913-020-05369-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 05/26/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The Partners at Care Transitions Measure (PACT-M) is a patient-reported questionnaire for evaluation of the quality and safety of care transitions from hospital to home, as experienced by older adults. PACT-M has two components; PACT-M 1 to capture the immediate post discharge period and PACT-M 2 to assess the experience of managing care at home. In this study, we aim to examine the psychometric properties, factor structure, validity and reliability of the PACT-M. METHODS We administered the PACT-M over the phone and by mail, within one week post discharge with 138 participants and one month after discharge with 110 participants. We performed principal components analysis and factors were assessed for internal consistency, reliability and construct validity. RESULTS Reliability was assessed by calculating Cronbach's alpha for the 9-item PACT-M 1 and 8-item PACT-M 2 and exploratory factor analysis was performed to evaluate dimensionality of the scales. Principal components analysis was chosen using pair-wise deletion. Both PACT-M 1 and PACT-M 2 showed high internal consistency and good internal reliability values and conveyed unidimensional scale characteristics with high reliability scores; above 0.8. CONCLUSIONS The PACT-M has shown evidence to suggest that it is a reliable measure to capture patients' perception of the quality of discharge arrangements and also on patients' ability to manage their care at home one month post discharge. PACT-M 1 is a marker of patient experience of transition and PACT-M 2 of coping at home.
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Affiliation(s)
| | | | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, UK
- Bradford Institute For Health Research, Bradford, UK
| | - Jenni Murray
- Bradford Institute For Health Research, Bradford, UK
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Forchuk C, Martin ML, Sherman D, Corring D, Srivastava R, O'Regan T, Gyamfi S, Harerimana B. Healthcare professionals' perceptions of the implementation of the transitional discharge model for community integration of psychiatric clients. Int J Ment Health Nurs 2020; 29:498-507. [PMID: 31863520 DOI: 10.1111/inm.12687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2019] [Indexed: 12/17/2022]
Abstract
Research has demonstrated the benefits of mental healthcare interventions that ensure a safe transition of clients throughout the discharge and community integration process. This paper reports on qualitative data from focus groups with health professionals collected as part of a larger a mixed method study designed to examine the effectiveness and sustainability of implementing the transitional discharge model. Data collection involved two sets of focus groups, which were held at six months and one-year post-implementation. There were 216 health professional participants from nine (9) hospitals across the Province of Ontario, Canada. Data analysis used a four-step ethnographic framework by Leininger (1985) to identify descriptors and recurrent and major themes. The study identified four major themes, including healthcare professionals' roles and positive experiences in implementing the transitional discharge model; perceived benefits of the model; challenges to implementing the model; and suggestions for sustaining the model's implementation. Healthcare professionals felt that the implementation of the transitional discharge model has the potential for increasing their awareness of the process of clients' integration, serving as a framework for discharge planning, and reducing hospital readmissions. The study findings may provide healthcare providers with information on pragmatic ways to plan clients' discharge, to bridge the gap between hospital and community care, and to positively impact client health outcomes.
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Affiliation(s)
- Cheryl Forchuk
- Lawson Health Research Institute, London, Ontario, Canada.,Arthur Labatt School of Nursing, Western University, London, Ontario, Canada
| | - Mary-Lou Martin
- St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | | | - Deborah Corring
- Division of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Rani Srivastava
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tony O'Regan
- Lawson Health Research Institute, London, Ontario, Canada.,Arthur Labatt School of Nursing, Western University, London, Ontario, Canada
| | - Sebastian Gyamfi
- Lawson Health Research Institute, London, Ontario, Canada.,Arthur Labatt School of Nursing, Western University, London, Ontario, Canada
| | - Boniface Harerimana
- Lawson Health Research Institute, London, Ontario, Canada.,Arthur Labatt School of Nursing, Western University, London, Ontario, Canada
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O'Hara JK, Baxter R, Hardicre N. 'Handing over to the patient': A FRAM analysis of transitional care combining multiple stakeholder perspectives. APPLIED ERGONOMICS 2020; 85:103060. [PMID: 32174348 DOI: 10.1016/j.apergo.2020.103060] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/18/2019] [Accepted: 01/13/2020] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The period following discharge can present risks for older adults. Most research has focused on hospital discharge with less attention paid to on-going care needs. Despite evidence that patients undertake 'invisible work' to improve care safety, their reported willingness to be involved in care, and the consensus that successful transitions interventions include patient involvement, in reality, this is variable. Further, little research has viewed transitional care as a 'system', with gaps, interdependencies and variability across settings, nor the role of patients and families in supporting the system resilience. RESEARCH OBJECTIVES 1) model transitional care from multiple perspectives using the Functional Resonance Analysis Method (FRAM); 2) use the model to develop a theory of change to support intervention development. METHOD We drew data from two studies: i) exploring the perspective of older adults across transitional care, and ii) exploring how health services experience transitional care. We employed the FRAM to develop a model of transitional care, with a system boundary spanning an older patient's admission to hospital, through to thirty days post-discharge. FINDINGS Modelling transitional care from multiple perspectives was challenging. 27 functions were identified with interdependencies between hospital-based functions and patient-led functions once home, the success of which may impact on transitions 'outcomes' (e.g. safety events, readmissions). The model supported development of a theory of change, to guide future intervention development. CONCLUSIONS Supporting certain patient-facing upstream hospital functions (e.g. encouraging mobility, supporting a better understanding of medication and condition), may lead to improved outcomes for patients following hospital discharge.
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Affiliation(s)
- Jane K O'Hara
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9JT, UK. Jane.O'
| | - Ruth Baxter
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Natasha Hardicre
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
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