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Cross DA, Bucy TI, Rahman M, McHugh JP. Access to preferred skilled nursing facilities: Transitional care pathways for patients with Alzheimer's disease and related dementias. Health Serv Res 2024; 59:e14263. [PMID: 38145955 PMCID: PMC10915496 DOI: 10.1111/1475-6773.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high-volume preferred skilled nursing facility (SNF) partners. DATA SOURCES The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017-2019. STUDY DESIGN We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. DATA COLLECTION Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. PRINCIPAL FINDINGS Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital-SNF relationship, and (c) comparing patients with more versus less advanced ADRD. CONCLUSIONS Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high-volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).
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Affiliation(s)
- Dori A. Cross
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Taylor I. Bucy
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Momotazur Rahman
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - John P. McHugh
- Department of Health Policy and ManagementMailman School of Public Health, Columbia UniversityNew YorkNew YorkUSA
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Poulin LIL, Colibaba A, Skinner MW, Balfour G, Byrne D, Dieleman C. Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults' transitions into long-term care. BMC Geriatr 2023; 23:180. [PMID: 36978019 PMCID: PMC10045254 DOI: 10.1186/s12877-023-03807-3] [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: 07/08/2022] [Accepted: 02/07/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Establishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum. METHODS We performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process. RESULTS The findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care. CONCLUSIONS We emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.
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Affiliation(s)
- Laura I L Poulin
- Trent Centre for Aging & Society, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada.
| | - Amber Colibaba
- Trent Centre for Aging & Society, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada
| | - Mark W Skinner
- Trent School of the Environment, Trent University, 1600 West Bank Dr., Peterborough, ON, K9L 0G2, Canada
| | - Gillian Balfour
- Office of the Provost and Vice-President Academic, Thompson River University, 805 TRU Way, Kamloops, BC, V2C 0C8, Canada
| | - David Byrne
- Community and Justice Services, Centennial College, 941 Progress, Ave, Scarborough, ON, M1G 3T8, Canada
| | - Crystal Dieleman
- School of Occupational Therapy, Dalhousie University, 5869 University Ave., Halifax, NS, B3H 4R2, Canada
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Evaluating a transitional care program for the oldest adults: results from the quantitative phase of a mixed-methods study. QUALITY IN AGEING AND OLDER ADULTS 2023. [DOI: 10.1108/qaoa-03-2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Purpose
This quantitative phase of a mixed-methods study aims to describe the effect of the Transitional Care Bridge (TCB) programme on functional decline, mortality, health-care utilisation and health outcomes compared to usual care in a regional hospital in the Netherlands.
Design/methodology/approach
In a pre- and post-cohort study, patients aged ≥70 years, admitted to the hospital for ≥48 h and discharged home with an Identification of Seniors at Risk score of ≥2, were included. The TCB programme, started before discharge, encompassed six visits by the community nurse (CN). Data were obtained from the hospital registry and by three questionnaires over a three months period, addressing activities of daily living (ADL), self-rated health, self-rated quality of life and health-care utilisation.
Findings
In total, 100 patients were enrolled in this study, 50 patients in the TCB group and 50 patients in the usual care group. After three months, 36.7% was dependent on ADL in the TCB group compared to 47.1% in the usual care group. Mean number of visits by the CN in the TCB group was 3.8. Although the TCB group had a lower mortality, this study did not find any statistically significant differences in health outcomes and health-care utilisation.
Research limitations/implications
Challenges in the delivery of the programme may have influenced patient outcomes. More research is needed on implementation of evidence-based programmes in smaller research settings. A qualitative phase of the study needs to address these outcomes and explore the perspectives of health professionals and patients on the delivery of the programme.
Originality/value
This study provides valuable information on the transitional care programme in a smaller setting.
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Saragosa M. Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers. DEMENTIA 2022; 21:153-180. [PMID: 34333996 PMCID: PMC8721620 DOI: 10.1177/14713012211031779] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Older adults living with dementia are at risk for more complex health care transitions than individuals without this condition, non-impaired individuals. Poor quality care transitions have resulted in a growing body of qualitative empirical literature that to date has not been synthesized. We conducted a systematic literature review by applying a meta-ethnography approach to answer the following question: How do older adults with dementia and/or their caregivers experience and perceive healthcare transition: Screening resulted in a total of 18 studies that met inclusion criteria. Our analysis revealed the following three categories associated with the health care transition: (1) Feelings associated with the healthcare transition; (2) processes associated with the healthcare transition; and (3) evaluating the quality of care associated with the health care transition. Each category is represented by several themes that together illustrate an interconnected and layered experience. The health care transition, often triggered by caregivers reaching a "tipping point," is manifested by a variety of feelings, while simultaneously caregivers report managing abrupt transition plans and maintaining vigilance over care being provided to their family member. Future practice and research opportunities should be more inclusive of persons with dementia and should establish ways of better supporting caregivers through needs assessments, addressing feelings of grief, ongoing communication with the care team, and integrating more personalized knowledge at points of transition.
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Affiliation(s)
- Marianne Saragosa
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto; Sinai Health, Canada
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5
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Vaismoradi M, Behboudi-Gandevani S, Lorenzl S, Weck C, Paal P. Needs Assessment of Safe Medicines Management for Older People With Cognitive Disorders in Home Care: An Integrative Systematic Review. Front Neurol 2021; 12:694572. [PMID: 34539551 PMCID: PMC8446192 DOI: 10.3389/fneur.2021.694572] [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: 04/13/2021] [Accepted: 07/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives: The global trend of healthcare is to improve the quality and safety of care for older people with cognitive disorders in their own home. There is a need to identify how medicines management for these older people who are cared by their family caregivers can be safeguarded. This integrative systematic review aimed to perform the needs assessment of medicines management for older people with cognitive disorders who receive care from their family caregivers in their own home. Methods: An integrative systematic review of the international literature was conducted to retrieve all original qualitative and quantitative studies that involved the family caregivers of older people with cognitive disorders in medicines management in their own home. MeSH terms and relevant keywords were used to search four online databases of PubMed (including Medline), Scopus, CINAHL, and Web of Science and to retrieve studies published up to March 2021. Data were extracted by two independent researchers, and the review process was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Given that selected studies were heterogeneous in terms of the methodological structure and research outcomes, a meta-analysis could not be performed. Therefore, narrative data analysis and knowledge synthesis were performed to report the review results. Results: The search process led to retrieving 1,241 studies, of which 12 studies were selected for data analysis and knowledge synthesis. They involved 3,890 older people with cognitive disorders and 3,465 family caregivers. Their methodologies varied and included cohort, randomised controlled trial, cross-sectional studies, grounded theory, qualitative framework analysis, and thematic analysis. The pillars that supported safe medicines management with the participation of family caregivers in home care consisted of the interconnection between older people's needs, family caregivers' role, and collaboration of multidisciplinary healthcare professionals. Conclusion: Medicines management for older people with cognitive disorders is complex and multidimensional. This systematic review provides a comprehensive image of the interconnection between factors influencing the safety of medicines management in home care. Considering that home-based medicines management is accompanied with stress and burden in family caregivers, multidisciplinary collaboration between healthcare professionals is essential along with the empowerment of family caregivers through education and support.
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Affiliation(s)
| | | | - Stefan Lorenzl
- Palliative Care, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
| | - Christiane Weck
- Palliative Care, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
| | - Piret Paal
- WHO Collaborating Centre at the Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
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Gilmore-Bykovskyi AL, Hovanes M, Mirr J, Block L. Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions. J Geriatr Psychiatry Neurol 2021; 34:378-388. [PMID: 32812457 PMCID: PMC7892639 DOI: 10.1177/0891988720944245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia-who often cannot communicate these needs on their own-in facilitating high-quality transitions.
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Affiliation(s)
- Andrea L Gilmore-Bykovskyi
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, Madison, WI, USA
| | - Melissa Hovanes
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
| | - Jacquelyn Mirr
- Division of Geriatrics, Department of Medicine, 5228University of Wisconsin-Madison School of Medicine & Public Health, Madison, WI, USA
- Mercy Hospital St. Louis, MO, USA
| | - Laura Block
- 5228University of Wisconsin-Madison School of Nursing, Madison, WI, USA
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Ashbourne J, Boscart V, Meyer S, Tong CE, Stolee P. Health care transitions for persons living with dementia and their caregivers. BMC Geriatr 2021; 21:285. [PMID: 33926380 PMCID: PMC8086075 DOI: 10.1186/s12877-021-02235-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Persons with dementia are likely to require care from various health care providers in multiple care settings, necessitating navigation through an often-fragmented care system. This study aimed to create a better understanding of care transition experiences from the perspectives of persons living with dementia and their caregivers in Ontario, Canada, through the development of a theoretical framework. METHODS Constructivist grounded theory guided the study. Seventeen individual caregiver interviews, and 12 dyad interviews including persons with dementia and their caregivers, were recorded and transcribed verbatim. The data were coded using NVivo 10 software; analysis occurred iteratively until saturation was reached. RESULTS A theoretical framework outlining the context, processes, and influencing factors of care transitions was developed and refined. Gaining an in-depth understanding of the complex care transitions of individuals with dementia and their caregivers is an important step in improving the quality of care and life for this population. CONCLUSION The framework developed in this study provides a focal point for efforts to improve the health care transitions of persons living with dementia.
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Affiliation(s)
- Jessica Ashbourne
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Veronique Boscart
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
- School of Health and Life Sciences, Conestoga College Institute of Technology and Advanced Learning, Kitchener, Ontario, N2G 4M4, Canada
| | - Samantha Meyer
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Catherine E Tong
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
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Henning-Smith C, Cross D, Rahman A. Challenges to Admitting Residents: Perspectives from Rural Nursing Home Administrators and Staff. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211005191. [PMID: 33769114 PMCID: PMC8743937 DOI: 10.1177/00469580211005191] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rural residents are older, on average, than urban residents, with more underlying health conditions and higher rates of disability. Rural nursing homes face unique challenges admitting medically-complex patients and meeting their needs throughout their stay. These challenges may be amplified for certain health conditions. Greater geographic distances also strain transitional care coordination practices with health system referral hubs in urban areas. In this study, we assess perceptions of difficulty rural nursing homes encounter in admitting and serving individuals with dementia, obesity, mental and behavioral health conditions, and medically complex conditions. Using a survey of nursing home administrators located in non-metropolitan counties across the U.S. (n = 209), we assessed the self-reported degree of difficulty identified in serving each of the 4 type of conditions, coupled with qualitative analysis of open-ended questions identifying specific challenges. Rural nursing homes have capacity constraints owing to lower population density, limited financial resources, and unique challenges recruiting and retaining workforce to rural areas. Nursing home administrators reported the most challenges to providing high-quality care to residents with mental and behavioral health challenges, followed by obesity. For specific challenges, administrators focused primarily on staffing concerns, as well as space and equipment needs. Rural nursing home administrators identified challenges related to specific conditions and capacity constraints. To ensure appropriate and high-quality nursing home placement for rural residents, and to minimize the disruption of transitions into nursing home settings, more attention is needed on addressing the constraints identified by rural nursing home administrators in this study.
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Affiliation(s)
| | - Dori Cross
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Adrita Rahman
- University of Minnesota School of Public Health, Minneapolis, MN, USA
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Gilmore-Bykovskyi A, Cotton Q, Morgan J, Block L. Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study. BMJ Open 2021; 11:e043016. [PMID: 33550256 PMCID: PMC7925923 DOI: 10.1136/bmjopen-2020-043016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION People living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers' perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention. METHODS AND ANALYSIS We will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide. ETHICS AND DISSEMINATION The study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Quinton Cotton
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Morgan
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laura Block
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Gilbert T, Occelli P, Rabilloud M, Poupon-Bourdy S, Riche B, Touzet S, Bonnefoy M. A Nurse-Led Bridging Program to Reduce 30-Day Readmissions of Older Patients Discharged From Acute Care Units. J Am Med Dir Assoc 2020; 22:1292-1299.e5. [PMID: 33229305 DOI: 10.1016/j.jamda.2020.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Older hospitalized patients are at high risk of early readmissions, requiring the implementation of enhanced coordinated transition programs on discharge. The objective of this study was to evaluate the impact of a nurse-led transition bridging program on the rate of unscheduled readmissions of older patients within 30 days from discharge from geriatric acute care units. DESIGN A stepped-wedge cluster randomized trial. SETTING AND PARTICIPANTS Seven hundred five patients aged ≥75 years hospitalized in one of 10 acute geriatric units, with at least 2 readmission risk-screening criteria (derived from the Triage Risk Screening Tool), were included from July 2015 to August 2016. METHODS The intervention condition consisted in a nurse-led hospital-to-home bridging program with 4 weeks postdischarge follow-up (2 home visits and 2 telephone calls). Unscheduled hospital readmission or emergency department (ED) visits were compared in intervention and control condition within 30 days from discharge. RESULTS The rate of 30-day readmission or ED visit was 15.5% in the intervention condition vs 17.6% in the control condition [hazard ratio stratified on clusters: 0.61 (upper limit unilateral 95% confidence interval = 1.11), P = .09]. Rate of presence of professional caregivers was increased in the intervention condition (P < .001). CONCLUSIONS AND IMPLICATIONS Although the intervention resulted in an increase in the rate of implementation of a package of care at the 4-week of follow-up, we could not demonstrate a reduction in the rate of 30-day readmissions or ED visits of older patients at risk of readmission. These findings support the evaluation of this type of program on the longer term.
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Affiliation(s)
- Thomas Gilbert
- Service de médecine gériatrique, Hospices Civils de Lyon, Groupement Hospitalier Sud, CHU de Lyon, Bénite-Pierre Cedex, France; HESPER, EA 7425 Université Claude Bernard lyon 1, Lyon 8 Cedex, France.
| | - Pauline Occelli
- HESPER, EA 7425 Université Claude Bernard lyon 1, Lyon 8 Cedex, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Recherche clinique et Epidémiologique, Lyon, France
| | - Muriel Rabilloud
- Université de Lyon, F-69000, Lyon, France; Université Lyon 1, Villeurbanne, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Stéphanie Poupon-Bourdy
- HESPER, EA 7425 Université Claude Bernard lyon 1, Lyon 8 Cedex, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Recherche clinique et Epidémiologique, Lyon, France
| | - Benjamin Riche
- Université de Lyon, F-69000, Lyon, France; Université Lyon 1, Villeurbanne, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Sandrine Touzet
- HESPER, EA 7425 Université Claude Bernard lyon 1, Lyon 8 Cedex, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Recherche clinique et Epidémiologique, Lyon, France
| | - Marc Bonnefoy
- Service de médecine gériatrique, Hospices Civils de Lyon, Groupement Hospitalier Sud, CHU de Lyon, Bénite-Pierre Cedex, France; Université de Lyon, F-69000, Lyon, France; Université Lyon 1, Villeurbanne, France; CarMeN, U1060 INSERM, Oullins Cedex, France
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Ullrich P, Werner C, Bongartz M, Eckert T, Abel B, Schönstein A, Kiss R, Hauer K. Increasing Life-Space Mobility in Community-Dwelling Older Persons With Cognitive Impairment Following Rehabilitation: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2020; 76:1988-1996. [PMID: 33021670 DOI: 10.1093/gerona/glaa254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Community-dwelling older persons with cognitive impairment (CI) following discharge from geriatric rehabilitation are at high risk of losing life-space mobility (LSM). Interventions to improve their LSM are, however, still lacking. The aim of this study was to evaluate the effects of a CI-specific, home-based physical training and activity promotion program on LSM. METHODS Older persons with mild-to-moderate CI (Mini-Mental State Examination: 17-26 points) discharged home from rehabilitation were included in this double-blinded, randomized, placebo-controlled trial with a 12-week intervention period and 12-week follow-up period. The intervention group received a CI-specific, home-based strength, balance, and walking training supported by tailored motivational strategies. The control group received a placebo activity. LSM was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment, including a composite score for LSM and 3 subscores for maximal, equipment-assisted, and independent life space. Mixed-model repeated-measures analyses were used. RESULTS One hundred eighteen participants (82.3 ± 6.0 years) with CI (Mini-Mental State Examination: 23.3 ± 2.4) were randomized. After the intervention, the home-based training program resulted in a significant benefit in the Life-Space Assessment in Persons with Cognitive Impairment composite scores (b = 8.15; 95% confidence interval: 2.89-13.41; p = .003) and independent life-space subscores (b = 0.39; 95% confidence interval: 0.00-0.78; p = .048) in the intervention group (n = 63) compared to control group (n = 55). Other subscores and follow-up results were not significantly different. CONCLUSIONS The home-based training program improved LSM and independent life space significantly in this vulnerable population. Effects were not sustained over the follow-up. The program may represent a model for improved transition from rehabilitation to the community to prevent high risk of LSM restriction.
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Affiliation(s)
- Phoebe Ullrich
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany
| | - Christian Werner
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany.,Center of Geriatric Medicine, Heidelberg University, Germany
| | - Martin Bongartz
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany
| | - Tobias Eckert
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany
| | - Bastian Abel
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany
| | | | - Rainer Kiss
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany.,FHM Bielefeld, University of Applied Sciences, Germany
| | - Klaus Hauer
- AGAPLESION Bethanien Hospital Heidelberg, Geriatric Center at the Heidelberg University, Germany.,Center of Geriatric Medicine, Heidelberg University, Germany
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Odeh M, Scullin C, Hogg A, Fleming G, Scott MG, McElnay JC. A novel approach to medicines optimisation post-discharge from hospital: pharmacist-led medicines optimisation clinic. Int J Clin Pharm 2020; 42:1036-1049. [PMID: 32524511 PMCID: PMC7476989 DOI: 10.1007/s11096-020-01059-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/11/2020] [Indexed: 11/11/2022]
Abstract
Background There is a major drive within healthcare to reduce patient readmissions, from patient care and cost perspectives. Pharmacist-led innovations have been demonstrated to enhance patient outcomes. Objective To assess the impact of a post-discharge, pharmacist-led medicines optimisation clinic on readmission parameters. Assessment of the economic, clinical and humanistic outcomes were considered. Setting Respiratory and cardiology wards in a district general hospital in Northern Ireland. Method Randomised, controlled trial. Blinded random sequence generation; a closed envelope-based system, with block randomisation. Adult patients with acute unplanned admission to medical wards subject to inclusion criteria were invited to attend clinic. Analysis was carried out for intention-to-treat and per-protocol perspectives. Main Outcome Measure 30-day readmission rate. Results Readmission rate reduction at 30 days was 9.6% (P = 0.42) and the reduction in multiple readmissions over 180-days was 29.1% (P = 0.003) for the intention-to-treat group (n = 31) compared to the control group (n = 31). Incidence rate ratio for control patients for emergency department visits was 1.65 (95% CI 1.05-2.57, P = 0.029) compared with the intention-to-treat group. For unplanned GP consultations the equivalent incident rate ratio was 2.00 (95% CI 1.18-3.58, P = 0.02). Benefit to cost ratio in the intention-to-treat and per-protocol groups was 20.72 and 21.85 respectively. Patient Health Related Quality of Life was significantly higher at 30-day (P < 0.001), 90-day (P < 0.001) and 180-day (P = 0.036) time points. A positive impact was also demonstrated in relation to patient beliefs about their medicines and medication adherence. Conclusion A pharmacist-led post-discharge medicines optimisation clinic was beneficial from a patient care and cost perspective.
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Affiliation(s)
- Mohanad Odeh
- Pharmacy Management and Pharmaceutical Care Innovation Centre, Hashemite University, 13133 Hashemite University, Zarqa, Jordan
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Claire Scullin
- Medicines Optimisation Innovation Centre (MOIC), Bretten Hall, Northern Health and Social Care Trust, Antrim Site, Antrim, UK
| | - Anita Hogg
- Medicines Optimisation Innovation Centre (MOIC), Bretten Hall, Northern Health and Social Care Trust, Antrim Site, Antrim, UK
| | - Glenda Fleming
- Medicines Optimisation Innovation Centre (MOIC), Bretten Hall, Northern Health and Social Care Trust, Antrim Site, Antrim, UK
| | - Michael G Scott
- Medicines Optimisation Innovation Centre (MOIC), Bretten Hall, Northern Health and Social Care Trust, Antrim Site, Antrim, UK
| | - James C McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
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Prusaczyk B, Fabbre V, Morrow-Howell N, Proctor E. Understanding transitional care provided to older adults with and without dementia: A mixed methods study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2020. [DOI: 10.1177/2053434520908122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction There are numerous effective transitional care interventions yet they are not routinely implemented. Furthermore, few interventions exist for older adults with dementia. A first step in developing effective interventions for dementia patients and increasing intervention uptake for all patients is to understand the current delivery process of transitional care. Methods A mixed methods study using an explanatory multiphase design was conducted. Guided by provider interviews, medical charts were reviewed to collect information on the day-to-day transitional care being delivered to older adults. Then providers were interviewed again to assess the accuracy of those results and provide context. Results The medical charts of 210 older adults (126 with dementia and 84 without) were reviewed and nine providers representing various professional roles including social work, nursing, and case management were interviewed. Social workers and case managers were primarily involved in discharge planning, communicating with providers outside the hospital, advanced care planning, providing social and community supports, and making follow-up appointments. Registered nurses were the primary providers of patient education and medication safety while physicians were primarily involved in ensuring that necessary information was available in the discharge summary and that it was available in the chart. Discussion This study found distinct patterns in the delivery of transitional care, including the unique roles nursing, social work, and case management have in the process. Furthermore, these patterns were found to differ between patients with and without dementia. These findings are both consistent and inconsistent with the existing literature on transitional care interventions.
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Affiliation(s)
- Beth Prusaczyk
- Washington University School of Medicine in St. Louis, USA
| | - Vanessa Fabbre
- Brown School of Social Work, Washington University in St. Louis, USA
| | | | - Enola Proctor
- Brown School of Social Work, Washington University in St. Louis, USA
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The Impact of Peer Support on the Risk of Future Hospital Readmissions among Older Adults with a Medical Illness and Co-Occurring Depression. SOCIAL SCIENCES 2018. [DOI: 10.3390/socsci7090156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Older adults account for 60% of all preventable hospital readmissions. Although not all readmissions are preventable, evidence indicates that up to 75% of hospital readmissions can be prevented with enhanced patient education, pre-discharge assessment, and effective care upon discharge. Social support, specifically peer support, after discharge from hospital may be a crucial factor in minimizing the risk of preventable hospital readmission. The pilot study reported here evaluated the relationship between peer support and hospital readmissions in a sample of depressed older adults (N = 41) who were recently discharged from hospital due to a medical condition and who simultaneously had an untreated mental health diagnosis of depression. As hypothesized, participants who received the 3-month long peer support intervention were significantly less likely to be readmitted compared to those who did not receive the intervention. Findings from this preliminary information suggest that peer support is a protective factor that can positively affect patient outcomes, reduce the risk of hospital readmission, and reduce depressive symptoms among older adults with health and behavioral health comorbidities.
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15
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Gilmore-Bykovskyi AL, Roberts TJ, King BJ, Kennelty KA, Kind AJH. Transitions From Hospitals to Skilled Nursing Facilities for Persons With Dementia: A Challenging Convergence of Patient and System-Level Needs. THE GERONTOLOGIST 2018; 57:867-879. [PMID: 27174895 DOI: 10.1093/geront/gnw085] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/29/2016] [Indexed: 11/15/2022] Open
Abstract
Purpose of the Study To describe skilled nursing facility (SNF) nurses' perspectives on the experiences and needs of persons with dementia (PwD) during hospital-to-SNF transitions and to identify factors related to the quality of these transitions. Design and Methods Grounded dimensional analysis study using individual and focus group interviews with nurses (N = 40) from 11 SNFs. Results Hospital-to-SNF transitions were largely described as distressing for PwD and their caregivers and dominated by dementia-related behavioral symptoms that were perceived as being purposely under-communicated by hospital personnel in discharge communications. SNF nurses described PwD as having unique transitional care needs, which primarily involved needing additional discharge preplanning to enable preparation of a tailored behavioral/social care plan and physical environment prior to transfer. SNF nurses identified inaccurate/limited hospital discharge communication regarding behavioral symptoms, short discharge timeframes, and limited nursing control over SNF admission decisions as factors that contributed to poorer-quality transitions producing increased risk for resident harm, rehospitalization, and negative resident/caregiver experiences. Engaged caregivers throughout the transition and the presence of high-quality discharge communication were identified as factors that improved the quality of transitions for PwD. Implications Findings from this study provide important insight into factors that may influence transitional care quality during this highly vulnerable transition. Additional research is needed to explore the association between these factors and transitional care outcomes such as rehospitalization and caregiver stress. Future work should also explore strategies to improve inter-setting communication and care coordination for PwD exhibiting challenging behavioral symptoms.
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Affiliation(s)
- Andrea L Gilmore-Bykovskyi
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,University of Wisconsin-Madison School of Nursing
| | - Tonya J Roberts
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,University of Wisconsin-Madison School of Nursing
| | | | - Korey A Kennelty
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Medicine, Division of Geriatrics, University of Wisconsin-Madison School of Medicine & Public Health
| | - Amy J H Kind
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Medicine, Division of Geriatrics, University of Wisconsin-Madison School of Medicine & Public Health
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Ballard J, Rankin W, Roper KL, Weatherford S, Cardarelli R. Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates. Am J Med Qual 2018; 33:583-589. [PMID: 29745236 DOI: 10.1177/1062860618775528] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A process improvement initiative for transitional care management (TCM) was evaluated for effectiveness in reducing 30-day readmission rates in a retrospective cohort study. Regression models analyzed the association between level of TCM component implementation and readmission rates among patients discharged from a university medical center hospital. Of the 1884 patients meeting inclusion criteria, only 3.7% (70) experienced a 30-day readmission. Patients receiving the full complement of TCM had 86.6% decreased odds of readmission compared with patients who did not receive TCM ( P < .001). However, the complete package of TCM services under Medicare guidelines may not be essential. A postdischarge telephone call did not reduce readmission odds, provided a TCM office visit occurred. Important for risk assessment models targeting patients for TCM, the number of previous hospital admissions, not age, predicted 30-day readmission risk. This study provides evidence that primary care-based TCM can reduce 30-day readmissions even when overall rates are low.
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Aprahamian I, Suemoto CK, Aliberti MJR, de Queiroz Fortes Filho S, de Araújo Melo J, Lin SM, Filho WJ. Frailty and cognitive status evaluation can better predict mortality in older adults? Arch Gerontol Geriatr 2018; 77:51-56. [PMID: 29669268 DOI: 10.1016/j.archger.2018.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/11/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES to evaluate the improvement in one-year mortality prediction after adding a 2-min cognitive screening to a simple 1-min frailty detection instrument. Secondary outcomes were new activities of daily living (ADL) disability and falls. DESIGN Prospective cohort study. SETTING A geriatric day-hospital for intermediate care. PARTICIPANTS A total of 701 older adults with an acute or decompensated disease (79.5 (8.3) years, 64% female). MEASUREMENTS A rapid and simple frailty evaluation was performed using the FRAIL questionnaire. The presence of cognitive impairment was defined by previous diagnosis of dementia or a score of five or less on an education-corrected 10-point cognitive screening tool. RESULTS Frail participants with normal (hazard risk [HR] 4.0, 95% confidence interval [CI], 1.73-9.25) and impaired cognition had a higher risk of death (HR 4.38, 95% CI, 1.95-9.87) than robust participants. The presence of cognitive impairment increased the risk of death in prefrail (HR 3.60, 95% CI, 1.55-8.34) and robust participants (HR 3.49, 95% CI, 1.22-9.96). Cognitive impairment was associated with an increased risk of incident ADL disability in all frailty categories. The presence of cognitive impairment was associated with a significantly higher risk of fall in robust seniors. The predictive accuracy of the FRAIL scale was lower than expected (between 0.58 and 0.69), and a small improvement was observed after adding the cognitive screening (between 0.61 and 0.72). CONCLUSION Despite of significant results in predicting relevant clinical events, the present combination of the FRAIL and 10-CS scales may not be ideal in clinical practice.
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Affiliation(s)
- Ivan Aprahamian
- Division of Geriatrics, Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil; Department of Internal Medicine, Faculty of Medicine of Jundiaí, Jundiaí, Brazil.
| | - Claudia Kimie Suemoto
- Division of Geriatrics, Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Juliana de Araújo Melo
- Division of Geriatrics, Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
| | - Sumika Mori Lin
- Division of Geriatrics, Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
| | - Wilson Jacob Filho
- Division of Geriatrics, Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
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Mabire C, Dwyer A, Garnier A, Pellet J. Effectiveness of nursing discharge planning interventions on health-related outcomes in discharged elderly inpatients: a systematic review. ACTA ACUST UNITED AC 2018; 14:217-260. [PMID: 27755325 DOI: 10.11124/jbisrir-2016-003085] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Inadequate discharge planning for the growing elderly population poses significant challenges for health services. Effective discharge planning interventions have been examined in several studies, but little information is available on nursing's role or the specific components of these interventions. Despite the research published on the importance of discharge planning, the impact on patient's health outcomes still needs to be proven in practice. OBJECTIVES To determine the best available evidence on the effectiveness of discharge planning interventions involving at least one nurse on health-related outcomes for elderly inpatients discharged home and to assess the relative impact of individual components of discharge planning interventions. INCLUSION CRITERIA TYPES OF PARTICIPANTS Elderly inpatients aged 65 years or older, discharged from acute care and post-acute care rehabilitation hospitals to home. TYPES OF INTERVENTIONS The review focused on the six keys components of Naylor's Transitional Care Model: early geriatric assessment, discharge preparation, patient or caregiver's participation, continuity of care, day of discharge assessment and post-discharge follow-up. TYPES OF STUDIES This review considered randomized and non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. OUTCOMES The outcomes for this review were functional ability, symptoms management, adverse outcomes, unmet needs after discharge, coping with disease, health-related quality of life (QoL), satisfaction with care, readmission rate and healthcare utilization. SEARCH STRATEGY A systematic search was undertaken across 13 databases to retrieve published and unpublished studies in English between 2000 and 2015. METHODOLOGICAL QUALITY Critical appraisal was undertaken by two independent reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). DATA EXTRACTION Quantitative data were extracted from included studies independently by the two reviewers using the standardized data extraction tool from JBI-MAStARI. DATA SYNTHESIS Due to the wide range of outcome measures, a comprehensive meta-analysis for all studies was not possible. However, meta-analysis was conducted for specific outcome measures, such as readmission, length of stay and QoL. RESULTS Thirteen studies met the inclusion criteria and were included in the review. Two out of the 13 studies were pilot studies and one had a pre-post design. Included studies involved a total of 3964 participants with a median age of 77 years. Nurse discharge planning did not significantly reduce hospital readmission rate (odds ratio [OR] = 0.73, 95% confidence intervals [CIs] = 0.53-1.01, P = 0.06). The overall effect score for length of stay was significant (weighted mean difference = 0.29, P < 0.01), suggesting that discharge planning increased the length of hospitalization. The effectiveness of discharge planning did not significantly impact QoL (mental OR = 0.37, P = 0.19 and physical OR = 0.47, P = 0.15). CONCLUSION Findings of this review suggest that nursing discharge planning for elderly inpatients discharged home increases length of stay, yet neither reduces readmission rates nor improves QoL.
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Affiliation(s)
- Cedric Mabire
- 1University of Applied Sciences and Arts Western Switzerland (HES-SO), School of Health Sciences (HESAV), Lausanne, Vaud, Switzerland 2Bureau d'Echange des Savoirs pour des praTique exemplaires de soins (BEST): a Joanna Briggs Institute Centre of Excellence 3Institute of Higher Education and Research in Healthcare (IUFRS), Lausanne University and CHUV, Vaud, Switzerland 4Lausanne University Hospital - CHUV, Lausanne, Vaud, Switzerland
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19
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Mabire C, Dwyer A, Garnier A, Pellet J. Meta-analysis of the effectiveness of nursing discharge planning interventions for older inpatients discharged home. J Adv Nurs 2017; 74:788-799. [DOI: 10.1111/jan.13475] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Cédric Mabire
- Institute of Higher Education and Research in Healthcare (IUFRS); Lausanne University and Lausanne University Hospital; Lausanne Switzerland
- Bureau d'Echange des Savoirs pour des praTique exemplaires de soins: an Affiliate Center of the Joanna Briggs Institute; Lausanne Switzerland
- Lausanne University Hospital (CHUV); Lausanne Switzerland
| | - Andrew Dwyer
- Institute of Higher Education and Research in Healthcare (IUFRS); Lausanne University and Lausanne University Hospital; Lausanne Switzerland
- Lausanne University Hospital (CHUV); Lausanne Switzerland
- Boston College William F. Connell School of Nursing; Chestnut Hill MA USA
| | | | - Joanie Pellet
- Institute of Higher Education and Research in Healthcare (IUFRS); Lausanne University and Lausanne University Hospital; Lausanne Switzerland
- Bureau d'Echange des Savoirs pour des praTique exemplaires de soins: an Affiliate Center of the Joanna Briggs Institute; Lausanne Switzerland
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20
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Morrison J, Palumbo MV, Rambur B. Reducing Preventable Hospitalizations With Two Models of Transitional Care. J Nurs Scholarsh 2016; 48:322-9. [PMID: 27074394 DOI: 10.1111/jnu.12210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of health care through temporary follow-up after hospital discharge. This study describes the approaches and outcomes of two distinct transitional care programs serving different populations: one is provided by master's-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPCs). Existing research has shown that transitional care programs with intensive follow-up reduce hospitalizations, emergency department (ED) visits, and costs. Few studies, however, have included side-by-side descriptions of the efficacy of transitional care programs varying by healthcare providers or program focus. DESIGN This is a retrospective cohort study comparing the number of ED visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included differences in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program (September 2014 to December 2014) were analyzed (n = 98). The average age of participants was 69 years and 65% were female. Data were collected from patients from the PPC program from September 2014 to April 2015 (n = 71). Thirty participants died within 120 days after the intervention and were excluded; the remaining 41 were included in the analysis. Participants had an average age of 81 years and 63% were female. METHODS For the CNS program, a secondary analysis of existing data was performed. For the PPC program, a review of patient charts was done to collect data on encounters. A Wilcoxon matched-pairs signed-rank test was performed to test for significance. FINDINGS Patients in the CNS intervention had significantly fewer ED visits (p < .005) and hospitalizations (p < .005) in the 4 months after the intervention than in the 4 months before the intervention. Patients in the PPC program had a nonsignificant reduction in ED visits (p = .327) and a significant reduction in hospitalizations postintervention (p = .03). CONCLUSIONS Both transitional programs have value in decreasing rehospitalizations. The CNS intervention also significantly reduced ED visits for their target population. Further study with randomized controlled trials is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed. CLINICAL RELEVANCE Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.
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Affiliation(s)
- Jessica Morrison
- Kappa Tau, Support and Services at Home (SASH) Wellness Nurse, Cathedral Square Corporation, S. Burlington, VT, USA
| | - Mary Val Palumbo
- Associate Professor, Department of Nursing, University of Vermont, Burlington, VT, USA
| | - Betty Rambur
- Professor, Department of Nursing, University of Vermont, Burlington, VT, USA
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21
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Kable A, Chenoweth L, Pond D, Hullick C. Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study. BMC Health Serv Res 2015; 15:567. [PMID: 26684210 PMCID: PMC4683856 DOI: 10.1186/s12913-015-1227-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals' (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers. METHODS A qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers. RESULTS There were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components. Two main themes with belonging sub-themes derived from the analysis were: Barriers to effective discharge planning for PWD and their carers - the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation. Transitional care process failures and associated outcomes for PWD - the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD. CONCLUSIONS Although acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.
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Affiliation(s)
- Ashley Kable
- School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Lynnette Chenoweth
- Faculty of Health, University of Technology, 15 Broadway, Ultimo, NSW, 2007, Australia. .,Centre for Healthy Brain Ageing, University of New South Wales, G27, Botany Rd, Randwick, NSW, 2031, Australia.
| | - Dimity Pond
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Carolyn Hullick
- Hunter New England Local Health District, Rankin Park, NSW, 2287, Australia.
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Callahan KE, Lovato JF, Miller ME, Easterling D, Snitz B, Williamson JD. Associations Between Mild Cognitive Impairment and Hospitalization and Readmission. J Am Geriatr Soc 2015; 63:1880-5. [PMID: 26313420 DOI: 10.1111/jgs.13593] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether older adults with mild cognitive impairment (MCI), a condition not previously explored as a risk factor, have more hospitalizations and 30-day readmissions than those with normal cognition. DESIGN Post hoc analysis of prospectively gathered data on incident hospitalization and readmission from the Ginkgo Evaluation of Memory Study (GEMS), a randomized, double-blind, placebo-controlled trial designed to assess the effect of Ginkgo biloba on incidence of dementia. SETTING GEMS was conducted in five academic medical centers in the United States. PARTICIPANTS Community-dwelling adults aged 75 and older with normal cognition (n = 2,314) or MCI (n = 428) at baseline cognitive testing (N = 2,742). MEASUREMENTS Index hospitalization and 30-day hospital readmission, adjusted for age, sex, race, education, clinic site, trial assignment status, comorbidities, number of prescription medications, and living with an identified proxy. RESULTS MCI was associated with a 17% greater risk of index hospitalization than normal cognition (adjusted hazard ratio (aHR) = 1.17, 95% confidence interval (CI) = 1.02-1.34)). In participants who lived with a proxy, MCI was associated with a 39% greater risk of index hospitalization (aHR = 1.39, 95% CI = 1.17-1.66). Baseline MCI was not associated with greater odds of 30-day hospital readmission (adjusted odds ratio = 0.90, 95% CI = 0.60-1.36). CONCLUSION MCI may represent a target condition for healthcare providers to coordinate support services in an effort to reduce hospitalization and subsequent disability.
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Affiliation(s)
- Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina.,Sticht Center on Aging, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - James F Lovato
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - Michael E Miller
- Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - Doug Easterling
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina
| | - Beth Snitz
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina.,Sticht Center on Aging, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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Abstract
Readmissions are a significant element in the ongoing healthcare debate, and new evidence suggests that high readmissions can be a surrogate marker for poor quality healthcare. Additionally, although readmissions can offer a financial incentive for some hospitals, that model is being phased out; readmissions in a pay-for-performance or bundled payment model represent significant financial risk for providers and hospitals. Although no specific strategy at discharge has proven to be effective in reducing readmissions, practices that include good posthospital communication to the patient and care team, access to follow-up, and attention to mobility and self-care deficits are important factors in limiting readmissions. PAs play a key role in assessing for high readmission risk and implementing prevention strategies in real time.
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24
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Son YJ, You MA. Transitional Care for Older Adults with Chronic Illnesses as a Vulnerable Population: Theoretical Framework and Future Directions in Nursing. J Korean Acad Nurs 2015; 45:919-27. [DOI: 10.4040/jkan.2015.45.6.919] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/22/2015] [Accepted: 11/27/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Mi-Ae You
- College of Nursing, Institute of Nursing Science, Ajou University, Suwon, Korea
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25
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Abstract
BACKGROUND An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. OBJECTIVES To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living. METHODS AND DESIGN Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. RESULTS Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. CONCLUSION Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.
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Affiliation(s)
- Olga Jarrín
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Linda Flynn
- University of Colorado, College of Nursing, Anschutz Medical Campus, Aurora, CO
| | - Eileen T. Lake
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Wharton School of Business, University of Pennsylvania, Pennsylvania, Philadelphia, PA
| | - Linda H. Aiken
- Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, Wharton School of Business, University of Pennsylvania, Pennsylvania, Philadelphia, PA
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Quality in transitional care of the elderly: Key challenges and relevant improvement measures. Int J Integr Care 2014; 14:e013. [PMID: 24868196 PMCID: PMC4027895 DOI: 10.5334/ijic.1194] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/20/2022] Open
Abstract
Introduction Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures. Methodology Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers. Results Six main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment). Conclusion Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.
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