Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program

BACKGROUND

Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC.

METHODS

Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery).

RESULTS

We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs.

CONCLUSIONS

HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

A Delphi Study to Construct an Index of Practice for Community Nurses Providing Transitional Home Care for Patients with Chronic Diseases

Community nurses play a key role in providing continuous home care for patients with chronic diseases. However, a perfect system of responsibilities and requirements has not yet been formed, and nurses cannot provide high-quality nursing services for home-based patients. We attempted to construct an index of the scope of practice for community nurses providing home-based transitional care for patients with chronic diseases and to guide nurses in playing an active role in transitional care work. From March to May 2023, 14 representative community nurses from the Shanghai Community Health Service Center were selected for group interviews and 2 rounds of Delphi consultation. A total of 14 valid questionnaires were collected. The authority coefficients were 0.94 and 0.93, and the Kendall coefficients were 0.56 and 0.59 for the 2 rounds of expert consultation (P < .05). Finally, an index system, including 6 primary indices (transitional caring provider, patient self-management facilitator, community group intervention organizer, home caregiver supporter, family physician team collaborator and supervisor of home medical equipment use, and medical waste disposal) was constructed for community nurses involved in providing home-based transitional care for patients with chronic diseases. The weight values of the 6 indices were 0.19, 0.17, 0.21, 0.13, 0.14 and 0.16, respectively (CR = 0.035, and the consistency test was passed), and 16 secondary indicators and 42 tertiary indicators were identified. In this Delphi study, an index system that can be used to determine community nurses' roles in providing home-based transitional and continuous care for patients with chronic diseases was successfully established. The index system is considered reliable and easy to use and will provide a meaningful reference for community nurses and policy-makers.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers

BACKGROUND

Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking.

AIM

To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs.

METHODS

We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis.

RESULTS

Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation.

CONCLUSION

Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness

OBJECTIVE

To evaluate the impact of Maryland's behavioral health homes (BHHs) on receipt of follow-up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI).

DATA SOURCES

Maryland Medicaid administrative claims for 12 232 individuals.

STUDY DESIGN

Weighted marginal structural models were estimated to account for time-varying exposure to BHH enrollment and time-varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow-up care within 7 and 30 days following hospitalization.

DATA COLLECTION/EXTRACTION METHODS

Eligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21-64 years; and use of psychiatric rehabilitation services.

PRINCIPAL FINDINGS

Over three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow-up service within 7 days of discharge from a mental illness-related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow-up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission.

CONCLUSIONS

BHHs may improve follow-up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.

Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis

Purpose of Study:

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States ? and How effective are they in reducing low-value utilization and in improving continuity ?

Primary Practice Settings:

U.S. urban, suburban, and rural health care sites within primary care, veterans’ services, behavioral health, and palliative care.

Methodology and Sample:

Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included.

Results:

Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact.

Implications for Case Management Practice:

[Perception of hospital-based nurses on the discharge from hospital.]

Numerous studies show the risk of a breakdown in the continuity of care when a patient leaves hospital. A study was carried out of hospital-based nurses, to find out their representations with regard to their role in the hospital-home transition. The results enable areas of improvement to be identified.

Nurses' experiences on the road during transition into community care: An exploratory descriptive qualitative study in Singapore

Healthcare systems are evolving to meet the demands of an ageing population whereby the provision of health care services in the community has increased to alleviate the burden faced by acute care health facilities. As the result, the number of community nurses are expected to increase in order to meet the demand. Several studies have identified the unique challenges faced by the growing responsibilities of community nurses. However, fewer studies focused on the experiences of nurses transitioning to become community nurses as they rise to meet the unique challenges of working in the community. This study aimed to explore the experiences of nurses' transitions into community care while gaining insight into the transition process. The study adopted the exploratory qualitative approach. Data collection was performed through semi-structured interviews with 14 community nurses in Singapore. Interview sessions were digitally recorded and transcribed into verbatim, and the thematic analysis approach was used for data analysis. Three major themes and nine subthemes were developed from the data of 14 interviews. The three major themes are: 'Changes in Dynamics in a Nurse-Patient Relationship', 'To Live Up to Expectations', and 'Negotiating the Landscape in the Community'. New community nurses are experiencing stress and struggling to adapt with performing nursing care in uncontrolled environments. Additionally, higher expectations have been set on them even when they are still in transition. It is important to provide support for nurses, including in-service talks, courses and formal orientation programs. The study findings highlighted the importance of adequately preparing new community nurses and provided insights on developing a customised formal orientation program. This study also contributed to the limited body of knowledge with respect to nurses' transition experiences into community care.

A telephone-based surgical transitional care program with improved patient satisfaction scores and fiscal neutrality

BACKGROUND

Limited data exist regarding the downstream effects of surgical transitional care programs. We explored the impact of such programs on patient satisfaction and fiscal metrics.

METHODS

A telephone-based surgical transitional care program enrolled patients undergoing complex abdominal surgery between 2015 to 2017. A matched cohort undergoing similar procedures between 2010 to 2015 were used as controls. Press Ganey scores were used to reflect patient satisfaction. Hospital costs, reimbursements, and margins were analyzed for index hospitalizations and readmissions within 90 days of surgery.

RESULTS

There were 607 patients in the control group and 608 in the transitional care program; survey response rates were 37% and 35%, respectively. Transitional care patients rated their understanding of personal responsibilities in post-discharge care higher than controls (59% vs 69%, P = .02). Transitional care patients felt they received better educational materials about their condition or treatment (55% vs 68%, P < .01) and rated their global hospital experience higher (46% vs 57%, P = .02). The aggregate (index plus readmission) cost was greater for the transitional care ($22,814 vs $25,827, P < .01), but there was no difference in aggregate margin ($7,027 vs $4,698, P = .25). Multivariable adjustment yielded similar results for the aggregate cost (ref vs $2,232, P = .03) and margin (ref vs $1,299, P = .23).

CONCLUSION

The use of this dedicated abdominal surgery transitional care program is associated with improved Press Ganey patient education and global rating scores. The cost to support this program did not adversely affect the hospital margin when considering all factors. These data support broader investment in patient centered initiatives that may significantly enhance patient experience.

Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management: A Scientific Statement From the American Heart Association

This scientific statement summarizes the current state of knowledge related to interstage home monitoring for infants with shunt‐dependent single ventricle heart disease. Historically, the interstage period has been defined as the time of discharge from the initial palliative procedure to the time of second stage palliation. High mortality rates during the interstage period led to the implementation of in‐home surveillance strategies to detect physiologic changes that may precede hemodynamic decompensation in interstage infants with single ventricle heart disease. Adoption of interstage home monitoring practices has been associated with significantly improved morbidity and mortality. This statement will review in‐hospital readiness for discharge, caregiver support and education, healthcare teams and resources, surveillance strategies and practices, national quality improvement efforts, interstage outcomes, and future areas for research. The statement is directed toward pediatric cardiologists, primary care providers, subspecialists, advanced practice providers, nurses, and those caring for infants undergoing staged surgical palliation for single ventricle heart disease.

Validation of the Partners at Care Transitions Measure (PACT-M): assessing the quality and safety of care transitions for older people in the UK

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.

Programmes to support transitions in care for children and youth with complex care needs and their families: a scoping review protocol

INTRODUCTION

Children and youth with complex care needs (CCNs) and their families experience many care transitions over their lifespan and are consequently vulnerable to the discontinuity or gaps in care that can occur during these transitions. Transitional care programmes, broadly defined as one or more intervention(s) or service(s) that aim to improve continuity of care, are increasingly being developed to address transitions in care for children and youth with CCNs. However, this literature has not yet been systematically examined at a comprehensive level. The purpose of this scoping review is to map the range of programmes that support transitions in care for children and youth with CCNs and their families during two phases of their lifespan: (1) up to the age of 19 years (not including their transition to adult healthcare) and (2) when transitioning from paediatric to adult healthcare.

METHODS AND ANALYSIS

The Joanna Briggs Institute methodology for scoping reviews (ScR) will be used for the proposed scoping review. ScR are a type of knowledge synthesis that are useful for addressing exploratory research questions that aim to map key concepts and types of evidence on a topic and can be used to organise what is known about the phenomena. A preliminary search of PubMed was conducted in December 2018.

ETHICS AND DISSEMINATION

Ethical approval is not required where this study is a review of the published and publicly reported literature. The research team's advisory council will develop a research dissemination strategy with goals, target audiences, expertise/leadership, resources and deadlines to maximise project outputs. The end-of-grant activities will be used to raise awareness, promote action and inform future research, policy and practice on this topic.

Mapping transitional care pathways among young people discharged from adolescent forensic medium secure units in England

This study tracked young offenders transitioning from national adolescent forensic medium secure units to adult services in the UK within a six-month period. We used a mapping exercise to identify eligible participants moving during the study period from all national adolescent forensic medium secure units in England. Young people older than 17.5 years or those who had turned 18 years (transition boundary) and had been referred to adult and community services were included. Of the 34 patients identified, 53% moved to forensic adult inpatient services. Psychosis was the most prevalent symptom among males (29%), and emerging personality disorder symptomatology was commonly reported among females (18%) followed by learning disability (24%). The mean time for transition to adult mental-health services and community settings was eight months. There were no shared transition or discharge policies, and only two hospitals had discharge guidelines. The findings highlight the need for consistency between policy and practice among services along with the development of individualised care pathways. Future qualitative research is needed to understand and reflect on young people’s and carers’ experiences to improve transition service delivery.

Changes in Care- A Systematic Scoping Review of Transitions for Children with Medical Complexities

BACKGROUND

Children with medical complexity (CMC) and their parents are affected physically and mentally during transitions in care. Coordinated models of care show promise in improving health outcomes.

OBJECTIVE

The purpose of this scoping review was to examine research related to CMC and their parents and transitions in care. The aim was 3-fold: (1) to examine the extent, range, and nature of research activity related to the impact of transitions on physical and mental health for CMC and their parents; (2) to summarize and disseminate research findings for key knowledge users; and (3) to identify research gaps in the existing literature to inform future studies.

METHODS

Twenty-three sources were identified through database searches and five articles met the inclusion criteria of CMC (multi-organ involvement or technology-dependent) (or parents of CMC) transitioning from hospital to alternate levels of care where outcome measures were physical or mental health-related.

RESULTS

Numerical analysis revealed substantial variation in methodological approaches and outcome measures. Content analysis revealed two themes for parents of CMC during this transition: (1) emotional distress, and (2) high expectations; and three themes for CMC: (1) improved health, (2) changes in emotion, and (3) disrupted relationships.

CONCLUSION

The findings from this scoping review reveal for parents, transitions in care are fraught with emotional distress and high expectations; and for CMC there are improvements in quality of life and emotional health post- hospital to home transitions when collaborative models of care are available. This review serves as an early attempt to summarize the literature and demonstrate a need for further research.

Avoidable 30-day readmissions in patients undergoing vascular surgery

BACKGROUND

Vascular surgery has one of the highest unplanned 30-day readmission rates of all surgical specialties. The degree to which these may be avoidable and the optimal strategies to reduce their occurrence are unknown. The aim of this study was to identify and classify avoidable 30-day readmissions in patients undergoing vascular surgery in order to plan targeted interventions to reduce their occurrence, improve outcomes and reduce cost.

METHODS

A retrospective analysis of discharges over a 12-month period from a single tertiary vascular unit was performed. A multidisciplinary panel conducted a manual case-note review to identify and classify those 30-day unplanned emergency readmissions deemed avoidable.

RESULTS

An unplanned 30-day readmission occurred in 72 of 885 admissions (8·1 per cent). These unplanned readmissions were deemed avoidable in 36 (50 per cent) of these 72 patients, and were most frequently due to unresolved medical issues (19 of 36, 53 per cent) and inappropriate admission with the potential for outpatient management (7 of 36, 19 per cent). A smaller number were due to inadequate social care provision (4 of 36, 11 per cent) and the occurrence of other avoidable adverse events (4 of 36, 11 per cent).

CONCLUSION

Half of all 30-day readmissions following vascular surgery are potentially avoidable. Multidisciplinary coordination of inpatient care and the transition from hospital to community care after discharge need to be improved.

Transitioning from an ICU ventilator to a portable home ventilator

There is a variety of portable ventilators on the market, each with its' own features. A clinician needs to understand the unique characteristics of the ventilators available in his or her region, as well as the nuances of primary and secondary settings for these portable home ventilators in order to create a comfortable breath that allows for adequate gas exchange for the patient. Understanding the interplay of the portable home ventilator and the ventilator circuit is also a key component of transitioning a patient to a portable home ventilator. This review details characteristics of some of the more commonly used machines in the United States, as well as the settings to be considered in supporting a child with chronic respiratory failure outside of the hospital. As more patients are being discharged from the hospital with mechanical home ventilation, new ventilators are being developed that expand upon features of current machines.

Canadian Hospital and Home Visiting Nurses' Attitudes Toward Families in Transitional Care: A Descriptive Comparative Study

Despite the key role that hospital and home care nurses have in supporting family carers in transitional care, there is limited comparative information on their attitudes toward supporting family carers during care transitions. As part of a larger research project, we conducted a descriptive comparative study using a cross-sectional survey. Canadian nurses (105 hospital, 34 home visiting) completed a demographic questionnaire and the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) measurement tool. There were no statistically significant differences between hospital and home visiting nurses' attitudes, which were positive about including families in care. Nurses who reported having a workplace philosophy or general approach to the care of family held more positive attitudes toward families than those who did not. This is important because positive attitudes are often linked to better communication with family carers and thus, better patient and carer outcomes. To our knowledge, only one Canadian master's thesis has used this tool. Thus, this research furthers understanding of nurse attitudes within a Canadian context. Furthermore, this article adds to the literature by including suggestions for future research that are based in social psychological theories. Interdisciplinary knowledge can help pre- and postlicensure clinicians in advanced family nursing to better lever barriers and facilitators within family nursing practice.

[General surgery referral´s outcomes and solution time]

BACKGROUND

There are a variety of instruments and indicators to assess continuity of care; however there is a lack of those that describe the result of coordination between the health care levels.

OBJECTIVE

To show two indicators that summarizes the result of the complete circuit primary level-secondary level-primary level.

METHODS

An observational prospective cohort study was conducted, with a one-year follow-up of a random sample of the references to general surgery services in a family medicine unit of the IMSS. Two indicators were analyzed: the outcome of the reference to general surgery, categorized as resolved, withdrawal and not resolved; and the time of solution of the surgical problem, which measures the median in calendar days from the issuance of the reference to the counter-reference for the reason of original sending. The indicators were compared by characteristics of the patient and the first level physician.

RESULTS

The 84.8% of cases were resolved in a median time of 72 days (50-112), 14.1% of patients reject surgery and 1% wasn´t resolved. No statistically significant differences were found according the evaluated characteristics.

CONCLUSIONS

The overall solution time of the surgical problem in the medical unit is within the range built with previous studies, but in specific diagnoses there are significant variations. The frequency of solution of the surgical problem was high for diagnoses of greater risk.

Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

BACKGROUND

To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) - RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.

METHODS

Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.

RESULTS

Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs' level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.

CONCLUSION

This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.

Mothers' Voices Related to Caregiving: The Transition of a Technology-Dependent Infant from the NICU to Home

PURPOSE

The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge.

DESIGN

A qualitative, descriptive, longitudinal design was employed.

SAMPLE

Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU.

MAIN OUTCOME VARIABLE

Description of mothers' transition experience.

RESULTS

Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.

Social work-based transitional care intervention for super utilizers of medical care: a retrospective analysis of the bridge model for super utilizers

The present study was a retrospective evaluation of a social worker-led transitional care intervention that addresses the medical and social needs of inpatient super utilizers with ≥5 inpatient admissions in a 12-month period. Bivariate analyses revealed significant reductions in the total number of hospital admissions, 30-day readmission rates, number of emergency department visits, average hospital charges per episode, and total hospital charges per person after the intervention. This social work intervention may be of interest to providers and payers, particularly regarding addressing the psychosocial needs of complex patients who account for most of health care costs.

A systematic review of the involvement of students with autism spectrum disorder in the transition planning process: Need for voice and empowerment

BACKGROUND

Students with autism spectrum disorder (ASD) typically struggle with post-school employment, post-secondary education, and independent living outcomes. This may be due to their limited input on the goals that are set for their future during the transition planning process.

AIM

The aim of this systematic review was to investigate the extent of involvement of students in their IEP transition planning meetings in published research on the topic to date.

METHOD AND PROCEDURES

The authors reviewed articles published between 1994 and 2016. Searches were performed in ERIC, ProQuest Education Journals, PsycINFO, and Scopus databases, resulting in 15 articles meeting the inclusion criteria.

OUTCOMES AND RESULTS

Out of the 15 articles included in this review, five were survey research articles and ten were intervention studies. The overall results of the studies revealed that students with ASD had minimal active involvement in the transition planning process.

CONCLUSIONS AND IMPLICATIONS

It is essential for teachers to educate students about the transition planning process to increase their awareness of the purposes and procedures of the transition planning meeting. There is a pressing need for a more student-centred approach in transition planning to empower students and support them in becoming better self-advocates.

Caseworker-assigned discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness

BACKGROUND

Chronic respiratory conditions are major causes of mortality and morbidity. Children with chronic health conditions have increased morbidity associated with their physical, emotional, and general well-being. Acute respiratory exacerbations (AREs) are common in children with chronic respiratory disease, often requiring admission to hospital. Reducing the frequency of AREs and recurrent hospitalisations is therefore an important goal in the individual and public health management of chronic respiratory illnesses in children. Discharge planning is used to decide what a person needs for transition from one level of care to another and is usually considered in the context of discharge from hospital to the home. Discharge planning from hospital for ongoing management of an illness has historically been referral to a general practitioner or allied health professional or self management by the individual and their family with limited communication between the hospital and patient once discharged. Effective discharge planning can decrease the risk of recurrent AREs requiring medical care. An individual caseworker-assigned discharge plan may further decrease exacerbations.

OBJECTIVES

To evaluate the efficacy of individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, in preventing hospitalisation for AREs in children with chronic lung diseases such as asthma and bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, and reference lists of articles. The latest searches were undertaken in November 2017.

SELECTION CRITERIA

All randomised controlled trials comparing individual caseworker-assigned discharge planning compared to traditional discharge-planning approaches (including self management), and their effectiveness in reducing the subsequent need for emergency care for AREs (hospital admissions, emergency department visits, and/or unscheduled general practitioner visits) in children hospitalised with an acute exacerbation of chronic respiratory disease. We excluded studies that included children with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review methodological approaches. Relevant studies were independently selected in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted the authors of one study for further information.

MAIN RESULTS

We included four studies involving a total of 773 randomised participants aged between 14 months and 16 years. All four studies involved children with asthma, with the case-planning undertaken by a trained nurse educator. However, the discharge planning/education differed among the studies. We could include data from only two studies (361 children) in the meta-analysis. Two further studies enrolled children in both inpatient and outpatient settings, and one of these studies also included children with acute wheezing illness (no previous asthma diagnosis); the data specific to this review could not be obtained. For the primary outcome of exacerbations requiring hospitalisation, those in the intervention group were significantly less likely to be rehospitalised (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.16 to 0.50) compared to controls. This equates to 189 (95% CI 124 to 236) fewer admissions per 1000 children. No adverse events were reported in any study. In the context of substantial statistical heterogeneity between the two studies, there were no statistically significant effects on emergency department (OR 0.37, 95% CI 0.04 to 3.05) or general practitioner (OR 0.87, 95% CI 0.22 to 3.44) presentations. There were no data on cost-effectiveness, length of stay of subsequent hospitalisations, or adherence to medications. One study reported quality of life, with no significant differences observed between the intervention and control groups.We considered three of the studies to have an unclear risk of bias, primarily due to inadequate description of the blinding of participants and investigators. The fourth study was assessed as at high risk of bias as a single unblinded investigator was used. Using the GRADE system, we assessed the quality of the evidence as moderate for the outcome of hospitalisation and low for the outcomes of emergency department visits and general practitioner consultations.

AUTHORS' CONCLUSIONS

Current evidence suggests that individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, may be beneficial in preventing hospital readmissions for acute exacerbations in children with asthma. There was no clear indication that the intervention reduces emergency department and general practitioner attendances for asthma, and there is an absence of data for children with other chronic respiratory conditions. Given the potential benefit and cost savings to the healthcare sector and families if hospitalisations and outpatient attendances can be reduced, there is a need for further randomised controlled trials encompassing different chronic respiratory illnesses, ethnicity, socio-economic settings, and cost-effectiveness, as well as defining the essential components of a complex intervention.

Transitions of Care in Geriatric Medicine

Elderly patients are at increased risk for morbidity and mortality after injury or surgery in both the inpatient and postdischarge settings. The importance of discharge destination after the index hospitalization is increasingly recognized as a determinant of long-term survival, with discharge to a post-acute care facility portending a worse prognosis. Efforts to minimize discharge to post-acute care facilities should include early discharge planning. Communication among a multidisciplinary care team sets the groundwork for effective discharge planning and transitions of care. The elderly face several systematic, psychosocial, functional, and financial barriers that pose significant challenges to successful transitions of care.

Partners at Care Transitions: exploring healthcare professionals' perspectives of excellence at care transitions for older people

INTRODUCTION

Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing ('positively deviant') teams successfully support transitions from hospital to home for older people.

METHODS AND ANALYSIS

Six high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.

What happens for informal caregivers during transition to increased levels of care for the person with dementia? A systematic review protocol

BACKGROUND

Dementia is a globally prevalent disease that requires ongoing and increasing levels of care, often provided in the first instance by informal caregivers. Supporting transitions in informal caregiving in dementia is a pertinent issue for caregivers, care providers and governments. There is no existing systematic review that seeks to identify and map the body of literature regarding the review question: 'What happens for informal caregivers during transition to increased levels of care for the person with dementia?'

METHODS/DESIGN

ASSIA, CINAHL+, MEDLINE, PsycINFO, SCIE, Social Service Abstracts and Web of Science will be systematically searched. Specialist dementia research libraries will be contacted. Reviews identified as relevant during the search process, their reference lists, and reference lists of accepted papers will be hand-searched. Qualitative, quantitative and mixed methods studies that seek to represent the experiences of, or examine the impact upon, informal caregivers during transition to increased formal care for the person with dementia will be eligible for inclusion. Synthesis will be segregated into qualitative and quantitative papers. Findings will be summarised, and the review will be prepared for publication.

DISCUSSION

The review will seek to identify potentially vulnerable groups in need of support and as such, inform the practice of those offering support. It will also inform future research by highlighting areas in which current literature is insubstantial.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067248.

Medical students' reflections of a posthospital discharge patient visit

Transitions of care is an important part of patient safety that is not often taught in medical schools. As part of a curriculum for patient safety and transitions of care, third-year medical students followed patients they cared for during their inpatient rotations on a posthospital discharge visit. Students answered reflection questions on these visits, which were reviewed at a group debriefing session. The written reflections and oral debriefings were analyzed qualitatively to identify what medical students were able to learn from a posthospital discharge visit. Of the students who visited patients, 265 participated in the debriefing sessions, and their responses were grouped into 7 domains and 33 themes. Students commented most often on the importance of family and caregivers who provided support for the patient after hospitalization. They identified problems specific to the discharge process and factors that helped or hindered transitions, noted new experiences visiting postacute care facilities, and also developed solutions to improve transitions. Postdischarge visits combined with brief reflection writing and debriefing allowed students to better understand difficulties that can be faced in care transitions.

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

OBJECTIVES

To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use.

DESIGN

Prospective observational cohort.

SETTING

Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.

PARTICIPANTS

Individuals aged 65 and older in the ED (N = 57,287).

INTERVENTION

The intervention was first TCN contact. Controls never saw a TCN during the study period.

MEASUREMENTS

We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits.

RESULTS

A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).

CONCLUSION

Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population.

The Impact of a Transition of Care Program on Acute Myocardial Infarction Readmission Rates

Hospital discharge is a high-risk time period, and acute myocardial infarction (AMI) patients often have early readmissions. The authors hypothesized that a multifaceted AMI care coordination program would reduce early hospital readmission rates. The outcomes of patients receiving care coordination (n = 304) were compared to patients receiving standard care (n = 192). Multivariable analyses of the outcomes were conducted by conditional logistic regression of propensity score matched sets. The primary outcome-hospital readmission within 30 days of discharge-occurred in 18% of standard care patients and 11.8% of care coordination patients. Patients receiving care coordination demonstrated a 48% reduction in odds of readmission within 30 days (odds ratio = 0.52; P = .04; 95% CI = 0.28-0.97). These results are the first to demonstrate that inclusion in an AMI-specific care coordination program is associated with a significantly lower risk of 30-day hospital readmission.

The impact of transitional programmes on post-transition outcomes for youth leaving out-of-home care: a meta-analysis

Youth residing in out-of-home care settings have often been exposed to childhood trauma, and commonly report experiencing adverse outcomes after transitioning from care. This meta-analysis appraised internationally published literature investigating the impact of transitional programme participation (among youth with a baseline age of 15-24 years) on post-transition outcomes of housing, education, employment, mental health and substance use. A comprehensive search of sociology (e.g. ProQuest Sociology), psychology (e.g. PsycInfo) and health (e.g. ProQuest Family Health) electronic abstraction databases was conducted for the period 1990-2014. Search terms included 'out-of-home care', 'transition', 'housing', 'education', 'employment', 'mental health' and 'substance use'. Nineteen studies, all from the United States, met the inclusion criteria and were included in the meta-analysis. Living independently and homelessness were the most commonly described housing outcomes. Rates of post-transition employment varied, while rates of post-secondary education were low. Depression and alcohol use were commonly reported among transitioning youth. Findings of the meta-analysis showed that attention should be given to the potential benefit of transitional programme participation on outcomes such as housing, employment and education. Moderator analyses showed that these benefits may differ based on study design, sample size and sampling unit, but not for mean age or gender. Detailed and rigorous research is needed internationally to examine the characteristics of transitional programmes resulting in more successful outcomes for youth, and whether these outcomes are sustained longitudinally.

Biliary atresia: unity in diversity

Biliary atresia (BA) is a rare disease of unknown origin and unsatisfying outcome. Single, multicenter and national evaluations of epidemiological and outcome data on BA have been periodically published over the course of decades. However, the diversity of the registered parameters and outcome measures impede comparability and cumulative analysis of these very worthwhile studies. Taking into account the fact that BA is a good example of translational research and transition of patients from pediatric surgery and hepatology to transplant surgery and hepatology in general, the interdisciplinary community should make every effort to develop a common platform upon which further activities are conducted. Extending this topic to BA-related diseases might increase the acceptance of research studies and enhance the effectiveness of any recommendations outlined therein. The use of the Internet-based communication platform and registry on http://www.bard-online.com represents the first step in this direction, and the database should be viewed as a helpful tool that guides further activities.

Partners at Care Transitions (PACT) xploring older peoples' experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions

INTRODUCTION

Length of hospital inpatient stays have reduced. This benefits patients, who prefer to be at home, and hospitals, which can treat more people when stays are shorter. Patients may, however, leave hospital sicker, with ongoing care needs. The transition period from hospital to home can be risky, particularly for older patients with complex health and social needs. Improving patient experience, especially through greater patient involvement, may improve outcomes for patients and is a key indicator of care quality and safety. In this research, we aim to: capture the experiences of older patients and their families during the transition from hospital to home, and identify opportunities for greater patient involvement in care, particularly where this contributes to greater individual-level and organisational-level resilience.

METHODS AND ANALYSIS

A 'focused ethnography' comprising observations, 'Go-Along' and semistructured interviews will be used to capture patient and carer experiences during different points in the care transition from admission to 90 days after discharge. We will recruit 30 patients and their carers from six hospital departments across two National Health Service (NHS) Trusts. Analysis of observations and interviews will use a framework approach to identify themes to understand the experience of transitions and generate ideas about how patients could be more actively involved in their care. This will include exploring what 'good' care at transitions looks like and seeking out examples of success, as well as recommendations for improvement.

ETHICS AND DISSEMINATION

Ethical approval was received from the NHS Research Ethics Committee in Wales. The research findings will add to a growing body of knowledge about patient experience of transitions, in particular providing insight into the experiences of patients and carers throughout the transitions process, in 'real time'. Importantly, the data will be used to inform the development of a patient-centred intervention to improve the quality and safety of transitions.

Care Coordination and Transitions of Care

Care coordination and effective transitions of care are essential for high-quality care in cancer survivors. Aspects of care that require coordination include cancer surveillance, managing the effects of cancer and its treatment, and preventive care, including screening for new cancers, with the clinician responsible for each aspect of care clearly defined. There are many barriers to transitioning and coordinating care across cancer specialists and primary care physicians; possible solutions include survivorship care plans and certain care models. Improving these areas, along with survivorship care training and education, may lead to more effective care coordination and transitions in the future.

Developing a Transition Care Coordination Program for Youth With Spina Bifida

INTRODUCTION

This quality improvement pilot study focused on developing and facilitating readiness for transition in youth with spina bifida. The results contribute to a broader institution-wide initiative at a subspecialty pediatric organization.

METHODS

The clinical roles of six nurse care coordinators were restructured to add responsibility for transition care coordination. Together, parents, youth, and nurse transition care coordinators created and implemented individualized family-centered care plans focused on improving self-management and readiness for transition to adulthood. The Transition Readiness Assessment Questionnaire was administered before and after intervention initiation.

RESULTS

Fourteen youth-parent pairs participated in this study. Postintervention Transition Readiness Assessment Questionnaire results indicated that both parents and youth perceived improvement in transition readiness. Youth perceived more improvement than did parents.

DISCUSSION

This pilot study showed that budget-neutral processes can be systematically implemented to facilitate transition preparation from pediatric to adult health care services for youth with spina bifida and their families.

How collaboration is improving acute hospital admission for people with dementia

In November 2015 it became apparent that a person with dementia's journey through the acute hospital was not always as streamlined as it should have been. There was evidence of late and multiple inter-ward transfers for this patient group that could potentially have a detrimental effect on individuals' and carers' well-being. The aim of this project was to examine current processes around patient flow and decision-making, explore any themes arising and identify opportunities for improving transitions of care. Collaborative working among various specialties has resulted in increased transfers before 8pm, a reduction in transfers after midnight and a reduction in inter-ward transfers.

Improving care transitions: complex high-utilizing patient experiences guide reform

OBJECTIVES

Care management has been adopted by many health systems to improve care and decrease costs through coordination of care across levels. At our academic medical center, several care management programs were developed under separate management units, including an inpatient-based program for all patients and an outpatient-based program for complex, high-utilizing patients. To bridge administrative silos between programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care.

STUDY DESIGN

This descriptive study analyzed the care experiences of 17 high-utilizing patients within the authors' health system.

METHODS

Chart audits were conducted for 17 high-utilizing patients with 30-day hospital readmissions during 2013. Clinical and social characteristics were reviewed for patterns of care potentially driving readmissions.

RESULTS

Patients had heterogeneous social factors and medical, psychological, and cognitive conditions. Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization included movement to supervised living, depression treatment, and achievement of sobriety. Monthly case management meetings were restructured to include inpatient, outpatient, ambulatory care, and emergency department care managers to improve communication and process. During 2014 and 2015, hospital readmission rates were overall unchanged compared with base year 2013 among a comparable cohort of high-utilizing patients.

CONCLUSIONS

Joint review of clinical characteristics and longitudinal care experiences of high-utilizing, complex patients facilitated movement of historically siloed care management programs from their focus along administrative lines to a longitudinal, patient-centered focus. Decreasing readmission rates among complex patients may require direct linkages with social, mental health, and substance use services outside the healthcare system and improved discharge planning.

Bringing it all back home: Understanding the medical difficulties encountered by newly released prisoners in New Orleans, Louisiana - a qualitative study

Formerly incarcerated persons (FIPs) face a disproportionate risk of death and serious illness in the immediate post-release period. Therefore, it is a critical time to initiate community-based care for chronic illnesses and behavioural disorders. Little is known about the unique transitional health and social support needs of FIPs in Louisiana, which has the highest incarceration rate in the world. As the average age of prisoners in the United States rises, the release of older prisoners with chronic conditions will become increasingly common. The aim of this study was to explore the healthcare experiences of FIPs in Louisiana in order to inform delivery of services tailored to this population. This research was done in partnership with a community organisation that advocates for restoration of voting rights to FIPs and helps newly released individuals transition back into society. This organisation identified FIPs in the Greater New Orleans area, and from January to May 2015, we conducted 24 semi-structured, in-person, audio-recorded interviews at the community organisation's transitional living facility. The interviews assessed FIPs' experiences with and barriers to receiving healthcare during and after incarceration. These discussions also explored FIPs' desires for services and attitudes towards health and healthcare. Interviews were transcribed and independently coded by two researchers. Interviewees reported negative experiences with healthcare during incarceration, and limited health guidance during the pre-release process. Post-release concerns included lack of insurance, difficulty accessing care and medication, and interest in learning about healthy lifestyles. Results suggest a need for a formalised system of transitional healthcare for FIPs. Findings are being used to inform a pilot transitional care clinic in New Orleans, Louisiana.

Transition Consultation Models in Two Academic Medical Centers

Health care transition (HCT), the organized progression from pediatric- to adult-focused models of care, is crucial for patients with chronic childhood conditions. More adolescents with chronic conditions now survive into adulthood and have increased risk of adverse events during HCT. Got Transition-an agreement between the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health-developed the Six Core Elements of Health Care Transition 2.0, defining the components of HCT. Most HCT programs incorporate these elements, but delivery varies. Additional studies are needed to determine the most efficacious interventions to improve HCT outcomes. Here, we introduce two approaches to improve HCT. The first is a clinic dedicated to HCT coupled with a life skills program. The other is a HCT consult service using existing resources to provide resident education and address HCT. Together, these programs provide examples that can be adapted to other settings. [Pediatr Ann. 2017;46(6):e235-e241.].

Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease

One of the goals of the National Plan to Address Alzheimer's Disease is to ensure safe care transitions. To facilitate safe and effective transitions from home to hospital, the ADMIT (Alzheimer's, Dementia, Memory Impaired Transitions) Me tool was developed and three focus groups were conducted with caregivers (n = 6), emergency department nurses (n = 6), and first responders (n = 14) to determine its usefulness and applicability to practice. Feedback was used to enhance the tool to reflect their needs. Each group expressed that the tool would help promote safety in care transitions. Using ADMIT Me, nurses can practice with clear communication and collaboration in care transitions, and provide patient-centered care based on the behaviors and unique needs of the individual with dementia. [Journal of Gerontological Nursing, 43(5), 32-38.].

The Impact of Medical/Behavioral Support Needs on the Supports Needed by Adolescents With Intellectual Disability to Participate in Community Life

As adolescents with intellectual disability (ID) transition to adulthood, there is a need to plan for effective community-based supports that address the post-school life. There is also a need to plan for the impact of factors (e.g., medical/behavioral support needs) on supports needed for community participation. Data from the Supports Intensity Scale-Adult Version (SIS-A) was used to examine relations between medical/behavior support needs and support needs assessed in the standardized portion of the SIS-A. Results suggested that the presence of medical/behavioral needs had a strong impact on supports needed to participate in the community activities, and that more intensive medical support needs were related to higher support needs in the Home Living, Community Living, and Health and Safety domains.

Impact of a pharmacy-based transitional care program on hospital readmissions

OBJECTIVES

Avoidable readmissions of patients discharged from hospitals are a major concern. This study evaluates the impact of pharmacist-provided postdischarge services on hospital readmissions for members of a US managed Medicaid health plan.

STUDY DESIGN

Prospective cohort study.

METHODS

Synergy Pharmacy Solutions (SPS) initiated a transition of care (TOC) service for high-risk members of the Kern Health Systems (KHS) managed Medicaid plan. Over 1100 patients were referred to SPS between April 2013 and March 2015. KHS classified hospitalized members as high risk for readmission based on prior healthcare utilization, a health risk assessment questionnaire, and the use of the Johns Hopkins predictive modeler. This study compares SPS TOC recipients with a matched sample of KHS members discharged from nonintervention hospitals. Thirty-day and 180-day readmissions and time-to-readmission were defined as outcomes. Logistic regression and Cox model were estimated, controlling for demographics, diagnostic and drug profiles, and prior hospital utilization.

RESULTS

KHS identified 1763 high-risk discharges from nonintervention hospitals, of which 1005 and 669 were matched to 830 and 558 selected SPS patients in 30-day and 180-day populations, respectively. The SPS postdischarge intervention reduced the risk of readmission within 30 days by 28% (odds ratio [OR], 0.720; 95% confidence interval [CI], 0.526-0.985) and within 180 days by 31.9% (OR, 0.681; 95% CI, 0.507-0.914). The estimated effect of the SPS intervention from the Cox model was a reduction in risk of 25% (hazard ratio, 0.749; 95% CI, 0.566-0.992).

CONCLUSIONS

A community pharmacy-based postdischarge TOC program can significantly reduce readmission rates at 30 and 180 days compared with usual discharge care.

Transitioning Patients from the Intensive Care Unit to the General Pediatric Unit: A Piece of the Puzzle in Family-Centered Care

Transitioning patients from one unit to another is a nursing function that occurs daily. When done effectively, it streamlines continuity of care, decreases anxiety, ensures patients and families maintain confidence in care providers, and avoids readmissions to the intensive care unit (ICU). This article describes a transition plan for transferring patients from the ICU to the general pediatric unit developed by an inpatient, non-critical care cardiology/neuro logical unit to facilitate a smooth and informational transition from the ICU to the non-critical unit. Subse quently, this program incorporated the development of educational materials and a program that provides patients and families with clear information on what to expect, the differences between the two units, and the services available by their healthcare team on the unit to which they are transferred. By establishing a process and a liaison to guide and educate patients and families on what to expect during transition, fears and anxieties are decreased or eliminated, while the promotion of healing and successful outcomes for discharge home becomes the focus.

Transitional care for formerly incarcerated persons with HIV: protocol for a realist review

BACKGROUND

Little is known about the mechanisms that influence the success or failure of programs to facilitate re-engagement with health and social services for formerly incarcerated persons with HIV. This review aims to identify how interventions to address such transitions work, for whom and under what circumstances.

METHODS

We will use realist review methodology to conduct our analysis. We will systematically search electronic databases and grey literature for English language qualitative and quantitative studies of interventions. Two investigators will independently screen citations and full-text articles, abstract data, appraise study quality and synthesize the literature. Data analysis will include identifying context-mechanism-outcome configurations, exploring and comparing patterns in these configurations, making comparisons across contexts and developing explanatory frameworks.

DISCUSSION

This review will identify mechanisms that influence the success or failure of transition interventions for formerly incarcerated individuals with HIV. The findings will be integrated with those from complementary qualitative and quantitative studies to inform future interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016040054.

The transition of care from hospital to home for patients with hypertension

Approximately 50% to 75% of hospital patients have hypertension. At the time of discharge, patients experience a transition of care as they move from the hospital to home. This article describes the transition of care from the hospital to home for patients with hypertension and discusses practice implications for NPs.