Transitional Care Interventions Research Articles

Sustainability and Well-being in Geriatrics: proposing a performance-based approach for the implementation of geriatric care activities

The evaluation and measurement of Sustainable Development and Well-being represent a widespread emerging theme in healthcare, especially concerning, among others, the concepts of social equity and universality of health from an intergenerational perspective. To achieve such goals, Geriatrics would play a prominent role, especially considering the growing portion of the senior population in developed countries. This work intends to explore the possibility to connect Sustainable Development Goals and dimensions of Well-being to a set of performance indicators which are representative of geriatric activities in different settings of care. To this purpose, a pattern of indicators from Emilia- Romagna Region (RER) in Italy is considered. Furthermore, a range of Transitional Care interventions is discussed and proposed in order to ameliorate (or keep stable) the performance.

A scoping review of interventions for older adults transitioning from hospital to home.

Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers. Scoping review. Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results. Five hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality. To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.

Geriatric co-management and interdisciplinary transitional care reduced hospital readmissions in frail older patients in Argentina: results from a randomized controlled trial.

Hospitalization is a moment of extreme vulnerability for frail older adults. There is scarce evidence on the effectiveness of geriatric co-management or transitional care interventions in Latin America. To assess whether geriatric co-management combined with an interdisciplinary transitional care intervention could reduce 30-day hospital readmission rate compared to usual care in hospitalized frail older patients in a tertiary hospital in Argentina. Single-blinded randomized controlled trial. Usual care treatment arm: all procedures performed during hospitalization were overseen by a senior internal medicine specialist and complied with pre-defined protocols. Patients had access to specialist care if needed, as well as hospital-at-home or home-based primary care services after discharge. Intervention treatment arm: in addition to usual care, a geriatric co-management team performed a comprehensive geriatric assessment during hospitalization, provided tailored recommendations to minimize geriatric syndromes and planned transition of care. A health and social care counselor oversaw continuity of care in patients' homes after discharge. We included 120 participants in each of the intervention and usual care (control) arms. Thirty-day hospital readmissions were 47.7% lower in the intervention arm (18.3% vs 35.0%; P = 0.040); and emergency room visits within the first 6months after discharge were 27.8% lower (43.3% vs 60.0%; P = 0.010). There was a non-statistically significant decrease in 6-month mortality in the intervention arm (25.0% vs 35.0%; P = 0.124). Geriatric co-management of frail older patients during hospitalization combined with an interdisciplinary transitional care intervention reduced 30-day hospital readmissions and emergency visits 6months after discharge. Trial registration number: RENIS IS003081.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64–93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention

ABSTRACT Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.

Accuracy of the French Administrative Database to Describe Patients' Medication and Primary Care Visits: A Validation Study.

To evaluate the accuracy of the French health administrative database to describe patients' medication and primary care visits, in the context of a transitional care intervention including an in-hospital medication reconciliation followed by a structured community follow-up by the patient's general practitioner and pharmacist. A retrospective cohort study of older persons enrolled in the transitional care intervention between January 1st, 2015 and December 31st, 2018. Only 46.1% of the community follow-up were timely billed, in the 3 months after the patient discharge. The sensitivity of the health administrative database to identify medications was 90.0%. Its positive predictive value was 50.1%. This study reveals that the French health administrative database was poorly reliable to identify both community follow-up and chronic medications.

Person-centred communication with cancer survivors: Exploring the meaning of follow-up coaching conversations.

The aim of this study was to explore the meaning of a coaching intervention for cancer survivors. Cancer survivors often experience existential concerns and worries after adjuvant treatment. A number of "care transition interventions" have been developed to improve person-centred care by empowering patients. Several of these interventions include a "care transition coach". A coaching approach to communication used in health care communication have among others shown to assists in establishing confidential relationships between health professionals, increase the patient's well-being and support the patient's experience of being met and viewed as a whole person. This is a qualitative study using semi-structured interviews to explore the meaning of a coaching intervention. In analyzing and interpreting the qualitative interviews Ricoeur's theory of interpretation was applied. The intervention consisted of two parts: (1) a two-day training program in coaching for nurses and (2) a specially developed communication intervention for cancer survivors. The analysis of the transcribed interview material led to the development of two themes: (1) Support in moving forward in life, and (2) An opportunity to talk about existential thoughts and worries. Our results show how the experience of cancer, even when cured, leaves the survivors with profound existential worries. The cancer survivors described how coaching conversations allowed them to express their current concerns and provided them with an opportunity to discuss wider issues than treatment, symptoms, and after-effects, which had been the main focus during treatment. The time immediately after the end of adjuvant treatment can be challenging, with many existential concerns and opposing emotions. We found that the follow-up coaching conversations performed helped the cancer survivors to process many of these difficult thoughts and feelings.

Effect of Nurse Practitioner Interventions on Hospitalizations in the Community Transitions Intervention Trial.

Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites. The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches. We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention. The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC. The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.

Unmet Opportunity: Intensive Care Transition Intervention for Individuals With Serious Medical-Psychiatric Illnesses.

Individuals with serious mental illnesses and poorly managed medical conditions known as serious medical-psychiatric illnesses (SMPIs) are vulnerable to disruptions in care, resulting in poor outcomes. Intensive integrated care management approaches are indicated when these individuals are hospitalized on medical-surgical inpatient units in order to ensure continuity of medical and psychiatric services. This column describes a manualized intervention for hospitalized individuals with SMPIs that was developed in a National Institute of Mental Health ALACRITY research center. The approach uses a critical time intervention model incorporating motivational interviewing and shared decision making to maximize engagement and continuity of care for individuals with SMPIs.

Hospital to Home Transition for Patients With Stroke Under Bundled Payments

Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

Early Prediction of Unplanned 30-Day Hospital Readmission: Model Development and Retrospective Data Analysis.

BackgroundExisting readmission reduction solutions tend to focus on complementing inpatient care with enhanced care transition and postdischarge interventions. These solutions are initiated near or after discharge, when clinicians’ impact on inpatient care is ending. Preventive intervention during hospitalization is an underexplored area that holds potential for reducing readmission risk. However, it is challenging to predict readmission risk at the early stage of hospitalization because few data are available.ObjectiveThe objective of this study was to build an early prediction model of unplanned 30-day hospital readmission using a large and diverse sample. We were also interested in identifying novel readmission risk factors and protective factors.MethodsWe extracted the medical records of 96,550 patients in 205 participating Cerner client hospitals across four US census regions in 2016 from the Health Facts database. The model was built with index admission data that can become available within 24 hours and data from previous encounters up to 1 year before the index admission. The candidate models were evaluated for performance, timeliness, and generalizability. Multivariate logistic regression analysis was used to identify readmission risk factors and protective factors.ResultsWe developed six candidate readmission models with different machine learning algorithms. The best performing model of extreme gradient boosting (XGBoost) achieved an area under the receiver operating characteristic curve of 0.753 on the development data set and 0.742 on the validation data set. By multivariate logistic regression analysis, we identified 14 risk factors and 2 protective factors of readmission that have never been reported.ConclusionsThe performance of our model is better than that of the most widely used models in US health care settings. This model can help clinicians identify readmission risk at the early stage of hospitalization so that they can pay extra attention during the care process of high-risk patients. The 14 novel risk factors and 2 novel protective factors can aid understanding of the factors associated with readmission.

Interventions to Improve the Transition From Home to a Nursing Home: A Scoping Review.

Background and ObjectivesThe transition from home to a nursing home is a stressful event for both older persons and informal caregivers. Currently, this transition process is often fragmented, which can create a vicious cycle of health care-related events. Knowledge of existing care interventions can prevent or break this cycle. This project aims to summarize existing interventions for improving transitional care, identifying their effectiveness and key components.Research Design and MethodsA scoping review was performed within the European TRANS-SENIOR consortium. The databases PubMed, EMBASE (Excerpta Medica Database), PsycINFO, Medline, and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they described interventions designed to improve the transition from home to a nursing home.Results17 studies were identified, describing 13 interventions. The majority of these interventions focused on nursing home adjustment with 1 study including the entire transition pathway. The study identified 8 multicomponent and 5 single-component interventions. From the multicomponent interventions, 7 main components were identified: education, relationships/communication, improving emotional well-being, personalized care, continuity of care, support provision, and ad hoc counseling. The study outcomes were heterogeneous, making them difficult to compare. The study outcomes varied, with studies often reporting nonsignificant changes for the main outcome measures.Discussion and ImplicationsThere is a mismatch between the theory on optimal transitional care and current transitional care interventions, as they often lack a comprehensive approach. This research is the first step toward a uniform definition of optimal transitional care and a tool to improve/develop (future) transitional care initiatives on the pathway from home to a nursing home.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation.

AimTo evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.DesignA mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.MethodsQuantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.ResultsThe overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.ConclusionAlthough involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.ImpactIn addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

BackgroundSkilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home.MethodsThe study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress.DiscussionStudy results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications.Trial registrationClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

Development of claims‐based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care

To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays. Medicare claims data from January 1, 2015, to October 31, 2017, for 1261707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices. Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+data. Repeat UAC events are common among Medicare beneficiaries served by the CPC+practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions. This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.

57. Improving the Transition of Adolescents From Pediatric to Adult Primary Care

The lack of structured health care transition interventions for adolescents aging out of pediatric care is associated with discontinuity of care, increased emergency department and hospital use, and poor health outcomes. The existing literature on transition of care primarily focuses on adolescents with chronic conditions in sub-specialty care, and there is limited information about interventions used in primary care settings for all adolescents. We assessed the effectiveness of a transition protocol that aimed to improve the transition of adolescents from pediatric to adult primary care services within an urban academic medical center.

Measurement of unnecessary psychiatric readmissions in the context of care transition interventions: a scoping review

ObjectiveThe objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.DesignScoping review using Levac et al’s...

The Impact of a Care Transitions Intervention on People With Brain Injuries and Their Caregivers

As our population ages, the prevalence of brain injuries increases due to strokes and falls. Brain injuries are a leading cause of rehospitalization for patients, and most brain injury survivors experience depression soon after hospital discharge. This study assessed the difference between: 1) survivors of brain injury’s baseline and 30-day depression, functional ability, and quality of life and caregivers’ depression and caregiver burden among those that received the Care Transitions intervention, and 2) 30-day hospital readmissions between survivors of brain injury that received Care Transitions and a control group. The study used a quasi-experimental pre-posttest design. Participants included people with brain injuries who received the Care Transitions intervention (n = 22) and their caregivers (n = 20) compared to a services-as-usual control group of brain injury survivors (n = 27). Care Transitions is a 90-day family-focused, home visitation, coaching hospital-to-home transition intervention. Outcomes were self-reported baseline and 30-day depression, functional independence, quality of life, and caregiver burden. Hospital record data was used to report readmissions. Study results showed that there were statistically significant differences between depression, functional ability, and caregiver burden between pre- and post-survey scores among Care Transitions participants. Care transitions’ participants experienced lower brain injury-related hospital readmissions than the services as usual control group. Social work hospital discharge planning needs to continue beyond the hospital and include home visitation to ensure patient and caregiver needs are met post-hospital discharge.

“Just tell me in a simple way”: A qualitative study on opportunities to improve the transition from acute hospital care to home from the perspectives of patients with traumatic brain injury, families, and providers

Objective: The purpose of this study was to identify areas to improve the transition from acute hospital care to home for patients with traumatic brain injury and their families. Design: Qualitative, descriptive. Setting: Level I trauma centered located in the Southeastern United States. Subjects: A total of 36 participants (12 patients with traumatic brain injury, 8 family caregivers, 16 providers). Main Measures: We conducted 55 semi-structured interviews with participants and used conventional content analysis to analyze the data. Results: Findings showed patients, families, and providers recommend three areas for improvement in the transition home from acute hospital care, described in three themes. Theme 1 was “improving patient and family education,” with the following sub-themes: (a) TBI-related information and (b) discharge preparation. Theme 2 was “additional provider guidance,” with the following sub-themes: (a) communication about patient’s recovery timeline and (b) recovery roadmap development. Theme 3 was “increasing systems-level support,” with the following sub-themes: (a) scheduling follow-up appointments, (b) using a patient navigator, (c) creating a provider follow-up structure, (d) linking pre-discharge care with post-discharge resources, and (e) addressing social issues. Conclusions: These findings delineate multiple areas where patients and families need additional support and education during the transition from acute hospital care to home in ways that are currently not being addressed. Findings may be used to improve education and support from providers and health systems given to patients with traumatic brain injury and families and to inform development and testing of transitional care interventions from acute hospital care to home.

The Impact of Telephonic Follow-Up Within 2 Business Days Postdischarge on 30-Day Readmissions for Patients With Heart Failure.

Heart failure (HF) is a chronic condition associated with high rates of hospital readmissions. The prevalence and costs of HF are expected to rise dramatically by 2030 (Heidenreich,et al., 2013). A 24-month, retrospective study was conducted using electronic medical record (EMR) chart review, seeking to identify if postdischarge follow-up phone calls decreased 30-day readmissions in individuals with HF. The study included 705 adult participants who were admitted to the hospital for HF. Some received a postdischarge call within 2 business days of discharge, and some did not. Participants who received the postdischarge call were less likely to be readmitted (20.1%) than participants who did not receive a postdischarge call (28.8%; p = .007). Participants who received the postdischarge call were more likely to have a follow-up visit within 14 days (70.1%) than participants who did not receive a postdischarge call (30.2%; p < .001). The findings from this study may help to drive future transitional care strategies for individuals diagnosed with HF. Nurse-led transitional care interventions offer potential solutions to ensure safe, effective hospital discharges.