Transitional Care Model Research Articles

Effect of transitional care model on the treatment of patients with transitional period of intensive care

Objective To study the effect of transitional care model on the treatment of patients with transitional period of intensive care. Methods A total of 80 cases of patients who were admitted to the hospital from May 2015 to September 2016 were selected as the study subjects and were randomly divided into the control group and the intervention group, 40 cases of each group.The patients in the control group were given routine care, and the intervention group carried out transitional nursing mode.The changes of oxidative stress index, inflammatory factor level, psychological status score, incidence of adverse events and the return of ICU rate and nursing satisfaction of the two groups were compared. Results The serum superoxide dismutase (SOD) and glutathione (GSH) levels in the intervention group were significantly higher than those in the control group at the end of 7 days, and the differences were statistically significant(P<0.05). The level of serum malondialdehyde (MDA) in the intervention group was significantly lower than that in the control group, and the difference was statistically significant(P<0.05). The levels of serum hypersensitivity C-reactive protein (hs-CRP), tumor necrosis factor (TNF-α), interleukin (IL)-10 were significantly lower than those in the control group, and the differences were statistically significant(P<0.05). Self-evaluation of Anxiety Scale (SAS), Hamilton Anxiety Scale (HAMA), Depression Self-rating Scale (SDS) and Hamilton Depression Scale (HAMD) scores of the intervention group were significantly lower than those of the control group, and the differences were statistically significant, and the difference was statistically significant(P<0.05). The occurrence rate of adverse event of intervention group was 5.00%, which was significantly lower than control group that was 12.50%(P<0.05). The rate of intervention group returning to ICU was 7.50%, which was significantly lower than control group that was 20.00%(P<0.05). The nursing satisfaction of patients in intervention was 97.50%, which was significantly higher than control group that was 80.00%, and the difference was statistically significant(P<0.05). Conclusion The transitional period nursing mode implemented in the curing process for intensive care patients during transitional period can reduce oxidative stress level and inflammatory factor level, improving the mental state of patients, reducing the occurrence rate of adverse event and the rate of returning to ICU.In addition, the nursing satisfaction of patients can also be improved, which is worth popularizing and applying. Key words: Transitional care model; Critically ill patients; ICU monitoring; Oxidative stress; Inflammatory factors

Progress on family caregiver′s burden of the elderly patients

It introduced the definition of the caregiver and at home and abroad, and also reviewed influencing factors of family caregiver′s burden of the elderly patients. At last, it put forward the essentiality to perfect the nursing intervention and improve caregivers' coping capacity, as well as the transitional care model and the linkage hospital - community - family, and improve national legislation and policy support in order to structure the social support system at the same time, so as to provide reference for study of reducing the family caregiver′s burden of the elderly patients. Key words: Aged; Family caregiver; Caregiver′s burden

PD48-02 CARING FOR ADULTS WITH CONGENITAL GENITOURINARY ANOMALIES: ADULT UROLOGY DEPARTMENT LEADERS' PERSPECTIVES ON PROGRAMMATIC CHANGE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Transitional Urology & GU Congenitalism1 Apr 2018PD48-02 CARING FOR ADULTS WITH CONGENITAL GENITOURINARY ANOMALIES: ADULT UROLOGY DEPARTMENT LEADERS' PERSPECTIVES ON PROGRAMMATIC CHANGE Briony Varda, Carlos Estrada, Caleb Nelson, and Erin McNamara Briony VardaBriony Varda More articles by this author , Carlos EstradaCarlos Estrada More articles by this author , Caleb NelsonCaleb Nelson More articles by this author , and Erin McNamaraErin McNamara More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transitional and longitudinal multidisciplinary care models for adults with congenital genitourinary anomalies (CGA) are lacking. Prior research has studied various causes, but no studies have focused on the concerns of department leaders, who are central to supporting and promoting new programs. This study sought their perspectives to better understand a) the perceived role of adult programs in caring for CGA patients, and b) the barriers and facilitators to developing comprehensive care for this population. METHODS We conducted semi-structured interviews with adult urology chairs/division chiefs. Criterion-type sampling was used to create a heterogeneous sample reflecting programs of varying sizes and pediatric affiliations. An interview guide was created and iteratively revised via 5 pilot interviews. We used a framework approach (a systematic methodology often used in qualitative healthcare research) for analysis. This approach includes: 1) immersion with the data (reading of transcripts, explicit coding, and group discussions of emerging themes), 2) independent closed-coding using a code book based on emerging themes and research aims, and 3) a final interpretation of the data by evaluating coding reports to identify convergence, divergence and variation in themes, as well as contextual meaning and connotation. RESULTS Of 45 contacted, 20 leaders participated. There was wide variation regarding the perceived role of caring for CGA patients, ranging from episodic care by individual providers to comprehensive multidisciplinary care led by a urology team. Barriers related to cost prevailed, in particular the financial risk of taking on a population perceived to have high resource utilization with low compensation. This was often compounded by a lack of provider capacity and/or difficulty obtaining support from academic/hospital entities. Although the risk of unfavorable quality metrics was noted, this was ascribed nominal importance. Only 3 participants had established care models for patients with CGA, but intentions to develop programs were common. Motivated pediatric and adult providers were clear facilitators. There was a general sense of duty to care for the CGA population, and an educational value was widely noted. CONCLUSIONS Among adult urology program leaders, opinions vary regarding their programs' role in managing CGA patients with considerable concerns related to the cost of comprehensive care models. Our results highlight the need for strategic program development to overcome these barriers. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e961 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Briony Varda More articles by this author Carlos Estrada More articles by this author Caleb Nelson More articles by this author Erin McNamara More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The genesis of systems of care for transition to adulthood services: emerging models in primary and subspecialty care.

Transitioning adolescents and young adults with chronic conditions can be complex. Expert recommendations support a transition process that starts in early adolescence, provides continuous guidance and support and allows for care opportunities with patients and caregivers, with the patient alone and between paediatric and adult providers. As most of the guidance is focused on individual patients, providers and clinical programmes, much less is known about how health systems as a whole might support effective transitions of care. Many intervention studies focus on the preparation necessary to successfully transition adolescents, young adults and their families to adult care. Although randomized controlled trials of transition interventions are few and standards of care not yet established, promising models are being developed and tested. This review will describe the development and implementation of emerging models of transitional care in primary and subspecialty care, paying special attention to evaluation outcomes that can inform model selection. The emerging models described here highlight the importance of and guidance for invested clinicians and health systems to create effective methods for successful transition. Additional research using rigorous methodology is necessary.

Make the Payer a Player on the Transition Team

Make the Payer a Player on the Transition Team

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Transitional care incorporates actions to ensure the coordination and continuity of care between provider settings (ie, hospitals, nursing homes, home health care, patients’ home, and physician offices) occurs to meet the patient’s goals relative to their disease management. The evolution of transitional care over the past decade has facilitated the emergence of several transitional care models. However, there is a dearth of understanding related to the collaboration between nurse transition coaches and home care nurses when implementing transitional care model activities to achieve desired patient outcomes in the home health care setting. This case study describes the enactment of a specific transitional care model’s conceptual framework to derive an in-depth understanding of the collaborations between nurse transition coaches and home health nurses in the unique context of home health care. The case is a specific patient-centered Care Transitions Intervention (CTI) model with 4 embedded subunits: (1) the experiences and actions of the nurse transitions coach, (2) the experiences and actions of the home health nurse, (3) document and artifacts review, and (4) the experiences and observations of key leadership stakeholders involved in transitional care activities in one home health care organization located in Michigan.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device.

The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%. Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices. Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team. The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%. Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

The impact of a well breast cancer patient transition model of care on oncologists’ practice.

39 Background: The transitioning of well breast cancer patients, post-treatment, to family physicians is accepted as a safe and effective model of care. Numerous studies have focused on patients’ experience and health outcomes, but research has not examined the experience of oncologists who are practicing in this model of care. The purpose of this research is to explore the impact of a transition model of care on oncologists’ practice. Methods: Purposive sampling was employed to recruit and interview oncologists who have been transitioning patients to family physicians for two or more years. A total of 15 medical and radiation oncologists practicing in Ontario, Canada were interviewed. Data were analyzed using thematic analysis. Results: Most oncologists interviewed were confident that the transitioning of patients to family physicians is safe for many patients post-treatment. Despite some concerns about the feasibility of the model, namely acceptance of the model among patients and family physicians, oncologists perceived that the model enhances efficiency and sustainability of the cancer system. As the volume of patients in follow-up decreased, oncologists saw a variety of impacts including: a reduction in overbooking in their clinics; more new patients able to be seen in consultation each week; more flexibility in their schedules to accept urgent appointments; and an increased ability to spend more time with patients who are dealing with complex issues. For some oncologists, well patient appointments are a rewarding part of their work. Meanwhile, many experience challenges with increased intensity of workload. Oncologists recognize that some patients and family physicians may be reluctant but they believe that early communication with patients about eventual transition, and improved communication with family physicians can enhance the acceptability of this model of care. Conclusions: Oncologists interviewed in this study reported that the time they used to spend with well follow-up patients can now be spent on other activities that contribute to the enhancement of quality of care for cancer survivors and efficiency in the broader cancer system.

Seamless Transitions: Achieving Patient Safety Through Communication and Collaboration.

Although more than a decade has passed since the imperative to reduce fragmentation of care, high rehospitalization rates among Medicare patients with chronic diseases persist; at least 25% of these are considered preventable. Transitional care models that emphasize coordination among providers have demonstrated significant reductions in hospitalization rates. However, achieving effective collaboration among providers across disciplines and/or facilities through implementation of transitional care models can be challenging. The aims of this article are to (1) describe a collaborative transitional care program implemented by a 7-hospital health care system and a postacute senior care service provider organization to pilot a transitional care program (Transitions Across Care Settings [TRACS]) for improving coordination of care for their mutual patients and (2) share results and lessons learned from this quality initiative. The goal of the TRACS program, which used the Coleman Care Transitions Intervention model, was to reduce 30-day readmissions to lower than the national averages for an initial target population of inpatients with pneumonia, congestive heart failure, and acute myocardial infarction diagnoses. The overall readmission rate for 104 patients in the pilot TRACS program was 4.8%. Readmission rates were 0% for acute myocardial infarction, 7.1% for congestive heart failure, and 4.4% for pneumonia. A culture of patient safety was facilitated by a registered nurse transitions coach through consistent communication and flow of patient information during patient hand offs across the care continuum. More than 1000 patients are already admitted to the next iteration of the TRACS program, resulting in a sustainable enterprise.

Implementing and sustaining evidence-based practice in health care: The Bridge Model experience

ABSTRACTThis qualitative study analyzed the experience of community-based organizations (CBOs) implementing and sustaining the Bridge Model of Transitional Care, a social work-based health service intervention for reducing hospital readmissions. We conducted semi-structured interviews with clinical supervisors from 13 CBOs that received Bridge Model training between 2012 and 2015. CBOs faced significant challenges implementing and sustaining transitional care programs, particularly related to building effective and sustainable partnerships with hospitals. Additional barriers to program implementation and sustainability included financial barriers and staff turnover. Facilitators to implementation and sustainability included organizational champions, organizational culture, and value of evidence. Recommendations for CBOs to implement health service interventions include gaining early buy-in from hospital partners, creating a contractual arrangement with the hospital partner, understanding changes in health-care payment models, diversifying funding sources, developing an evaluation plan, and nurturing organizational champions.

Descriptive Analysis and Profile of Health Care Transition Services Provided to Adolescents and Emerging Adults in the Movin' On Up Health Care Transition Program

Global efforts are underway to develop, implement and test health care transition (HCT) models of care. Most studies have focused on the transfer of care models. In contrast, the nurse-led interdisciplinary HCT model, Movin' On Up, provides comprehensive HCT services beginning in early adolescence. A retrospective analysis was conducted of data extracted from HCT records of 146 adolescents and emerging adults with spina bifida (with a mean age of 13.91 years) who were provided services in the Movin' On Up HCT program. Data were categorized based on the Health Care Transition Research Consortium HCT model and the Omaha System framework and as to type of direct HCT services provided by the HCT Specialist and nurse-led interdisciplinary team conferences conducted. Findings revealed that the scope of services provided represented the scope of comprehensive needs beyond those associated with the transfer of care.

Abstract NS7: Driving Down Readmissions With Dynamic Discharge Follow up Team

Introduction: Stroke patients have complex discharge needs and benefit from strong care transition models. A common care transition model is to perform discharge phone calls to eliminate gaps that may have occurred after discharge. Institutions often struggle with performing discharge phone calls - who should perform this task and what the optimal timeframe should be. Ninety percent of this institution’s 30-day readmissions occur within the first 7 days of hospital discharge, with majority due to medication misunderstanding and poor communication. Hospital readmissions have negative consequences for patients and are costly, accounting for $15 billion of Medicare dollars annually. Methods: In 2014, stroke discharges to home received a 48 hour phone call from an outpatient Registered Nurse (RN) Care Manager. In 2015, to address the medication challenges, a Pharmacist was added to the discharge follow-up team, making phone calls within 7 days of discharge. Results: In 2016, 233(61%) of the 48-hour calls by RNs connected successfully with stroke patients discharged to home. Pharmacist calls reached a higher percentage of patients discharged to home at 83% (n=321). There were 53% (n=208) receiving both calls, and 25% (n=97) of patients being unable to reach after three attempts. The resultant 30-day readmission rate has declined from 8-10% in 2013 and 2014 (when we first started tracking 30-day readmission rates) to 2-3% in 2015. This low rate has remained consistent for 2016 and 2017. Conclusion: Although post-discharge calls can be very labor intensive and time consuming, it is possible to clarify communication, ensure understanding of discharge instructions, and intervene before medication errors occur. The unique combination of an RN and Pharmacist performing the discharge phone calls has been shown to be quite effective; the RN triages acute issues, while the Pharmacist ensures accurate medication list and compliance - and ensures no medication changes were inadvertently made at a primary care provider appointment post-discharge. These interventions reduce readmissions by closing the post-discharge gaps in care that can occur, resulting in a win for both the patient and the institution.

Developing a Policy Flight Simulator to Facilitate the Adoption of an Evidence-Based Intervention.

While the use of evidence-based interventions (EBIs) has been advocated by the medical research community for quite some time, uptake of these interventions by healthcare providers has been slow. One possible explanation is that it is challenging for providers to estimate impacts of a specific EBI on their particular organization. To address that concern, we developed and evaluated a type of simulation called a policy flight simulator to determine if it could improve the adoption decision about a specific EBI, the transitional care model (TCM). The TCM uses an advanced practice nurse-led model of care to transition older adults with multiple chronic conditions from a hospitalization to home. An evaluation by a National Advisory Committee, made up of senior representatives from various stakeholders in the U.S. healthcare system, found the policy flight simulator to be a useful tool that has the potential to better inform adoption decisions. This paper describes the simulation development effort and documents lessons learned that may be useful to the healthcare modeling community and those interested in using simulation to support decisions based on EBIs.

Knowledge to action: Rationale and design of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) stepped wedge cluster randomized trial

IntroductionHeart Failure (HF) is a common cause of hospitalization in older adults. The transition from hospital to home is high-risk, and gaps in transitional care can increase the risk of re-hospitalization and death. Combining health care services supported by meta-analyses, we designed the PACT-HF transitional care model. MethodsAdopting an integrated Knowledge Translation (iKT) approach in which decision-makers and clinicians are partners in research, we implement and test the effectiveness of PACT-HF among patients hospitalized for HF. We use a pragmatic stepped wedge cluster randomized trial design to introduce the complex health service intervention to 10 large hospitals in a randomized sequence until all hospitals initiate the intervention. The goal is for all patients hospitalized with HF to receive self-care education, multidisciplinary care, and early follow-up with their health care providers; and in addition, for high-risk patients to receive post-discharge nurse-led home visits and outpatient care in Heart Function clinics. This requires integration of care across hospitals, home care agencies, and outpatient clinics in our publicly funded health care system. While hospitals are the unit of recruitment and analysis, patients (estimated sample size of 3200) are the unit of analysis. Primary outcomes are hierarchically ordered as time to composite all-cause readmissions / emergency department (ED) visits / death at 3 months and time to composite all-cause readmissions / ED visits at 30 days. In a nested study of 8 hospitals, we measure the patient-centered outcomes of Discharge Preparedness, Care Transitions Quality, and Quality Adjusted Life Years (QALY); and the 6-month health care resource use and costs. We obtain all clinical and cost outcomes via linkages to provincial administrative databases. ConclusionsThis protocol describes the implementation and testing of a transitional care model comprising health care services informed by high-level evidence. The study adopts an iKT and pragmatic approach, uses a robust study design, links clinical trial data with outcomes held in administrative databases, and includes patient-reported outcomes. Findings will have implications on clinical practice, health care policy, and Knowledge Translation (KT) research methodology.

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 Temple Star Transitional Model of Care for epilepsy; the outcome of a quality improvement project

ObjectiveThe aim and objective of this study was to assess the knowledge and views of parents on transitional and adolescent care in young adults with epilepsy, and to develop a transitional and adolescent program for epilepsy. MethodsData were collected from questionnaires completed by parents during focus groups exploring transitional care and inherent issues for young adults, aged 12–18years, with epilepsy. The questionnaire assessed the current knowledge and views of parents of children with epilepsy on transitional care, and following a presentation on “Transition in Epilepsy” (including themes such as self-advocacy, independent healthcare behavior, sexual health, psychosocial support, educational and vocational planning, health and lifestyle issues) assessed feedback on the proposed model of care in transitional and adolescent care. ResultsData were collected from 34 parents; the majority of parents, 74% (n=25), wish their children to be transitioned and transferred over to the adult epilepsy sites at the age of 18years. Over 82% (n=28) of parents believe the concept of transition should be introduced between the ages of 12–16years. ConclusionThis quality improvement initiative identified the need for transitional care to begin at an early age. This study engaged parents in a process to improve adolescent and transitional care for adolescents with epilepsy. This study also highlights the importance of introducing a detailed preparatory phase for a transitional and adolescent care in epilepsy.

Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients.

Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.

Self-management and health care transition: Trials, tribulations and triumphs.

The purpose of this article is to provide perspectives pertaining to the importance of fostering comprehensive self-management competencies of AEA-SHCN, with attention directed to AEA with spina bifida based upon the Health Care Transition Research Consortium Health Care Transition model. This article is based upon the plenary presentation given at the Spina Bifida 3rd World Congress, entitled, Self-Management and Health Care Transition: Trials, Tribulations and Triumphs. A historical perspective of healthcare transition initiatives and best practice guidelines is provided that have influenced the field of research and practice. Relatively scant attention has been directed to the development and refinement of self-management competencies prior to the transfer of care and transition to adulthood. Against this backdrop of the predominant framework of care focused on the transfer of care, a discussion of our team's experience with the provision of healthcare transition services and the complexity of addressing the self-management needs of the adolescents and emerging adults (AEA) with spina bifida served in the Movin' On Up HCT program will be presented. Through our clinical and research healthcare transition experience, insights pertaining to self-management will be presented. The acquisition of self-management knowledge and skills is a complex process that extends far beyond learning the fundamental skills of daily condition management.

Prolonged Hospital Discharge for Children with Technology Dependency: A Source of Health Care Disparities.

Children with ventilator assistance have been supported in living at home since 1981 when parental advocacy ushered in a change to Medicaid policy. As the population of children who use medical technology such as long-term ventilation increases, we must critically evaluate our systems for preparing families for home life. Discharge delays persist in the modern era because of fragmentation between hospital and home systems. These discharge delays result in children spending time in less developmentally rich environments, further exacerbating the health and development disparities of children with complex disabilities. In this article, we discuss the complication of hospital discharge and how it contributes to health and developmental disparities. We also describe a hospital-to-home transitional care model, which presents a home-like environment to provide developmental support while focusing on parental training, home nursing, and public-funding arrangements. [Pediatr Ann. 2017;46(10):e365-e370.].

What is Care Like for Young Adults with Type 1 Diabetes Mellitus (T1DM)? An Environmental Scan of Current Transition Care Models

What is Care Like for Young Adults with Type 1 Diabetes Mellitus (T1DM)? An Environmental Scan of Current Transition Care Models