Care Transition Planning Research Articles

Experience of Transitional Care Among Thai-Isan Older Stroke Survivors and Their Family Caregivers.

The transitional care model for people who have suffered brain injuries is a relatively recent addition to the Thai healthcare system. The aim of this study was to explore experience of Thai Isan older stroke survivors and their family caregivers across different points of transition from hospital to home. Fifteen dyads of older stroke survivors and their family caregivers were recruited following the inclusion and exclusion criteria. Data were collected through participant observations and semi-structured interviews. Forty-seven participation observation field notes and twenty-four interview transcriptions were analyzed using the Four Phases of the Data Analysis Enabler and the Leininger-Templin-Thompson Ethnoscript Coding Enabler. Three themes emerged: I feel lost with managing care at home; it has been challenging for our family to maintain continuity of care; and it is a matter of who fits in and is convenient for family care responsibilities. The findings of this study have highlighted the dispersion of care among Thai-Isan people during the patient's transition to home. Therefore, a transitional care plan should be developed that specifies who is responsible for monitoring and supporting patients and families throughout this period.

A Quality Improvement Initiative to Improve Health Care Transition Planning at Adolescent Well Visits

ObjectiveHealth care transition (HCT) planning supports adolescents as they move from pediatric to adult health care and is recommended for all youth. HCT planning uptake remains low, with little known about HCT in the adolescent well child check (WCC) setting. We sought to increase rates of HCT planning at WCCs by adapting best practices for HCT from specialty and chronic care. MethodsThis quality improvement initiative at 12 to 17-year-old WCCs at four Internal Medicine-Pediatrics primary care clinics, was based on the first three of the “Six Core Elements” of HCT framework and integrated into the electronic health record. Two uptake measures were assessed via chart review after three plan-do-study-act (PDSA) cycles, with two provider surveys and an implementation science analysis further informing interpretation. ResultsBy the final PDSA cycle, the percentage of 14 to 17-year-old WCCs at which HCT planning was discussed and a screening tool completed increased from 5% to 31%, and the percentage of 12 to 13-year-old WCCs at which the HCT policy was discussed increased from 6% to 47%. Provider survey results revealed endorsement of HCT goals, but time and technological barriers, which were further elucidated in the implementation science analysis. ConclusionsThis quality improvement initiative increased rates of HCT planning during adolescent WCCs. While limited to three Core Elements and Internal Medicine-Pediatrics clinics, strengths include measures capturing all WCCs, contextualized by provider surveys and an implementation science framework. Lessons from this effort can inform future tailored HCT initiatives at adolescent WCCs.

133. Health Literacy in Foster Care Transition Planning: Perspectives of Adolescents and Young Adults Formerly in Foster Care and Stakeholders on Barriers to Care

133. Health Literacy in Foster Care Transition Planning: Perspectives of Adolescents and Young Adults Formerly in Foster Care and Stakeholders on Barriers to Care

Transition of Care of Pediatric Patients with Special Needs to Adult Care Settings: Children with Diabetes Mellitus and Other Endocrine Disorders.

Childhood onset endocrine disorders need long-term medical, psychological and social management. Over time, many illnesses evolve, while others may witness onset of new complications. Thus, the components of the care change as the child grows into adolescence and then adulthood. The transition of children and adolescents with chronic endocrine disorders to adult care continues to be a major challenge. Pediatric and adult healthcare teams should together design a transitional care plan that is developmentally appropriate and responsive to the needs of young adults. The preparation for transition to adult care should begin early in adolescence and involve both the adolescent and his parents. A structured and planned transitional care bridges the gap between pediatric and adult care teams, promote ongoing engagement and build trust with the new healthcare teams. Combined pediatric-adult care transition model for endocrine conditions has yielded high adherence rates and patient satisfaction.

Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities: Distinctions and challenges.

The purpose of this article is to provide the reader with insight and enhanced understanding of the health care transition planning process for adolescents and emerging adults with intellectual disabilities and developmental disabilities. There are distinctly different programmatic considerations that need to be addressed in advancing their transfer of care to adult providers and promoting their transition to adulthood. These differences are due in part to the federal and state legislative initiatives that were established in the education, rehabilitation, employment, and developmental disabilities service systems. In contrast, no comparable federal and state mandates exist in the system of health care. The legislative mandates in education, rehabilitation, and employment are presented and discussed as well as the federal legislation on rights and protections for individuals with intellectual disabilities and developmental disabilities. Consequently, health care transition (HCT) planning involves application of a framework of care that is characteristically different than the planning efforts undertaken for adolescents and emerging adults (AEA) with special health care needs (SHCN)/disabilities and for typically developing AEA. The best practice HCT recommendations are discussed in the context of this intellectual disabilities and developmental disabilities framework of care. Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities involves additional and distinctly clinical and programmatic models of care. Health care transition planning guidance for adolescents and emerging adults with intellectual disabilities and developmental disabilities are provided based upon best practice recommendations.

Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review.

To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity. Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions. Scoping review. Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies. Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences. The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.

DEVELOPMENT OF A TRANSITIONAL CARE PROGRAM FOR FRAIL OLDER ADULTS BETWEEN HOSPITAL AND HOME

Abstract Frail older adults particularly need transitional care between hospital and home due to physical function decline and psychological instability after discharge. This study aimed to develop a transitional care for frail older adults in Korea who are discharged home following hospitalization. The Returning Home (Rehome©) program was established through the three phases according to the Medical Research Council’s 2013 guidelines. 1) Identifying the evidence base phase included a systematic review of literature and needs assessments from interviews with frail older adults. The core intervention components (e.g., geriatric assessment, transitional care planning, home visits, phone follow-up, community service liaison, and family engagement) were determined. 2) At the phase of identifying theory, the transition theory was selected and modified to fit the target population in the context of the Korean healthcare system. 3) Phase three was for the modeling process and outcomes. Based on the result from phases 1 and 2, the Rehome program was developed considering clinically applicable strategies. The final Rehome program consisted of a comprehensive geriatric assessment at admission; structured discharge/transitional care planning (e.g., medication review, education for chronic disease management, emergencies, and geriatric syndromes, and community resource) at discharge; a home visit and six phone follow-up calls up to 12 weeks after discharge; and emotional support and engagement of the family during the entire period. The Rehome program showed good content validity. The Rehome as a frailty-focused transitional care program could improve the transition through implementing a tailored intervention that meets the care needs of these vulnerable populations.

Survivorship, Quality of Life, and Transition to Adult Care for Pediatric and Adolescent Thyroid Cancer Survivors.

The importance of long-term survivorship care to reduce survivor and family anxiety and burden, decrease emergency visits and health care costs, improve knowledge, as well as implement timely surveillance is widely accepted. Most childhood cancer survivors suffer from an increased number of medical and psychosocial comorbidities as they age and are at a higher risk for early mortality, which differs by cancer diagnosis. Childhood thyroid cancer survivors fall within this spectrum. Some have significant complications and/or late effects from treatment, whereas others have no long-term medical late effects, but almost all will require life-long thyroid hormone replacement therapy. Therefore, providing survivorship and transitional care, including a survivorship and/or transitional care plan (SCP/TCP), as well as periodically assessing the needs and quality of life for the patient and their family, should be implemented for our young thyroid cancer survivors.

A snapshot of geriatric rehabilitation: one year experience.

Frailty is a common condition in older adults, characterized by multimorbidity, physical weakness and nutritional deficit. Frailty can be detected early and a prehabilitation treatment could reduce the incidence of disability. Two-hundred-fifteen elderly patients were admitted to the Rehabilitation and Physical Medicine Unit of Policlinico Gemelli for one year. Patients were clinically assessed by Charlson Comorbidity Index (CCI) and blood sample values. Numerical Pain Rating Scale (NRS) and Hand Grip Test were assessed before (T0) and after (T1) hospitalization. Number of drugs and number of infections were recorded. Patients were originally hospitalized in orthopaedic, neurology and medical ward. Most patients (68%) after discharge return home. Negative correlations between albumin and CCI and between total protein and CCI were recorded. Positive correlation between CCI cognitive subscore and number of drugs and a negative correlation between that subscore and Vitamin D were detected. An improvement in NRS and in the handgrip strength was recorded. At discharge an increase in the number of drugs and the number of infections was noted. The handgrip strength improvement increases quality of life. Pain management and NRS indicate a better recovery of activities of daily living. Malnutrition is a real problem; albumin is the principal negative acute-phase reactant and is related to a worse clinical condition and low vitamin D levels are associated with worse cognitive function. The goal of a Rehabilitation Unit is to create an effective multidisciplinary transitional care plan, involving the patient and caregivers, creating a continuity of care after discharge and a sustainable project.

Using drawing and situated learning to teach transitional care to post-graduate residents

BackgroundThe “draw-and-talk” technique has become popular in medical training, as it can help healthcare practitioners develop empathic understanding of patients and contribute to personal transformation. We adopted this method to make the teaching of transitional care planning more relevant to post-graduate residents undergoing their internal medicine training at a medical center in Taiwan.MethodsBefore the conventional lecture on discharge planning, trainees were invited to draw their “home” and “life as older adults” and share their drawings with others. Subsequently, they were guided to consider whether their home would be livable if they either had a disability or were old. The drawings and narratives were analyzed thematically, and feedback on the session was collected.ResultsTrainees were initially of the opinion that they did not have any role in discharge planning. However, the emphasis on the self-experience of drawing and the thematic use of “home” and “elderly life” led to reflective discussions about post-discharge care. The session provoked constructive self-reflection and meta-cognitive awareness and encouraged residents to actively participate in transition care plans. Response to the draw-and-talk session was overwhelmingly favorable.ConclusionsPost-graduate residents in Taiwan conventionally do not have much interest or autonomy regarding their patients’ lives outside the hospital. The use of drawing and reflection is a simple and inexpensive method to contextualize discharge planning in participants’ real lives, engage them in actively visualizing the healthcare needs of older adults and patients with disability, and initiate thinking about the impact of discharge preparations, follow-up care, and barriers to care at home. Draw-and-talk might be helpful in improving residents’ knowledge and empathy toward patients preparing for discharge, which is crucial for the quality of transitional care.

Care Pattern for Fontan-Associated Liver Disease by Academic Pediatric Hepatologists in Canada.

The current study aims to determine academic pediatric hepatologists' practices and identify variability in management provided to children with FALD in Canada. Using the infrastructure of the Canadian Pediatric Hepatology Research Group, a nationwide survey was distributed electronically to all pediatric hepatologists practicing in university-affiliated hospitals. Twelve pediatric hepatologists from 12 of 13 academic centers (92%) responded to the survey. The institutions of only 2 (17%) physicians offer post-Fontan care with a multidisciplinary team, both from different provinces. The screening for other comorbidities, use of noninvasive modality, and timing of liver biopsy for estimation of liver fibrosis and screening for esophageal varices differ from program to program. The frequency of outpatient clinic follow-up varies significantly. Education and counseling concerning liver health are generally used as treatment; only 58% of academic centers have a formal adult care transition plan. Significant discrepancies exist in the care provided to children with FALD by hepatologists practicing in academic centers across Canada. Future study is needed to develop a standardized protocol for managing and following children and youth with FALD.

Calibrating Readmission Risk Prediction Models for Determining Post-discharge Follow-up Timing.

The soaring hospital readmission rates are straining the already limited financial resources in the US health system. Meanwhile, timely outpatient follow-up, an efficient and cost-effective intervention following hospital discharge, has been shown to reduce the readmission risk. However, the current and projected shortage of physicians in primary and specialty care poses a unique dilemma in transitional care planning: optimizing the utilization of post-discharge follow-up to reduce readmission rate while limiting the strain on the limited pool of outpatient physicians. The ideal solution would entail a strategy whereby patients at higher risk for readmission are stratified towards earlier outpatient follow-up and vice versa. This article explores the utility of Institution-specific readmission risk prediction algorithms for assessing patient population for diverse administrative, clinical and socioeconomic risk factors and further classifying the hospital’s patient population into high- and low-risk strata, so that appropriate risk-concordant timing of follow-up can be assigned at the time of hospital discharge, with earlier follow-up assigned to high readmission risk strata. This stratification shall help ensure judicious and equitable human resource allocation while simultaneously reducing hospital readmission rates.

Health Care Transition Planning: Educational Needs of Pediatric Nurses and Pediatric Nurse Practitioners.

The purpose was to identify the educational needs of pediatric nurses and pediatric nurse practitioners providing direct care to transition-aged youth with chronic illness and disability and to identify strategies to develop health care transition planning (HCTP) expertise. Mixed-methods descriptive analyses were performed on survey data extracted from a larger national study exploring the provision of HCTP activities performed by nurses of two pediatric nursing professional organizations. Items querying educational needs were completed by 1,162 pediatric nurses serving in advanced practice and staff roles. Twenty percent reported having specialized HCTP education. Of which more than half received it outside of the workplace. Factor analysis revealed two constructs explaining 73.4% of the variance in nurses' reported level of knowledge. HCTP education and the development of nurse-led services to facilitate optimal health care transitions outcomes are necessitated. Academia and service have a shared responsibility in educating nurses.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

ObjectiveTo synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders’ transition...

Improving transitional care communication for older Australians from hospital to home: Co-design of the TRANSITION tool.

This study aimed to develop and evaluate a communication tool to guide transitional care for older patients. Using experience-based co-design, a communication tool resulted from the triangulation of data collected from three study phases. From 2015 to 2016, semi-structured interviews and co-design focus groups were undertaken with older patients, carers and healthcare practitioners across acute, rehabilitation and community settings. The evaluation phase, conducted in 2017-2018, involved use of the communication tool by healthcare practitioners in a multidisciplinary care team with older patients in acute care and semi-structured interviews with healthcare practitioners about the acceptability and feasibility of the tool. A total of 103 patients, carers and healthcare practitioners took part. In semi-structured interviews, patients and carers reported needing to become independent in care transitions, which was supported by discussing the transitional care plan with healthcare practitioners. Interviews with healthcare practitioners identified that their need for fast and safe care transitions was supported by team discussion and by engaging patients and carers in their transitional care plan. Co-design focus group participants identified principles guiding transitional care including patient-centred communication. Data collected from semi-structured interviews and co-design focus groups were used to develop a prototype communication tool to guide conversations about discharge care between healthcare practitioners and older patients. Following use, healthcare practitioners reported that the communication tool was feasible and acceptable although some nurses perceived that transitional care was not their role. The communication tool provides an evidence-based resource for ward nurses to support transitional care continuity in multidisciplinary models.

Health care transition planning: A potpourri of perspectives from nurses.

Nurses have important roles as members of the healthcare transition (HCT) planning interdisciplinary team. Nursing's scope of practice and framework of care brings a distinctive and complementary approach to this expanding field in pediatric care. It is therefore relevant to better understand the extent to which pediatric nurses are involved with the provision of HCT services and model development. This was a qualitative analysis of a national survey of pediatric nurses. A thematic iterative process was used to code data. Three coders separately analyzed responses and then met to compare and discuss until a final list of codes was achieved. The codes were further analyzed until themes and subthemes emerged. Throughout the process, disagreements were discussed and resolved until consensus was achieved. A sample of 1814 pediatric nurses and nurse practitioners from two US professional organizations participated in this national survey to gather data on their involvement in HCT planning. This survey contained 17 items, one of which was an open-ended question stating: Is there anything else you would like to share about your role with the population of transitioning youth and young adults with chronic illness and/or disability? The analysis of responses provided by 154 nurses is presented. Initial coding resulted in 11 categories of data. Four major themes, including four subthemes, emerged from the analysis of responses: Support for the need for transition (subtheme: Nursing involvement); Guidance needed for professional practice (subtheme: Types of guidelines and training); Lack of service linkages to adult providers; and Difficulty letting go (two subthemes: Pediatric providers; Parents). These findings indicated strong support for the need of HCT services and the importance of nursing involvement. However, challenges to HCT implementation were identified that include systemic, psychosocial, and educational barriers. As this field of practice and research continues to grow, it is important that pediatric nurses recognize the opportunities to have a clinical voice to develop nurse-led HCT services and programs.

Thirty-Day Unplanned Readmissions Following Hospitalisation for Atrial Fibrillation in Australia and New Zealand

Atrial fibrillation (AF) is a leading cause of hospitalisations, yet little is known about 30-day readmissions following discharge despite increasing policy focus on reducing readmissions. We assessed the rate, timing, causes and predictors of 30-day unplanned readmission following an acute and elective AF hospitalisation using population-wide data. We studied all patients hospitalised for AF from 2010 to 2015 at all public and most private hospitals in Australia and New Zealand. The main outcome measures were unplanned readmissions within 30 days of discharge, primary diagnosis associated with these readmissions, and their predictors as modelled by logistic regression. Among 301,654 patients hospitalised for AF (mean age 69.2±13.6 yrs, 55.6% female, 65.2% acute presentations), 29,750 (9.9%) experienced an unplanned readmission within 30 days with 62.6% occurring by 14 days. Unplanned readmissions occurred more frequently following an acute versus elective AF hospitalisations (12.5% vs 4.9%, p<0.001). The most common diagnoses associated with readmissions were recurrence of AF (n=9,890, 33.2%), and preventable conditions including heart failure (n=2,683, 9.0%), pneumonia (n=724, 2.4%) and acute myocardial infarction (n=510, 1.7%). A higher risk of 30-day readmission was associated with congenital cardiac/circulatory defect (OR 2.18, CI 1.44-3.30), congestive heart failure (OR 1.34, CI 1.30-1.39), and arrhythmia/conduction disorders (OR 1.25, CI 1.21-1.28). Almost 1 in 10 AF hospitalisations resulted in unplanned readmission within 30-days, mostly for AF recurrence. Improved clinical management of AF and transitional care planning are required to reduce unplanned readmissions following AF hospitalisations.

Implementation of Transitional Care Planning Is Associated With Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease

Patients undergoing lower extremity bypass (LEB) are at risk of postdischarge complications and requiring readmission. Health systems have developed strategies to mitigate this risk. Our study aimed to assess the short-term readmission, mortality, and amputation rates of patients who had participated in transition care planning by completing at least one postdischarge follow-up telephone call after undergoing LEB for revascularization to treat peripheral artery disease.

The transitional care pathway following traumatic dental injuries: Patient perspectives.

The nature of complex traumatic dental injuries (TDIs) often means that management continues through paediatric to adult dental services. Evidence suggests that failure in transitional care can have detrimental impacts on health. There is limited evidence regarding patients' experiences of transitional care pathways (TCPs) in dentistry. The aim of this study was to investigate the views and experiences of the TCP from paediatric to adult care for individuals who have experienced TDIs. Semi-structured interviews were undertaken. Ethical approval was granted by the Health Research Authority and sponsored by the University of Liverpool. Inclusion criteria included individuals aged 16 to 21years old who had received care in both paediatric and adult restorative dentistry departments at Liverpool University Dental Hospital following a TDI. Five purposively sampled patients were interviewed. Thematic analysis was undertaken using NVivo. Thematic analysis identified 5main themes with regard to transitional care experience: patient-clinician communication, impact of dental trauma, feelings of uncertainty, patient personal development and transitional care planning. Feelings of uncertainty with regard to the long-term prognosis of traumatized teeth were highlighted. Clear communication and involvement of young people in decision-making was identified as a vital factor to facilitate a successful TCP experience. The involvement of young people in decision-making is essential for a successful TCP. Consideration should be given to development of TCP guidance, to allow for the provision of timely and consistent information regarding the process. Despite this, there needs to be adaptivity within the TCP to create a successful TCP for every young person.

An electronic tool for health systems to assess and communicate discharge medication access.

The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge. Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board-approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge. The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system.