Care Transition Process Research Articles

Prospective analysis of sex differences and factors associated with suicidal thoughts and behaviours in young people from the MILESTONE Italian sample

Suicide is a significant leading cause of death among young people, particularly those struggling with mental disorders. The present study utilised data from 230 young people (aged 16–18 years) undergoing a transitional care process from Child and Adolescent Mental Health Services to Adult Mental Health Services within the MILESTONE European project (2014–2019), a longitudinal cluster randomised controlled trial. The objectives of this study were to monitor temporal patterns of general health and social functioning over two years, to detect sex differences, and to identify factors associated with Suicidal Thoughts and Behaviours (STB) at the first and last time points. The results demonstrate a decrease in STB over the two-year follow-up period among all participants. Females exhibited a higher prevalence of STB across all time points, whereas males only exhibited STB at the nine-month follow-up. The most influential factors associated with STB were previous suicide attempts and mood disorders at baseline, and mood disorders and relational problems at the end of follow-up. These findings emphasise the importance of monitoring STB and informing young people undergoing a transitional care period about its key risk factors. Moreover, sex differences in STB suggest the need for different preventive strategies for males and females.

Transition Guide Dissemination to Foster Patient-Care Team Conversations: A Childhood Arthritis Rheumatology Research Alliance Transition Learning Collaborative Pilot Implementation Study.

Uptake of evidence-informed health care transition processes among pediatric rheumatologists is low despite poor outcomes of transition from pediatric to adult care. We piloted a learning collaborative model to implement transition guides. We dually assessed implementation outcomes and changes in reported patient-care team discussions about transition. This was a type II hybrid effectiveness-implementation pilot study of transition guide dissemination to patients at least 14 years old with rheumatic conditions across nine pediatric rheumatology centers in the Childhood Arthritis Rheumatology Research Alliance Transition Learning Collaborative. We evaluated implementation outcomes (feasibility, adaptations, and fidelity) and the proportion of patients surveyed that reported having discussions with their care team regarding transfer planning. Six sites were retained through the COVID-19 pandemic (below 70% target). Five out of six sites contributed outcome data (met 80% target) but with substantial heterogeneity in how transition guides were shared (eg, in-person, electronic messages, and posted flyers), and data were collected. The pooled proportion of respondents having discussed transfer planning with their care team was 39% preimplementation (n = 239; 95% confidence interval [CI] 32%-46%) and 55% postimplementation (n = 864; 95% CI 36%-73%). After implementation, there were significant increases in the likelihood of respondents recalling receiving a transition guide (odds ratio [OR] 2.58, 95% CI 1.35-4.92) and discussing transfer planning (OR 2.14, 95% CI 1.30-3.52), adjusted for age and site of care. Transition guide dissemination is a simple intervention associated with increased awareness among young people with rheumatic conditions and discussions with their care team about transition preparation. The learning collaborative model facilitated identification of several dissemination strategies adaptable to site-specific resources.

Enhancing care coordination through transitional care management.

232 Background: West Cancer Center and Research Institute (WCCRI) serves Memphis and the Arkansas, Mississippi, and Tennessee tri-state region as the comprehensive care leader in adult cancer care and research, amounting to over 260,000 visits across 57,000 unique patients in 2023. Cancer patients are predisposed for higher risk of hospital admissions, making uniform care coordination between the discharging hospital and their outpatient oncology care home essential to care continuity. While WCCRI attempted to mitigate readmissions, there was no formalized managed care approach for capturing and responding to unplanned patient hospital visits to prevent readmission. Auditing of claims data suggested nearly 500 patient care opportunities within a four-month period. Methods: To improve continuity of care and decrease preventable readmissions, WCCRI implemented a care transitions process based on the Centers for Medicare and Medicaid's Transitional Care Management (TCM). This required a repeatable approach of proactive outreach to patient upon discharge, a clinical assessment of patient need, and an office visit within fourteen days of discharge. To maximize impact, this project was scoped to patients with unplanned hospital admissions who are at moderate to high risk for readmission. Results: Twelve months after implementation, WCCRI has proactively identified 974 patients qualifying for TCM and successfully scheduled 91.48% for a hospital follow-up appointment with their oncologist. Proactive outreach to patients has led to a 35% increase in office visits within fourteen days of discharge, a key measure of care continuity. Conclusions: Learnings from this implementation project have been spread to formalize hospital follow-up approaches across WCCRI. By aligning policies, engaging stakeholders, and fostering a culture of collaboration and accountability, WCCRI has delivered high-quality, coordinated care, and achieved better patient outcomes.

Caregivers' burden of care during emergency department care transitions among older adults: a mixed methods cohort study.

Improving care transitions for older adults can reduce emergency department (ED) revisits, and the strain placed upon caregivers. We analyzed whether caregivers felt a change in burden following a care transition, and what may be improved to reduce it. This mixed-methods observational study nested within LEARNING WISDOM included caregivers of older patients who experienced an ED care transition. Burden was collected with the brief Zarit Burden Interview (ZBI-12), and caregivers also commented on the care transition. A qualitative coding scheme of patient care transitions was created to reflect themes important to caregivers. Comments were randomly analyzed until saturation and themes were extracted from the data. We followed both the SRQR and STROBE checklists. Comments from 581 caregivers (mean age (SD) 64.5 (12.3), 68% women) caring for patients (mean age (SD) 77.2 (7.54), 48% women) were analyzed. Caregivers overwhelmingly reported dissatisfaction and unmet service expectations, particularly with home care and domestic help. Communication and follow-up from the ED emerged as an area for improvement. Caregivers who reported an increased level of burden following a patient's care transition had significantly higher ZBI scores than caregivers who self-reported stable burden levels. Caregivers with increasing, stable, and improved levels of subjective burden all reported areas for improvement in the care transition process. Themes centering on the capacity to live at home and inadequate communication were most frequently mentioned and may represent serious challenges to caregivers. Addressing these challenges could improve both caregiver burden and ED care transitions.

Challenges and opportunities in transitional care process in Behçet's syndrome.

Behçet's syndrome (BS) is a rare chronic multi-systemic inflammatory disorder that usually involves adults between third and fourth decades of life, while pediatric and juvenile onset are relatively rare. BS young patients (YP) often develop a full-blown disease late after onset, requiring careful diagnostic workup and regular follow-up while they grow up. In this regard, the purpose of transitional programs is to ensure continuous high-quality care to YP with chronic conditions, providing them with the skills necessary to become independent and empowered adults able to chronically self-manage their disease. EULAR/PReS released the first set of standards and recommendations for transitional care (TC) of YP with juvenile-onset rheumatic diseases, but the appropriate timing for transition, the tools to evaluate patients' readiness, and indicators of transition plans effectiveness still need to be identified. Although little is known regarding TC in BS, it is easy to assume that BS YP will benefit from developmentally and disease-specifically appropriate transition plans, which may promote continuity of care, improve perceived quality of life and prevent poor disease outcomes. This perspective article discusses the key concepts and the goals of TC, addressing the potential challenges and opportunities of TC for YP with BS in clinical practice.

Creating a data collection and management platform to support measurement of adolescent HIV care transition processes within low- and middle-income countries: The GRADUATE project.

Few national programs and research cohorts within low- and middle-income countries (LMICs) document transition-related processes and outcomes for adolescents and young adults living with HIV (AYLH) transitioning to adulthood. Between 2017-2020, The Global fRAmework of Data collection Used for Adolescent HIV Transition Evaluation (GRADUATE) project convened a collaborative advisory group to identify key variables and definitions capturing the process, predictors, and outcomes across the transition period. In total, 114 variables identified as essential to measuring AYLH transition-related data were identified and formatted into a GRADUATE Data Exchange Standard (DES), which was added to and harmonized with the existing International epidemiology Databases to Evaluate AIDS (IeDEA) DES. In 2019, the GRADUATE DES was pilot tested at four IeDEA facilities in Malawi, South Africa, and Thailand through a cross-sectional study. Upon comparing the variables to routine medical records, available data were too limited to adequately capture transition-related processes and outcomes. However, additional data collection using GRADUATE tools was feasible and improved completeness. Of the 100 (52% female) AYLH included in the pilot study, 71% had transitioned/transferred to adult care, with 42% transitioning from an adolescent-specific model of care within an integrated family clinic to having their clinic visits scheduled on a different day of the week while 58% transferred from a pediatric facility to one offering adult HIV care. While almost all (94%) had a transition-related discussion with their healthcare providers prior to the transition, we found that 69% (95% CI 49-85%) were somewhat or very satisfied/comfortable with the post-transfer clinic and the staff. Utilization of the GRADUATE DES better characterized AYLH transitioning to adulthood across LMICs, and optimally measured transition preparation activities and outcomes. Utilization of the GRADUATE DES in other settings could facilitate comparisons and identify gaps in the care of transitioning adolescents that need to be addressed.

"I Finally Feel Like I Have Help. Before, I Was Completely Alone": A Grounded Theory of Community-Based Hospice Transitions.

Little is known about community-based transitions to home hospice care. We used a Straussian grounded theory approach to understand the basic social process of care transitions that patients and their caregivers use when electing hospice care. Participants were recruited from hospice agencies serving 3 counties in New York State. Data were collected through 7 interviews of patients, patient-and-caregiver dyads, and a hospice nurse (n = 10). Data were analyzed using the constant comparative method. Our results generated an emerging grounded theory of the hospice care transition processes rooted in maintaining personhood and autonomy. There were 5 contemporaneous steps: (1) recognizing futility and pursuing comfort; (2) seeking help and input as health declines; (3) shopping for the right services, overcoming obstacles, and self-referring to hospice care; (4) attending to the business of dying while living; and (5) processing and expressing emotions. Although not central to the care transition process, an additional step was identified that occurred after the transition to hospice care: planning for an uncertain future. The hospice care transition process identified in the study reveals important mechanistic targets for the development of interventions that promote patient-centered hospice care transitions in the home setting.

Transitional care for older persons with need of geriatric rehabilitation nursing interventions

BackgroundThe literature review notes that people in need of care from Rehabilitation Programs do not always see their continuity ensured.ObjectiveThis study aim to analyze the perspective of Specialists Nurse in Rehabilitation Nursing in relation to the organization and specialized intervention of transitional care for older people in need of rehabilitation programs.MethodsThis is a qualitative study within the interpretivist paradigm. A focus group with 8 nurses and 13 interviews with Portuguese nurses were carried out between April 2022 and February 2023. Content analysis was carried out.ResultsThe triangulation of the data made it possible to identify 3 categories: Coordination of a transitional care program; Empowering the person to self-manage the transitional care process and Empowering the Informal Caregiver. ConclusionsIt is imperative to promote the coordination of transitional care, increase the functional capacity of the person and empower the informal caregiver.

Development and Implementation of a Stroke Nurse Navigator Position to Improve Program and Patient Outcomes

Background Transitions in stroke care across the healthcare system are complex, requiring significant patient and family support. Navigation has been used in other disease states including oncology but has not been described well in the stroke population. Methods Our stroke program leadership performed a gap analysis to identify opportunities to streamline the care transition process. The emerging stroke nurse navigator role was implemented to meet patient/family needs and ensure implementation of evidence-based stroke services throughout transitions across the stroke system of care. Results The stroke navigator role was formally implemented in April 2018, along with adaptive patient selection criteria that have evolved as expertise in navigation has grown. Clarity in role function between the stroke coordinator and stroke navigator positions was established demonstrating the synergistic relationships between these two roles. Similarly, interventions and services performed routinely by stroke navigators developed over time as navigators became well versed in the needs of patients and families in the post-acute phase of care. We provide a detailed history of our 6-year experience with stroke navigation and make recommendations for role adoption and enactment. Conclusion Stroke navigator roles are likely to continue to grow to support the complex needs of stroke survivors and family members. Flexibility in role development and reflective role evolution are encouraged to support growth of the stroke navigator position and measures of role effectiveness.

A92 THE CURRENT STATE OF PEDIATRIC TO ADULT TRANSITION OF CARE: A ROUND TABLE DISCUSSION WITH KEY STAKEHOLDER GROUPS

Abstract Background There is a severe paucity in available resources to facilitate a safe and effective pediatric to adult health care transition for patients with chronic disease. Aims This study aims to better understand the experiences of key stakeholder groups involved in pediatric to adult transition of care across various chronic disease specialties within a tertiary care urban environment. Methods A focus group was conducted on July 12th, 2018 at Women’s College Hospital with key stakeholder groups. Questions focused on the top issues related to pediatric to adult transition of care and an ideal transition model for their respective patient populations. The second part of this study included individual interviews with patients and carepartners. Focus group meetings and individual interviews were both audio-recorded and transcribed for qualitative thematic analysis. Results Seventeen pediatric and adult care physicians representing ten chronic disease specialties were represented. Seven patients and care partners were interviewed. Major focus group themes included: disproportionate access to resources between and within specialties (n=10), lack of mental health support in the adult setting (n=8), fragmentation of care due to multiple providers as a result of patients leaving for employment or education (n=6), patients feeling alienated due to decrease in allied health support or due to shorter appointment times (n=8), and difficulty retaining consistent care due to missed appointments as a result of inconsistent communications or change in location for education or employment (n=7). Ideal care models were suggested to include: centralized intake procedure to identify patients who may require extra support (n=9), education for scheduling administrators about second chances after a no-show (n=5), implementation of joint clinics with pediatric and adult care teams or back-and-forth clinic sessions to ensure bidirectional provider comfort before discharge to adult care system (n=4), and implementation of a dedicated transitions navigator or point of contact for patients (n=10). The individual patient and carepartner interviews emphasized the need for: centralized and comprehensive online resource (n=7), simple and clear educational content introducing the adult healthcare system (n=7), opportunities to meet and share information with other individuals in a similar position (n=3), and availability of a transitions navigator (n=4). Conclusions Current pediatric to adult transition of care resources are fragmented, allocated inefficiently, difficult to ascertain and often constrained to a specific condition or location. Future efforts should focus on improving the care transition process for high-risk patient populations by taking a comprehensive approach utilizing innovative, and multidisciplinary solutions. Funding Agencies None

The Needs of Patients With Chronic Disease in Transitional Care From Hospital to Home in Sudan: A Qualitative Study.

The growing burden of chronic non-communicable diseases demands improved post-discharge care. The Sudanese healthcare system faces challenges in providing coordinated care for patients with chronic conditions after hospital discharge. This qualitative study explored the experiences of patients with chronic disease in transitional care from hospital to home to identify improvement targets. Purposive sampling was used to interview 17 participants from different hospitals in Khartoum, Sudan. Audio recordings were transcribed and analyzed using principles of content analysis to identify themes and the relationship between them. Thematic analysis revealed 4 main themes describing the perceived needs of the patients. These were (1) feeling well-informed about post-discharge care goals and plans; (2) feeling cared for during hospital admission and follow-up visits; (3) feeling safe during the transitional care process; and (4) having access to follow-up services. This study highlights the importance of improving hospital patient education through effective communication to facilitate care transitions.

Improving transition of care from pediatric to adult endocrinology for adolescents with diabetes

IntroductionAdolescence is a challenging time in a child’s life and can be even more stressful for those with a chronic medical condition such as diabetes mellitus. Adolescents and young adults with type 1 and type 2 diabetes experience worsening glycemic levels as they enter adulthood. Data suggest that a formalized health care transition process and beginning transition preparation in early adolescence leads to better transition outcomes. MethodsThe aim of this study was to create a transition of care program for youth with diabetes in a standalone children’s hospital by following the Got Transition Six Core Elements of Health Care Transition. First, we implemented a transition of care policy and formalized how we discussed transition of care with patients and families in early adolescence. Further improvements have included assessing readiness to transition, designing a curriculum centered around adolescent-specific issues and how they relate to diabetes management, and forming connections with adult endocrinologists in the area to establish a seamless transition process. ResultsAfter implementing our program, 90 % (28/31) of our patients indicated they were very or somewhat ready to transition to adult care. DiscussionWe outline our process for developing a transition of care program and provide a practical tool for other pediatric diabetes providers who are interested in implementing a similar program.

Understanding the role of digital technologies in the transitional care process: a user perspective

The literature defines transitional care as the coordination and continuity of care during the transition from one health care setting to another or to home. Referred to as transition of care, between health care professionals and settings, as their condition and care needs change during the course of a chronic illness, acute illness or acute admission. In this scenario, the transition of care from hospital to home carries a number of risks of adverse events and poor care continuity. Therefore, daily technologies such as wearables and smart devices can support the improvement of interventions as they can collect up-to-date daily data from patients, helping to gain an in depth understanding of the real situation and their healthcare needs, improving the transition care process. 
 The aim of this research, integrated in VITALISE Project (H2020.GA101007990), is to identify and explore the needs, barriers and challenges of transitional care by involving different stakeholders in different participating countries. In Spain 3 patients, 2 carers and 7 health professionals participated in co-creation sessions with a person-centred approach addressing the topic of using ICT tools to gather information/data to support the transitional care process (hospital discharge process and recovery at home) and to collect information on current practices in transitional care processes (from hospital to home).
 Two sessions with patients, carers and with professionals, aimed to understand the different perspectives on each profile, enriching the comments and contributions. Two facilitators with experience guiding accessible co-creation sessions ensured each participant had a space for participation. The sessions were distributed in four blocks: 1) understanding the current practice in transitional care; 2) experience in the use of smart devices and digital tools; 3) understanding the barriers, difficulties and challenges in using digital tools in this process and 4) what the ideal role of technology would be. 
 As a finding, during the patients and carers session participants highlighted that there should be a protocol for the transition process but that it is currently not established and it all depends on how ""fortunate"" you are. They appreciate the advantages given by the health system in their respective country, but they do not agree with the organisational set-up or with some specific actions. Regarding technology, they mostly accept technology in transition processes and believe that it can bring many benefits helping to improve (as long as it is not used to replace human care). On the other hand, professionals use technology in their work on a daily basis and have a very broad view of its impact on people's experiences and its acceptability. Finally, beyond the benefits for the user, professionals take advantage of these technologies to improve individual care and systematise the collection of information. Overall, the inclusion of digital technologies is accepted in integrated and transitional care processes, when adapted to the users and not the other way around. These findings are key for the preparations of the small-scale studies phase “Digital Biomarkers for Supporting Transitional Care Decisions: Protocol for a Transnational Feasibility Study” [JMIR Res Protoc.2022Jan19;11(1):e34573.doi:10.2196/34573].

Towards a better understanding of goal oriented care by means of co-creating an interprofessional training program with experts by experience

The literature defines transitional care as the coordination and continuity of care during the transition from one health care setting to another or to home. Referred to as transition of care, between health care professionals and settings, as their condition and care needs change during the course of a chronic illness, acute illness or acute admission. In this scenario, the transition of care from hospital to home carries a number of risks of adverse events and poor care continuity. Therefore, daily technologies such as wearables and smart devices can support the improvement of interventions as they can collect up-to-date daily data from patients, helping to gain an in depth understanding of the real situation and their healthcare needs, improving the transition care process. 
 The aim of this research, integrated in VITALISE Project (H2020.GA101007990), is to identify and explore the needs, barriers and challenges of transitional care by involving different stakeholders in different participating countries. In Spain 3 patients, 2 carers and 7 health professionals participated in co-creation sessions with a person-centred approach addressing the topic of using ICT tools to gather information/data to support the transitional care process (hospital discharge process and recovery at home) and to collect information on current practices in transitional care processes (from hospital to home).
 Two sessions with patients, carers and with professionals, aimed to understand the different perspectives on each profile, enriching the comments and contributions. Two facilitators with experience guiding accessible co-creation sessions ensured each participant had a space for participation. The sessions were distributed in four blocks: 1) understanding the current practice in transitional care; 2) experience in the use of smart devices and digital tools; 3) understanding the barriers, difficulties and challenges in using digital tools in this process and 4) what the ideal role of technology would be. 
 As a finding, during the patients and carers session participants highlighted that there should be a protocol for the transition process but that it is currently not established and it all depends on how ""fortunate"" you are. They appreciate the advantages given by the health system in their respective country, but they do not agree with the organisational set-up or with some specific actions. Regarding technology, they mostly accept technology in transition processes and believe that it can bring many benefits helping to improve (as long as it is not used to replace human care). On the other hand, professionals use technology in their work on a daily basis and have a very broad view of its impact on people's experiences and its acceptability. Finally, beyond the benefits for the user, professionals take advantage of these technologies to improve individual care and systematise the collection of information. Overall, the inclusion of digital technologies is accepted in integrated and transitional care processes, when adapted to the users and not the other way around. These findings are key for the preparations of the small-scale studies phase “Digital Biomarkers for Supporting Transitional Care Decisions: Protocol for a Transnational Feasibility Study” [JMIR Res Protoc.2022Jan19;11(1):e34573.doi:10.2196/34573].

Understanding and Managing Fragmented Transitions in Care: Learning from and Guided by Patient, Family, Health Care Provider and System-Level Experiences Before, During and Follow-up to COVID-19

One ongoing challenge in health care is ensuring patients/families and also health care providers have clear direction and implementation guidance around transitions in care across all care and community settings that includes integration, continuity and coordination. Clearly understanding patient, family, care provider and system-level experiences including what works and where improvements are needed with care transitions across acute and community settings has been an ongoing challenge for most health care systems before and during COVID-19. However, although efforts to identify and use experience measures were complicated and impacted during COVID-19 because of rapidly enforced restrictions and emergent safety protocols, learning to adapt to change was also essential.
 Our study explored the experiences of patients/clients, families, care providers and system leaders regarding their care transitions between acute and community-based care settings prior to and during COVID-19, along with changes in care outcomes, practices, policies and services became the focus of a two-year pilot study in one Canadian provincial health system. We co-designed relevant acute to community care transition process and outcome/impact experience indicators/measures with patients/clients, families and care providers; and explored the feasibility for transferring measures and lessons learned for practice, policy and service changes as part of follow-up and post COVID new ‘norm’ transformation of care transitions. 
 The study involved the Provincial Seniors and Continuing Care Advisory Council, Continuing Care Quality Committee, Transition Services, primary care and eight pilot care settings involving patients/clients transitioning from acute to community settings. Each care setting involved patient/family advisors co-designing and implementing the initiative with care providers and transition leaders. This included survey development, and gathering, analyzing and interpreting client/patient and care provider experiences. Findings in each and across settings included identifying common core patient/family and care provider experience indicators/measures regarding acute to community care transitions, before and during COVID. System-level factors and experiences were also gathered. Themes for what makes transitions in care successful before, during and follow-up to COVID were also confirmed – e.g. clear communication, navigation and information/direction for all stakeholders. The aggregated findings targeted health outcomes and guided changes in transition practices from across acute points of care as well as Emergency, to various community-based care settings including Home Care, Long-term or other interim programs utilized while patients waited for final transition decisions – e.g. CHOICE programs.
 Essential learnings include having a clear understanding of the experiences of patients/clients, families, care providers and system-level regarding care transitions, and how well integrated, coordinated and continuity-aligned this care is. This includes understanding what works well and where there are gaps in the system. Managing the gaps helps mitigate failed or unsatisfactory patient transitions across care settings. Such findings also guide or inform quality and safety improvement. 
 Identified transition core measures continue to be studied beyond the pilots for transferability across acute, emergency, primary and community care settings. As well, COVID-19 impacts on practice, policy and service changes involving coordinated and integrated transitions need to be monitored for how well care settings adapt to “new norms” and meet patient/client needs. This work continues.

Implementing a Structured Health Care Transition (HCT) Process for Sickle Cell Disease Using Quality Improvement: Results from the Sickle Cell Trevor Thompson Transition Project HCT Learning Collaborative

Ensuring consistent healthcare during transition is challenging for sickle cell disease (SCD). Emerging adults with SCD (EASCD) experience triple the mortality rates and double the acute care utilization rates compared to younger and older ages. The transition period is also plagued by reduced quality of life (QOL) with increased missed school days per year and worse standardized test scores. The Sickle Cell Trevor Thompson Transition (ST3P-UP) study aimed to improve acute care utilization and QOL for EASCD by standardizing the transition process while engaging the community as an equal partner. A prior regional stakeholder needs assessment identified care standardization, establishing individual emergency care plans (ECPs), and community engagement as critical success factors for improved access to and engagement in care during transition. The ST3P-UP SCD health hare transition (HCT) learning collaborative engaged 14 pediatric and adult paired sites that included a partner community-based organization (CBO) using the concept of a site “Triad” as the critical framework of each sites transition team. The collaborative aim statement established at a kickoff meeting was “ to improve the health of EASCD by implementing an education-based transition program in pediatric and adult SCD clinics to be accomplished by 24 months, using the Model for Improvement and the Got Transition Six Core Elements of Transition (6CE) model. ” Using the 6CE framework established by Got Transition® and the Model for Improvement QI methodology, we established a SCD HCT Process Measurement Tool (PMT) and 2 outcome measures for the transition learning collaborative namely: transition readiness assessment (RA), and an individualized emergency care plan (ECP). Monthly virtual meetings provided coaching on HCT recommendations, use of Plan-Do-Study-Act cycles, and practical guidance on implementing the 6CE. Sites were given a change package that included provider and patient education materials, resources to establish and strengthen a QI team, transition billing and coding resources etc.) to improve their transition processes. Implementation of 6CE was measured across 14 clinical sites, each comprised of both pediatric and adult clinics, who cared for 1625 EASCD aged 16-25. Clinical programs varied: 12 urban, 2 rural; 12 academic, 2 non-academic; 6 small, 8 large. The HCT-PMT assessed 6CE implementation adherence using iterative QI strategies at baseline (2018) and every six months thereafter for 54mo (2022). Pre-post results were compared for the overall group and by practice size. All 14 sites made substantial progress towards implementing a structured HCT process within 24 months. Overall HCT-PMT scores improved by 402% by the end of the 54mo collaborative (19.4 ± 14.1 to 97.4 ± 5.2). PMT scores improved significantly by 312% (24 to 99) for pediatrics and 539% (15 to 96 for adult sites. Pediatric PMT scores were higher at each assessment interval vs. adult scores, however adult sites achieved a higher degree of improvement. Smaller sites achieved a higher degree of improvement vs. large sites. Large site PMT scores improved 362% (21 to 97); small site PMT scores improved 444% (18 to 98). Additionally, sites demonstrated substantial improvements with having current ECPs for EASCD annually (completed and reviewed within the past year). At baseline, only 20% of pediatric and 3% of adult EASCD had a current ECP; only 38% of pediatric and 20% of adult EASCD had a current RA. Run charts demonstrated significant improvement with implementing the ECP measure. Pediatric sites had significant and sustained improvement in adherence to the ECP measure for >6mo. Adult sites started with a lower baseline score. Although they met their goal of showing process capability, they have not yet demonstrated sustained improvement. By Dec. 2022, site adherence with current ECP improved to 84% and 70% for pediatric and adult sites respectively. Adherence with current RA also improved to 76% and 70% for pediatric and adult sites respectively. All 14 sites showed significant improvement with implementing a structured HCT process aligned with the 6CE using QI confirming its feasibility in establishing a standardized and measurable transition process that can be applied to various chronic conditions.

Care transition processes in the Singapore healthcare system: process mapping and perspectives of private primary care practitioners.

Care transition processes in the Singapore healthcare system: process mapping and perspectives of private primary care practitioners.

Urgent Communication and Interdepartmental Collaboration Across the Continuum of Care: An Ischemic Limb Patient Case

Through an urgent patient case of acute limb ischemia and intervention, care transitions are examined. The importance of safe, consistent transitions of care has become even more apparent after the COVID-19 pandemic when face-to-face communication was inhibited in many areas. The impact of urgent patient needs coupled with a high number of inexperienced staff enhances the need for appraisal of current handoff communication practices in all patient care areas. The reality is this; many of the most serious medical errors are linked to miscommunication. This ischemic limb patient case highlights inconsistencies in patient care transition processes and the associated risks that need to be addressed to improve patient care.

1041-P: Health Care Transition Practices in the T1D Exchange Quality Improvement Collaborative

Background: Implementation of a structured health care transition (HCT) process is associated with positive outcomes in population health, experience of care, and health care utilization. Objective: To describe pediatric and adult clinic HCT practices in the T1D Exchange Quality Improvement Collaborative (T1DX-QI). Methods: Got Transition’s Six Core Elements of HCT offer a structured approach to the phases of transition support: 1) transition and care policy, 2) tracking and monitoring, 3) transition readiness, 4) transition planning, 5) transfer of care, and 6) transfer completion. T1DX-QI institutions (n=53) were surveyed to examine the integration of the Six Core Elements into diabetes HCT practices. Results: The survey response rate was 94.3% (n=50 clinics; 33 pediatric, 17 adult). A majority of T1DX-QI pediatric clinics (72.7%, n=24) report having a HCT policy compared to 29.4% (n=5) of adult clinics. Among pediatric institutions, 45.4% (n=15) maintain a tracking system to identify transition-aged youth, 39.4% (n=13) formally assess HCT readiness, 52% (n=17) document and update a plan of care for transition and 27.3% (n=9) have a process in place to confirm successful transfer of care completion with adult diabetes providers. Approximately two-thirds of T1DX-QI pediatric institutions (63.6%, n=21) have a formal structured HCT program and 29% (n=6) of these HCT programs report incorporating all 6 elements. Conclusions: Data from T1DX-QI centers highlight opportunities to further enhance transition preparation and receivership for emerging adults with type 1 diabetes. The Six Core Elements offer a potential avenue to structure improvement initiatives since many diabetes clinics only partially incorporate these elements in current practice. Partnerships between pediatric and adult diabetes centers should be considered as part of quality improvement efforts to facilitate incorporation of challenging HCT elements such as transfer of care completion. Disclosure F.Malik: None. G.T.Alonso: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. S.Corathers: None. T1dx-qi collaborative: n/a. J.Cases-villablanca: None. M.E.Hilliard: None. S.Lyons: None. L.M.Jacobsen: None. A.J.Roberts: None. A.Mucci: None. S.Agarwal: Advisory Panel; Medtronic, Consultant; Beta Bionics, Inc., Research Support; Abbott Diabetes, Dexcom, Inc. C.Demeterco-berggren: Speaker's Bureau; Glooko, Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Facilitating and Preventing Factors of Tracheostomy Patient Care by Home Caregivers: A Qualitative Study

Background: The unstable condition of tracheostomy patients and the lack of support resources for patients and their families during discharge is the biggest challenge, especially for their home and non-professional caregivers. The present study aimed to identify the factors affecting the care of tracheostomy patients provided by home caregivers. Materials and Methods: This qualitative research was conducted from September 2018 to December 2019 using the content analysis method and interviews with nine home caregivers and one professional caregiver in Lorestan Province, Iran. The required data were collected by holding in-depth semi-structured interviews and continued until reaching data saturation. Simultaneously, the gathered data were analyzed using the 5-step approach of Graneheim and Lundman (2004). Results: The results led to the extraction of 2 themes of preventing and facilitating care factors, 7 categories, and 21 subcategories. The categories related to the theme (preventing factors) of patient care challenges included neglecting the caring role of informal caregivers by the healthcare system, interaction challenges, the high pressure of caregiving, and lack of trust. The categories related to the facilitating factors theme were the experience of the care facilitating over time, the intensification of care with the aim of prevention, and hope and inner satisfaction underlying the care. Conclusion: The challenges of the family's lack of readiness to accept the new role, the exhausting nature of caregiving, and the caregivers’ lack of skills, and as a result, the imposition of a burden of caregiving, and the emergence of harmful consequences for them in various dimensions, the existence of non-governmental organizations that aim to continue to care for these patients and support their families seems necessary. With support systems and gaining experience over time, the care transition process is facilitated.