Care Transition Process Research Articles

Digital Biomarkers for Supporting Transitional Care Decisions: Protocol for a Transnational Feasibility Study.

BackgroundVirtual Health and Wellbeing Living Lab Infrastructure is a Horizon 2020 project that aims to harmonize Living Lab procedures and facilitate access to European health and well-being research infrastructures. In this context, this study presents a joint research activity that will be conducted within Virtual Health and Wellbeing Living Lab Infrastructure in the transitional care domain to test and validate the harmonized Living Lab procedures and infrastructures. The collection of data from various sources (information and communications technology and clinical and patient-reported outcome measures) demonstrated the capacity to assess risk and support decisions during care transitions, but there is no harmonized way of combining this information.ObjectiveThis study primarily aims to evaluate the feasibility and benefit of collecting multichannel data across Living Labs on the topic of transitional care and to harmonize data processes and collection. In addition, the authors aim to investigate the collection and use of digital biomarkers and explore initial patterns in the data that demonstrate the potential to predict transition outcomes, such as readmissions and adverse events.MethodsThe current research protocol presents a multicenter, prospective, observational cohort study that will consist of three phases, running consecutively in multiple sites: a cocreation phase, a testing and simulation phase, and a transnational pilot phase. The cocreation phase aims to build a common understanding among different sites, investigate the differences in hospitalization discharge management among countries, and the willingness of different stakeholders to use technological solutions in the transitional care process. The testing and simulation phase aims to explore ways of integrating observation of a patient’s clinical condition, patient involvement, and discharge education in transitional care. The objective of the simulation phase is to evaluate the feasibility and the barriers faced by health care professionals in assessing transition readiness.ResultsThe cocreation phase will be completed by April 2022. The testing and simulation phase will begin in September 2022 and will partially overlap with the deployment of the transnational pilot phase that will start in the same month. The data collection of the transnational pilots will be finalized by the end of June 2023. Data processing is expected to be completed by March 2024. The results will consist of guidelines and implementation pathways for large-scale studies and an analysis for identifying initial patterns in the acquired data.ConclusionsThe knowledge acquired through this research will lead to harmonized procedures and data collection for Living Labs that support transitions in care.International Registered Report Identifier (IRRID)PRR1-10.2196/34573

Investigation of the Quality of Recovery of Surgical Patients Based on the Chinese Version of the Quality of Recovery-15 Survey, a Cross-Sectional Study

PurposeThe quality of recovery (QoR) is an important indicator of a patient's health status in the early postoperative period. Despite its importance, the QoR from the patient's perspective is often neglected in clinical practice. This study was performed to survey and determine the QoR of surgical patients from their own subjective perspective and to provide a reference for the targeted postoperative care of surgical patients in the future. DesignA descriptive and cross-sectional study. MethodsThe Chinese version of the Quality of Recovery-15 (QoR-15) scale was used to survey the QoR of 503 surgical patients in 20 surgical wards from 17 surgical departments of a large tertiary hospital in Sichuan Province, China. A questionnaire survey was administered to each patient before and after the operation, and the scores were compared. FindingsThere were no significant differences in "feeling worried or anxious" and "feeling sad or depressed" between the preoperative and postoperative periods (P > 0.05). The postoperative scores for the other items were significantly lower than the preoperative scores. The total postoperative QoR-15 score was significantly lower than the total preoperative score (P < 0.001). ConclusionsThe QoR-15 scores of surgical patients were lower after the surgery than before, and patients still needed care after discharge. Therefore, due to the gradual shortening of the length of stay (LOS) of surgical patients, it is necessary for hospitals to construct a complete surgical patient transitional care process to meet the needs of patients after discharge and promote patient rehabilitation.

Using natural language processing to understand, facilitate and maintain continuity in patient experience across transitions of care

BackgroundPatient centred care necessitates that healthcare experiences and perceived outcomes be considered across all transitions of care. Information encoded within free-text patient experience comments relating to transitions of care are not captured in a systematic way due to the manual resource required. We demonstrate the use of natural language processing (NLP) to extract meaningful information from the Friends and Family Test (FFT). MethodsFree-text fields identifying favourable service (“What did we do well?”) and areas requiring improvement (“What could we do better?”) were extracted from 69,285 FFT reports across four care settings at a secondary care National Health Service (NHS) hospital. Sentiment and patient experience themes were coded by three independent coders to produce a training dataset. The textual data was standardised with a series of pre-processing techniques and the performance of six machine learning (ML) models was obtained. The best performing ML model was applied to predict the themes and sentiment from the remaining reports. Comments relating to transitions of care were extracted, categorised by sentiment, and care setting to identify the most frequent words/combinations presented as tri-grams and word clouds. ResultsThe support vector machine (SVM) ML model produced the highest accuracy in predicting themes and sentiment. The most frequent single words relating to transition and continuity with a negative sentiment were “discharge” in inpatients and Accident and Emergency, “appointment” in outpatients, and “home’ in maternity. Tri-grams identified from the negative sentiments such as ‘seeing different doctor’, ‘information aftercare lacking’, ‘improve discharge process’ and ‘timing discharge letter’ have highlighted some of the problems with care transitions. None of this information was available from the quantitative data. ConclusionsNLP can be used to identify themes and sentiment from patient experience survey comments relating to transitions of care in all four healthcare settings. With the help of a quality improvement framework, findings from our analysis may be used to guide patient-centred interventions to improve transitional care processes.

The Roles of Pharmacists in Cardiac Care units in Hospitals

Inpatients managed in cardiology units have shown high risks of encouraging drug-related adverse reactions. This is coupled with the influx of diuretics and cardioprotective drug mechanism. The support played by a clinical pharmacist in this context remains largely underscored cored. They play an essential role in supporting the overall pharmacological care for patients through clinical conditions evaluations and assessments. Further, it has been established that poor adherence to drug regimens is among the key exacerbating factors for heart failure occurrence. The need for conducting patient education process is essential in drug adherence process. This elevates the roles of clinical pharmacist in the care delivery through drug use optimization process, minimization of occurrence of adverse drug events and activities in the transitional care process with a key focus on medical reconciliation approaches in the care practice. This study has focused on systematic reviews, Meta-analysis and randomized controlled studies focusing on the pharmacist intervention in improving outcomes of cardiology patients in the hospital care settings. The results have demonstrated that their role can no longer be underestimated and play an important role in the care delivery process and reducing the overall drug-related complications in the care process.

Lessons Learned from the Pathways to Community Health Study to Evaluate the Transition of Care from Jail to Community for Men with HIV.

Time spent in jail can provide opportunities to deliver comprehensive medical care, including screening and treatment for HIV; however, engagement in HIV care postrelease is often fragmented. Identifying ways to improve the transition of care from jail to community for people with HIV (PWH) may help with engagement in HIV care postrelease. We evaluated the current HIV care transition processes of one jail in Massachusetts and identified change ideas to facilitate improving the transition of care from the jail to the community for PWH. We conducted qualitative interviews in 2018–2019 with incarcerated men with HIV (n = 17), jail staff (n = 7), and community providers (n = 6) to understand the processes of HIV care prerelease from the jail and engagement in care on release. Data from these interviews and quality improvement tools were used to identify ways to improve the release process for PWH, such as using a release planning checklist, to help ensure that a 30-day supply of HIV medication and an appointment with a community provider within 30 days of release were provided. We identified communication process inefficiencies related to knowing release dates between the HIV care team and case managers that prevented providing HIV medications on release. We worked with jail administrators to find ways to improve the prerelease planning process, which is vital to the continuity of successful HIV care. The use of quality improvement methods generated a list of testable change ideas to improve the release planning process to better align with the Centers for Disease Control and Prevention guidelines, which has implications for PWH and public health.

Closing the Compliance Loop on Follow-Up Imaging Recommendations: Comparing Radiologists’ and Administrators’ Attitudes

PurposeTo compare non-physician healthcare professional and radiologists' survey responses regarding attitudes and current practices, policies, and procedures related to the follow-up of nonemergent actionable incidental findings (AIF). Materials and MethodsThe American College of Radiology (ACR) developed a survey with input from a technical expert panel (TEP). Survey items were developed by TEP members, refined by an ACR market research expert, and were examined for face and construct validity. The survey was distributed among ACR membership and various medical professional organizations. Responses from non-physician responders and radiologists were analyzed and compared using descriptive statistics. ResultsThe analysis included 375 responses, 247 from radiologists and 128 from non-physicians. All respondent groups stated that radiology follow-up recommendations are evidence-based. Both respondent groups indicated that there is up to moderate risk associated with AIF follow-up. Both respondent groups similarly favored that the accountability for communicating AIF lies first with the ordering provider, followed by primary care providers, then the patient, and lastly an automated process that is managed by a staff member and/or the radiologist. All respondent groups indicated that tracking processes were more commonly funded by the healthcare system than through the radiology budget. ConclusionThere is alignment between non-physicians and radiologists regarding the implementation of tracking systems that assure completion of radiology follow-up recommendations. Building tracking systems represents an opportunity for multi-disciplinary collaboration to address care transition communication and process gaps.

Improving Team Collaboration in Patient Transfer Processes by Co-Workers’ Perceptions and Suggestions

Purpose: The purpose was twofold: first to describe how co-workers within a team perceived team collaboration in patient transfers from an intensive care unit (ICU) to general wards and, second, to describe co-workers’ suggestions for an improved future state of team collaboration. Methodology/Approach: Focus group discussions (FGDs) were conducted at two medium-sized hospitals located in Sweden. Participants were multidisciplinary and from both ICUs and general wards. Data were analysed using qualitative deductive content analysis. Findings: An expressed need for improving team collaboration was a defined and well-designed ICU transitional care process with a holistic view of how to create quality of care, and a standardised process for continuous improvements. This should involve co-workers from different professions and hospital units, as well as patients and relatives. Other views raised by the co-workers were clearer definitions of roles, responsibilities and deeper insights on how team members depend on each other’s work efforts to succeed. Research Limitation/Implication: This study was conducted at two hospitals, hence no generalizable conclusions can be made. Originality/Value of paper: Co-workers collaborating in a ICU transitional care process can have important insights in how to improve team collaboration. This can be of great importance in increasing quality of care where multiprofessional teams from different organisational cultures are collaborating.

Transition of Care Model for Pediatric Patients With Nonalcoholic Fatty Liver Disease.

Transition of Care Model for Pediatric Patients With Nonalcoholic Fatty Liver Disease.

Provider Perspectives of Necessary Factors in Sickle Cell Disease Health Care Transition: Results from an Online Survey

Introduction: Survivorship of children with sickle cell disease (SCD) has substantially increased due to the advent of medical advances, such as sepsis prevention (prophylactic penicillin) and exposure to disease-modifying therapies (chronic transfusion and hydroxyurea). Despite greater longevity in SCD, the period surrounding the transition from pediatric to adult care has the highest prevalence of undesirable outcomes: youth aged 18-30 years are at high risk for mortality and high rates of healthcare utilization, resulting in increased healthcare costs. As such, health care transition programs have been created to prepare patients with SCD for adult-centered care and subsequently, improve health outcomes. However, few programs have been evaluated for effectiveness in achieving optimal health outcomes in SCD in part because of a lack of identifiable predictors and outcomes.Objective: To identify factors necessary for successful health care transition, as judged by pediatric and adult healthcare professionals involved with the SCD population.Method: Individuals who provide clinical care for or conduct clinical research with patients with SCD were eligible to participate in the survey and were collectively defined as providers. Providers were recruited online through nationally recognized professional societies, SCD provider contact lists and in person at a national SCD conference. Links to an online survey, administered via Qualtrics software, were distributed to potential participants. The survey included demographic questions and a list of 36 transition factors, including disease knowledge, self-management behaviors, and independent living skills. Participants were asked to rate the level of importance of each factor in helping a patient with SCD successfully transition from pediatric to adult care on a scale from 1 (not important) to 10 (very important). They were then asked to select five of the 36 factors they believed were most necessary for a successful transition, ranking them from 1 (highest) to 5 (lowest). Descriptive statistics were conducted to determine the top ratings and rankings. A two-way MANOVA was conducted to examine whether the top ratings were different according to provider gender and occupation.Results: The sample included 258 providers (74% female, 65% White). The majority were hematologists (41%); 38% were other medical staff (e.g., nurse, midlevel providers, other physicians) and 21% were non-medical staff (e.g., psychologist, social worker, researchers). The transition factor ratings (scale 1 to 10) ranged from 5.82-9.62 (M=8.05, SD=1.74). The factors with the highest ratings included: Knows how to take medications (M=9.62, SD=0.82), Explains/communicates medical needs to medical personnel (M=9.50, SD=0.93), Knows when to seek medical assistance if home management fails (M=9.32, SD=1.12), and Knows how to manage pain episodes (M=9.31, SD=1.18). These same four factors also were ranked as the top five most relevant factors: Knows how to manage pain episodes (N=138, 53%, M=2.59, SD=1.30), Explains/communicates medical needs to medical personnel (N=115, 45%, M=2.54, SD=1.38), Knows how to take medications (N=135, 52%, M=2.67, SD=1.31), Knows when to seek medical assistance if home management fails (N=102, 40%, M=2.97, SD=1.46). Knows medical history (N=100, 39%, M=2.57, SD=1.35) was the fifth most relevant factor. Multivariate results indicated a trend toward hematologists giving lower ratings compared to other medical and non-medical professionals, F (8, 486) = 1.91, p = .057.Conclusions: Our findings reveal the importance of attainment of disease knowledge and self-management skills for optimal transition from pediatric to adult care. Interventions and programming designed to prepare adolescents for transition should target these areas. Furthermore, disease knowledge and self-management skills may be meaningful predictors when evaluating transition outcomes and the effectiveness of transition programs during and after the health care transition process. Our data also indicated differences in provider ratings by profession, demonstrating the value of incorporating a variety of perspectives in assessing transitioning needs. Such efforts are essential to improve health outcomes and quality of care for patients with SCD transitioning to adult care. DisclosuresPorter:NHLBI: Research Funding.

Disparate perspectives: Exploring healthcare professionals' misaligned mental models of older adults’ transitions of care between the emergency department and skilled nursing facility

Care transitions that occur across healthcare system boundaries represent a unique challenge for maintaining high quality care and patient safety, as these systems are typically not aligned to perform the care transition process. We explored healthcare professionals' mental models of older adults’ transitions between the emergency department (ED) and skilled nursing facility (SNF). We conducted a thematic analysis of interviews with ED and SNF healthcare professionals and identified three themes: 1) ED and SNF healthcare professionals had misaligned mental models regarding communication processes and tools used during care transitions, 2) ED and SNF healthcare professionals had misaligned mental models regarding healthcare system capability, and 3) Misalignments led to individual and organizational consequences. Overall, we found that SNF and ED healthcare professionals are part of the same process but have different perceptions of the process. Future work must take steps to redesign and realign these distinct work systems such that those involved conceptualize themselves as part of a joint process.

852-P: Improving the Quality of Health Care Transitions for Young Adults at an Adult Endocrinology Clinic

Background: Young adults, transitioning from pediatric to adult endocrinology clinics, are at risk for adverse events. As these patients assume responsibility for their care, ensuring an effective process for health care transition (HCT) and integration into an adult clinic is imperative. Yet, there is a scarcity of data on implementing HCT best practice guidelines into adult endocrinology care using QI methodology. Objective: To improve the quality of HCTs for young adult patients (18-26 years of age) diagnosed with a variety of endocrinologic conditions by implementing Got Transition’s Six Core Elements of Health Care Transition 2.0 and utilizing the Integrating Young Adults into Adult Health Care toolkit. Methods: A team of pediatric and adult endocrinology clinicians, QI experts, and patient and family advisors (PFAs) was established to guide implementation of the Six Core Elements. Got Transition measurement tools (Current Assessment of Health Care Transition Activities-CAHCTA; Health Care Transition Process Measurement Tool-HCTPMT) were used to establish baseline scores and track progress on a quarterly basis. The team developed a “Welcome Packet” to orient and integrate young adults into adult endocrinology care. QI tools were used to identify current clinical processes and opportunities for system changes through Plan-Do-Study-Act (PDSA) cycles. Results: From October 2019 to July 2020, baseline scores improved on both the CAHCTA by 84.6% (Baseline: 13; Q1: 15; Q2: 23; Q3: 24) and the HCTPMT by 1,250.0% (Baseline: 2; Q1: 16; Q2: 25; Q3: 27). PFAs provided feedback about the Welcome Packet. PDSA Cycle 1 included a “pre-visit” during new patient visits to orient patients to adult endocrinology care using the Welcome Packet. PDSA Cycle 2 focused on piloting the Endocrine Society Patient Self-assessment. Conclusion: The implementation of HCT best practice guidelines using rigorous QI methodology can significantly improve young adults’ integration into adult health care. Disclosure M. P. Gilbert: Consultant; Self; Novo Nordisk. S. G. DeVoe: None. A. G. Kennedy: None. M. Ogelby: None. A. Consigli: None. P. Zimakas: None. A. B. Repp: None. K. J. Robinson: None.

Pulmonary arterial hypertension in the emergency department: A focus on medication management.

Pulmonary arterial hypertension (PAH) is a chronic progressive incurable condition associated with a high degree of morbidity and mortality. With over five drug classes FDA approved in the last decade, the significant advancements in the pharmacologic management of PAH has improved long-term outcomes. Drug therapies have been developed to directly target the underlying pathogenesis of PAH including phosphodiesterase type-5 inhibitors (PDE-5i), endothelin-receptor antagonists (ERAs), guanylyl-cyclase inhibitors, prostacyclin analogues, and prostacyclin receptor agonists. Although these agents offer remarkable benefits, there are significant challenges with their use such as complexities in medication dosing, administration, and adverse effects. Given these consequences, PAH medications are classified as high-risk, and the transitions of care process to and from the hospital setting are a vulnerable area for medication errors in this population. Thus, it is crucial for the emergency department provider to appropriately identify, manage, and triage these patients through close collaboration with a multidisciplinary team to ensure safe and effective medication management for PAH patients in the acute care setting.

Transitions: Supporting youth and young adult health and wellness

Adolescence is an important period to begin the process of transition into the adult health care system for youth with and without special health care needs. This health care transition process — moving a child to an adult health care delivery model — aims at ensuring continuity of care and positive health outcomes for young adults. It does not have to involve changing to a new provider, although sometimes that is necessary. However, for most adolescents in the United States, this process is fraught with difficulty and does not always take place in a manner that supports good health.

Evidence based processes to prevent readmissions: more is better, a ten-site observational study

Background30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR).MethodsDesign: Mixed method, multi-stepped observational study. Data collection occurred 2014–2018 with data analyses completed in 2021. Setting: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. Participants: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. Exposure: Frequency of use of twenty recommended care transition processes, scored 0–3. Sites’ individual process scores and cumulative total scores were tested for correlation with RSRR. Outcome: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits.ResultsTotal scores: Mean 38.3 (range 24–47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007).ConclusionsSites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

The development of a measurement instrument focusing on team collaboration in patient transfer processes

Purpose Team collaboration is essential to ensure the quality of care and patient safety when critically ill patients are transferred from an intensive care unit (ICU) to a general ward. Measuring team collaboration in the patient transfer process can help gain insights into how team collaboration is perceived and how it can be improved. The purpose of this paper is to describe the development and testing of a questionnaire aiming to measure perceived team collaboration in the patient transfer process from ICU to the general ward. This study also aims to analyze the results to see how the survey could help improve team collaboration within ICU transitional care. Design/methodology/approach Statements, factors and main areas intended to measure perceived team collaboration were developed from a theory. The questionnaire was tested in two ICUs at two hospitals located in Sweden, and the results were analyzed statistically. Findings The results showed that the questionnaire could be used for measuring perceived team collaboration in this process. The results from the survey gave insights that can be useful when improving team collaboration in ICU transitional care. Research limitations/implications The collaboration between two research subjects, Nursing Science and Quality Management, has given new perspectives in how cultural and systemic differences and opportunities can help improving team collaboration in ICU transitional care, by shifting focus from the individual to team, culture, system, process and continuous improvement. Practical implications The developed questionnaire can be used to measure perceived team collaboration and to identify areas for improving team collaboration in the ICU transitional care process. Originality/value There is a sparse amount of research about measuring team collaboration in ICU transitional care, and this study contributes to filling this research gap.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives.

Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions. We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions. Semi-structured interviews with interdisciplinary hospital and SNF providers. Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6). Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs. Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge. As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

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

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

The Impact of a Standardized Discharge Process on 30-Day Readmissions for Patients on Outpatient Parenteral Antibiotic Treatment.

Introduction: Outpatient parenteral antibiotic treatment (OPAT) is associated with shorter length of hospital stay and reduced cost. Yet, patients discharged home on OPAT are at risk of hospital readmissions due to adverse events and complications. Although the impact of a multidisciplinary approach to readmission has been assessed by previous studies, addition of an innovative technology has not been evaluated for OPAT. This study examines the impact of a multidisciplinary approach including automated voice calls on 30-day readmissions of OPAT patients. Methods: A post-discharge transitional care process (PDTCP) targeting OPAT patients was implemented in fall 2016. This process included an automated telephone patient engagement service and coordination among pharmacy, nursing, medicine, and social work personnel. The patients on OPAT received automated telephone calls at 2, 9, 16, 28, and 40 days post-discharge to ensure medication availability and adherence and to circumvent issues that would otherwise result in an emergency room visit or readmission to the hospital. Results: A total 429 voice calls were made to 148 patients from November 8, 2016 to February 28, 2019. Overall, 61% (n = 90/148) of the patients were successfully reached by the automated voice system. The patients who were reached by the automated voice system were less likely to be readmitted than those not reached (18.9% vs 41.4%; relative risk (RR) 0.46, 95% CI 0.27-0.77, P = .003). Conclusion: Our study demonstrated that a multidisciplinary approach involving the use of automated telephone calls was associated with decreased hospital readmissions.

What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

Evaluating a Standardized Transition of Care Process for Pediatric Inflammatory Bowel Disease Patients.

To reduce lapses in care for pediatric inflammatory bowel disease (IBD) patients approaching adulthood, a health maintenance transition visit (HMV) was developed to supplement standard medical care (SMV). Our aim was to assess the effect of the HMV on transition readiness. A retrospective chart review was conducted at a single center with demographics and clinical data from HMV and SMV visits. Effectiveness of the HMV was assessed by the patient health questionanaire-9 (PHQ-9) and transition readiness assessment questionnaire (TRAQ) scores. A total of 140 patients, 80% Caucasian and 59% male completed an HMV. The mean age was 18 ± 2 years old, and 93% of patients reported inactive or mild disease. Patients who completed at least 1 prior HMV scored significantly higher on the TRAQ when transferring to adult care compared to patients transferred at their first HMV visit (92 vs. 83, p < 0.05). Of patients with no prior depression diagnosis, 36% had a positive screen for depression. A significant relationship was identified between disease status and PHQ-9 (p < 0.05). This study demonstrated a structured HMV increased transition readiness and quantified the significant under-diagnosis of depression in this population, emphasizing the importance of screening. These results indicate depression may affect patients’ transition preparedness.