Transitional Care Program Research Articles

Emergency Department Care Transition Programs—Value-Based Care Interventions That Need System-Level Support

Emergency Department Care Transition Programs—Value-Based Care Interventions That Need System-Level Support

Time trends in cancer and dementia related hospital admissions among Medicare fee-for-service population, 2013–2018

Cancer and dementia are two complicated morbidities that are commonly found in older adults and require substantial healthcare resources.[ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar ] Caring for patients with the co-presence of cancer and dementia, who suffer from impaired cognitive function with complex medical needs, is challenging for clinicians, caregivers, and healthcare systems. With the aging US population, the increasing number of older adults with these two comorbid conditions is likely to place a high demand on hospitals. Meanwhile, the shift of care delivery from inpatient to settings such as outpatient and homes, increasing reliance on family caregivers, and improved community care support may help reduce unnecessary hospitalizations.[ 3 2021 Alzheimer's disease facts and figures Alzheimers Dement. 2021; 17: 327-406 Crossref PubMed Scopus (739) Google Scholar , 4 Federman A.D. et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018; 178: 1033-1040 Crossref PubMed Scopus (88) Google Scholar , 5 Handley N.R. Bekelman J.E. The oncology hospital at home. J Clin Oncol. 2019; 37: 448-452 Crossref PubMed Scopus (23) Google Scholar ] It is important to understand the pattern of hospitalization, which is one of the major drivers of healthcare costs and high financial and caregiving burden for patients and their families, among the growing population with cancer and dementia. While there has been extensive research on the incidence, prevalence, and healthcare utilization among older adults with either cancer or dementia, existing literature examining older adults with both conditions is scarce and limited in scope. [ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar , [6] Kedia S.K. et al. Health care utilization among elderly medicare beneficiaries with coexisting dementia and cancer. Gerontol Geriatr Med. 2017; 3 (p. 2333721416689042) Crossref PubMed Google Scholar , [7] Liu B. et al. Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017. Healthc (Amst). 2021; 9100565 Google Scholar ] In particular, no national estimates exist regarding the hospitalization rates among older adults with comorbid cancer and dementia. To fill this gap, we examined the national and state-level trends in hospitalization rates among Medicare fee-for-service (FFS) beneficiaries with the co-presence of a major cancer (breast, prostate, lung, and colorectal) and dementia diagnoses. We hypothesized a growing trend of inpatient use among this population during the years 2013–2018. Due to the heterogeneity in cancer-specific prognosis and treatment, we also examined the trend of hospitalizations among this population by cancer types.

Transitions of care at an ambulatory care clinic: An implementation science approach.

Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients' reported needs. The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service. The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service. Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n=22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy). Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

Evaluating a transitional care programme for the average and the oldest old: a presentation of results from the quantitative phase of a mixed methods study

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

The Impact of Critical Care Transition Programs (CCTPs) on Relocation Stress in Patients and Patient Families in the Intensive Care Unit

The intensive care unit (ICU) is designed to care for patients with high disease severity who require critical care and close monitoring. Patients in the ICU may be transferred to the general ward for further treatment following recovery from the acute phase. Transferring from the ICU to the general ward after acute phase recovery is a stressful event that may stress both the patient and their family, potentially resulting in relocation stress syndrome (RSS). RSS has been found to be closely related to unplanned ICU readmissions, prolonged hospitalization, and adverse events, affecting recovery to health and family peace of mind. Furthermore, RSS may result in ineffective disease coping, feelings of uncertainty, and poor treatment response, leading to prolonged hospitalization, reduced trust in medical staff, and decreased happiness and quality of life. In recent years, the nursing profession has attached increasing importance to holistic health care. This has encouraged critical care teams to map out customized relocation plans for patients who are about to be transferred from the ICU that use standardized evaluation tools for transfers and elicit the situation and needs from patients or their family. Through the setting of care goals, shared decision making, and cross-unit support, enhanced communications among the medical team facilitate transition preparation and improve the quality and effect of intensive care.

Implementation of a pharmacist-led transitional pharmaceutical care programme: Process evaluation of Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH).

What is known and objectiveThe recently conducted Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH) transitional care programme, which aimed to test the effectiveness of a transitional care programme on the occurrence of ADEs post‐discharge, did not show a significant effect. To clarify whether this non‐significant effect was due to poor implementation or due to ineffectiveness of the intervention as such, a process evaluation was conducted. The aim of the study was to gain more insight into the implementation fidelity of MARCH.MethodsA mixed methods design and the modified Conceptual Framework for Implementation Fidelity was used. For evaluation, the implementation fidelity and moderating factors of four key MARCH intervention components (teach‐back, the pharmaceutical discharge letter, the post‐discharge home‐visit and the transitional medication review) were assessed. Quantitative data were collected during and after the intervention. Qualitative data were collected using semi‐structured interviews with MARCH healthcare professionals (community pharmacists, clinical pharmacists, pharmacy assistants and pharmaceutical consultants) and analysed using thematic analysis.Results and DiscussionNot all key intervention components were implemented as intended. Teach‐back was not always performed. Moreover, 63% of the pharmaceutical discharge letters, 35% of the post‐discharge home‐visits and 44% of the transitional medication reviews were not conducted within their planned time frames. Training sessions, structured manuals and protocols with detailed descriptions facilitated implementation. Intervention complexity, time constraints and the multidisciplinary coordination were identified as barriers for the implementation.What is new and ConclusionOverall, the implementation fidelity was considered to be moderate. Not all key intervention components were carried out as planned. Therefore, the non‐significant results of the MARCH programme on ADEs may at least partly be explained by poor implementation of the programme. To successfully implement transitional care programmes, healthcare professionals require full integration of these programmes in the standard work‐flow including IT improvements as well as compensation for the time investment.

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 bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD). A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls. A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P=0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05-0.66], P=0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P=0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P=0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P=0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P=0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P=0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of -8.7% (CI: -15.9%, -1.4%). This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.

Effects of a transitional home-based care program for stroke survivors in Harbin, China: a randomized controlled trial.

China has the biggest stroke burden in the world. Continued measures have been taken to enhance post-stroke rehabilitation management in the last two decades. The weak link is with home-based rehabilitation, with more attention and resources devoted to inpatient rehabilitation. to address the service gap, this study tested a home-based transitional care model for stroke survivors. a randomized controlled trial was conducted from February 2019 to May 2020 in Harbin, China, involving 116 patients with ischemic stroke. The intervention group participants (n = 58, 50%) received a 12-week home-based care program with components of transitional care measures and the national guidelines for facilitating patients to perform home-based exercises with continued monitoring and gradual progression. Control group participants received standard care including medication advice, rehabilitation exercise and one nurse-initiated follow-up call. Data were collected at baseline and after a 90-day (post-intervention) and a 180-day (post-intervention) follow-up. The primary outcome was quality of life (QOL), measured using the EuroQol-Five Dimension 5-Level scale (EQ-5D-5L). both intervention and control groups showed improvement in EQ-5D-5L from baseline to post-intervention (0.66 versus 0.83, P < 0.001) and (0.66 versus 0.77, P < 0.001), respectively, and there was significant group-by-time interaction in EuroQol-Visual Analogue Scale from baseline to post-intervention at 90days and follow-up at 180days with the intervention group experiencing better improvement. Similarly, significant interaction effects were also found in the Stroke Impact Symptom scale, self-efficacy and modified Barthel Index. home-based transitional care was effective in improving QOL, symptoms, self-efficacy and activities of daily living.

Abstract 34: A Stroke Transition Of Care Intervention With Stroke Nurse Navigator And Early Stroke Clinic Follow-up Reduces Readmissions For Stroke At 12 Months

Introduction: Stroke is a leading cause of disability in the United States, and one in four occur in people who have already had a stroke. Preventable hospital readmissions contribute to the high medical costs of stroke. Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke is mixed. A transition of care program was implemented at a large urban stroke center, utilizing interventions shown to be effective in the literature, with the goal of reducing recurrent strokes and hospital readmissions. Methods: The transition of care program consisted of: two Stroke Nurse Navigators, personalized stroke education in the hospital, two-day phone call reinforcing education and reviewing medications, early follow-up within 7-10 business days with a Stroke Neurologist, and further education on personalized risk factors in the clinic. Baseline data from the year prior to intervention, and each quarter of the three-year project period were obtained on the following measures: Rate of recurrent stroke admissions within one year, all-cause readmission within one year, all-cause readmission within 30 days, patient scheduled for initial follow-up within 7-10 days, compliance with follow up in the stroke clinic, and percent of patients receiving two-day post discharge phone call. Discharge data were reviewed on 949 patients in 2016 (year 0) and on 2,328 patients in the three-year project period (starting in July 2017). Results: The rate of readmission for stroke was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively. This represents a reduction of 50% from the year prior to the intervention to year 3 of the grant. All-cause readmission remained stable, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. An improvement was seen in process measures: patients scheduled for early follow up in the stroke clinic, adherence to follow-up, and two-day post-discharge phone calls. Conclusions: In conclusion, the transition of care intervention led to a reduction from baseline in readmissions for stroke within one year, but did not impact all cause readmission at one year or 30 days. This is a meaningful outcome for those who have suffered strokes. This program can serve as a model.

Abstract TP28: Stroke Care Doesn't End At Hospital Discharge: What Patients Need After Hospital Discharge May Not Always Be Obvious

Introduction: Mood disorders after stroke are common, with up to one-third of patients developing depression and/or anxiety. Identifying those at greatest risk may be challenging in the acute care setting. We sought to better understand post-hospital barriers impacting emotional well-being for those who suffered a stroke and to evaluate needs for additional resources post hospital discharge. Methods: A Stroke Transitional Care Program (STCP) was initiated at a large two-campus hospital in Southern California in October 2020. All patients discharged home with acute ischemic stroke (AIS), hemorrhagic stroke (HS), and transient ischemic attack (TIA) received a follow-up phone within 3-7 days of hospital discharge from a community health worker familiar with the community and language. An initial needs assessment was completed over the phone to evaluate barriers for post-hospital care, address social and economic needs, and help patients navigate the healthcare system. Data from the initial needs assessment results were analyzed and 30-day readmission data reviewed. Results: A total of 145 patients with a stroke diagnosis were discharged home between October 2020 and June 2021. Of those, 68.3% were discharged with AIS, 21.4% with TIA, and 10.3% with HS. Initial assessments of the 100 patients accepting enrollment into the STCP were reviewed. Fifty-six patients required additional resources, of which 55% required counseling, emotional support, and/or mental health resources. Nine percent of patients were readmitted to the hospital within 30 days. Of these, 22% were admitted for isolated psychiatric issues. Conclusion: A large portion of the stroke patients in our analysis required additional resources post discharge to support emotional well-being, and 22% of patients who required hospital readmission were admitted for psychiatric issues. As a result of these findings, our STCP incorporated the PHQ-2 screening as a standard part of initial post-discharge assessment and implemented a referral process to mental health services. Our results suggest the need for stroke programs to consider implementing processes to assess emotional/psychiatric needs for stroke patients post discharge by incorporating community-based models of care.

Evaluation of a nurse practitioner-led transitional care program: The effects on 30-day Medicare readmission rates and patient satisfaction scores.

Data suggest that nurse practitioner (NP)-led transitional care models can reduce 30-day readmission rates. It remains unclear if transitional care has any impact on Press Ganey's Hospital Consumer Assessment of Health Provider and Systems (HCAHPS) patient satisfaction scores. A transitional care encounter program (TCEP) was designed and implemented by an NP at an internal medicine private practice in response to an increase in Medicare 30-day readmission rates and lower HCAHPS results. A program evaluation was carried out to determine any impact on 30-day readmissions and HCAHPS. The evaluator used CDC's Framework for Program Evaluation in Public Health for program evaluation. Quantitative retrospective data collection of Medicare 30-day readmission rates was obtained and compared preimplementation/postimplementation. HCAHPS results were collected from the data analytics department at Methodist Health System and compared preimplementation/postimplementation. All Medicare patients followed by the private practice discharged from hospital to home had a TCEP visit within 7 days of discharge. The NP extensively reviewed the hospital records, medication reconciliation, education about current medications, diagnoses, and treatment plan with the patient. Readmission rates and HCAHPS are tracked by physician name at discharge. The TCEP resulted in a 2.1% reduction in Medicare 30-day readmission rate. Physician A pre-/post-HCAHPS score was 74% increased to 81.3%. Physician B pre-/post-HCAHPS score was 75.8% increased to 78.6%. The TCEP model became an integral part of the clinic's daily operations. Transitional care has potential for decreasing Medicare 30-day readmission rate and improving HCAHPS.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial.

ObjectiveTo evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care.MethodsThe intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression.ResultsNo significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained.ConclusionThe CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.

An Online-Based Transition Care Program for Adolescents with Spina Bifida Using Intervention Mapping: A Protocol for Program Development.

Adolescents with spina bifida (SB) face challenges in their transition to adulthood due to intensive medical regimens and delayed development of independence. Despite an increasing interest in the transition of adolescents with SB to adulthood, the clinical evidence of transition care remains limited, and existing studies have focused on the effects of intervention programs. This study aims to describe the process of systematically developing an online-based transition care program for adolescents with SB using the intervention mapping (IM) protocol. IM consists of six steps: (1) logic model of the problem; (2) program objectives; (3) program design; (4) program production; (5) plan to implement the program; (6) plan for evaluation. At first, five problems faced during the transition were identified, based on which four program objectives and six program strategies were established. The online transition care program for adolescents with SB was developed as a six-week program. The main strength of this program is that it reflects the diverse perspectives of adults with SB and health care professionals and is easy to apply because it is online. We aim to further validate the feasibility of this transitional care program to evaluate its effect based on our evaluation plan.

The Impact of an Intensivist-Led Critical Care Transition Program.

Objective: Evaluate the impact of a post-discharge critical care transition program (CTP) on intensive care unit (ICU) readmission, in-hospital mortality, and six-month survival.Methods: This was a prospective observational, single-center study, with a before-after design, in a critical care department in a tertiary hospital in Northern Portugal. Critically ill patients with ICU stay > 48 h or intermediate care stay >72 h or tracheostomized patients were included in the program. Historic controls included critically ill patients admitted in the six months prior to program implementation. The follow-up visit included a medical evaluation by an intensivist and a meeting with the attending physician. The primary outcome was critical care department readmission. Secondary outcomes were mortality at hospital discharge, 28-day, and six-month mortality. The readmission rate was compared between groups. Multivariate analysis and Kaplan-Meyer survival analysis were used to evaluate survival benefits.Results: Between September 2020 and March 2021, 132 patients were included in the CTP. The Control group included 196 patients. The intensivist’s assessment led to management change in 15.1% of patients. The CTP group had a non-significant lower readmission rate (0.8% vs. 4.1%; p=0.09). Multivariate analysis showed a benefit for the CTP regarding in-hospital, 28-day, and six-month mortality. Kaplan-Meyer survival analysis showed improved survival in the CTP group.Conclusions: The CTP reduced, non-significantly, the readmission rate, and significantly improved in-hospital and six-month mortality. Further analyses are needed to improve inclusion criteria and better allocate human resources.

Toward a better understanding of transition from paediatric to adult care in type 1 diabetes: A qualitative study of adolescents.

Type 1 diabetes is associated with significant morbidity, with an increasing risk of acute diabetes-related complications in adolescence and emerging adulthood. Purposeful transition from paediatric to adult-oriented care could mitigate this risk but is often lacking. Detailed understanding of the perspectives of adolescents in their final year of paediatric care is essential to inform delivery of transition care programs. We conducted semi-structured interviews with adolescents (aged 17years) with type 1 diabetes at an academic institution from April 2017 to May 2018. Participants were recruited through convenience sampling. Sixty-one interviews were transcribed for analysis. Coding followed the principles of thematic analysis. Thirty-six percent of participants were male, and participants were from diverse socioeconomic backgrounds. We found three overarching themes in our analysis: first, difficulties navigating changing relationships with parents and healthcare teams; second, the need to increase type 1 diabetes self-management and differing comfort levels based on age of diagnosis; and third, perceived responsibilities for transition care preparation (for both the paediatric team and adolescents themselves) focused not only on type 1 diabetes-specific skills but also on healthcare system structures. Our findings suggest that novel transition programs addressing changing inter-personal relationships, disease-specific self-management (adapted for age of diagnosis), and healthcare system navigation, supported by parents and peers, may be needed to improve transition care for adolescents with type 1 diabetes.

Impact of a pharmacy department-wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge.

To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Single-center before-and-after study. Acute-care, academic, community hospital in Santa Barbara, California. Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Antimicrobial stewardship-initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

A consensus statement on health‐care transition for childhood‐onset inflammatory bowel disease patients

Inflammatory bowel disease (IBD) is a chronic relapsing inflammatory disorder of the intestine. The incidence of IBD is increasing worldwide, including Japan, and in approximately 25% of all affected patients it is diagnosed before 18 years of age. For the health maintenance of such patients, planned transition to adult care systems is essential. Previous Japanese surveys have revealed gaps between adult and pediatric gastroenterologists with regard to their knowledge and perception of health-care transition for patients with childhood-onset IBD. In 2021-2022, several Web workshops to discuss issues related to the transitional care of IBD patients were held by the Ministry of Health, Labour and Welfare of Japan as part of their program for research on intractable diseases. Clinicians experienced in IBD treatment for pediatric and adult patients participated. As a result, this panel of adult and pediatric gastroenterologists developed five consensus statements on the issue of "transfer from pediatric to adult care" and nine statements on the issue of "addressing transitional care (transition program)." To address current gaps in health-care transition for childhood-onset IBD patients, a programmed approach to transition, and better partnerships between pediatric and adult gastroenterologists are indicated. It is hoped that this consensus statement will provide a basis for the development of appropriate guidelines for clinical practice.

Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities.

We explore whether the frequency of post-hospital discharge transitional care calls affects patients’ adherence to their discharge plans. We reviewed 1,000 call records of a post-discharge transitional care program run by a large U.S. tertiary care hospital in 2018–2019 and generated binary outcomes capturing patient self-reports of (1) scheduling or completing follow-up appointments, procedures, or prescription fills, (2) missing a scheduled event, and (3) reporting a new adverse clinical event. Our predictor variables captured callers’ success in completing the first and each subsequent call with discharged patients. We ran linear probability models (LPM) for each binary outcome after controlling for sociodemographic and clinical characteristics. Results indicate successful completion of the first two calls was associated with the increased probability of scheduling or completing follow-up appointment (15.5% points, p < 0.01) and follow-up procedure (13.5% points, p < 0.01), and reporting new adverse event (5.9% points, p < 0.05). Our findings suggest that making the first phone call to patients, while crucial, may not be sufficient for effective care transition; making two to three phone calls seems to be more optimal, while further calls may have limited value.

Protocol for the MobiMD trial: A randomized controlled trial to evaluate the effect of a self-monitoring mobile app on hospital readmissions for complex surgical patients

BackgroundHospital readmissions are estimated to cost $17.4 billion per year in the Medicare population alone, with readmission rates as high as 30% for patients undergoing complex abdominal surgery. Improved transitional care and self-monitoring may reduce preventable readmissions for such high-risk populations. In this study, we will conduct a single-institution randomized controlled trial (RCT) to assess the effect of a novel transitional care mobile app, MobiMD, on hospital readmission in complex abdominal surgery patients. MethodsThree hundred patients will be randomized 1:1 to standard of care (SOC) versus SOC plus MobiMD app in a parallel, single-blinded, two-arm RCT. Eligible patients are those who undergo complex abdominal surgery in the division of Surgical Oncology, Colorectal Surgery or Transplant Surgery. The MobiMD app provides push notification reminders directly to the patient's smart device, prompting them to enter clinical data and patient-reported outcomes. Clinical data collected via the MobiMD app include vital signs, red flag symptoms, daily wound and surgical drain images, ostomy output, drain output, medication compliance, and wound care compliance. These data are reviewed daily by a physician. The primary outcome is the proportion of participants readmitted to the hospital within 30 days of surgery. Secondary outcomes are 90-day hospital readmission, emergency department and urgent care visits, complication severity, and total readmission cost. DiscussionIf effective, mobile health apps such as MobiMD could be routinely integrated into surgical transitional care programs to minimize unnecessary hospital readmissions, emergency department visits and healthcare resource utilization.Clinical trials identifier: NCT04540315

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis.

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups.Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral.Results: We included 497 patients in the study and found 5 distinct groups: “low morbidity” (referent), “high comorbidity,” “high tri-morbidity,” “high alcohol use,” and “high medical illness.” All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the “low morbidity” group. The “high medical illness” group had greater mortality 12 months after referral compared to the “low morbidity” group (OR, 2.53, 1.03–6.16; 95% CI, 1.03–6.16; p = 0.04). The “high comorbidity” group (OR, 5.23; 95% CI, 1.57–17.39; p < 0.007) and “high tri-morbidity” group (OR, 4.20; 95% CI, 1.26–14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group.Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.