Transitional Care Research Articles

Bridging the gap: a qualitative process evaluation from the perspectives of healthcare professionals of an audit-and-feedback-based intervention to improve transition to adult care for young people living with type 1 diabetes

BackgroundThe transition from pediatric to adult care is a vulnerable time for young people living with type 1 diabetes (T1D). Bridging the Gap (BTG) is an audit-and-feedback (AF) intervention aimed at improving both transitions-in-care processes and diabetes management in the year following transition. As part of BTG, we conducted a qualitative process evaluation to understand: (a) what was implemented and how; and (b) the contextual factors (micro-, meso- and macro-) that affected implementation, outcomes and study processes.MethodsUsing qualitative descriptive methodology, interviews were conducted with 13 healthcare professionals (HCPs) delivering diabetes care to transitioning youth. Participants were asked about their experiences of BTG study processes and feedback tools, the quality improvement (QI) initiatives implemented at their site, and potential spread and scale. Interviews also explored the impacts of COVID-19 on transition care and study processes and results.ResultsFive key themes were identified. Participants’ reflections on the BTG study design indicated they appreciated its flexible, site-specific approach to QI, which they saw as crucial to the success of their initiatives. Engagement with feedback reports and other study resources provided comparative, site-specific data. Participants described the challenges posed by the COVID-19 pandemic and its impacts on patients, care provision and study implementation. Their site-specific QI initiatives resulted in changes to their transition practices. Finally, participants commented on how BTG and its processes fostered a community of practice (CoP) between sites, resulting in new opportunities to collaborate and share experiences.ConclusionsBTG resulted in a CoP among practitioners delivering transition care to youth with T1D, which could be scaled up to promote a learning health system in pediatric diabetes care. Qualitative process evaluation is a useful tool for understanding how contextual factors affect the implementation and outcomes of complex QI interventions.

Toward a Consensus on Strategies to Support Opioid Use Disorder Care Transitions Following Hospitalization: A Modified Delphi Process.

Despite proliferation of acute-care interventions to initiate medications for opioid use disorder (MOUD), significant challenges remain to supporting care continuity following discharge. Research is needed to inform effective hospital strategies to support patient transitions to ongoing MOUD in the community. To inform a taxonomy of care transition strategies to support MOUD continuity from hospital to community-based settings and assess their perceived impact and feasibility among experts in the field. A modified Delphi consensus process through three rounds of electronic surveys. Experts in hospital-based opioid use disorder (OUD) treatment, care transitions, and hospital-based addiction treatment. Delphi participants rated the impact and feasibility of 14 OUD care transition strategies derived from a review of the scientific literature on a scale from 1 to 9 over three survey rounds. Panelists were invited to suggest additional care transition strategies. Agreement level was calculated based on proportion of ratings within three points of the median. Forty-five of 71 invited panelists participated in the survey. Agreement on impact was strong for 12 items and moderate for 10. Agreement on feasibility was strong for 11 items, moderate for 7, and poor for 4. Strategies with highest ratings on impact and feasibility included initiation of MOUD in-hospital and provision of buprenorphine prescriptions or medications before discharge. All original 14 strategies and 8 additional strategies proposed by panelists were considered medium- or high-impact and were incorporated into a final taxonomy of 22 OUD care transition strategies. Our study established expert consensus on impactful and feasible hospital strategies to support OUD care transitions from the hospital to community-based MOUD treatment, an area with little empirical research thus far. It is the hope that this taxonomy serves as a stepping-stone for future evaluations and clinical practice implementation toward improved MOUD continuity and health outcomes.

Differences in setting of initial dementia diagnosis among fee-for-service Medicare beneficiaries.

Accurate and timely diagnosis of dementia is necessary to allow affected individuals to make informed decisions and access appropriate resources. When dementia goes undetected until a hospitalization or nursing home stay, this could reflect delayed diagnosis or misdiagnosis, and may reflect underlying disparities in healthcare access. In this retrospective cohort study, we used 2012-2020 Medicare claims and other administrative data to examine variation in setting of dementia diagnosis among fee-for-service Medicare beneficiaries with an initial claims-based dementia diagnosis in 2016. We used multinomial logistic regression to evaluate the association of person and geographic factors with diagnosis location, and Cox proportional hazards regression to examine 4-year survival relative to diagnosis location. Among 754,204 Medicare beneficiaries newly diagnosed with dementia in 2016, 60.3% were diagnosed in the community, 17.2% in hospitals, and 22.5% in nursing homes. Adjusted 4-year survival rates were significantly lower among those diagnosed in hospitals [-16.1 percentage points (95% CI: -17.0, -15.1)] and nursing homes [-16.8 percentage points (95% CI: -17.7, -15.9)], compared to those diagnosed in the community. Community-diagnosed beneficiaries were more often female, younger, Asian or Pacific Islander, Native American or Alaskan Native, Hispanic, had fewer baseline hospitalizations and higher homecare use, and resided in wealthier ZIP codes. Rural beneficiaries were more likely to be diagnosed in hospitals. Many older adults are diagnosed with dementia in a hospital or nursing home. These individuals have significantly lower survival than those diagnosed in the community, which may indicate diagnosis during an acute illness or care transition, or at a later disease stage, all of which are suboptimal. These results highlight the need for improved dementia screening in the general population, particularly for individuals in rural areas and communities with higher social deprivation.

Utilizing Care Transitions for Diagnostic Error Detection in Hospital Medicine Patients.

Utilizing Care Transitions for Diagnostic Error Detection in Hospital Medicine Patients.

Bridging gaps at key intersections: Strategies to improve early intervention and treatment access for eating disorders

ABSTRACTMental health is at the forefront of discussions in healthcare, education, and social settings, yet eating disorders remain poorly understood and inadequately treated. This paper presents evidence on risk factors for insufficient recognition and intervention for eating disorders across clinical and community healthcare settings and proposes actionable strategies to improve awareness and early intervention for eating disorders. Specifically, gaps in eating disorder awareness and treatment access are exacerbated at two key intersections within health and social systems. First, eating disorders manifest themselves at the intersection of mental and physical categories of health, which places them at risk of being misunderstood, poorly diagnosed, and insufficiently intervened upon. Second, the peak onset of eating disorders falls at the intersection of adolescence and young adulthood, which is a period of rapid developmental, social change, and transitions in care. This analysis highlights how systemic issues within existing social and health systems underlie these intersections and contribute to the continued stigmatization and inadequate treatment access for eating disorders. Given their increased incidence and severity, there is an urgent need to address both the individual and societal burden of these disorders. Healthcare systems must prioritize coordination between physical and mental health practices and improve transitions in care from pediatric and adult healthcare services. Identifying gaps at intersections provides the opportunity to make concrete progress toward improving awareness and treatment.

Epidemiology and Outcomes Associated with New Persistent Opioid Use After Transabdominal Operation.

Overall, 3-12% of opioid-naïve patients develop persistent opioid use after surgery. It's still unclear whether persistent opioid use after transabdominal surgery is associated with adverse surgical outcomes. We aimed to assess if new persistent opioid use after transabdominal surgery is associated with increased long-term mortality and readmission rates. Opioid-naïve patients >18 years undergoing transabdominal surgery at Landspitali University Hospital, the only tertiary hospital in Iceland, from 2006-2018 were included. Persistent opioid use was defined as opioid use more than 3 months postoperatively. Inverse probability weighting (IPW) was used to yield balanced study groups accounting for baseline characteristics. Long-term mortality (during median follow-up of 5.2 years) was compared using propensity-weighted Cox regression and readmission within 3-6 months using propensity-weighted logistic regression. Overall, 3923 patients were included (laparoscopy-2680, laparotomy-1243). Rates of new persistent opioid use were 13.0%. Rates were higher after laparotomy than laparoscopy in the crude analysis but not in the propensity-weighted analysis. New persistent opioid use was associated with higher long-term mortality (hazard ratio 1.84, 95% CI 1.41-2.40) and readmission rates (odds ratio 3.24, 95% CI 2.25-4.76). This was consistent for both patients undergoing laparoscopy and laparotomy. Moreover, there were signs of a dose-response relationship, with patients in higher quartiles of postoperative opioid consumption having higher mortality and readmission rates. New persistent opioid use following transabdominal surgery was associated with higher rates of mortality and readmission rates. This calls for increased postoperative support for at-risk patients and increased support during transitions of care for these patients.

Bridging the Gap: A Pilot Study of a Health Care Transition Podcast Curriculum and Standardized Patient Case for Graduate Medical Education Trainees

Bridging the Gap: A Pilot Study of a Health Care Transition Podcast Curriculum and Standardized Patient Case for Graduate Medical Education Trainees

Adverse drug reactions in older people following hospitalisation: a qualitative exploration of general practitioners' perspectives.

Older people have greater comorbidity and medication burden. Adverse drug reactions occur in up to 30% of older people within one month of hospital discharge. General practitioners are key stakeholders in transitions of care from hospital to the community. The study aimed to explore general practitioner perspectives of adverse drug reactions in older people after hospitalisation, investigating the medication-related issues encountered and possible approaches to reduce the risk. An invitation to participate in the study was sent to general practitioners in Southern Tasmania, Australia. A semi-structured interview occurred in person at their practice or online. The questions covered experiences with managing medication in older people after hospital discharge, challenges and risks involving adverse drug reactions and suggestions to prevent adverse drug reactions. The interviews were transcribed and analysed through thematic analysis. Twelve general practitioners were interviewed, revealing four themes describing challenges, including (i) complex patients and acceptance of risk, (ii) patient confusion and decline in hospital, (iii) time taken to manage older patients and (iv) communication challenges. Three themes describing recommendations were identified, including (i) clear communication on discharge, (ii) patient involvement and (iii) roles for pharmacists. Prevention of adverse drug reactions after hospital discharge may require clear and timely communication to general practitioners, patients and families to be educated and empowered to help manage their own health and risk, and pharmacists to support both patients and general practitioners in managing the risks.

A WeChat platform program (WCPP) for full-process management of patients with cardiac valve interventional surgery based on psycho-cardiology: protocol of a mixed-method study

BackgroundValvular heart disease is the third most common cardiovascular disease; it significantly diminishes patients’ quality of life and imposes burdens on individuals, families, and healthcare systems. In recent years, psycho-cardiology has emerged as a prominent field in which to explore the link between mental illness and heart disease. This mixed-method study aims to assess the effectiveness of the WCPP, which includes hospital-to-home transitional care, remote intelligent monitoring, and decision aids, in improving the physical and mental health of patients.MethodsA mixed-method study was conducted at a cardiac valve interventional surgery (CVIS) center in Southwest China. A total of 154 CVIS patients participated, with the intervention group receiving the WCPP and the control group following the traditional CVIS management program. Both groups were followed up at 1, 3, 6, and 12 months. The primary outcome is measured via the Chinese version of the 36-item Short Form Health Survey (SF-36). The Secondary outcomes included the 6-min walk test (6MWT), modified Barthel index (MBI), major adverse cardiovascular events (MACE), patient satisfaction, and length of hospital stay (LOS). Additionally, qualitative research will assess the psychological state and experiences of the patients.DiscussionOur study is one of the few involving patients with CVIS and the first to apply psycho-cardiology through a full-process management platform. The study population is predominantly from Southwest China and includes a diverse range of demographic and socioeconomic backgrounds. Upon completion, this study will provide valuable insights into the use of a remote, full-process management platform for CVIS patients.Trial registrationChinese Clinical Trial Registry ChiCTR2400081052. Registered on 21 February 2024. The trial complies with the SPIRIT and CONSORT guidelines.

Evaluating the Safety and Quality of Intraoperative Anesthesia Handoffs from the Perspective of Anesthesia Providers

Handoffs, that is, care transitions, convey information, responsibility, and authority between care providers. Intraoperative handoffs, which occur during surgery either due to shift changes or breaks, are high-risk, error-prone and linked with inadequate verbal communication and documentation. We explored perspectives about safety and quality of intraoperative handoffs between anesthesia providers at an academic medical center. Through an anonymous online survey, we asked participants to share their opinions on current handoff practices including teamwork, staffing and work pace, and handoffs and information exchange. The results showed positive perceptions about teamwork, while only half of the participants were positive about staffing and work pace. We also found that opinions of participants about staffing and work pace vary based on their role. Our study emphasizes the importance of considering diverse perspectives and employing a systems-based approach to address challenges and implement effective interventions for safe, high-quality handoffs in intraoperative care.

Medical silos, social identity, and duty of care: A call for health leaders to improve transitions of care.

This article explores the concept of medical silos, particularly within hospital systems, and examines their deeper roots in social identity and the fiduciary duty of care of healthcare providers. While traditional perspectives focus on informational and communication barriers, this analysis highlights how professional identity and moral obligations contribute to the persistence of silos. Social identity theory reveals that strong in-group affiliations, formed during medical training and specialization, fosters collaboration within groups but also create divisions between them. Similarly, the fiduciary duty of care, central to ethical medical practice, may inadvertently reinforce silo boundaries in resource-limited environments. By emphasizing the role of centralized leadership, the article proposes that health system managers and leaders, with the broadest possible duty of care, must take action to dismantle these barriers. Recommendations include re-evaluating policies for patient transitions and fostering integrated care pathways to improve overall system flow, rather than simply balancing the agendas of stakeholders within their silos.

Patients’ experiences of very early supported discharge after stroke: safety, emotional support and feelings of control in everyday life

Objective Early supported discharge (ESD) aims to enable the transition of care from specialised stroke units to patients’ homes. Even though ESD is well-researched, little is known about the experiences faced by persons with stroke in very early supported discharge (VESD). The aim of this study was to understand these experiences when participating in a VESD rehabilitation program. Methods Qualitative individual and semi-structured interviews were held (at 3 months post-discharge) with stroke survivors discharged home at a very early stage and participating in a VESD programme. A thematic analysis process was applied. Results Nine participants living in Sweden and following a mild or moderate stroke expressed their narratives through the following themes: “The importance of the VESD team intervention during the initial home rehabilitation”; “Everyday life was perceived as a struggle depending on close relatives”; “Experiencing problems with fatigue and low energy” and “Feeling angrier or more worried in everyday life” Conclusions Home-based VESD rehabilitation was important for increasing patients’ sense of independence and control in daily life, while at the same time making them feel secure in the support from the rehabilitation team. Future research may investigate how VESD functions in other countries and healthcare systems.

Evaluation of a Model of Transitional Care After Preterm Birth on Parents' Mental Health and Self-Efficacy: A Randomized Controlled Pilot Trial.

Parents of premature infants experience depression, anxiety, post-traumatic stress disorder, and increased stress, which can negatively impact parent-infant relationships and infant development. To reduce negative consequences and optimally support families, we developed the Transition to Home model (TtH). In this randomized controlled pilot trial (RCT), the feasibility of performing an experimental study to analyse the effects of TtH on parental mental health over time was evaluated. The following domains were assessed: recruitment, follow-up and study burden, outcome measures used and parental mental health outcomes. We included n = 22 parent couples with their preterm infants in the control group and n = 23 in the intervention group. Depression, anxiety and post-traumatic stress disorders, parenting stress, and parental self-efficacy were assessed at five timepoints. The study burden was evaluated once at the end of the study. The control and intervention groups had similar socio-demographic characteristics. The groups showed no differences in the mental health outcomes except for depression in mothers at T2 (p = 0.042) and T5 (p = 0.027) and state anxiety in fathers at T2 (p = 0.016). This pilot RCT established a framework for the evaluation of the TtH model of care and demonstrated the viability of the evaluation scheme. The results confirm the suitability of the RCT's structure and the feasibility of the methods and instruments used. Minor adjustments are recommended to include a more diverse sample in future studies.

A public health/hospital partnership to improve Emergency Department transitions of care for vulnerable older adults.

Community-dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care. Setting: A medium-sized urban ED with 55,000 patient visits a year. Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community-dwelling older patients, perform an in-person intake assessment, and initiate needed community services (including home-delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail. From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long-term care ombudsman. The program did not increase ED length of stay or hospital admission rates. Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self-neglect.

Promoting health literacy of older post-discharge patients in general practice - Creation of the GP-MATE communication tool through co-design

ObjectiveWork with older patients and their carers to co-design a tool that improves patient - general practice communication and continuity of care following discharge of an older person from hospital. MethodsExperience Based Co-Design with three teams of six to seven lay people (older patients and their carers), each supported by a corresponding general practice group. The process included an implementation-focused event with participants using the intervention in a live role-play. ResultsCo-design generated a patient-held tool (GP-MATE) that focuses on four areas of post-discharge care: carers/caring; continuity; medication safety and information power. Access to general practice for patients/carers post-discharge was considered to be vital to improving communication. Discussion and conclusionThe co-design process enabled patients and carers to be involved through all stages of intervention development, ensuring relevance and alignment. Practice implicationsThe intervention is uniquely suited to general practice, comprehensive yet brief enough to be usable within a 20-minute consultation. While the domains of GP-MATE compare well with existing care transitions literature, it will be important to assess impact on already busy practice schedules and impact on care.

Planetary Health in Rehabilitation: A Call to Arms… and legs, gait aids, and other equipment.

Sometimes out of necessity and sometimes out of convenience, medicine is wasteful. Resource stewardship is a critical and expanding field for reducing wasteful practices. Numerous international organizations are driving resource stewardship globally, including >20 countries worldwide participating in Choosing Wisely initiatives. However, opportunities for environmental stewardship have been long overlooked. Planetary health, climate action, and environmental stewardship in medicine consider opportunities which offer a co-benefit to the planet while improving or maintaining appropriate patient care across the healthcare continuum, including acute care, transitions in care, and post-acute care, as well as in primary, secondary, and tertiary care settings. As rehabilitation is necessary across all healthcare settings, developing a culture amongst rehabilitation care providers that is conscientious about planetary health is imperative for sustainability of rehabilitation medicine and the health of our planet. We devised a recommendation for Choosing Wisely Canada's planetary health focus: don't dispose of adaptive equipment, mobility devices, orthoses, and prostheses that could be reused or recycled. This brief report discusses 1) why rehabilitation providers should engage with planetary health and climate action; 2) the rationale for the Choosing Wisely Canada Physical Medicine & Rehabilitation planetary health recommendation, and 3) existing avenues and novel opportunities for rehabilitation care providers worldwide to reduce waste in rehabilitation.

Female breast cancer survivor narratives on paths to healing after the conclusion of primary treatment: A qualitative study.

Female breast cancer survivors (BCS) experience different paths to healing after the conclusion of primary treatment. This study sought to describe the experiences of female BCS in the months and years after primary treatment by determining how and when healing happens, as well as what healing means to BCS. A qualitative approach was used through thematic analysis of data collected through questionnaires and semi-structured interviews from 17 female BCS. Data analysis identified four major themes: (i) the process of finishing treatment and continuity of care, (ii) support systems for BCS, (iii) self-efficacy and personal accountability, and (iv) the social transition after cancer. Factors that affect the healing of BCS can be conceptualized as external or personal. Participants found that barriers to healing created by external factors were addressed by improved coordination of care and high-involvement transition programs as opposed to conversational support groups. Barriers created by personal factors were mitigated through organically formed support systems and promotion of self-efficacy and resilience. Participants expressed a desire for a shift in mainstream discourse to better reflect their experiences. Each BCS conceptualized survivorship differently, with some seeing a clear end to healing, and others who viewed it as a lifelong process. Understanding the many paths to healing taken by BCS after concluding primary treatment, as well as common barriers to and catalysts for healing, can aid providers in addressing patient needs based on their individual experiences.

Concept Analysis: The Occupational Experiences of Long-Term Care Nurses-Navigating Fragmented Transitions.

Transitions are broadly defined as movements from one place, stage, or subject to another. However, transitions which are broken and incomplete are referred to fragmented transitions. The aims of this concept analysis were to analyze the navigation of fragmented occupational transitions among long-term care nurses and to develop a working conceptual definition of fragmented occupational transitions to inform diverse stakeholders. Concept analysis. Google Scholar, PubMed, and the Cumulative Index of Nursing and Allied Health Literature databases were accessed. Identified sources were interprofessional scholarly literature published between January 1, 2018, and January 1, 2024, and seminal references. Walker and Avant's eight-stage concept analysis method. Occupational transitions in long-term care are fragmented leading to grievous challenges across multiple aspects of nurses' lives. An analysis of the literature using a Transitions Theory lens reveals that their thoughts, feelings and ethical decisions are influenced over time by these transitions. Cardinal attributes include: (1) Fragmentation, (2) Ill-timing, (3) Disruption, (4) Liminality, (5) Ambiguity, (6) Ambivalence and (7) Facilitators/Inhibitors. Antecedents stem from external sources and facility-led initiatives. Consequences encompass product and process outcomes. Product outcomes include physical and psychological conditions, and process outcomes encompass resilience, flexibility, connection, coping, creativity, and communication. This concept analysis advances the science for understanding nurses' occupational transitional experiences in long-term care. It will assist in risk assessment and instrument development ultimately improving the quality of long-term care. Fragmented occupational transitions in long-term care are multifaceted and complex phenomena that require distinct responses from government, healthcare leaders, and scholars to improve the plight of long-term care nurses and stakeholders. Dr. A. I. Meleis contributed to this article by sharing her vast insight into transitions.

Experiences with healthcare navigation and bias among adult women with sickle cell disease: a qualitative study.

The purpose of this study was to use qualitative interviews to understand the experiences of adult women with sickle cell disease (SCD) through daily life and navigating the healthcare system. We conducted semi-structured interviews with reproductive-aged women with SCD and performed thematic analysis. We analyzed interviews from 20 participants. Our data demonstrated three overarching themes: perceptions of disease, transitions of care, and stigma and bias. Participants identified feelings of both empowerment and powerlessness from SCD that evolved over time and globally impacted their lives. The transition from pediatric to adult care was a vulnerable period, both surrounding changes in disease character and challenges transitioning healthcare systems. Finally, participants faced discrimination and prejudice within SCD care, which manifested as disvaluing of their own disease expertise or perpetuation of a "drug-seeking" stereotype. In the context of this bias, some participants prioritized seeking same-race providers. Experiences with SCD contribute significantly to daily quality of life in women with SCD, and ongoing care gaps exist in relation to their disease. Within our population, SCD as a physical and mental stressor requiring interdisciplinary support should not be underestimated. More robust systems to support the transition from pediatric to adult care are also necessary, both on a healthcare institution level and to support patients' engagement in their care. Finally, provider education and training on anti-racist practice and both recognizing and eliminating bias are essential to improving care of SCD patients. Possible interactions between sex, gender, and race in the experience of SCD warrant further exploration.

Single versus dual fixation of distal femur fractures: A retrospective cohort study at a level one trauma centre in New Zealand

Background The study compares single versus combination fixation of distal femur fractures. Method We retrospectively reviewed patients over 60 between January 2016 and December 2022. Union rate, ambulatory status and complication rate were primary outcomes. Secondary outcomes included quality of reduction, operative time and rate of blood transfusion. Results A total of 92 patients received single fixation, and 22 patients received combination fixation. There was no difference in rate or time of fracture union. Patients with dual fixation were allowed to weight bear on discharge significantly more than single fixation patients (50% vs. 18.9%, p = 0.003). Intramedullary nail fixation, as a single method or combined with lateral plating, was associated with earlier weight bearing. Immediate post-operative weight bearing significantly increased the likelihood of discharging to home or rehabilitation versus discharging to a transitional care facility ( p < 0.00001). There was no difference in the rate of blood transfusion, complication or mortality. Medial translation of the distal articular block was significantly lower with dual fixation (1.2% vs. 3.4%, p = 0.021). Operation time was longer with combination fixation (183 min vs. 134 min p < 0.001). Conclusion Combination fixation allows earlier weight bearing, at the cost of longer operation time.