Post-discharge Care Coordination Research Articles

Hospital discharge processes: Insights from patients, caregivers, and staff in an Australian healthcare setting

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme ‘Communication’ highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme ‘System Pressure’ referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The ‘Continuing Care’ theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process.

Asthma Care from Home: Study protocol for an effectiveness-implementation evaluation of a virtually enabled asthma care initiative in children in rural NSW.

Asthma is the leading source of unscheduled hospitalisation in Australian children, with a high burden placed upon children, their parents/families, and the healthcare system. In Australia, there are widening disparities in paediatric asthma care including inequitable access to comprehensive ongoing and planned asthma care for children. The Asthma Care from Home Project is a comprehensive virtually enabled asthma model of care that aims to a. supports families, communities and healthcare providers, b. flexible and locally acceptable, and c. allow for adoption of innovations such as digital technologies so that asthma care can be provided "from home", reduce potentially preventable asthma hospitalisation, and ensure satisfaction at a patient, family, and healthcare provider level. The model of care includes standardisation of discharge care through provision of an asthma discharge resource pack containing individual asthma action plan, follow-up letters for the child's general practitioner (GP) and school/child care, and access to online asthma educational sessions and resource; post-discharge care coordination through text message reminders for families for regular GP review, email correspondence with their child's GP and school/childcare; and virtual home visits to discuss home environmental triggers, provide personalised asthma education and respond to parental concerns relating to their child's asthma. This study is comprised of three components: 1) a quasi-experimental pre/post impact evaluation assessing the impact of the model on healthcare utilisation and asthma control measures; 2) a mixed-methods implementation evaluation to understand how and why our intervention was effective or ineffective in producing systems change; 3) an economic evaluation to assess the cost-effectiveness of the proposed model of care from a family and health services perspective. This study aims to improve access to asthma care for children in rural and remote areas. Implementation evaluation and economic evaluation will provide insights into the sustainability and scalability of the asthma model of care.

Mapping the Discharge Process After Surgery

Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Postoperative hospital discharge. Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

Healthcare self-management support of stroke patients after discharge: A conceptual analysis using Rodger's evolutionary approach.

To explore the meaning of healthcare self-management support for post-discharged stroke patients. Rodgers' evolutionary approach was used to identify antecedents, attributes, related terms, surrogate terms and consequences. Literature from 2012 to 2022 was searched from MEDLINE, CINAHL, PsycINFO and Google Scholar. Three antecedents preceded healthcare self-management support for post-discharged stroke patients: loss of inpatient support, preparedness for self-management and presence of self-management support. Healthcare self-management support for post-discharged stroke patients was defined by eight attributes: pre-discharge assessment and planning; provision of continuous education and training; collaborative goal-setting; reinforcement and documentation of vital information; coordination of post-discharge care; provision of rehabilitation support and promoting community reintegration; provision of counselling support; and using clear communication, patient empowerment and promoting self-efficacy. The identified consequences of the concept were as follows: improved patient outcomes; improved life quality; decreased healthcare cost; decreased re-admission rate and inpatient care burden; and decreased complication rate. Healthcare self-management support for post-discharged stroke patients is an emerging concept that can help to significantly improve stroke patients' health outcomes and life quality. However, its applicability is uncertain considering the workload, time and resources available to healthcare professionals. There is a need for future studies to focus on the feasibility and applicability of this concept in clinical practice and to identify any challenges healthcare providers may have in supporting stroke patients after discharge. This concept analysis brings clarity to the concept of healthcare self-management support of post-discharged stroke patients and distinguishes it from other self-management supports. It provides an opportunity for further studies and a pathway for generalized healthcare self-management support for stroke patients after discharge to improve health outcomes and quality of life. No patients, service users, caregivers or members of the public were involved in conducting this concept analysis.

Physical and mental health impact of Stevens-Johnson syndrome/toxic epidermal necrolysis and post-hospital discharge care: Identifying practice gaps

To the Editor: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a drug-induced eruption that causes acute and long-term health complications. A survey of adults diagnosed with SJS/TEN showed that long-term physical and mental health sequelae are common.1Hoffman M. Chansky P.B. Bashyam A.R. et al.Long-term physical and psychological outcomes of Stevens-Johnson syndrome/toxic epidermal necrolysis.JAMA Dermatol. 2021; 157: 712-715Crossref PubMed Scopus (7) Google Scholar Identification of practice gaps provides opportunity for improving care. We evaluated patient perspectives on the health impact of SJS/TEN and posthospital care. This survey study included adults who registered for the virtual SJS/TEN 2021 Meeting as an SJS/TEN survivor or family member. Potential participants were contacted by email and completed the survey electronically using Research Electronic Data Capture in a deidentified manner. Participants who identified as a family member or a child were excluded. This study was approved by the Institutional Review Board of the University of Pennsylvania. A total of 66 individuals initiated the survey (Table I), a response rate of 47%. Twelve (18.2%) identifying as family members were excluded, resulting in a total of 54 participants. Of these, 45 (83.3%) completed the survey in its entirety.Table IDemographic and clinical characteristics of survey respondentsCharacteristicRespondents (n = 54)Age, y (%) 18-243 (5.5) 25-3410 (18.5) 35-4419 (35.2) 45-548 (14.8) 55-6411 (20.4) 65-743 (5.5) 75-840 (0) 85-940 (0) >900 (0)Years since diagnosis of SJS/TEN (%) <6 mo1 (1.9) 6-12 mo7 (13) 1-2 y3 (5.6) 3-5 y9 (16.7) 6-10 y8 (14.8) >10 y26 (48.1)Female sex, n (%)48 (88.9)Race, n (%) Asian or Pacific Islander13 (24.1) Black or African American8 (14.8) Native American or Alaskan Native1 (1.9) White or Caucasian30 (55.6) Other2 (3.7)Ethnicity, n (%) Hispanic or Latino/Latinx5 (9.3) Non-Hispanic or non-Latino/Latinx49 (90.7)SJS/TEN, Stevens-Johnson syndrome/toxic epidermal necrolysis. Open table in a new tab SJS/TEN, Stevens-Johnson syndrome/toxic epidermal necrolysis. Of participants, 88.2% and 94.1% indicated that their diagnosis of SJS/TEN impacted their physical and mental health respectively; 74.5% of participants follow regularly with a primary care physician and some follow with a medical specialist (Fig 1). Most (70.2%) do not feel their physicians adequately address the long-term health impacts of SJS/TEN. Participants reported organ-specific sequelae of their SJS/TEN along with corresponding specialty care received (Fig 1). Of participants who do not see a specialist, the majority felt that they would benefit from specialty care but reported barriers to receiving it. Thirty-four percent of participants reported receiving assistance with postdischarge care coordination; 87.2% had difficulty establishing care with a provider knowledgeable in SJS/TEN, 63.8% were uncertain regarding which medications or vaccines to avoid in the future, and 76.1% had other unanswered questions regarding their SJS/TEN. Most participants (87%) would like the opportunity to meet with a medical provider with expertise in SJS/TEN; 97.1% of participants believe it would be beneficial to have better SJS/TEN-related care coordination. This survey serves as a needs assessment regarding postdischarge SJS/TEN care from the patient perspective. Prior work similarly highlights significant long-term care needs and inadequate patient education and support services. SJS/TEN research focuses primarily on acute management. No formal guidelines exist for postdischarge care and management of chronic sequelae. The results of this survey identify ways in which postdischarge care of those with SJS/TEN is inadequate. Survey findings will increase awareness of these practice gaps and inform ongoing work to establish formal guidelines for postdischarge care and education through consensus of disease experts and patient partners. Survey participants attended the SJS/TEN 2021 Meeting and self-identified as having a history of SJS/TEN. Response rate for the survey was <50%. We acknowledge the potential bias of the survey participants. The data obtained may therefore not be fully generalizable to the larger community of SJS/TEN survivors. Despite these limitations, it is eye opening that survivors who are engaged in the SJS/TEN medical community identify significant barriers to receiving the care they need. None disclosed.

Using Mobile Integrated Health and telehealth to support transitions of care among patients with heart failure (MIGHTy-Heart): protocol for a pragmatic randomised controlled trial

IntroductionNearly one-quarter of patients discharged from the hospital with heart failure (HF) are readmitted within 30 days, placing a significant burden on patients, families and health systems. The objective of...

Race, Ethnicity, and 60-Day Outcomes After Hospitalization With COVID-19

ObjectiveTo examine racial and ethnic disparities in clinical, financial, and mental health outcomes within a diverse sample of hospitalized COVID-19–positive patients in the 60 days postdischarge. DesignA cross-sectional study. Setting and ParticipantsA total of 2217 adult patients who were hospitalized with a COVID-19–positive diagnosis as evidenced by test (reverse-transcriptase polymerase chain reaction), a discharge diagnosis of COVID-19 (ICD-10 code U07.1), or strong documented clinical suspicion of COVID-19 but no testing completed or recorded owing to logistical constraints (n=24). MethodsPatient records were abstracted for the Mi-COVID19 data registry, including the hospital and insurer data of patients discharged from one of 38 participating hospitals in Michigan between March 16, 2020, and July 1, 2020. Registry data also included patient responses to a brief telephone survey on postdischarge employment, mental and emotional health, persistence of COVID-19–related symptoms, and medical follow-up. Descriptive statistics were used to summarize data; analysis of variance and Pearson chi-squared test were used to evaluate racial and ethnic variances among patient outcomes and survey responses. ResultsBlack patients experienced the lowest physician follow-up postdischarge (n = 65, 60.2%) and the longest delays in returning to work (average 35.5 days). More than half of hospital readmissions within the 60 days following discharge were among nonwhite patients (n = 144, 55%). The majority of postdischarge deaths were among white patients (n = 153, 21.5%), most of whom were discharged on palliative care (n = 103). Less than a quarter of patients discharged back to assisted living, skilled nursing facilities, or subacute rehabilitation facilities remained at those locations in the 60 days following discharge (n = 48). Conclusions and ImplicationsIncreased attention to postdischarge care coordination is critical to reducing negative health outcomes following a COVID-19–related hospitalization.

Discharge nurse intervention on a pediatric rehabilitation unit: Retrospective chart review to evaluate the Does it impact on number of unmet needs during the transition home following neurological injury

ABSTRACT Purpose The purpose of this study is to describe the post-discharge needs of children and adolescents when transitioning home after an inpatient comprehensive rehabilitation stay following an acute neurological injury and to evaluate if trends in those needs changed with implementation of a discharge nurse intervention. Design Retrospective medical record review was conducted 1-year prior (T1) and 1-year after (T2) a discharge nurse intervention. Methods Medical charts of 80 pediatric patients with acute neurological injury (T1 = 39; T2 = 41) were reviewed. Post-discharge communication from the 8-week post-discharge period was reviewed to identify and categorize care coordination needs, using 18 pre-defined care coordination categories. T1 and T2 findings were compared using two sample proportion z-test. Findings Patients discharged following inpatient rehabilitation for acute neurological injury have unmet care coordination needs. The proportion of unmet needs decreased significantly for 10/18 care coordination categories after implementation of the discharge nurse intervention. Conclusions Data from this study support proactive care coordination by inpatient rehabilitation nurses to reduce unmet post-discharge care coordination needs and provides preliminary evidence that the role of a discharge nurse may have a positive impact on the transition from inpatient rehabilitation to home.

The Effects of Accountable Care Organizations Forming Preferred Skilled Nursing Facility Networks on Market Share, Patient Composition, and Outcomes.

Through participation in payment reforms such as bundled payment and accountable care organizations (ACOs), hospitals are increasingly financially responsible for health care use and adverse health events occurring after hospital discharge. To improve management and coordination of postdischarge care, ACO hospitals are establishing a closer relationship with skilled nursing facilities (SNFs) through the formation of preferred SNF networks. We evaluated the effects of preferred SNF network formation on care patterns and outcomes. We included 10 ACOs that established preferred SNF networks between 2014 and 2015 in the sample. We first investigated whether hospitals "steer" patients to preferred SNFs by examining the percentage of patients sent to preferred SNFs within each hospital before and after network formation. We then used a difference-in-difference model with SNF fixed effects to evaluate the changes in patient composition and outcomes of preferred SNF patients from ACO hospitals after network formation relative to patients from other hospitals. We found that preferred network formation was not associated with higher market share or better outcomes for preferred SNF patients from ACO hospitals. However, we found a small increase in the average number of Elixhauser comorbidities for patients from ACO hospitals after network formation, relative to patients from non-ACO hospitals. After preferred SNF network formation, there is some evidence that ACO hospitals sent more complex patients to preferred SNFs, but there was no change in the volume of patients received by these SNFs. Furthermore, preferred network formation was not associated with improvement in patient outcomes.

796. Improving Clostridioides difficile Infection Treatment and Outcomes Using a Web-based Tool to Support a Care Coordination Intervention

Background Clostridioides difficile infection (CDI) is a highly burdensome disease, affecting 500,000 Americans each year. Despite extensive efforts to prevent and treat CDI, variability remains in the treatment guidelines, particularly as new medications are released. Treating CDI is particularly difficult, as approximately 25% of infected individuals experience recurrent CDI (rCDI).MethodsWe used a pre-post design to measure the impact of an intervention on rCDI, CDI readmission, and guideline-adherent treatment rates in adult patients who were admitted with or contracted CDI in the hospital. The intervention included the following:• Web-based performance platform delivering education and care coordination support• CDI care coordination for 8 weeks post-discharge (Figure 1)• Education and tools for addressing CDI guidelines, workflow needs, and patient engagement• Best practice sharing through peer-to-peer discussion callsPatient Contacts ResultsAmong the 77 patients consented in the Pre-Intervention period, 12 (15.6%) patients reported a recurrence of CDI, compared to 6 (15.4%) of the 39 Intervention patients who provided a response (P = 0.98). While a total of 55 patients were consented in the Intervention period, none reported a readmission for CDI, however 9 (11.7%) of Pre-Intervention patients reported a readmission for CDI (P = 0.03). There was a significant difference (P < 0.001) between the use of appropriate treatment, as defined by the 2018 SHEA/IDSA guidelines, between the Pre-Intervention and Intervention groups (55.8% vs. 94.3%).ConclusionA comprehensive multi-disciplinary team approach to preventing rCDI, including post-discharge care coordination, provides support to patients and caregivers. Future research is needed to evaluate how web-based tools, like those used in this study, could engage patients in the management of CDI and rCDI. Interventions aimed at improving the care of these patients may reduce recurrences and rehospitalizations.Disclosures All Authors: No reported disclosures

618. Post-discharge Care Coordination Telephone Call for Patients Enrolled in the UNC OPAT Program

BackgroundAt hospital discharge, patients enter a transition period that carries risks for their health and access to care, particularly those receiving home infusion. In April 2019, to enhance care coordination at discharge, our OPAT program implemented a structured telephone outreach program.MethodsStarting in April 2019, the UNC OPAT program rolled out a patient outreach intervention. Within approximately 3 days after discharge, a pharmacist or nurse coordinator called the patient or caregiver to discuss UNC’s OPAT program, review all medications and potential adverse effects, discuss home infusion and line care, schedule relevant follow-up appointments and transportation, and address patient/caregiver concerns. To evaluate dissemination and impact, we analyzed data from UNC OPAT patients from April 2019-May 2020. We abstracted EHR data for unplanned readmissions and adverse events (hepatotoxicity, nephrotoxicity, neutropenia, eosinophilia, thrombocytopenia, creatine kinase elevation, rash, Clostridioides difficile infection, line complications). We estimated risk differences (RD) to compare outcomes between contacted versus uncontacted patients. To provide context, we also assessed unplanned readmissions and adverse events in a historical control period from April 2018-March 2019, before implementation of the outreach program.ResultsAfter rollout of the outreach program, 374 patients completed their OPAT course and all were targeted for outreach. The success rate of contacting patients was 61%. Median age was similar between contacted and uncontacted patients (52 versus 55). Unplanned readmissions occurred less frequently for contacted patients (14% versus 21%; RD -7%; 95%CI -15%, 1%). Risk of adverse events was similar between contact groups (58% versus 54%; RD 4%; 95%CI -6%, 15%). In the historical control period (n=287, median age 56), unplanned readmission risk was 22% and adverse event risk was 63%.ConclusionPatients who completed the outreach phone call had lower risk of readmission compared to those who could not be reached. This intervention may be a simple, low-cost way to reduce readmissions for OPAT patients, but further study and a sustainable reimbursement structure are needed.Disclosures All Authors: No reported disclosures

Medicare Advantage and postdischarge quality: evidence from hospital readmissions.

To compare relative readmission rates for beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM) as suggestive evidence of changes in postdischarge care coordination and the quality of care delivered to Medicare beneficiaries. We used the Agency for Healthcare Research and Quality's 2009 and 2014 Healthcare Cost and Utilization Project State Inpatient Databases for 4 states with reliable sources of payment identifiers, linking these data to local area characteristics. Our outcome was the probability of a hospital readmission within 30 days of an index admission. We computed readmission rates overall and by subgroups, including for patients with multiple chronic conditions, by patients' state of residence, and by type of index admission. We estimated linear probability models with hospital fixed effects including a wide array of patient-level characteristics relating to health status and sociodemographic characteristics. Standard errors were adjusted for clustering at the area level. Significantly lower all-cause readmission rates were found among MA enrollees relative to those in TM in both 2009 and 2014, suggesting an association between MA enrollment and higher quality of care. However, over the 2009-2014 period, MA enrollment was not associated with an increased reduction in readmission rates relative to TM. Although our focus was on a single measure of performance, the claims that managed care plans are spearheading changes in the delivery system are not supported by our finding that relative readmission rates were stable over the 2009-2014 period.

Implications of Post-Discharge Care Coordination on Survival and Healthcare Utilization for Hospitalized Heart Failure Patients

Introduction With the current global pandemic, implementation of telemedicine transitional care programs has increased across healthcare systems. These programs are also important in the care of patients with chronic comorbidities such as advanced heart failure (HF), where novel cost-effective measures are increasingly sought to improve patient-related outcomes and healthcare utilization. This study explored the impact of tailored, telemedicine-based HF care coordination (HFCC) on 12-month survival and healthcare utilization after hospital discharge. We hypothesized that HFCC improves 12-month mortality and healthcare utilization. Methods Adults (n=1994) admitted with acute decompensated HF at our center from March 2015-December 2016 underwent HFCC (n=277) vs standard care only (non-HFCC, n=1717) for up to 30-days after hospital discharge. Cardiac nurse-led HFCC provided education, coaching, and coordination of medications and HF care needs. HFCC was delivered mainly by telemedicine supplemented with in-person visits as deemed necessary by routine care providers. Survival outcomes, emergency room (ER) visits, and hospital readmissions were evaluated within 12 months of discharge from index hospitalization. Results The study cohort (mean age of 62 ± 15 years) was predominantly Caucasian males (both ≥68%), with a Charlson Comorbidity Index of 5 [3, 5]. The majority were discharged home (90% HFCC vs 84% non-HFCC, p=0.53). The HFCC cohort had a longer index hospital stay (7 [5, 10] vs 5 [3, 9] days, p Conclusions Telemedicine-based transitional care programs such as HFCC can significantly reduce the burden of ER visits during the first year after HF hospitalization. Our analysis did not reveal a benefit on subsequent hospitalization or mortality within 12-months post-discharge. Future studies are warranted to examine the impact of HFCC on guideline-directed medical therapies and additional long-term outcomes.

31 Strengthening care for infants with medical complexity during the transition from the neonatal intensive care unit to the community

Abstract Background With advances in technology and innovative medical treatments, infants who previously would have died in early infancy are living longer. These infants have significant needs in the medical system and pose challenges in coordinating care from multiple providers, especially after discharge from NICU. Objectives To engage neonatal-to-early-childhood care-transition stakeholders in implementing system-level change to champion the successful transition of infants with medical complexity into early childhood. We believe this engagement activity will spark action amongst stakeholders to adopt best practices leading to improvements in care for this vulnerable patient population. Design/Methods We explored four key care transition related questions: We organized journey mapping and focus groups with NICU alumni families whose children have medical complexity. We conducted a literature review to identify evidence-based interventions. We compiled this information to create evidence briefs that were presented to an interprofessional group of senior stakeholders using the deliberative dialogue approach. Following presentation of the evidence briefs surveys were administered to measure stakeholder intention to act on solutions presented. Results Twenty-five opportunities for improving transitions between hospital and community care teams were identified through engagement with families and project team members (graphic A). These opportunities focused on facilitating clinical navigation, navigating community services, and improving parental mental health. Forty-two stakeholders representing a children’s and women’s hospital, families, community care providers, and provincial bodies were engaged in this project. A rapid review of the literature was carried out using multiple databases searches to ensure comprehensiveness and flexible search strategies to ensure literature was found for all issues. This included a broader search of NICU discharges and nine targeted searches with medical complexity populations. Proposed solutions from stakeholders were further validated through comparisons with the literature and ultimately thirty-five papers were included in the evidence briefs. Specific care interventions were recommended to key healthcare decision makers, such as providing post-discharge care coordination in a specialized complex care clinic, implementing patient-oriented discharge summaries, and facilitating access to mental health resources. Using a seven point Likert scale the majority of stakeholders agreed that both the evidence briefs and deliberative dialogues were very successful in achieving their aim. Stakeholder intention to act on solutions presented in evidence briefs and deliberative dialogues were rated as very likely. Conclusion

Caring for people with serious injuries in urban and regional communities: a qualitative investigation of healthcare providers’ perceptions

Purpose To understand the factors that affect the management of people after serious injury in urban and regional settings, beyond hospital discharge from the perspectives of allied health professionals (AHPs). Materials and methods An exploratory qualitative study of AHPs caring for people with serious injuries post-hospital discharge in urban and regional areas of Victoria, Australia was completed. Twenty-five semi-structured interviews were undertaken with AHPs and thematically analysed. Results Allied health professionals in urban and regional settings reported the benefits of a multi-disciplinary team to deliver high-quality care. However, a number of barriers to service delivery were identified that impacted on their ability to meet the needs of patients. These included insufficient psychological services, a shortage of available carers and an unmet need for external clinical support in regional areas. Communication between AHPs and other services, and care co-ordination of post-discharge services, was also highlighted as key areas to improve for optimal patient care. Conclusions Factors that influenced optimal patient management included the availability of psychological and carer services, communication between health professionals and coordination of post-discharge care. The experiences of AHPs can offer practical suggestions to optimise service delivery and post-discharge care for people with serious injuries. Implications for Rehabilitation Allied health professionals (AHPs) face a number of challenges in the provision of optimal care to people with serious injuries. Improving the availability of psychological support and attendant carers is needed in regional areas. A designated care coordinator role may assist people with serious injuries transitioning between hospital and home to engage with necessary services and reduce administrative burden for AHPs. Telehealth may provide facilitate improved communication between health professionals and support regional clinicians caring for people with complex injuries.

Factors associated with bariatric postoperative emergency department visits

BackgroundUnplanned bariatric postoperative emergency department (ED) visits occur frequently and may represent inadequate coordination of postdischarge care. Multicenter data on this outcome is limited, as this metric has not traditionally been tracked in large clinical databases. ObjectivesTo describe the frequency of and risk factors associated with 90-day postoperative ED visits after bariatric surgery. SettingTruven Health Analytics MarketScan database. MethodsAll patients undergoing primary bariatric operations in the 2012 and 2013 MarketScan database were included. The primary outcome was the presence of an ED visit not resulting in a hospital readmission within 90 days of surgical discharge. Risk factors and demographic characteristics evaluated included age, sex, co-morbidities, insurance type, region, operation type, prior ED visits within 1 year, and index admission length of stay. ResultsPostoperative ED visits not associated with an inpatient admission occurred in 14.6% of patients. The most common diagnoses associated with these visits were abdominal pain (24.4%) and dehydration, nausea, or vomiting (20.8%). On multivariate analysis, younger age, female sex, greater number of co-morbidities, north-central region, open bariatric or laparoscopic gastric bypass operations,≥2 prior ED visits, and increased initial length of stay were all associated with increased odds of an ED visit. ConclusionsPostoperative ED visits are a frequent and potentially preventable occurrence with several risk factors. Tracking this metric as a quality indicator will allow for targeted interventions to improve the transition of care to the outpatient setting after bariatric surgery.

Patient perspective on care transitions after colorectal surgery

BackgroundThe surgical care pathway is characterized by multiple transitions, from preoperative assessment to inpatient stay, discharge from hospital, and follow-up care. Breakdowns in one phase can affect subsequent phases, which in turn can cause delays, cancellations, and complications. Efforts to improve care transitions focused primarily on post-discharge care coordination and inpatient education for medically complex patients have not demonstrated consistent effects. This study aimed to understand the expectations and perceptions of postoperative inpatients regarding transition from hospital to home in an effort to reduce patient burden. Materials and methodsPatients who underwent a colorectal resection at a large academic medical center and were discharged home were eligible to participate in the study. Patients were recruited during their postoperative hospital stays and interviewed over the phone within a week after discharge about their perceptions of care, values, and attitudes. Overall, we recruited 16 patients with benign (n = 8) and malignant (n = 8) indications. Recruitment continued until theme saturation. ResultsFactors that shaped patients' understanding of postsurgical recovery and that motivated them to seek provider attention post-discharge fell into three major groups: patient expectations versus reality, availability and role of informal caregivers in the postoperative recovery process, and communication as a key to patient confidence and trust. ConclusionsFor patients and caregivers, postoperative planning starts long before surgery and hospital admission. Providers should consider these dynamics in designing interventions to improve care transitions, patient satisfaction, and long-term outcomes. This study was limited to colorectal surgical patients treated in a single institution and may be not generalizable to other surgical procedures, non-academic settings or different regions.

Abstract 113: Predicting Short and Medium Term Hospital Readmission Following Heart Valve Surgery

Background: Although models exist for predicting hospital readmission following coronary artery bypass surgery, no similar models exist for predicting hospital readmission following heart valve surgery (HVS). Given Medicare’s financial penalties for 30-day hospital readmission and the ongoing implementation of 90-day bundled payments for cardiac surgical procedures, we developed a clinical predictive model to estimate both short and medium-term readmission for patients with HVS. Methods: Utilizing a geographically and structurally diverse sample of US hospitals (Premier Inpatient Database), we examined patient characteristics, hospital characteristics, and treatment factors predictive of short and medium term hospital readmission following HVS. The study period was from January 2007 to June 2011. A generalized estimating equation model accounted for clustering within hospitals. We set aside a random 20% of hospitals during model derivation for later use as an internal validation cohort. Results: At 219 hospitals, we identified 38,532 patients with HVS (73 years old, 56% male, 71% non-Hispanic White, with 61% aortic valve, 29% mitral valve, and 10% combination valve surgery.) A total of 3084 (8%) and 4943 (12.9%) patients were readmitted within 1 month and 3 months, respectively, with the most common reasons for readmission being heart failure, atrial fibrillation, and pleural/pericardial effusions. Among the &gt;60 factors examined, 18 independent factors were retained in the final model for predicting 3-month readmission (see table.) The strongest predictors of 3-month readmission were type of valve surgery, urgency of hospital admission, hospital length of stay, and discharge disposition. The final model had fair discrimination (C-statistic 0.667, p &lt; 0.001) and good calibration (predicted vs. observed differences of &lt;1-2% across all deciles of predicted readmission risk.) Conclusions: We described key factors that predict 3-month hospital readmission following HVS. This model should enable clinicians to identify individuals with HVS who are at increased risk of hospital readmission and who are most likely to benefit from improved coordination of post-discharge care and follow-up.

Implementing a Transitional Care Program for Older Adults at High Risk for Readmission

Background/Aims: This study describes the implementation of a transitional care program for older adults at high risk for hospital readmission. Despite increasing efforts to reduce preventable readmissions through postdischarge care coordination, little research has been done on how to operationalize transitional care in community settings. We sought to understand how implementation efforts were impacted by factors including intervention complexity, patient beliefs about transitional care, and program fidelity with ramifications on staff roles and scope of work.

Clinical characteristics associated with readmission among patients undergoing vascular surgery

Readmission after a vascular surgery intervention is frequent, costly, and often considered preventable. Vascular surgery outcomes have recently been scrutinized by Medicare because of the high rates of readmission. We determined patient and clinical characteristics associated with readmission in a cohort of vascular surgery patients. From 2009 to 2013, the medical records of all patients (n = 2505) undergoing interventions by the vascular surgery service at a single tertiary care institution were retrospectively reviewed. Sociodemographic and clinical characteristics were examined for association with 30-day readmission to the same institution. The 30-day readmission rate to the same institution was 9.7 % (n = 244). Procedures most likely to result in readmission were below-knee (25%), foot (22%), and toe amputations (19%), as well as lower extremity revascularization (22%). Patients covered by Medicaid (16.8%) and Medicare (10.0%) were most likely to be readmitted, followed by fee-for-service (9.5%), self-pay (8.0%), and health maintenance organizations (5.5%; P < .05). Patients urgently admitted were more likely to be readmitted (16.2%) than those electively admitted (9.1%; P < .01). Patient severity as rated using the All Patient Refined Diagnosis Related Groups software (3M Health Information Systems, Wallingford, Conn) predicted readmission (16.2% high vs 6.2% low severity; P < .01). Initial length of stay was longer for readmitted than nonreadmitted patients (8.5 vs 6.1 days, respectively; P < .01). Intensive care unit admission during the initial hospitalization was associated with higher readmission rates in univariable analysis (18.3% with vs 9.5% without intensive care unit stay; P < .05). Discharge destination was also a strong predictor of readmission (rehabilitation, 19.2%; skilled nursing facility, 16.2%; home, 6.2%; P < .01). The effects of urgent admission, proximity to hospital, length of stay, lower extremity open procedure or amputation, and discharge destination persisted in multivariable logistic regression (P < .05). To reduce readmission rates effectively, institutions must identify high-risk patients. Efforts should focus on subgroups undergoing selected interventions (amputations, lower extremity revascularization), those with urgent admissions, and patients with extended hospital stays. Patients in need of postacute care upon discharge are especially prone to readmission, requiring special attention to discharge planning and coordination of postdischarge care. By focusing on subgroups at risk for readmission, preventative resources can be efficiently targeted.