Post-discharge Support Research Articles

Pilot Trial of a Speech-Language Pathology Telehealth Service to Enhance Postdischarge Dysphagia Care in Singapore.

Patients and caregivers in Singapore experience issues managing dysphagia care at home following hospital discharge, and they prioritized improving access to postdischarge dysphagia care and support. Hence, a postdischarge dysphagia telehealth service was developed. This study aimed to evaluate the feasibility of this service by examining patient and service outcomes, preliminary costs, and consumer satisfaction. Patients with dysphagia and their caregivers attended one or more telehealth sessions over the initial month post-hospital discharge. Reviews of dietary adherence and preparation, swallowing function, and therapy progress were conducted. If needed, clinical support and intervention were provided. Data related to patient and service outcomes, preliminary costs, and consumer satisfaction were collected and analyzed using descriptive statistics and content analysis. Twenty patients attended 42 telehealth sessions. No support was provided during 10 sessions, minor support was provided during 13 sessions, and major support and intervention were provided to address patient and swallowing safety during 19 sessions. Out of 20 patients, 19 required support and intervention during the first week postdischarge, but they experienced fewer issues with each subsequent session. They were highly satisfied with the service. The average session duration was 29.6 min. No sessions were cancelled. This service can be delivered with minimal additional health service resources and at a low cost to consumers. This service is feasible, cost-effective, and well accepted by consumers. It facilitates early identification and management of swallowing and patient safety during the initial month post-hospital discharge. Wider implementation of this service model should be considered. https://doi.org/10.23641/asha.27327345.

Effect of a cardiovascular post discharge sms support program on healthcare utilisation - the hearthealth program

Abstract Background Cardiovascular disease (CVD) is a leading cause of mortality worldwide[1]. Targeting modifiable risk factors is key to primary and secondary prevention of CVD but many barriers to good risk factor control exist[2]. SMS message programs have shown to be an efficient modality to deliver information to improve knowledge and risk factor profiles for CVD patients[3]; however, their impact on healthcare utilisation has not been thoroughly examined. The HeartHealth program is a text message post-discharge support program delivered to CVD patients. It comprised regular semi-personalised text messages providing CVD information, advice, and support to patients over a 6-month period. Purpose This study aimed to examine the impact of the Heart Health program on healthcare service utilisation. Methods Patients ≥18 years old who recently attended cardiology clinics or were discharged from a cardiology unit, between April 2020 and April 2022 were invited to the program. We compared healthcare utilisation rates in patients who enrolled into the HeartHealth text program (intervention group) to contemporaneous patients who did not enrol in the program (control group). The primary outcome was the incidence rate of all-cause healthcare utilisation events (composite of ED presentations and/or hospital admissions for any medical cause) in the 6 months post-discharge. The secondary outcomes were incidence rates of CVD events and unplanned CVD events. All analyses were adjusted for demographic and co-morbidity variables. Results 11542 patients were included in analysis (intervention: 4324, control: 7218), mean age 58.8 years, 60.7% were male, and 78.3% with English as their preferred language. HeartHealth Intervention participants had lower rates of the primary outcome of healthcare service events compared to control participants (mean number of events 0.43 intervention vs 0.52 control, adjusted rate ratio [RR], 0.91 [95% CI, 0.83-0.99], p=0.033, Table 1). The intervention was significantly more effective in older patients compared to younger patients (RR, 0.82, [95% CI, 0.72-0.93] in patients aged ≥65 years, compared to patients <65 years, RR, 0.98, [95% CI, 0.87-1.10]; p-value for interaction =0.043, Figure 1). The subset of CVD events and unplanned CVD events were numerically lowering in the intervention group compared to the control, but the risk ratio not statistically significantly different in adjusted models (Table 1). Conclusion This analysis demonstrates that a text message post-discharge support program for CVD patients decreased the need for healthcare service utilisation for all medical causes. Future randomised controlled trials are required to further support these findings.Figure 1:Adjusted interaction analysisTable 1:Adjusted Incidence of events

Reducing rehospitalization in cardiac patients: a randomized, controlled trial of a cardiac care management program (“Cardiolotse”) in Germany

BackgroundWe conducted a prospective, randomized, controlled, two-group parallel trial investigating the effectiveness of a care management program employing cardiac care navigators providing post-discharge support to patients compared to standard care.MethodsThe intervention commenced in 2019/2020 for 2862 patients hospitalized with heart failure, coronary heart disease, or cardiac arrhythmias in departments of cardiology across eight participating sites of a hospital group in Berlin, Germany. We analyzed the results using an intention-to-treat approach. The primary outcome was the all-cause rehospitalization rate after 12 months. Secondary outcomes included rehospitalizations due to one of the qualifying cardiac diagnoses, duration of rehospitalization, mortality, health-related quality of life, and several process indicators.Trial data were collected from a combination of face-to-face and phone interviews conducted by hospital staff throughout the 12-month follow-up period using standardized questionnaires. Administrative claims data were provided by a large statutory health insurer. Outcomes for the intervention and control groups were compared using logistic regression, generalized linear models (GLMs) with a negative binomial distribution, ordinary least squares, and Cox proportional hazards regression.ResultsCompared to the control group (N = 1294), the intervention group (N = 1256) had a lower rate of all-cause rehospitalizations (62.6% vs. 66.4%, p = 0.05) and shorter lengths of stay (14.49 vs. 16.89 days, p = 0.02) during the 12-month follow-up period. These differences were also present for rehospitalizations due to the cardiac diseases qualifying for study recruitment, with rehospitalization rates for the intervention and control groups being 58.0% vs. 61.4% (p = 0.08) and particularly pronounced for lengths of rehospitalization stay of 12.97 vs. 15.40 days (p = 0.01), respectively. Subgroup analyses indicated positive effects of the intervention for patients 70 years and older (p = 0.05), females (p = 0.06), and those with little or no German language proficiency (p = 0.03). Furthermore, we found positive effects on patients’ adherence to health-related behavioral recommendations (81.91% vs. 73.95%, p = 0.000).ConclusionsThis study adds to the body of evidence indicating that care management interventions supporting patients as they transition from the inpatient to the outpatient sector can lower rehospitalizations, decrease length of rehospitalization stays, and improve adherence to post-discharge recommendations.Trial registrationGerman Clinical Trial Register, DRKS00020424. Registered 2020-06-18. (retrospectively registered).

From Hospital to Home: Applying a Co-design Approach to Determine Key Components of an Intervention to Support Transition-to-Home After Stroke

Abstract Background When people with stroke transition from the hospital back to their homes, they and their families frequently experience multi-faceted unmet needs and feelings of abandonment. Uncertainty surrounds the fundamental components of an intervention intended to support transition-to-home after a stroke. The aim of this study was to utilise a co-design process to identify key components for a patient-centred support intervention facilitating the transition home after stroke, and to explore what might be feasible within a real-world context. Methods The primary researcher, a larger team of researchers, and an individual with lived experience of stroke facilitated a series of three workshops for 12 people with stroke, 6 caregivers, 26 healthcare professionals, and 6 representatives from stroke organisations. World Café methodology and Liberating Structures facilitation techniques were adapted to meet the study aim. Data collection involved making observations during workshops, summarising findings, and reaching group consensus agreement on outputs. The final output was the consequence of facilitated consensus on a prioritisation task. Individuals with lived experience of stroke contributed to study design, ethics, and co-design outputs, providing input for future research and co-facilitating workshops with the research team. Results The co-design group identified 10 key intervention components to support people with stroke and their families during the transition from hospital-to-home. These components focussed on enhancing collaboration, streamlining transition processes, and facilitating post-discharge support. While a stroke coordinator was considered a top priority, increased cross-setting information sharing and community-based healthcare staff in-reach, were considered most feasible to implement. Conclusion The co-design approach, involving a multi-stakeholder group, was strengthened by patient and public involvement. This ensured that the identified transition-to-home intervention components are meaningful and relevant for people with stroke and their families. To further refine, and feasibility test the components for generalisability within the wider Irish healthcare context, additional co-design workshops are required.

From Hospital to Home: Applying a Co-Design Approach to Determine the Key Components of an Intervention to Support Transition-To-Home After Stroke.

People with stroke and their families face numerous challenges as they leave hospital to return home, often experiencing multifaceted unmet needs and feelings of abandonment. The essential elements of an intervention intended to support transition-to-home after stroke are unclear. The aim of the project was to engage in a co-design process to identify the key components of a pragmatic intervention to inform a transition-to-home support pathway following stroke. The study was conducted using a co-design process engaging multiple stakeholders, including 12 people with stroke, 6 caregivers, 26 healthcare professionals and 6 individuals from stroke organisations in a series of three workshops, facilitated by the primary researcher, a wider team of researchers and an individual with lived experience of stroke. World Café methodology and Liberating Structures facilitation techniques were adapted to meet the aim of the workshops. Data collection involved observations during workshops, followed by summarising of findings and reaching group consensus agreement on outputs. Facilitated consensus on a prioritisation task resulted in the final output. The co-design group identified 10 key intervention components of a transition-to-home support pathway following stroke. These components focussed on enhancing collaboration, streamlining transition processes and facilitating post-discharge support. While a stroke coordinator was considered a top priority, increased cross-setting information sharing and community in-reach, where community-based healthcare staff extended their services into hospital settings to provide continuity care, were considered most feasible to implement. The co-design approach, involving a multi-stakeholder group and strengthened by patient and public involvement, ensured that the identified transition-to-home intervention components are meaningful and relevant for people with stroke and their families. Further co-design workshops are required to refine, and feasibility test the components for generalisability within the wider Irish healthcare setting. Individuals who have experienced a stroke actively contributed to shaping the methodological design of this study and the ethics process. They engaged in the analysis of co-design outputs and provided input for the discussion and recommendations regarding future research. An individual who had experienced a stroke formed part of the research team, co-facilitating the co-design workshops and co-authoring this article.

Feasibility of a Dutch post-discharge parenting intervention (TOP program) for moderate preterm born infants

Background and aimModerate preterm (MP) birth is associated with an increased risk of developmental problems. However, post-discharge support for this group is scarce. The aim of this study was to evaluate the feasibility of a post-discharge parenting program (TOP program) for MP infants. Three feasibility dimensions were evaluated (1) recruitment capability and compliance, (2) intervention acceptability, and (3) limited efficacy testing. MethodsA group of MP infants with a gestational age (GA) between 320/7‐346/7 weeks and their parents received six home visits by a TOP interventionist until 6 months corrected age (CA). A pre-posttest intervention design with quantitative and qualitative measures was used.Recruitment capability and compliance, acceptability, and satisfaction with the intervention were evaluated using a questionnaire, checklists, interviews, and a focus group. Infant socio-emotional development, parental distress, self-efficacy, and reflective functioning were measured with questionnaires. Observation measurements were used for infant motor development and parental sensitivity. ResultsThirty-two families completed the six home visits. The satisfaction rate (scale 0–10) was remarkably high (Mean 9.4, range: 8–10). Parents reported that the program was suitable, enhanced their understanding of their infants' developmental needs, and increased their self-efficacy. The infants showed age-appropriate motor and socio-emotional development post-intervention. Parental self-efficacy, reflective functioning, and sensitivity improved from pre to post intervention, with small to large effect sizes. ConclusionThe study demonstrated high compliance, acceptability, and satisfaction with the TOP program for MP infants with promising infant and parent outcomes. This study contributes to the preparatory work prior to a larger scale evaluation and dissemination.

ThP1.4 - Evidence-Based Perioperative Improvements in Microvascular Breast Free Flap Reconstruction: An Audit-Centric Evaluation & Retrospective Cohort Study

Abstract Aim This audit aimed to evaluate and improve the results of microvascular breast free flap reconstruction by implementing an enhanced perioperative care approach. Method All microvascular breast free flap reconstructions between June to August 2023 were included. Additionally, a three year retrospective review was conducted in adherence to ABS and the BAPRAS guidelines. Our team plans to introduce an evidenced-based modified Enhanced Recovery After Surgery (ERAS) protocol via MDT collaboration with a focus on pre-operative and post-operative care to improve postoperative outcomes. Results During June – August 2023, 22 flaps were performed with an average length of stay (LOS) of 5.47 days (target <3d). There were no unplanned readmissions, an 18% return to theatre (RTT) rate and a total complication rate of 18%. Over the past three years, out of 323 flaps, there was a 13% RTT rate with no unplanned readmissions. Suggested modifications to reduce length of stay include pre-surgical counselling and nutritional loading. Post-operatively, using a multi-modal opioid sparing analgesia (MOSA) regime, along with laxatives, early mobilisation and feeding has proven to enhance recovery. Pre-admission patient optimisation, VTE and perioperative antibiotic prophylaxis have been shown to reduce rates of flap failures and post-operative complications. Effective wound care, post-discharge support and physiotherapy are also crucial in accelerating recovery and preventing readmissions. Conclusion Implementing these ERAS modification to our current protocol is predicted to significantly improve post-operative recovery, thus improving surgical outcomes. This underscores the potential for continual improvement in patient care through an efficient evidence-based perioperative pathway.

LIFE AFTER STROKE AND THE KEY ROLE OF COORDINATED REHABILITATION FROM THE PERSPECTIVE OF THE STROKE SURVIVOR FAMILIES

Introduction. Stroke significantly affects the lives of survivors, requiring adaptation to lost capabilities while impacting physical, mental, and emotional well-being. Stroke is a leading cause of acquired disability in adults and a significant contributor to mortality, particularly among older individuals and in low-income countries. A stroke is described as a neurological deficit caused by acute damage to the central nervous system. Aim. The study's main aim was to explore the use of coordinated stroke rehabilitation before, during, and after hospital discharge. It examined components of coordinated rehabilitation, focusing on the needs of the client's family. This study was conducted as part of the GAJU 066/2022/S project and approved by the ethics committee under 6/2022. Materials and methods. This study used a qualitative research approach and semi-structured interviews with family members caring for stroke patients. The data collected was then analyzed using various coding strategies with the assistance of ATLAS.ti software. This rigorous methodology ensured the reliability and validity of the study's findings. Results. The effects of strokes are profound, not only on patients but also on their families and caregivers. Adapting to life after a stroke necessitates significant changes in family dynamics, values, and norms. The importance of effective communication and support from healthcare staff during patient hospitalization cannot be overstated. Respondents highlighted the role of quality care and communication in ensuring a positive hospital stay. However, they also pointed out certain deficiencies, such as delayed stroke diagnosis and inadequate information about post-discharge care and rehabilitation. The study underscored the importance of at-home rehabilitation in familiar environments for functional improvement. Conclusions. Life after a stroke presents a substantial challenge for patients and their families, requiring physical, psychosocial, and emotional adaptation. Coordinated rehabilitation facilitates post-stroke adjustments for patients and families and increases overall quality of life. Improved coordination and communication among healthcare providers, development of multidisciplinary rehabilitation teams, and effective post-discharge monitoring and support systems are essential for comprehensive care tailored to the needs of the patient and their families. Stroke patient family members advocate for enhanced support and services for better rehabilitation and for coping with post-stroke challenges.

Discharging patients home from the intensive care unit: A new trend.

Discharging patients directly to home from the intensive care unit (ICU) is becoming a new trend. This review examines the feasibility, benefits, challenges, and considerations of directly discharging ICU patients. By analyzing available evidence and healthcare professionals' experiences, the review explores the potential impacts on patient outcomes and healthcare systems. The practice of direct discharge from the ICU presents both opportunities and complexities. While it can potentially reduce costs, enhance patient comfort, and mitigate complications linked to extended hospitalization, it necessitates meticulous patient selection and robust post-discharge support mechanisms. Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition. Through critical evaluation of existing literature, this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery. The insights provided contribute evidence-based recommendations for refining the direct discharge approach, fostering improved patient outcomes, heightened satisfaction, and streamlined healthcare processes. Ultimately, the review seeks to balance patient-centered care and effective resource utilization within ICU discharge strategies.

The relationship between psychiatric inpatient length of stay and suicide prevention

Suicide prevention remains a critical concern within mental health care, particularly for individuals with psychiatric disorders. This review examines the relationship between the length of inpatient psychiatric admission and its effectiveness in preventing suicide. The study analyzes existing literature on admission duration, in-hospital and post-discharge suicide rates, and factors influencing these outcomes such as treatment quality, patient characteristics, and post-discharge support systems. While some evidence suggests longer stays may be beneficial for certain diagnostic groups, the quality and intensity of care during admission and robust post-discharge support appear equally crucial. The review highlights the importance of individualized care plans, comprehensive suicide prevention programs, and strong transitional support. It also discusses international perspectives, ethical considerations, and special populations. The paper concludes that an effective approach to suicide prevention should focus on tailored admission lengths, high-quality care, and seamless transitions to community support, rather than solely on extending lengths of stay.

Preventing medication errors in patients with decompensated heart failure and cognitive impairment following hospital discharge, in Saudi Arabia

Abstract Background Heart failure (HF) is a progressive health challenge, with an increased prevalence of 30% in older adults. It is estimated that approximately 50% of patients with HF have a degree of cognitive impairment, affecting adherence to self-care and medication taking. Therefore, medication errors are becoming a global health challenge and account was estimated at 44.4% in Saudi Arabia. Purpose To explore the perspectives of patients with cognitive impairment and their caregivers on the pre-discharge medication education received. Methods A qualitative study, using semi-structured interviews. 7 dyads were recruited from a Cardiac center in Saudi Arabia The purposive sample was selected of patients who are identified as having cognitive impairment, as assessed by Montreal Cognitive Assessment scale (MoCA). Caregivers were nominated by the respective patient. Interviews were audio recorded, transcribed in Arabic, and translated into English. Transcripts were checked for authenticity. Data were analysis using thematic analysis. Results Most patients identified as male (n=5), including both patients with mild cognitive impairment (n=4) and moderate cognitive impairment (n=3). Four major themes were identified Complexity of Medication Management: Patients and caregivers struggle with the multifaceted nature of medication regimens, indicating a need for simplified schedules and clear instructions. Importance of Clear Communication and Education: There’s a critical need for comprehensive, understandable information about the indications and side effects of the medications. This should be tailored to individual learning preferences. Crucial Role of Caregiver Support: Caregivers have an important role in ensuring medication adherence. Some highlighted the benefit of being included in educational interventions. Challenges with Post-Discharge Support: All participants expressed a sense of abandonment post-discharge, with difficulties in accessing follow-up. Conclusion The study highlights the need for simplified medication regimens, enhanced communication, and comprehensive education for heart failure patients with cognitive impairment and their caregivers. Addressing these interconnected challenges through a multifaceted approach is crucial for improving medication management, adherence, and overall patient outcomes.

Usage and limitations of medical consultation with patients’ families using online video calls: a prospective cohort study

BackgroundFew studies have been conducted on the usage of telehealth focusing on consultations between patients’ families and physicians. This study aimed to identify the usage and limitations of online medical consultations with patients’ families compared to the traditional in-person consultations.MethodsWe conducted a prospective cohort study from April 1, 2020, to September 30, 2021, at an educational acute-care hospital in Japan. The study included hospitalized patients aged 20 years or older and their family members for whom an online or in-person medical consultation between the family member and physician was conducted during the hospitalization period. The primary endpoints assessed were three topics pertaining to medical consultation: medical conditions and treatment plans, policies for life-threatening events, and post-discharge support. The secondary endpoint was the number of consultations required.ResultsOnline consultations and traditional in-person consultations were provided to 58 and 53 patients’ families, respectively. Of the patients in the online consultation group who underwent multiple consultations, 46 (79%) also underwent in-person consultations. Regarding the topics, all the patients’ families in both consultation groups had consultations on medical conditions and treatment plans; regarding the policy for life-threatening events, 47% of patient families in the online consultation group were consulted compared to 53% of those in the in-person group. Regarding post-discharge support, 59% of patient families in the online group were consulted compared to 40% in the in-person group. In the online consultation group of 58 patients’ families, 188 consultations were conducted, including 95 online and 93 in-person consultations. Consultations on policy for life-threatening events were significantly more frequent in in-person consultations than in online consultations (p < 0.05). Regarding post-discharge support, online consultations were significantly more frequent than in-person consultations (p < 0.05). The number of family members who attended online consultations was significantly higher than those who attended in-person consultations (p < 0.05).ConclusionsOnline consultation between the physician and patient’s family may be an alternative to in-person consultation for explaining medical conditions and treatment plans. However, in-person consultation still plays an important role in sensitive topics, such as policy consultation for life-threatening events.

Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria

BackgroundSub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach.MethodsWe followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10–13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed.ResultsBased on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants.ConclusionsThrough dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.

Advancing Pediatric Care: The virtualKIDS Experience in Nursing-Led Audio-Visual Clinical Services.

During the COVID-19 pandemic, the escalating trend of pediatric patients, particularly non-urgent cases, going to the emergency departments (EDs) in New South Wales, Australia, prompted the establishment of virtualKIDS, a nursing-led telehealth service. This service, initiated in June 2021, operates 24/7 and provides comprehensive care through audio-visual consultations emphasizing a patient-centered approach. Three elements-COVID-19 Outpatient Response Team (CORT), virtualKIDS Acute Review (vKAR), and Virtual Urgent Care (VUC)-addressed specific needs during and beyond the pandemic, showcasing the adaptability and impact of virtual care. vKAR focuses on post-discharge support, allowing families access to telehealth for up to three days. Preliminary data indicates a 44% reduction in ED visits within 48 h. VUC employs nursing-led triaging paired with audiovisual assessment, demonstrating a 69% hospitalization avoidance rate. Hybrid ambulatory models such as a sleep study at home project, day-only tonsillectomies, and arthroscopic knee surgeries showcase innovative approaches to reducing hospital admissions and enhancing patient outcomes. This paper presents the evolution and diverse models of care implemented by the virtualKIDS service, offering insights into its potential as a nursing-led alternative to ED visits in acute-care pediatrics.

Hospitalized Patients with Delirium and 28-Day Unplanned Hospital Readmissions: A Longitudinal Retrospective Cohort Study

ObjectiveTo establish the predictors of 28-day unplanned hospital readmissions (28D-UHR) in older adults (aged >65 years) with delirium during index hospital admission. DesignRetrospective longitudinal cohort study. Setting and Participants1634 patients (aged >65 years) admitted to a Melbourne quaternary hospital with delirium during index admission. MethodsDelirium during hospital admission was defined by the inclusion of one of the following International Classification of Diseases, Tenth Revision, codes F05.0, F05.1, F05.8, or F05.9 in the hospital medical discharge summary. Descriptive statistics were obtained for baseline characteristics. Multivariate logistic regression model was developed to assess predictors of 28D-UHR. ResultsA total of 1634 patients with delirium during their inpatient admission were included, with 9.8% (160 patients) incidence of 28D-UHR. For patients who were readmitted, a shorter length of stay [odds ratio (OR) 0.98, 95% CI 0.96-0.99], higher number of medications on discharge from index admission (OR 1.10, 95% CI 1.06-1.14), and residing in a nursing home preadmission (OR 1.35, 95% CI 1.04-1.75) were associated with 28D-UHR. Conclusions and ImplicationsThis study found that nursing home residence pre index admission, shorter length of stay (LOS), and polypharmacy were predictors of 28D-UHR. Further research into strategies to minimize 28D-UHR is required. Exploration of predischarge pharmacy-driven deprescribing programs and hospital-based postdischarge support for nursing home staff are important areas for future intervention.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial.

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge. The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability. We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record. This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025. The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes. DERR1-10.2196/54211. ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center

BackgroundLow health literacy (HL) has been associated with poor health outcomes in children. Optimal recovery after pediatric injury requires caregiver participation in complicated rehabilitative and medical aftercare. We aimed to quantify HL among guardians of injured children and identify factors associated with low HL of guardians. MethodsA prospective observational cohort study was conducted to evaluate the HL using the Newest Vital Sign™ of guardians of injured children (≤18 years) admitted to a level 1 pediatric trauma center. Patient and guardian characteristics were compared across levels of HL using univariate statistics. We conducted multivariable logistic regression to identify factors independently-associated with low HL. ResultsA sample of 95 guardian-child dyads were enrolled. The majority of guardians had low HL (n = 52, 55%), followed by moderate HL (n = 36, 38%) and high HL (n = 7, 7%). Many families received public benefits (n = 47, 49%) and 12 guardians (13%) had both housing and employment insecurity. Guardians with low HL were significantly more likely to have insecure housing and not have completed any college. ConclusionThe majority of injured children had a primary guardian with low HL. Pediatric trauma centers should consider screening for low HL to ensure that families have adequate post-discharge support. Level of EvidenceLevel 3.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia.

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge. A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated. ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided. These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Novel Definitions of Wellness and Distress among Family Caregivers of Patients with Acute Cardiorespiratory Failure: A Qualitative Study.

Rationale: Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions. Objectives: To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress. Methods: Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach. Results: Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements: 1) positive versus negative physical and psychological outcomes, 2) high versus low capacity for self-care, 3) thriving versus struggling in the caregiving role, and 4) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes. Conclusions: Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.

Adult Burn Survivors and Burn Care Staff Perceptions Regarding Transitioning From the Burn Unit: A Cross-Country Qualitative Study in Ghana and China.

Rehabilitative care for burn patients in developing countries is often wrought with several issues. Post-discharge support is equally challenging as there is often limited rehabilitative care as the burn survivors and their families transition. To inform practice, this study sought to explore the perspectives of adult burn survivors and burn care staff regarding transitioning from the burn unit and the development of a transitional rehabilitation programme. We employed interpretive description for this study. Semi-structured face-to-face interviews were conducted with adult burn survivors and burn care staff across two tertiary healthcare facilities in Lanzhou, Gansu Province of China, and Ghana. The thematic analytical approach was employed to analyse the data. Forty-six participants comprising 26 adult burn survivors and 20 burn care staff participated in this study. Two themes and five subthemes emerged from the data. Transitioning from the burn unit to the home was described as complex with varied biopsychosocial needs emerging. However, available support was not comprehensive to resolve these needs. Existing pre-discharge support is limited across both settings. Burn survivors expressed interest in taking on an active role in the rehabilitation process and being able to self-manage their post-burn symptoms following discharge. Transitional rehabilitative support should include an active follow-up system, ensure patient- and family-centred support, and offer a bundle of comprehensive rehabilitative services using locally available items which do not financially burden burn survivors and their families. In conclusion, transitioning from the burn unit is filled with varied health needs. Transitional rehabilitative care is required to bridge the pre-discharge and post-discharge periods.