Successful Transition Of Care Research Articles

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Hospitalists' Attitudes and Experiences With Posthospitalization Care Transitions for Patients With Substance Use Disorders: A Cross-sectional Analysis.

Medical hospitalizations are relatively common among individuals who have substance use disorders (SUDs) and represent opportunities for patient engagement and treatment. Posthospitalization transitions of care are an important element of providing full-spectrum inpatient SUD care; however, little is known about clinicians' experiences with postdischarge care transitions. We conducted a cross-sectional study surveying hospital-based medical clinicians (ie, "hospitalists") across 2 large health systems in the state of Utah to assess current practices, barriers, facilitators, and perceptions toward posthospitalization care transitions for patients with SUDs. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of hospitalists' attitudes toward providing SUD care on perceived barriers and facilitators. The survey was distributed to 429 individuals across 15 hospitals. Eighty-two hospitalists responded to the survey (response rate, 21.4%). Most respondents frequently cared for hospitalized patients with SUDs (n = 63, 77%) and prescribed medications for SUDs (n = 44, 56%). Four respondents (5%) felt that patients received adequate support during care transitions. Lack of social support (P < 0.001) and social factors such as lack of transportation (P < 0.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician (P < 0.001) and outpatient-based care coordination (P < 0.001) were perceived as the strongest facilitators. Respondents' attitudes toward people with SUDs had a modest effect on perceived barriers and facilitators. Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating posthospitalization care transitions for patients with SUDs.

Transition of care of adolescents with rheumatic diseases in Saudi Arabia, current practice and obstacles

BackgroundThe importance of transition of care for adolescents with rheumatological illnesses from pediatric to adult rheumatology is increasing as the childhood rheumatologic diseases continue to adulthood. Despite that, transition practice in Saudi Arabia is not yet well-developed. ObjectivesThis study aims to evaluate the current transition of care practice for adolescents with rheumatological diseases to the adult healthcare facilities and the obstacles in achieving the best transition of care in Saudi Arabia. Setting and methodsThis is a non-interventional cross-sectional study conducted using an online survey that was distributed to pediatric and adult rheumatologists in Saudi Arabia. Google forms and Microsoft Excel 2016 were used for data entry and analysis. Descriptive statistics, frequencies and percentages were performed for categorical variables. ResultsA total number of 60 rheumatologists (27 pediatric and 33 adult) participated in the survey. Fifty-six (94%) of the participants do not follow any standardized programs for transition of care. All participants agreed on the need for a defined protocol for transition of care. The major barriers for successful transition of care were lack of protocols (63%), lack of healthcare providers (56%), and lack of well-developed systems that makes it difficult to access patient's electronic health records (55%). ConclusionA well-structured protocol for transition of care of adolescents with rheumatologic illnesses from pediatric to adult rheumatology in Saudi Arabia is still an unmet need. Efforts should be directed towards improving the practice of transition of care by establishing this protocol, enhancing the connectivity between pediatric and adult healthcare facilities, and encouraging pediatric and adult rheumatologists to adapt the transition of care protocol in their daily clinical practice.

Implementation of the Acute Care for Elders Strategy to Improve the Quality of Care Transitions in Quebec and Ontario: a Retrospective Multiple Case Study.

In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach. Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance. Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.

Optimum Care of AKI Survivors Not Requiring Dialysis after Discharge: An AKINow Recovery Workgroup Report.

AKI survivors experience gaps in care that contribute to worse outcomes, experience, and cost.Challenges to optimal care include issues with information transfer, education, collaborative care, and use of digital health tools.Research is needed to study these challenges and inform optimal use of diagnostic and therapeutic interventions to promote recovery AKI affects one in five hospitalized patients and is associated with poor short-term and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This article highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions, facilitated small group discussions, and debriefing. Core challenges and opportunities for AKI care identified were in the domains of transitions of care, education, collaborative care delivery, diagnostic and therapeutic interventions, and digital health applications. Integrated multispecialty care delivery was identified as one of the greatest challenges to AKI survivor care. Adequate templates for communication and documentation; education of patients, care partners, and clinicians about AKI; and a well-coordinated multidisciplinary posthospital follow-up plan form the basis for a successful care transition at hospital discharge. The AKINow Recovery workgroup concluded that advancements in evidence-based, patient-centered care of AKI survivors are needed to improve health outcomes, care quality, and patient and provider experience. Tools are being developed by the AKINow Recovery workgroup for use at the hospital discharge to facilitate care continuity.

Abstract 17643: Pharmacist-Driven Inpatient to Tele-Clinic Transitions of Care: The PICTOC Quasi-Experiment to Reduce 30-day Readmissions in Patients With Heart Failure

Introduction: Successful transitional care models leverage the same clinician, typically nurses, to deliver and coordinate interventions across settings for patients with heart failure. However, pharmacists may be well-suited to lead these efforts given that medication-related issues are often drivers for 30-day readmission. We implemented a pharmacist-driven inpatient to tele-clinic transitions of care (PICTOC) program and evaluated its impact on readmissions at an academic medical center. Methods: Pharmacists provided hospital-based transitional care services two half-days per week between June 2020 and September 2022. They identified patients admitted for heart failure who were established at or referred to specific primary care practices. Patients were prioritized by discharge date and interventions included medication optimization, education, appointment scheduling within 14 days, and a post-discharge telemedicine visit with the pharmacist. A quasi-experimental design was used to compare the 30-day readmission rate in PICTOC group to a control group of patients who met eligibility criteria but were discharged prior to receiving the intervention. Intention-to-treat and per-protocol analyses were performed using Chi-square test. Results: There were 1346 patients included. The mean (SD) age was 67.0 (13.8) years, 51.3% were male and 503 patients received the PICTOC intervention. The 30-day readmission rate in the intention-to-treat group was 15.5% compared to 17.9% in the control group (p=0.25). Among the 75% of patients who attended the pharmacist telemedicine visit per protocol, the readmission rate was 13.5% (p=0.059). Patients in PICTOC group had higher rates of scheduled follow-up with primary care (59.2% vs. 53.7%, p=0.048) and cardiology (48.7% vs. 37.6%, p=0.0001). Appointment attendance with primary care was significantly higher in the PICTOC group (72.5% vs. 61.8%, p=0.0023) and trended higher with cardiology (69.4% vs. 65.9%, p=0.39). Conclusion: The PICTOC program improved transitional care quality and outcomes among patients with heart failure. Additional analyses of this novel care delivery model are warranted.

Disparities in transitions of acute stroke care: The transitions of care stroke disparities study methodological report

ObjectiveThe Transitions of Stroke Care Disparities Study (TCSD-S) is an observational study designed to determine race-ethnic and sex disparities in post-hospital discharge transitions of stroke care and stroke outcomes and to develop hospital-level initiatives to reduce these disparities to improve stroke outcomes. Materials and methodsHere, we present the study rationale, describe the methodology, report preliminary outcomes, and discuss a critical need for the development, implementation, and dissemination of interventions for successful post-hospital transition of stroke care. The preliminary outcomes describe the demographic, stroke risk factor, socioeconomic, and acute care characteristics of eligible participants by race-ethnicity and sex. We also report on all-cause and vascular-related death, readmissions, and hospital/emergency room representations at 30- and 90-days after hospital discharge. ResultsThe preliminary sample included data from 1048 ischemic stroke and intracerebral hemorrhage discharged from 10 comprehensive stroke centers across the state of Florida. The overall sample was 45% female, 22% Non-Hispanic Black and 21% Hispanic participants, with an average age of 64 ± 14 years. All cause death, readmissions, or hospital/emergency room representations are 10% and 19% at 30 and 90 days, respectively. One in 5 outcomes was vascular-related. ConclusionsThis study highlights the transition from stroke hospitalization as an area in need for considerable improvement in systems of care for stroke patients discharged from hospital. Results from our preliminary analysis highlight the importance of investigating race-ethnic and sex differences in post-stroke outcomes.

Juvenile Idiopathic Arthritis (JIA) Transitional Care Systems Require Revision to Improve Patient Outcomes: Opinion Review

Juvenile Idiopathic Arthritis (JIA), encompassing a class of arthritis for which there is no known origin, is the most common chronic inflammatory rheumatic condition arising during childhood. It is associated with a diverse host of complications resulting from immune and growth dysregulation characteristic of JIA pathogenesis. Past evidence has shown that care of JIA patients as they transition into adulthood — whether it be psychological, rheumatological, etc. — has been significantly and systemically overlooked. Patients have reported feeling increasingly overwhelmed, unprepared, and dismissed during this time of care. Therefore, improving pediatric patients’ experiences, as they navigate transition readiness into the adult healthcare system is a prevalent issue. This report aims to provide evidence on JIA-specific institutional barriers to a successful transitional care experience into adulthood in multiple comparator jurisdictions. This investigation, which analyzed both qualitative and quantitative evidence, revealed that major obstructions to constructive transitional care experiences include: flaws in JIA classification and diagnosis, lack of critical skill building pre-transition, insufficient patient education on their condition, and absence of adult healthcare provider support post-transition. Despite major limitations existing within transitional care provision, there are a variety of successful frameworks that warrant more attention and analysis. Consequently, future directions should focus on these effective models for guidance in order to improve transitional care resources and services, and better support JIA patients.

Incorporating cancer survivorship care in dental education.

Incorporating cancer survivorship care in dental education.

Evaluation and Management of Rectal Prolapse Among Geriatric Patients.

Evaluation and management of older adults within emergency care settings is often complex and has the potential for avoidable complications. In an effort to prevent harm to the patient, treatment strategies need to be multifactorial. For geriatric patients presenting with rectal prolapse, unique management strategies, including the use of granulated sugar and gentle pressure, may assist in the reduction of the prolapsed tissue. Additional interventions that are important to incorporate into the older adult's plan of care include gentle approaches to positioning, involvement of family/caregivers, avoiding harmful medications, reducing risk for delirium, and a successful transition of care. A manual reduction completed in the emergency department can relieve discomfort and prevent further complications while the patient awaits surgical evaluation and intervention. Prompt evaluation and management by the advanced practice registered nurse may not only expedite recognition of the prolapse, but can reduce iatrogenic complications that may occur from delayed treatment.

Validation of the Transition Readiness Assessment Questionnaire (TRAQ) 5.0 for use among youth in mental health services.

Among youth with psychiatric disorders, the transition from child to adult mental health services is a period of vulnerability to discontinuous care and service disengagement. Regular assessment of transition readiness has been identified as a core component of transition planning, contributing to successful care transitions. The Transition Readiness Assessment Questionnaire (TRAQ) 5.0 is a 20-item questionnaire that measures transition readiness in youth preparing to transition to adult care. Although the TRAQ has been validated and used across many health settings, it has not been validated in youth with primarily mental health concerns. The objective of this study was to validate the TRAQ for use among youth accessing mental health services. This study used the Longitudinal Youth in Transition Study baseline cohort, which consists of 237 clinically referred youth (aged 16-18 years) receiving outpatient mental health treatment. Psychometric evaluation of the TRAQ 5.0 included confirmatory factor analysis (CFA), assessment of internal consistency, testing convergent validity using the Dimensions of Emerging Adulthood (IDEAS) and Difficulty in Emotional Regulation (DERS) scales, criterion validity using a question on whether the participant had talked about transition with their clinician and known-group testing based on age. The CFA indicated adequate fit of the five-factor TRAQ structure. The overall scale (=.86) and three of the subscales demonstrated adequate internal consistency. As hypothesized, overall TRAQ scores were higher for youth who had discussed transition and those aged 18. Small correlations were found between the overall TRAQ score and measures of developmental maturity (IDEAS) and emotional awareness (DERS); however, certain subscales did not demonstrate correlation with these constructs. The TRAQ 5.0 appears to be valid tool to assess the transition readiness of youth in outpatient mental health services. Additional work needs determine whether findings are similar among specific mental health conditions, including substance use disorders and psychotic disorders.

Barriers and Challenges to Successful Transition of Young People with Emotional Behavioral Disorders

The overriding aim of this study was to provide a critical and comprehensive qualitative review of the current evidence regarding the barriers and challenges that delay successful transition of children and youths with emotional behavioral disorders (EBD) from the child- to adult-centered care systems. Methodology: To achieve the research aim mentioned above, empirical studies were electronically searched from leading databases such as NCBI, MEDLINE, EMBASE, PsycINFO, Proquest, CINAHL, and Google Scholar among other databases. Journals and reference lists relating to the transition of young people with EBD were also hand-searched to help in identifying unpublished manuscripts. Results and Discussion: In total, 11 studies were identified and included in this systematic review. Following a careful and a critical analysis of the various evidence-based studies reviewed, it emerged that the primary barriers and challenges to successful transitional care include: funding restrains and lack of resources; training gaps and different working practices and treatment philosophies between child- and adult-centered care systems; lack of transition services such as age-specialized case management and vocational support; as well as poor communication and collaboration between child- and adult-centered care systems. Other barriers identified in the available evidence-based literature, though they were reported to have a minor impact on successful transitional care include the general practitioners’ failure to refer young people, young people are not engaging in any kind of services because of stigmatizing attitudes, and incapacity to engage in outreach work. Conclusions and Recommendations: Though most of the studies reviewed in this systematic review are US and UK based, there is high-quality evidence to affirm that the above-listed factors are the main challenges and barriers to the successful transition of young people with EBD from the child- to adult-centered care systems. Therefore, a robust transitional care for young people with EBD may be achieved by filling the policy-practice gap and addressing the barriers mentioned above. &nbsp;

Improving Transitions of Care: Designing a Blockchain Application for Patient Identity Management

Background: The current healthcare ecosystem in the United States is plagued by inefficiencies in transitions of patient care between healthcare providers due in large part to a lack of interoperability among the many electronic medical record (EMR) systems that exist today. Both providers and patients experience significant frustration due to the negative effects of increased costs, unnecessary administrative burden, and duplication of services that occur because of data fragmentation in the system. Blockchain technology provides a solution to mitigate or eliminate these gaps by allowing for healthcare information exchange that is distributed, auditable, immutable, and respectful of patient autonomy. Our multidisciplinary team identified key tasks required for a transition of care to design and develop a blockchain application, MediLinker, that served as a patient-centric identity management system to address the issues of data fragmentation ultimately allowing for the delivery of high value care. &nbsp; Methods: The MediLinker application was evaluated for its ability to accomplish various key tasks needed for a successful transition of patient care in an outpatient setting. Our team created twenty unique patient use cases covering a diversity of medical needs and social circumstances that were played out by participants who were asked to perform various tasks as they received case across a simulated healthcare ecosystem composed of four clinics, a research institution, and other ancillary public services. Tasks included, but were not limited to, clinic enrollment, verification of identity, medication reconciliation, sharing insurance and billing information, and updating demographic information. With this iteration of MediLinker, we specifically focused on the functionality of Guardianship and patient revocation of healthcare information. Additionally, throughout the simulation we surveyed participant perceptions regarding the use of MediLinker and blockchain technology to better ascertain comfortability and usability of the application. &nbsp; Results: Quantitative evaluation of simulation results revealed that MediLinker was able to successfully accomplish all seven clinical scenarios tested across the twenty patient use cases. MediLinker successfully achieved its goal of patient-centered interoperability as participants transitioned their simulated healthcare data, including COVID-19 vaccination status and current medications, across the four clinic sites and research institution. In addition to completing all key tasks designated, all eligible participants were able to enroll with and subsequently revoke data access with our simulated research site. A high degree of data accuracy was noted with most errors occurring due to inaccurate data entry from user input. Our qualitative analysis of user perceptions indicated that comfortability and trust with blockchain technology, such as MediLinker, grew with increased education and exposure to such technology. &nbsp; Conclusion: The ubiquitous problem of data fragmentation in our current healthcare ecosystem has placed considerable strain on providers and patients alike. Blockchain applications for health identity management, such as MediLinker, provide a viable solution to stem the inefficiencies that exist today. The interoperability that MediLinker provided across our simulated healthcare system has the potential to improve transitions of care by sharing key aspects of healthcare information in a timely, secure, and patent-centric fashion allowing for the delivery of consistent personalized high-value care. Blockchain technologies appear to face similar challenges to widespread adoption as other novel interventions, namely recognition, trust, and usability. Further development and scaling are required for such technology to realize its full potential in the real-world and transform the practice of modern healthcare.

Improving Transitions of Care: Designing a Blockchain Application for Patient Identity Management.

The current healthcare ecosystem in the United States is plagued by inefficiencies in transitions of patient care between healthcare providers due in large part to a lack of interoperability among the many electronic medical record (EMR) systems that exist today. Both providers and patients experience significant frustration due to the negative effects of increased costs, unnecessary administrative burden, and duplication of services that occur because of data fragmentation in the system. Blockchain technology provides a potential solution to mitigate or eliminate these gaps by allowing for exchange of healthcare information that is distributed, auditable, immutable, and respectful of patient autonomy. Our multidisciplinary team identified key tasks required for a transition of care to design and develop a blockchain application, MediLinker, which served as a patient-centric identity management system to address issues of data fragmentation ultimately aiding in the delivery of high-value care services. The MediLinker application was evaluated for its ability to accomplish various key tasks needed for a successful transition of patient care in an outpatient setting. Our team created 20 unique patient use cases covering a diversity of medical needs and social circumstances that were played out by participants who were asked to perform various tasks as they received case across a simulated healthcare ecosystem composed of four clinics, a research institution, and other ancillary public services. Tasks included, but were not limited to, clinic enrollment, verification of identity, medication reconciliation, sharing insurance and billing information, and updating demographic information. With this iteration of MediLinker, we specifically focused on the functionality of digital guardianship and patient revocation of healthcare information. In addition, throughout the simulation, we surveyed participant perceptions regarding the use of MediLinker and blockchain technology to better ascertain comfortability and usability of the application. Quantitative evaluation of simulation results revealed that MediLinker was able to successfully accomplish all seven clinical scenarios tested across the 20 patient use cases. MediLinker successfully achieved its goal of patient-centered interoperability as participants transitioned their simulated healthcare data, including COVID-19 vaccination status and current medications, across the four clinic sites and research institution. In addition to completing all key tasks designated, all eligible participants were able to enroll with and subsequently revoke data access with our simulated research site. MediLinker had a low data-entry error rate, with most errors occurring due to work-flow vulnerabilities. Our qualitative analysis of user perceptions indicated that comfortability and trust with blockchain technology, such as MediLinker, grew with increased education and exposure to such technology. The ubiquitous problem of data fragmentation in our current healthcare ecosystem has placed considerable strain on providers and patients alike. Blockchain applications for health identity management, such as MediLinker, provide a viable solution to stem the inefficiencies that exist today. The interoperability that MediLinker provided across our simulated healthcare system has the potential to improve transitions of care by sharing key aspects of healthcare information in a timely, secure, and patent-centric fashion allowing for the delivery of consistent and personalized high value care. Blockchain technologies appear to face similar challenges to widespread adoption as other novel interventions, namely recognition, trust, and usability. Further development and scaling are required for such technology to realize its full potential in the real world and transform the practice of modern health care.

113. Improving Transitions-of-Care for Patients Discharged on High-Risk Antimicrobial Therapy

BackgroundProviding effective transitions-of-care (TOC) services improves outcomes for patients discharged on high-risk medications. Literature has shown that successful TOC for certain antimicrobials reduces hospital readmissions, medication errors, and improves post-discharge follow-up and laboratory monitoring. Prior to this quality improvement (QI) initiative, there was no formal TOC process for patients discharged on high-risk antimicrobial therapy (HAT) at our institution. Without standardization, only 55.1% of patients discharged on HAT had successful TOC. The aim of this initiative was to develop and implement a TOC protocol in at least 90% of patients discharged on HAT.MethodsThis QI initiative utilized the Institute of Healthcare Improvement model for improvement. A workgroup of key stakeholders developed a protocol to identify and standardize TOC services provided to patients discharged on HAT. Successful protocol completion was achieved if the following process metrics were evaluated, obtained, and documented prior to discharge: baseline laboratory values, pharmacokinetic monitoring, appropriate intravenous access, drug-drug interactions, medication availability, discharge medication counseling, and formal pharmacist documentation in a discharge note. Outcome metrics included referral to outpatient infectious disease (ID) follow-up, 90-day readmissions, and successful TOC. Balancing metrics included pharmacist time and protocol initiation for patients not discharged on HAT. ResultsBetween October 2020 and May 2021, 218 patients met protocol inclusion criteria. Of these, 203/218 (93.1%) were appropriately identified with the new TOC process. The protocol was successfully followed in 78.9% of patients identified. Readmission rates were 42.8%, which was unchanged from baseline. Inpatient ID involvement increased from 80.9% to 95.7% and referral to outpatient ID follow-up from 59% to 94.8%.ConclusionThis newly developed TOC protocol successfully identifies patients discharged on HAT, improves provision of TOC services to these high-risk patients, and significantly improves the rate of infectious disease involvement while inpatient and after discharge.Disclosures All Authors: No reported disclosures

P018 How to Improve Transition of Pediatric IBD Patients Through Use of EMR.

Despite major medical advances in the IBD world, the incidence of Pediatric Inflammatory Bowel Disease (IBD) continues to increase. This patient population is at risk for higher rates of complications from their chronic disease. The transition from pediatric to adult care is crucial as this population is at an increased risk for loss to follow up, delays in receipt of appropriate medical care, poor adherence, and increased emergency department visits and hospital admissions. To address these issues at our academic center, we piloted an EMR template with the goal of improving the process from both the patient and provider perspectives. We present our review of what we learned from this process and how it shaped our final product. This study was an IRB-approved prospective cohort assessment performed at our academic tertiary care center from 2018-2021. An EMR template was designed as a comprehensive summary based on components of the medical record that adult gastroenterology (GI) providers identified as critical to successful transition of care. This template was then integrated into pediatric GI office notes provided to the adult GI team at the start of transition. A 7-question survey was distributed to pediatric providers to assess ease of use and provider perceptions of the template. A total of 64 patients transitioned following implementation of the template and 19 (29.7%) of those had a template in their chart upon transition. Audit of charts revealed that of the 13 pediatric GI providers, only one was actively using the template. Twelve (92%) of the 13 pediatric GI providers responded. Barriers to template use included: ease of use, lack of included narrative history, lack of auto-populated data and accessibility. Subsequently, stakeholders from our Pediatric and Adult IBD centers met to create a universal progress note that would provide one cohesive patient summary. The conception of this medical document now occurs in the pediatric setting; it will accompany the patient through their medical journey and be a permanent part of their medical record. Adult and Pediatric Gastroenterologists all agree that effective transition of IBD care is critical to the patient's well-being. However, adult and pediatric providers may have differing views of the importance of certain aspects of the psychosocial and preventative care components of IBD management. In our institution, we are able to provide IBD care to patients for their entire life span. To the benefit of patients, this is becoming more common at academic centers, making the use of a universal IBD template critical for excellent continuity of care. As a result of our inter-departmental meetings, we were able to learn why different aspects mattered at different stages of a patient's life. This allowed us to create a flexible template to incorporate these changing priorities. We believe that our current IBD progress note is a functional mesh of those factors and is less cumbersome than a separate template required by adult providers. Most importantly, it presents a united front, and demonstrates to patients that their care is a continuum within our institution.

Current practice of transitional care for adolescents and young adults in Swiss paediatric and adult rheumatology centres.

About half of all children with rheumatic diseases need continuous medical care during adolescence and adulthood. A good transition into adult rheumatology is essential. Guidelines for a structured transition process have therefore been recommended by the European League Against Rheumatism (EULAR) and the Paediatric Rheumatology European Society (PReS). However, implementation of these guidelines requires resources often not available in a busy clinical practice. To assess the current practice of transitional care in Switzerland in relation to EULAR/PReS recommendations and to describe gaps and challenges in following the recommendations. All paediatric Swiss rheumatology centres and their collaborating adult centres offering a transition service to adult care were invited to participate in this survey. The responsible paediatric and adult rheumatologist of each centre was interviewed separately using a structured manual addressing the EULAR/PReS transitional care recommendations. All 10 paediatric and 9 out of 10 adult rheumatologists agreed to participate. Centres varied in the number of patients in transition, from n = 0 to n = 111. The following EULAR/PReS recommendations were implemented and applied in most centres: continuity in the healthcare team, consultations focused on adolescents and young adults, joint consultations between the paediatric and adult rheumatologist, and access to the EULAR website. Only rarely did a centre have a written transition policy or evaluate their transitional care programme. The vast majority of the interviewees had no specific training in adolescent health. Most centres rated their transitional care performance as very good. Transition in Switzerland is not uniform and consequently the implementation of the EULAR/PReS recommendations is variable in Swiss rheumatology centres. Skills of healthcare professionals, continuity between clinical settings, size of the centres, and hospital focus on the needs of adolescents and young adults may represent key predictors of successful transitional care for patients with chronic rheumatic diseases. Future studies should examine these variables.

Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community.

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

Care transitions: opportunities to better serve the traveling patient.

The authors share a model that facilitates patient-centered care and can be adopted by other health systems to encourage successful care transitions for the traveling patient.

Staying Connected: Using Quality Improvement to Bridge the Communication Gap Between Pediatric Hospitalists and Primary Care Providers.

Staying Connected: Using Quality Improvement to Bridge the Communication Gap Between Pediatric Hospitalists and Primary Care Providers.