Transitional Care Research Articles

Pharmacist-Directed Transition of Care Services Decrease Readmissions at a Safety-Net Hospital.

Limited data exist describing the influence of pharmacist-led transition of care (TOC) services in safety-net hospital settings. This analysis assessed the impact of pharmacist-led TOC services on hospital readmissions in a high-risk managed Medicaid population impacted by housing instability, substance use disorder (SUD), and mental health issues. A retrospective evaluation of patients who received safety-net hospital-based TOC pharmacy services between January 1, 2022, and December 31, 2022, was conducted. Patients 18 years and older, insured by a select managed Medicaid plan, and admitted to an inpatient medicine service were included. Patients were excluded if they were admitted from or discharged to a facility or hospice, discharged before medically ready, or died within 30 days of discharge. Interventions included an initial visit, discharge medication delivery and education, and a post-discharge follow-up phone call within 24 to 72 hours. Patients were provided with a number to call for medication-related questions post-discharge. The primary outcome was 30-day hospital readmissions. Secondary outcomes included time to and reason for readmission and a description of TOC services. There were 292 patients engaged in pharmacist-led TOC services. Nearly 1 in 6 patients were experiencing homelessness and almost 40% were struggling with SUD during the index admission. The median readmission performance in the target population 6 months prior to TOC service implementation was 20.2% and fell to 12.3% post-intervention. Substance use disorder was the leading contributor to re-hospitalization, accounting for 58% of readmissions. Six (16.7%) readmissions were medication-related; 5 of 6 were complicated by SUD. There were no preventable medication-related readmissions. There are limitations to this study; not all patients received all TOC program components. Prospective, randomized-controlled studies are needed to show cause and effect. This evaluation suggests pharmacist-led TOC discharge services may lead to hospital readmission reduction in a socially complex managed Medicaid population in a safety-net hospital setting.

Bridging the continuity: Practice-enhancing publications about the ambulatory care medication-use process in 2023.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. This article identifies, summarizes, and prioritizes published literature on the ambulatory care medication-use process (ACMUP) from 2023 that can describe ambulatory pharmacy practice. The medication-use process is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The ACMUP is defined in this article as having the following components: transitions of care, prescribing, access, dispensing, adherence, and evaluating. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search was conducted in January 2024 for the publication year 2023 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 2,903 articles. A thorough review identified 52 potentially practice-enhancing articles: 6 for transitions of care, 11 for prescribing, 5 for access, 6 for dispensing, 8 for adherence, and 16 articles for evaluating. Trends gleaned from the highest-impact articles are described. It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article continues a series of articles defining and evaluating the currently published literature around the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Medication reconciliation: impact of an educational intervention on the knowledge, attitude and practices of healthcare professionals - a prospective quasi-experimental study in a Saudi referral hospital

BackgroundMedication reconciliation has been acknowledged as a key intervention against medication errors. More than half of the medication errors that happen during care transitions are caused by unjustified medication discrepancies and up to one-third of these mistakes may be harmful. The study aimed to evaluate the knowledge, attitude and practices (KAP) of health care providers in on medication reconciliation process, pre and post educational intervention.MethodsA hospital-based prospective quasi-experimental pre-post intervention study was conducted from November 2023 to February 2024 among 346 healthcare professionals (medical doctors, pharmacists and nurses) practicing in King Saud Hospital (KSH), Unayzah, Saudi Arabia. The subjects were recruited using the convenience sampling method.An educational intervention workshop was conducted among the healthcare professionals. The KAP was assessed before and after the educational intervention using a content and face validated self-administered questionnaire. The statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS). Wilcoxon Signed Rank Test was used to differentiate the mean response scores for knowledge, attitude, and practice domains, between pre and post intervention. Kruskal Wallis Test followed by Dunn’s post hoc test was used to compare the mean response scores for knowledge, attitude and practice domains based on educational qualification and practicing experience for the pre and post-test period. The level of significance is determined at P < 0.05.ResultsThere was a significant improvement in the participants’ knowledge, attitude and practice after the educational intervention with mean scores of 0.72 (SD = 1.67, p < 0.0001*), 0.76 (SD = 1.97, p < 0.0001*), and 0.56 (SD = 2.05, p = 0.001*) respectively. The overall KAP scores showed a statistically significant enhancement after the education intervention with a mean score difference of 2.04 (SD = 4.76, p < 0.0001*).Our study upholds that MedRec is highly valued by the participants due to its significant role in reducing medication errors and enhancing patient safety, and that it has the ability to recognize medication discrepancies and reduce adverse drug events.ConclusionThe education intervention effectively influenced the knowledge, attitude and practice of healthcare professionals regarding medication reconciliation. This study underscores the importance of continuous education and training for healthcare professionals to minimize medication discrepancies and improve patient care.

Interprofessional Collaboration as a Best Practice Across the Care Continuum.

Interprofessional teams are increasingly being recognized as a best practice for enhancing cooperation among multiple disciplines in delivering person-centered care and improving outcomes. Unlike previous models, such as the multidisciplinary team in which each profession or discipline remained largely siloed, with interprofessional teams collaboration occurs across disciplines. For case managers, the interprofessional team concept aligns with the collaborative, professionally diverse nature of the field of practice. As the Commission for Case Manager Certification (CCMC) states: "The practice of case management is professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system" (2024b, CCMC Definition and Philosophy, p.1). Although interprofessional teams may be more familiar in settings such as acute care, this dynamic can be found, formally and informally, across health and human services. Professional case managers who actively participate in interprofessional teams will likely find more opportunities to optimize collaboration and collective decision-making that bring out the best of every profession and discipline. Interprofessional teams can be found in multiple care settings including acute care, subacute care, community-based care, palliative/end-of-life and other settings that benefit from a person-centered approach that supports successful transitions of care and improved outcomes. Professional case managers are valued members of interprofessional teams, in that they are typically collaborative, promote open communication, and encourage cooperation among various disciplines. Interprofessional teams, however, may require a shift in thinking away from the former multidisciplinary model, in which case managers often acted as the hub connecting the spokes of each discipline. Within interprofessional teams, the individual is at the center, and every discipline will share leadership based on the individual's needs or the treatment protocol or other intervention needed in the moment. In this way, interprofessional teams become a model for empowering and allowing each discipline to step up and address specific aspects of treatment or other interventions.

Implementation of a Faith Community Nursing Transition of Care Program in the USA: A Propensity Score Matching Analysis.

Faith community nursing (FCN) is a specialty nursing practice that integrates spiritual and religious practices into patient care. This study aimed to quantitatively assess the impact of the standardized FCN transition of care (TOC) program on the rate of hospital readmission and length of stay (LOS) through propensity score matching and difference-in-differences methods. Compared with those in the non-FCN group (n = 409), patients in the FCN group (n = 66) had a reduced likelihood of hospital readmission at 30, 90, and 180days after discharge (by 8.8%, 9.0%, and 9.5%, respectively). Additionally, the FCN group exhibited a shorter LOS by 0.31, 0.53, and 0.87days at 30, 90, and 180days, respectively. The present study thus demonstrated the successful implementation of the FCN TOC program in a hospital setting, which reduced both the hospital readmission rate and LOS after discharge.

Rehabilitation, reablement, and restorative care approaches in the aged care sector: a scoping review of systematic reviews

BackgroundAgeing populations are set to drive up demand for aged care services, placing strain on economies funding social care systems. Rehabilitation, reablement, and restorative care approaches are essential to this demographic shift as they aim to support independent function and quality of life of older people. Understanding the impact of these approaches requires nuanced insights into their definitions, funding, and delivery within the aged care context. This scoping review mapped and compared systematic review-level research on rehabilitation, reablement, and restorative care approaches within aged care with the aim of determining definitional clarity, key themes, and the professional groups delivering each approach.MethodsNine databases were searched (2012 to September 2023) to identify English-language systematic reviews on aged care-based rehabilitation, reablement and/or restorative care. Two reviewers independently screened studies following predetermined eligibility criteria. Only reviews reporting quality appraisal findings were eligible. Data charting and synthesis followed the Arksey and O’Malley approach and are reported according to PRISMA-ScR guidelines.ResultsForty-one reviews met inclusion criteria. Most (68%) reported on rehabilitation in aged care, and eight (20%) combined the approaches. Only 14 reviews (34%) defined the approach they described. Reviews centred on services for older people in the home or community (n = 15), across a mix of settings including community, hospital, and residential care (n = 10). Ten distinct themes highlight the importance of multidisciplinary teams, allied health, risk of falls, hip fracture, reduced functional independence, and specific types of interventions including physical activity, technology, cognitive rehabilitation, goal setting, and transition care. Most reviews described the role of occupational therapists (n = 22), physiotherapists (n = 20) and nurses (n = 14) with wider support from the multidisciplinary team. The quality of primary studies within the reviews varied widely.ConclusionsThis scoping review summarises the evidence landscape for rehabilitation, reablement, and restorative care approaches in the context of aged care. Despite their role in enhancing independence and quality of life for older people, policy, funding, and terminology variation means the evidence lacks clarity. This fragmented evidence makes it challenging to argue the effectiveness of one approach over another for older people in receipt of aged care services.Clinical trial numberNot applicable.

Transition to Survivorship Care for Adolescents and Young Adults (AYAs) with Acute Leukemia: Provider Perspectives.

Purpose: Adolescent and young adult (AYA) survivors of acute lymphoblastic or myeloid leukemia diagnosed between the ages of 15 and 39 years are at risk for adverse late health effects following cancer treatment and require ongoing survivorship care. This study aims to understand the landscape of transitioning AYAs with leukemia from active treatment to survivorship care. Methods: A cross-sectional, anonymous online survey was sent out via listserv/email. Descriptive analyses were used to identify the proportion of providers whose institutions have AYA and/or survivorship programs, current practices in transitioning care, perspective on barriers and facilitators to transition, and preferred models of survivorship care. Differences by provider (i.e., adult medical oncologist vs. pediatric) were analyzed using chi-square or analysis of variance (ANOVA) analyses. Results: A total of 75 provider responses were analyzed; 51.4% of providers reported their institutions had an AYA program and over 80% had a survivorship program. Providers preferred the primary oncology team or survivorship specialist to address most survivorship care needs, except for the treatment of other comorbid conditions (primary care provider [PCP] preferred). Disease-related risks, lack of a PCP, and insurance concerns were commonly endorsed barriers to transition of care. Medical oncologists were more likely than pediatric providers to transition surveillance of new malignancies to PCPs. Conclusions: Providers preferred survivorship specialists to oversee AYA survivorship care, yet several barriers and concerns remain to implement the transition. Results indicate variability in transition care practices and preferences, particularly between medical and pediatric oncologists. Future work is needed to optimize transition practices to improve care for AYA survivors.

Starting a Prehospital Medication for Opioid Use Disorder Program.

Over 2.7 million people have an opioid use disorder (OUD). Opioid-related deaths have steadily increased over the last decade. Although emergency department (ED)-based medication for OUD (MOUD) has been successful in initiating treatment for patients, there still is a need for improved access. This study describes the development of a prehospital MOUD program. An interdisciplinary team expanded a MOUD program into the prehospital setting through the local city fire department Quick Response Team (QRT) to identify patients appropriate for MOUD treatment. The QRT consisted of a paramedic, social worker, and police officer. This team visited eligible patients (i.e., history of an opioid overdose and received prehospital care the previous week). The implementation team developed a prehospital MOUD protocol and a two-hour training course for QRT personnel. Implementation also required a signed contract between local hospitals and the fire department. A drug license was necessary for the QRT vehicle to carry buprenorphine/naloxone, and a process to restock the vehicle was created. Pamphlets were created to provide to patients. A clinical algorithm was created for substance use disorder (SUD) care coordinators to provide a transition of care for patients. Metrics to evaluate the program included the number of patients seen, the number enrolled in an MOUD program, and the number of naloxone kits dispensed. Data were entered into iPads designated for the QRT and uploaded into the Research Electronic Data Capture (REDCap) program. Over the six-month pilot, the QRT made 348 visits. Of these, the QRT successfully contacted 83 individuals, and no individuals elected to be evaluated for new MOUD treatment. Nine fatal opioid overdoses occurred during the study period. A total of 55 naloxone kits were distributed, and all patients received MOUD information pamphlets. A prehospital MOUD program can be established to expand access to early treatment and continuity of care for patients with OUD. The program was well-received by the local city fire department and QRT. There is a plan to expand the prehospital MOUD program to other local fire departments with QRTs.

Transition of Care for Pediatric Neurologic Disorders - Are We There Yet?

Transition of Care for Pediatric Neurologic Disorders - Are We There Yet?

Transition to Adult Care in Turner Syndrome: Research Gaps and Strategies for Achieving Success.

Health care transition is a process by which children with chronic medical conditions gradually and purposefully move from pediatric to adult-centered health care systems. While transition guidelines have been published by multiple national and international organizations, transition processes have not been optimized for many populations, including youth with Turner syndrome (TS). Numerous barriers exist, at both the system and individual/family level. Mitigating transition-related barriers requires a multi-faceted approach, including: conducting research to assess TS specific transition interventions and outcomes; developing educational/training initiatives and quality improvement efforts; engaging in advocacy/policy change; and implementing evidence-based strategies to optimize transition. The goals of this manuscript are to outline key research gaps that need to be addressed regarding health care transition in TS and to suggest strategies to optimize transition outcomes. Given the importance of a multi-disciplinary and patient-centered approach, we specifically outline the roles of pediatric health care teams (including navigators), adult health care teams, patients, caregivers, and institutional resources.

Case management in Emergency Care: Impact Evaluation of the CARED Program.

Hospitals face mounting pressure to reduce unplanned utilization amid rising healthcare demands from an aging population. The Case management for At-Risk patients in the Emergency Department (CARED) program is among the first ED transitional care strategies to focus on both frail older adults and Emergency Department (ED) re-attenders to reduce acute hospital utilization. This study aims to evaluate the effectiveness of the CARED program in reducing hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge. A retrospective, propensity-matched study was conducted from April 2022 to July 2023 in the ED of Ng Teng Fong General Hospital in Singapore. The CARED program identifies and enrols at-risk patients i.e., frail older adults and patients who re-attend the ED within 30 days of hospital discharge, for a geriatric assessment. This is followed by multidisciplinary team care, discharge planning and right siting of care from the ED to community-based services by ED case managers. The primary outcomes were hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge. Secondary outcomes were cost avoidance and bed occupancy days from reduced acute hospital usage. Nearest-neighbour 1:1 propensity score matching matched 1,615 intervention group to 1,615 control group. Baseline characteristics of the intervention and control groups did not differ significantly. Difference-in-differences (DID) analyses showed significantly lower 30-day (3.96%; 95% CI 2.71% to 5.23%) and 60-day (6.69%; 95% CI 5.47% to 7.91%) hospital admissions, as well as 30-day (4.89%; 95% CI 3.83% to 5.95%) and 60-day (6.50%; 95% CI 5.28% to 7.72%) ED re-attendances in the intervention group compared to the control group. Additionally, the reduced admission and ED re-attendance rates resulted in 30-day and 60-day inpatient admission costs avoidance ($1,553,548.96 (69.86%); 95% CI $1,525,827.76 to $1,581,270.15; P = 0.006; and $1,400,047.07 (32.56%); 95% CI $1,365,484.79 to $1,434,609.37; P = 0.048 respectively), ED attendance costs avoidance ($25,849.92 (23.70%); 95% CI $25,091.93 to $26,607.89; P = 0.096; and $37,538.39 (18.09%); 95% CI $36,470.27 to $38,606.53; P = 0.086 respectively) and bed occupancy days saved (1,212 days; 95% CI 1,191.80 days to 1,232.20 days; P = 0.003; and 1,267 days; 95% CI 1,242.58 days to 1,291.42 days; P = 0.011 respectively). CARED program effectively reduced unplanned hospital use within 30- and 60-days post-ED discharge for at-risk patients. It also significantly lowered inpatient admission and ED attendance costs and hospital bed occupancy days, highlighting its potential to improve patient outcomes and reduce healthcare expenses.

Geriatrics-Focused vs Traditional Primary Care in the Veterans Affairs Health Care System

Older adults often require specialized health care expertise, but the effects of geriatrics-focused models of primary care have not been fully evaluated. To compare the effects of geriatrics-focused primary care vs traditional primary care for older patients in the Veterans Affairs (VA) health care system. In this cohort study, geriatrics-focused primary care and traditional primary care patient dyads matched on variables associated with geriatrics-focused primary care entry and outcomes were enrolled from VA medical centers with operational geriatrics-focused primary care clinics serving 500 or more patients annually in fiscal year 2016. Across 57 eligible sites, patients 65 years or older who transferred their care to geriatrics-focused primary care within the previous 12 months (exposure period) (n = 291) and their matched traditional primary care controls (n = 277) were enrolled. Study recruitment occurred from March 22, 2018, through December 11, 2019, with patient outcomes data collection completed June 24, 2021. Data were analyzed from June 2023 to January 2024. At least 2 geriatrics-focused primary care visits during the exposure period. Geriatrics-focused primary care involves interprofessional teams of clinicians with geriatrics expertise to provide comprehensive primary care for older veterans with complex needs. The primary outcome was home time (days not in a hospital unit, short-term nursing facility, inpatient rehabilitation, or an emergency visit) within 18 months of the exposure period. Secondary outcomes were completion of advance directives, assessments (falls, incontinence, and function), and medication quality (potentially inappropriate medications, Anticholinergic Drug Scale score). Patients were surveyed over 18 months about care experiences using Patient Perceptions of Integrated Care subscales, and Patient-Reported Outcomes Measurement System self-reported health and well-being measures. A total of 568 patients were enrolled (mean [SD] age, 80.5 [7.0] years; 558 [98.2%] male), including 291 in the geriatrics-focused primary care and 277 matched in the traditional primary care groups; most baseline variables were comparable between the 2 groups. Geriatrics-focused primary care was not associated with more home time (rate ratio, 0.97; 95% CI, 0.62-1.51) over 18 months. Geriatrics-focused primary care was associated with higher odds of assessment for falls (odds ratio [OR], 2.86; 95% CI, 1.62-5.04), incontinence (OR, 2.73; 95% CI, 1.69-4.42), and function (OR, 4.05; 95% CI, 2.39-6.85) at 18 months. Geriatrics-focused primary care was not associated with advance directive completion, medication quality, or self-reported health and well-being. In this cohort study, geriatrics-focused primary care did not increase time at home or other measures of self-reported health and well-being or integration of care within the first 18 months after care transition. However, increases in some process measures important for quality of care were observed, suggesting that further studies are needed to evaluate outcomes over a longer time frame.

Guidance for Prescribing Oral Antihypertensive Medications in the Emergency Department.

To review the most current recommendations regarding assessment and treatment of asymptomatic hypertension treatment in the emergency department (ED) and to provide guidance for prescribing oral antihypertensive therapy for ED providers. There are varying management strategies for the treatment of asymptomatic hypertension in the ED likely due to a lack of direct guidelines for treatment. There is an increasing body of evidence for the safety of initiating therapy to treat chronic asymptomatic hypertension in the ED. Initiation and optimization of oral antihypertensive therapy in indicated patients can be done by ED providers to enhance and expediate transition of care for patients and can ultimately aid in prevention of cardiovascular disease (CVD). This review provides guidance of when oral antihypertensive therapy can be initiated, medication options depending on the patient's blood pressure and other concurrent medications (if applicable), as well as other factors that may influence choice of therapy are described. Oral antihypertensive therapies can be initiated and optimized in the ED for patients with asymptomatic chronic hypertension.

Navigating adulthood: Exploring the transition needs of adolescents and young adults affected by Duchenne or Becker muscular dystrophy.

For individuals with Duchenne or Becker muscular dystrophy (DMD and BMD, respectively), transitioning to adulthood presents significant challenges. Although considerable attention has been given to facilitating medical transitions due to the complexity of these conditions, less focus has been placed on other aspects of the transition, such as achieving independence. This study assessed the transition needs of people with DMD or BMD, exploring various domains including health, education, employment, living arrangements, transportation, daily activities, and independent personal life. Men with DMD or BMD participated in this cross-sectional study. Transition to adulthood was assessed using Transition Readiness Assessment for Young Adults with DMD. The questionnaire evaluates transitions in health care, education and employment, housing and transportation, activities of daily living, and independent life and autonomy. Factors associated with and predicting transition to adulthood were evaluated using Spearman's correlations and multiple regression analysis. Forty-two people with DMD or BMD (mean age: 24.3±5.3) participated in this study. The transition domains in which most participants needed help were education and employment (52.5%) and activities of daily living (57.0%). Transition needs that stood out included palliative care (66.6%), employment and education support (76.1%), social worker consultation for housing assistance (76.1%), and assistive device consultation (64.2%). Mobility and breathing function did not correlate with transition level. Number of siblings positively correlated with and predicted most transition domains. Older age predicted only education and employment status. In conclusion, the analysis showed that the most problematic transition domains among people with DMD or BMD were activities of daily living and education and employment. In most transition domains, help needed did not decrease with age and was not affected by function. However, adolescents and adults with more siblings typically reported being more ready to transit to adult life.

Development and validation of the Health Segment Classification of Population Encompassed within Singapore (HealthSCOPES) framework.

The population is heterogeneous with varying levels of healthcare needs. Clustering individuals into health segments with more homogeneous healthcare needs allows for better understanding and monitoring of health profiles in the population, which can support data-driven resource allocation. Using the developed criteria, data from several of Singapore's national administrative datasets were used to classify individuals into the various health segments. Cross-sectional analysis of healthcare utilization charges was conducted. Validation was done for the framework's prognostic ability of clinically relevant outcomes measured in the following year. The framework is comprised of twelve segments classed within four broad groups. The segments comprising individuals with cancer, with transitional care needs, and in the last year of their lives had the highest mean per resident healthcare charges. The segments comprising adults and seniors with complex chronic conditions and with transitional care needs had the highest percentage of individuals historically diagnosed with obesity. The framework was able to distinguish varying tiers of healthcare utilization charges and relative risk of death in the following year. The framework was developed using a hybrid approach, with expert input and comprehensive national data that extended beyond the usual hospital patient population. The framework can be directly applied for use in program or policy design, evaluation, and cost-effectiveness analyses. The HealthSCOPES framework was developed to segment the entire population in Singapore with similar healthcare needs.

Race and ethnic disparities in rehabilitation services and functional recovery post-stroke.

To identify race/ethnic disparities in rehabilitation services after stroke and characterize the independent associations of each of race/ethnicity and rehabilitation to functional recovery post-stroke. The Transitions of Care Stroke Disparities Study (TCSD-S) is a prospective cohort study designed to reduce disparities and to optimize the transitions of care for stroke survivors throughout the state of Florida. Participant characteristics were extracted from the American Heart Association's Get-With-The-Guidelines-Stroke dataset. Rehabilitation services, and modified Rankin Scale were recorded via follow up phone calls at 30- and 90-days after hospital discharge. Logistic regression models adjusted for potential confounders were used to determine: 1) race/ethnic differences in rehabilitation services received; 2) race/ethnic differences in functional change from discharge to 30- and 90-days, respectively; and 3) the influence of rehabilitation on functional change from discharge to 30- and 90-days. Of 1,083 individuals, 43% were female, 52% were Non-Hispanic White (NHW), 22% were Non-Hispanic Black (NHB), and were 22% Hispanic. Individuals who engaged in rehabilitation were more likely to show improvements [aOR=1.820, 95%CI (1.301,2.545)] at 90-days from hospital discharge. Irrespective of rehabilitation services, there were no differences in functional change between NHW and NHB individuals, yet Hispanic individuals were less likely to improve [aOR=0.647, 95%CI (0.425,0.983)] compared to NHW. Additionally, Hispanic individuals were significantly less likely to receive any rehabilitation services [aOR=0.626, 95%CI (0.442,0.886)] and were half as likely to receive outpatient services [aOR=0.543, 95%CI (0.368,0.800)] as compared to NHW. Rehabilitation is key to functional improvement after stroke. We are making strides in health equity between NHW and NHB individuals, yet there remain disparities in functional outcomes and in rehabilitation services particularly for Hispanic individuals after stroke.

Navigating Rural Care Transitions: A Qualitative Study of Nursing Leaders’ Unit‐Focused Approaches

Background: Leadership is vital for well‐coordinated healthcare and affects the quality of care and patient safety. Nursing leaders are crucial in creating appropriate structures and processes to enhance patient outcomes during care transitions in a rural context. Despite their importance to care transitions, there is limited research on nursing leaders’ perspectives in rural settings. This study explored nursing leaders’ concerns regarding the provision of quality care during transitions from hospital care to home healthcare in rural areas and their experiences in improving these processes.Methods: A qualitative study using constructivist grounded theory methodology was conducted. Twenty nursing leaders in hospital and rural municipal care in Sweden were interviewed. All were educated in social care or healthcare, most in nursing, and most had a master’s degree. Data were analyzed using constant comparative analysis.Results: Nursing leaders’ main concern about creating quality care in transitions was a lack of clearly defined, shared goals for a high-quality care transition. The core category explaining their approach was minding one’s unit by working within organizational unit borders. Three categories further explained this: (I) promoting nursing competence by recruiting and training nurses, emphasizing patient involvement, (II) ensuring continuous care flow by collaborating within one’s organization and clarifying rights and obligations, and (III) evaluating collaboration within each unit.Conclusions: Seamless care transitions are challenging when nursing leaders lack clear, mutually shared quality goals for care transitions. Implications for nursing management include improving collaborative routines, establishing common platforms, and integrating patient input throughout the process, as these measures are essential for enhancing interorganizational collaboration in rural care transitions.

Perspectives on Implementing a Communication Facilitator Intervention From a Critical Care Setting.

Critically-ill patients and their families often experience communication challenges during their ICU stay and across care transitions. An intervention using communication facilitators may help address these challenges. Using clinicians' perspectives, we identified facilitators and barriers to implementing a communication intervention. Using purposive sampling, we conducted semi-structured interviews with 17 clinicians from an intensive care unit at an academic health center that participated in a randomized trial of communication facilitators. We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. CFIR constructs of relative advantage, communication, and critical incidents facilitated the intervention's implementation. CFIR constructs of access to knowledge and information, relational connections, and clinician knowledge and belief hindered its implementation. Clinicians reported that facilitators provided continuity to patients and families, support in a trusting and proactive manner over transitions of care, and bridged communication between families and clinicians particularly during the Covid-19 pandemic. Limited information about the intervention prevented clinicians from working with facilitators earlier in the course of the intervention. Differences in beliefs regarding facilitator involvement during family meetings also hampered the intervention's implementation. Future studies should incorporate implementation strategies that help connect facilitators to clinicians early in the intervention period which may improve role clarity and enhance collaboration.

Health Equity In Transitions Of Care And Access To Conventional Heart Failure Therapies In A Large Urban Community Hospital

Health Equity In Transitions Of Care And Access To Conventional Heart Failure Therapies In A Large Urban Community Hospital

Key Transitional Care Interventions Needed to Decrease Readmissions and Emergency Department Return Visits

Reducing readmissions and emergency department return visits has long been considered a key indicator of healthcare quality. A variety of strategies and methodologies have been employed to achieve these goals, with their effectiveness depending on factors such as the type of organization, its vision and leadership, and its organizational culture, budget, and population health, among others. Studies have shown that care coordination and transitional care initiatives delivered within 14 days of hospital discharge can significantly reduce readmission rates. This article shares our most effective transitional care interventions that have contributed to our success in reducing readmissions and emergency department return visits.