Transitional Care Model Research Articles

Cost-effectiveness and cost-utility analysis of a nurse-led, transitional care model to improve care coordination for patients with cardiovascular diseases: results from the "Cardiolotse" study.

To assess the 12-month cost-effectiveness of the nurse-led transitional care program "Cardiolotse" (CL) for patients with cardiovascular diseases compared to usual care (UC). A cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) were conducted from the perspective of statutory health insurance (SHI), covering a time horizon of 12 months. Analyzed outcomes included the number of rehospitalizations and health-related quality of life (HRQoL). Total costs comprised program costs and the utilization of healthcare resources. Point estimates are presented as incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs). Sensitivity and subgroup analyses were conducted to illustrate uncertainty and provide insights into the impact mechanisms of the CL program. The study population consisted of 2550 patients, with 1256 allocated to the intervention group and 1294 to the control group. Patients who received support from CLs experienced fewer rehospitalizations and lower inpatient costs from an SHI perspective, compared to the UC group. HRQoL assessments indicated higher utility values for CL patients at the 12-month follow-up. Total program costs amounted to €1454.65 per patient. The CEA and CUA demonstrate that the CL program is dominant compared to UC from the SHI perspective. Our study shows that the CL program not only reduces the number of rehospitalizations and costs but increases HRQoL, resulting in a dominant ICER and ICUR. Further research is necessary to evaluate longer periods of time, different levels of care intensity, and perspectives of different healthcare stakeholders. German Clinical Trial Register DRKS00020424, 2020-06-18, retrospectively registered.

The effects of a dyadic empowerment-based heart failure management (De-HF) programme on self-care and HRQL : a randomized controlled trial

Abstract Background The ever-growing epidemiology of heart failure (HF) and its detrimental impacts on patients’ quality of life and healthcare cost urge for effective interventions to ameliorate the modifiable prognostic factors. As substantial evidence suggests ineffective self-care as an important candidate especially for the post-discharge outcomes, various care approaches are developed to optimize this behavioral outcome. However, even family carers are heavily involved in the self-care process, dyadic approach to improve the health outcomes of both interactive partners are least applied in the HF transitional care model. Purpose To evaluate the effects of a dyadic empowerment-based heart failure management program (De-HF) on dyadic health and hospital service utilization outcomes. Methods This double-blind RCT randomized 88 HF patient-carer dyads to receive the De-HF program or a dialectic education program, after hospital discharge. Based on the Theory of Dyadic Illness Management, the 16-week De-HF Program, comprising i) a dyadic assessment, ii) five online empowerment modules and iii) follow-up telecare, integrated explicit strategies (scenario-based training, teach-back and goal-setting) to actively engage the care dyads in collaborative disease management. Figure 1 is the graphical presentation of the De-HF Program. The primary outcome is health-related quality of life (HRQL) of the care dyads. Secondary outcomes include patients’ self-care as well as shared care and perceived control of the dyad. Results The mean age of the HF patients was 76.8 (9.4). The patients were in moderate disease severity [NYHA II/II: 56/44%; mean LVEF = 42.5%]. Figure 2 shows the consort flow diagram. After adjusting the socio-demographic characteristic, two-way analysis of covariance showed that patients in the De-HF program showed significantly greater improvement in patients’ self-care domains [Mean difference in change of score (95% CI): Self-care maintenance = 7.15 (1.82-12.46),Cohen’s d = 0.26, p=0.009; Self-care management = 10.04(3.29-16.79), Cohen’s d=0.65, p=0.004; symptom perception = 15.59 (8.20-22.98), Cohen’s d=0.928, p<0.001] and Minnesota Living with Heart Failure score [Mean different in the change of score (95% CI) = -11.45 (-18.24 - -4.66). Cohen’s d = -0.742, p=0.001]. The patient-carer dyads also have significantly greater improvement in perceived control (p=0.001) and collaborative disease management in terms of joint decision-making (p=0.001) and sense of reciprocity (p=0.026). Conclusion Dyadic science has evolved in self-care research for HF. This trial provides the first evidence to inform the positive effects of a theory-based dyadic transitional care program in improving the collaborative self-care management in a family context and patient health outcome. Longer-term evaluation on the effects of De-HF program on health service utilization outcomes and cost-effectiveness will be followed.The De-HF Managment ProgramThe Consort Flow Diagram

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

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

The pivotal role of neurosurgeons in transitional care: A comprehensive tertiary healthcare institution's experience.

Transitional care (TC) is increasingly crucial, particularly in neurosurgery, where optimal follow-through of patients' care is paramount. Challenges of transition are exacerbated by the complexity of neurosurgical conditions, with pediatric and adult neurosurgery often managed separately by different attending neurosurgeons or in different institutions. While numerous models for transitioning have been proposed, several barriers persist, impeding successful transfer from pediatric to adult settings. Our review focuses on important roles neurosurgeons can play in facilitating successful transition, exploring some existing TC models, with emphasis on the benefits of maintaining a single provider. Clinic visits data between 2019 to 2023 of patients between the ages of 16 to 26 was compiled retrospectively. Successful transition was defined as continued follow-up moving from pediatric to adulthood with lost to follow-up being that of unsuccessful transition. Age, diagnosis and whether patients were successfully transitioned or lost to follow-up were documented. 1829 neurosurgical patients between the ages of 16 to 26 were identified over 5 years. A snapshot review identified 78 adolescent patients deemed to require follow-up into adulthood. 13 patients had epilepsy, 32 central nervous system (CNS) tumors, 17 congenital conditions, 14 neurovascular, and 2 patients had idiopathic intracranial hypertension. All 78 were noted to have successfully transited into their adulthood (age 21 and beyond). Having the same providers; having pediatric and adult neurosurgery within the same institution, was the single most important factor in facilitating successful transition. Neurosurgeons in institutions, particularly those with experience and competencies in both pediatric and adult care, can serve as crucial anchors during the transitional period. At our institution, the implementation of this continuity of care model has demonstrated remarkable success. Institutions with both pediatric and adult services would be uniquely positioned to develop and implement effective transitional care.

Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders.

Hospitals are increasingly offering treatment for substance use disorders (SUDs) during medical admissions. However, there is a lack of consensus on the best approach to facilitating a successful transition to long-term medical and SUD care after hospitalization. We aimed to establish a hierarchy of existing SUD care transition models in 2 categories-effectiveness and implementation-using an expert consensus approach. We conducted a modified online Delphi study that convened 25 interdisciplinary clinicians with experience facilitating posthospitalization care transitions for patients with SUD. Panelists rated 10 prespecified posthospitalization care transition models according to 6 criteria concerning each model's anticipated effectiveness (eg, linkage to care, treatment retention) and implementation (eg, feasibility, acceptability). Ratings were made on a 9-point bidirectional scale. Group consensus was determined using the interpercentile range adjusted for symmetry. After 3 rounds of the Delphi process (96% retention across all 3 rounds), consensus was reached on all 60 rating criteria. Interdisciplinary addiction consult teams (ACTs) and in-reach from partnering outpatient clinics were rated highest for effectiveness. Interdisciplinary ACTs and bridge clinics were rated highest for implementation. Screening, brief intervention, and referral to treatment; protocol implementation; and postdischarge outreach received the lowest ratings overall. Feasibility of implementation was perceived as the largest challenge for all highly rated models. An expert consensus approach including diverse clinician stakeholders found that interdisciplinary ACT, in-reach from partnering outpatient clinics, and bridge clinics had the greatest potential to enhance posthospitalization care transitions for patients with SUD when considering both perceived effectiveness and implementation.

Autoimmune rheumatic transitional care model development

AimTo develop a transitional care model for autoimmune rheumatic disease patients based on the needs analysis.MethodMixed Method, Explanatory sequential design (QUAN-qual) has been conducted. Quantitative data were collected through medical record and structured interviews. Qualitative study has been done through Focused Group Discussion (FGD), based on problems met in previous quantitative study. We have done the coding processed, followed by determining categories and themes to reach the intercoder agreement with peer-debriefing. Analysis of the final results of research was assisted by the external auditor to form a model of care.ResultThe quantitative data collection from 27 patients showed that the transition age was 18–19 year-old, age of onset 4–17 year-old, 23 patients (85, 2%) with SLE, 4 patients (14.8%) with JIA. Two patients (7.4%) had different diagnosis from the pediatric clinic, 1 patient (3.7%) had no diagnosis from previous clinic. Drug switching during transition occurred in 14 patients (51.9%) and 3 patients (11.1%) has no known medication history. Data regarding disease activity at initial diagnosis were not available in 26 patients (96.3%). The combined FGD analysis found several key words related to “the need of change” in RSCM autoimmune rheumatic transitional care.ConclusionA development of transitional care model for autoimmune rheumatic disease consist of documents about service algorithm, transfer documents, systematic work protocols with education check list has been done.

Effectiveness of Transitional Care Model on Knowledge Regarding Quality of Life Among Clients with Post Myocardial Infarction

Myocardial Infarction is the major cause of disability in many developing countries and by 2020 is forecast to be the major cause of disease burden world-wide and it is a slow progressive disease and can be reduced by adhering to certain life modification strategies. The present study aimed to assess the effectiveness of transitional care model on knowledge regarding quality of life among clients with post Myocardial Infarction in a selected hospital at Chennai. A quantitative approach using pre-experimental one group pretest post-test research design was adopted for the study and 30 samples that full filled the inclusion criteria were selected. The structured knowledge questionnaires were used to assess the pre-test and post-test level of knowledge regarding quality of life among clients with post Myocardial Infarction. Following the intervention, a significant portion 19 (63.3%) exhibited moderately adequate knowledge, and 11(36.7%) achieved a level of adequate knowledge. Thus, the Transitional care model had a significant impact on enhancing client’s understanding regarding quality of life. Keywords: Transitional Care model, post myocardial infarction, quality of life, knowledge

The impact of the doctor-nurse-patient workshop transitional care model on the post-operative quality of life of patients with laryngeal cancer.

The aim of this study is to assess the efficacy of the doctor-nurse-patient workshop transitional care model on post-operative care for patients with laryngeal cancer and its influence on quality of life. A total of 68 patients with laryngeal cancer who underwent surgical treatment at the hospital between 2021 and 2022 were included in the study. The patients were divided into two groups, a control group and a research group, each consisting of 34 patients, based on the chronological sequence of their surgeries. Patients in the control group received standard nursing care, while those in the research group received the doctor-nurse-patient workshop transitional care model in addition to standard nursing care. After 2months of care, levels of albumin (ALB), total protein (TP), hemoglobin (Hb), and quality of life scores (measured using the Quality of Life Instrument for Head and Neck Cancer, QLICP-HN) were compared between the two groups. Additionally, the incidence of adverse events during the recovery period was assessed and compared between the two groups. Following 2months of care, patients in the research group exhibited elevated ALB, TP, and Hb levels compared to those in the control group. Additionally, the average QLICP-HN scores were higher in the research group, while the incidence of adverse events was lower compared to the control group. Implementing the doctor-nurse-patient workshop transitional care model in home care for patients with laryngeal cancer can enhance their nutritional status post-surgery and improve their quality of life during home rehabilitation. This, in turn, leads to a reduction in the incidence of adverse events and complications during the recovery period.

Health care transition models in spina bifida care: evidence-based lessons in support of neurosurgical practice.

The purpose of this study was to conduct a literature review on transition programs from pediatric to adult care and the role of neurosurgery as individuals with spina bifida (SB) transition, and to provide a framework for neurosurgical providers to assist in the transition to adult-centered care. A comprehensive literature review was conducted according to the PRISMA statement, with a search in Medline and Embase to identify US clinical programs reporting on their experiences establishing a transition program for adolescents and young adults with SB. Data were collected for authors, year, transition clinic location, model of care for transition clinic, ages served, and specialty clinical team. The literature search yielded 698 articles, 5 of which met the inclusion criteria. These 5 studies included 4 transition programs for which models of care and approach to transition, clinical services involved, establishment of goals, and age of initiation and transition were identified. All programs described setting transition goals, ranging from community services, to self-management, to health care navigation, to patient-driven goals, with 1 program reporting a quality-of-life measurement component to their model. Robust SB transition programs can be established by applying the expanded chronic care model, reviewing lessons learned by other programs, advocating at the institutional level, and seeking support via professional organizations. While the comprehensive role of neurosurgical providers in these programs is still being defined, a shared vision of enhancing the health and quality of life for individuals with SB and their families is needed by all subspecialists involved.

Effectiveness of the transitional care model in total knee arthroplasty patients: A randomized controlled trial.

This study has aimed to assess the effectiveness of the transitional care model (TCM) on functional status, perceived self-efficacy and healthcare utilization in patients undergoing total knee arthroplasty (TKA). This randomized controlled study was conducted between February and November 2021 in a public hospital. The study randomly assigned patients to either a 6-week 'TCM' program or usual care. The sample size was n = 70, with each group comprising 35 individuals. Patient outcomes, including self-efficacy, functional status and healthcare service readmission rates, were monitored for TKA patients. Nursing care based on the 'TCM' was found to enhance functional status and increase the level of self-efficacy among TKA patients, leading to a decrease in healthcare service readmissions. The study recommends preparing patients and their families for the preoperative and postoperative processes. It emphasizes the importance of providing necessary training and consultancy services under the leadership of orthopaedic nurses responsible for TKA patient care, guided by the principles of TCM.

Clinical outcomes of nurse-coordinated interventions for frail older adults discharged from hospital: A systematic review and meta-analysis.

To determine the effects of nurse-coordinated interventions in improving readmissions, cumulative hospital stay, mortality, functional ability and quality of life for frail older adults discharged from hospital. Systematic review with meta-analysis. A systematic search using key search terms of 'frailty', 'geriatric', 'hospital' and 'nurse'. Covidence was used to screen individual studies. Studies were included that addressed frail older adults, incorporated a significant nursing role in the intervention and were implemented during hospital admission with a focus on transition from hospital to home. This review searched MEDLINE (Ovid), CINAHL (EBSCO), PubMed (EBSCO), Scopus, Embase (Ovid) and Cochrane library for studies published between 2000 and September 2023. Of 7945 abstracts screened, a total 16 randomised controlled trials were identified. The 16 randomised controlled trials had a total of 8795 participants, included in analysis. Due to the heterogeneity of the outcome measures used meta-analysis could only be completed on readmission (n = 13) and mortality (n = 9). All other remaining outcome measures were reported through narrative synthesis. A total of 59 different outcome measure assessments and tools were used between studies. Meta-analysis found statistically significant intervention effect at 1-month readmission only. No other statistically significant effects were found on any other time point or outcome. Nurse-coordinated interventions have a significant effect on 1-month readmissions for frail older adults discharged from hospital. The positive effect of interventions on other health outcomes within studies were mixed and indistinct, this is attributed to the large heterogeneity between studies and outcome measures. This review should inform policy around transitional care recommendations at local, national and international levels. Nurses, who constitute half of the global health workforce, are ideally situated to provide transitional care interventions. Nurse-coordinated models of care, which identify patient needs and facilitate the continuation of care into the community improve patient outcomes. Review findings will be useful for key stakeholders, clinicians and researchers to learn more about the essential elements of nurse-coordinated transitional care interventions that are best targeted to meet the needs of frail older adults. When frail older adults experience transitions in care, for example discharging from hospital to home, there is an increased risk of adverse events, such as institutionalisation, hospitalisation, disability and death. Nurse-coordinated transitional care models have shown to be a potential solution to support adults with specific chronic diseases, but there is more to be known about the effectiveness of interventions in frail older adults. This review demonstrated the positive impact of nurse-coordinated interventions in improving readmissions for up to 1 month post-discharge, helping to inform future transitional care interventions to better support the needs of frail older adults. This systematic review was reported in accordance with the Referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No Patient or Public Contribution.

A scoping review of hospital to home transitional care programmes for stroke survivors.

The study was aimed at exploring the current scope of hospital to home transitional care programmes for stroke survivors. Stroke survivors face the dilemma of solving many complex problems that leave survivors at high risk for readmission as they discharge from hospital. The transitional care model has proved to be effective in reducing readmissions and mortality, thereby improving health outcomes and enhancing patient satisfaction for survivors with stroke. A scoping review. Conducted in accordance with the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews. A comprehensive search was conducted in nine databases, including PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL, Medline, China Knowledge Net-work, Wanfang Database and China Biomedical Literature Database (SinoMed) from January 2014 to June 2023. Title and abstract screening was performed on 10,171 articles resulting in 287 articles for full-text screening. Full-text screening yielded 49 articles that met inclusion criteria. This study identified transitional care programmes for stroke survivors, as well as areas for future consideration to be explored in more depth to help improve transitional care for stroke survivors as they transition from hospital to home. This study demonstrates that multidisciplinary collaboration becomes an integral part of the transitional care model for stroke survivors, which provides comprehensive and precise medical care to them. PRISMA checklist for scoping reviews. No patient or public contribution was part of this study.

Pilot Process Evaluation of the Supporting Older Adults at Risk Model: A RE-AIM Approach.

Despite evidence supporting transitional care models, hospitals report challenges implementing and sustaining them. The Discharge to Assess (D2A) Model is an innovative solution to this problem but required translation from a national health system context to an U.S.-based context. We translated the central tenets of the D2A model to establish the Supporting Older Adults at Risk (SOAR) Model, which unfolds in three phases: Prepare, Transition, and Support. The purpose of this project was to conduct a process evaluation of the SOAR Model in practice using the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). Forty patients completed all SOAR Model components for a Reach of 21%. Patients averaged 80 years of age, 53% were female, and 64% Black/AA. SOAR significantly improved discharge before noon, time to first home visit, and use of the in-house pharmacy. SOAR also improved length of hospital stay, emergency department visits, and readmissions. Twenty-one of the 26 Implementation measures unfolded with 75% or greater fidelity. Sixteen of the 24 Adoption measures unfolded with 75% or greater fidelity. COVID-19 limited Maintenance. Given the model unfolds across settings over time, requiring adoption from interprofessional team members, patients, and families, future work should focus on improving reach and adoption.

Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders.

Medical hospitalizations are increasingly recognized as important opportunities to engage individuals with substance use disorders (SUD) and offer treatment. While a growing number of hospitals have instituted interventions to support the provision of SUD care during medical admissions, post-hospitalization transitions of care remain a challenge for patients and clinicians and an understudied area of SUD care. Evidence is lacking on the most effective and feasible models of care to improve post-hospitalization care transitions for people with SUD. In the absence of strong empirical evidence to guide practice and policy, consensus-based research methods such as the Delphi process can play an important role in efficiently prioritizing existing models of care for future study and implementation. We conducted a Delphi study that convened a group of 25 national interdisciplinary experts with direct clinical experience facilitating post-hospitalization care transitions for people with SUD. Our panelists rated 10 existing care transition models according to anticipated effectiveness and facility of implementation based on the GRADE Evidence to Decision framework. Qualitative data on each care model were also gathered through comments and an online moderated discussion board. Our results help establish a hierarchy of SUD care transition models to inform future study and program development.

Experience of Transitional Care Among Thai-Isan Older Stroke Survivors and Their Family Caregivers.

The transitional care model for people who have suffered brain injuries is a relatively recent addition to the Thai healthcare system. The aim of this study was to explore experience of Thai Isan older stroke survivors and their family caregivers across different points of transition from hospital to home. Fifteen dyads of older stroke survivors and their family caregivers were recruited following the inclusion and exclusion criteria. Data were collected through participant observations and semi-structured interviews. Forty-seven participation observation field notes and twenty-four interview transcriptions were analyzed using the Four Phases of the Data Analysis Enabler and the Leininger-Templin-Thompson Ethnoscript Coding Enabler. Three themes emerged: I feel lost with managing care at home; it has been challenging for our family to maintain continuity of care; and it is a matter of who fits in and is convenient for family care responsibilities. The findings of this study have highlighted the dispersion of care among Thai-Isan people during the patient's transition to home. Therefore, a transitional care plan should be developed that specifies who is responsible for monitoring and supporting patients and families throughout this period.

Kidney adolescent and young adult clinic: A transition model in Africa.

Adolescents and Young Adults (AYAs) with chronic kidney disease (CKD) have challenges unique to this developmental period, with increased rates of high-risk behavior and non-adherence to therapy which may impact the progression of kidney disease and their requirement for kidney replacement therapy (KRT). Successful transition of AYA patients are particularly important in low- and middle-income countries (LMICs) where KRT is limited, rationed or not available. Kidney AYA transition clinics have the potential to improve clinical outcomes but there is a paucity of data on the clinical translational impact of these clinics in Africa. This review is a reflection of the 20-year growth and development of the first South African kidney AYA transition clinic. We describe a model of care for patients with CKD, irrespective of etiology, aged 10-25 years, transitioning from pediatric to adult nephrology services. This unique service was established in 2002 and re-designed in 2015. This multidisciplinary integrated transition model has improved patient outcomes, created peer support groups and formed a training platform for future pediatric and adult nephrologists. In addition, an Adolescent Centre of Excellence has been created to compliment the kidney AYA transition model of care. The development of this transition pathway challenges and solutions are explored in this article. This is the first kidney AYA transition clinic in Africa. The scope of this service has expanded over the last two decades. With limited resources in LMICs, such as KRT, the structured transition of AYAs with kidney disease is not only possible but essential. It is imperative to preserve residual kidney function, maximize the kidney allograft lifespan and improve adherence, to enable young individuals an opportunity to lead productive lives.

Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy.

Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.

Facilitating and barrier factors to the implementation of a transitional care program: a qualitative study of hospital coordinators in South Korea

BackgroundTransitional care is an integrated service to ensure coordination and continuity of patients’ healthcare. Many models are being developed and implemented for this care. This study aims to identify the facilitators and obstacles of project performance through the experiences of the coordinator in charge of the Community Linkage Program for Discharge Patients (CLDP), a representative transitional care program in Korea.MethodForty-one coordinators (nurses and social workers) from 21 hospitals were interviewed using a semi-structured questionnaire, and thematic analysis was performed.ResultThree themes were found as factors that facilitate or hinder CLDP: Formation and maintenance of cooperative relationships; Communication and information sharing system for patient care; and interaction among program, regional, and individual capabilities. These themes were similar regardless of the size of the hospitals.ConclusionA well-implemented transitional care model requires a program to prevent duplication and form a cooperative relationship, common computing platform to share patient information between institutions, and institutional assistance to set long-term directions focused on patient needs and support coordinators’ capabilities.

Mapping the Discharge Process After Surgery

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

Effect of a transitional care model following hospitalization for heart failure: 3-year outcomes of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) randomized controlled trial.

Patients are at high risk of death or readmission following hospitalization for heart failure (HF). We tested the effect of a transitional care model that included month-long nurse-led home visits and long-term heart function clinic visits - with services titrated to estimated risk of clinical events - on 3-year outcomes following hospitalization. In a pragmatic, stepped-wedge cluster randomized trial, 10 hospitals were randomized to the intervention versus usual care. The primary outcome was a composite of all-cause death, readmission, or emergency department (ED) visit. Secondary outcomes included components of the primary composite outcomes, HF readmissions and healthcare resource utilization. There were 2494 patients (50.4% female) with mean age of 77.7 years. The primary outcome was reached in 1040 (94.2%) patients in the intervention and 1314 (94.5%) in the usual care group at 3 years. The intervention did not reduce the risk of the primary composite outcome (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.81-1.05) nor the component outcomes overall, although numerically reduced the risk of ED visits in women but not men (HR 0.79, 95% CI 0.63-1.00 vs. HR 0.98, 95% CI 0.80-1.19; sex-treatment interaction p = 0.23). The uptake of guideline-directed medical therapy was no different with the intervention than with usual care, with the exception of sacubitril/valsartan, which increased with the intervention (3.3% vs 1.5%; relative risk 6.2, 95% CI 1.92-20.06). More than 9 of 10 patients hospitalized for HF experienced all-cause death, readmission, or ED visit at 3 years. A transitional care model with services titrated to risk did not improve the composite of these endpoints, likely because there were no major differences in uptake of medical therapies between the groups. ClinicalTrials.gov Identifier NCT02112227.