Transitional Care For Older Adults Research Articles

Appropriateness of Nursing Home to Emergency Department Transitional Care for Older Adults With Dementia: A Scoping Review.

To systematically identify knowledge patterns and gaps in the appropriateness of nursing home (NH) to emergency department (ED) transitional care for older adults with dementia. A systematic search of multiple information sources was performed from July to August 2023 using predesigned search strategies. From 13 articles, 54 identified pieces of specific care evidence were grouped into six major care domains: (1) Resource Support for Assessing Transfer Needs and Patient Status; (2) Resource Support, Shared Decision Making, and Early Advance Care Planning; (3) Standardized Multimodal Information Transfer; (4) Designated ED and NH Transition Coordinators; (5) Enhanced Interfacility Collaboration; and (6) Appropriate Transitional Care Education, Research, and Policy Beyond the Transfer Interface. A comprehensive, consensus-based body of evidence is lacking. Despite person-centered, standardized, and professional resources supporting transitional care, reorienting NH cultural models remains unclear. Gaps include evidence tailored to diverse participants and contexts. Thus, a focus on policies, education, and research is required. [Journal of Gerontological Nursing, 50(9), 37-45.].

Carer Perspectives About the Acceptability and Usability of the TRANSITION Tool to Support Preparation for Older Adult Care Transitions: A Qualitative Study.

Transitional care of older adults can be highly stressful for informal carers (carers) particularly when they are not involved in preparation and planning with health practitioners. This study aimed to ascertain carer perspectives about the potential acceptability and usability of a tool entitled the TRANSITION tool to support preparation and planning for the transition of an older adult from hospital to home. Exploratory qualitative. Semi-structured interviews were undertaken between March 2020 and October 2021. A focus group was conducted in July 2022 to seek additional information and support data saturation. A total of 23 participants took part. Data were thematically analysed. Participants explained their perspectives about the tool in four themes: (1) the TRANSITION tool has value, but health practitioners ask the questions; (2) the TRANSITION tool would be useful and acceptable, but not for all carers; (3) interacting with health practitioners is a barrier to using the tool and to communication; and (4) recognising us as part of the care team. While the tool was found to have potential value and utility, it would only be expected to support carers when they are valued and respected by health practitioners. Leadership is required in healthcare organisations to support genuine care for older adults and their carers, and to enable health practitioners to have time for transitional care communication. The findings from the study suggest that the TRANSITION tool could support carers by prompting them about important areas of care to include in communication with health practitioners during discharge preparation.

Transitional care for older adults with chronic illness: Aqualitative inquiry.

Improved public health strategies and medical advancements have expanded older adults' survival after acute insults from chronic diseases. The resultant increase in disability and care requirements among older adults is significant. However, transitional care interventions to support the efficient transition from acute care settings to home are primitive in developing countries like India. This qualitative survey aimed to estimate the transitional care requirements of older adults with chronic illness discharged from acute care facilities. Descriptive phenomenological approach was utilised for this qualitative study. The older adult-family caregiver dyads fulfilling the inclusion criteria were interviewed until the achievement of information saturation. The transcribed narratives between the researcher, older adults and their caregivers were thematically analysed. Consolidated Criteria for Reporting Qualitative Research (COREQ) served as the framework for reporting this research. Thirteen older adult-caregiver dyads participated in the semi-structured interview, which yielded six themes. Older adults have a hidden self with characteristics ranging between a continuum of 'insistence' to 'giving up'. Caregiver attributes identified from this inquiry were exhaustion, engagement and empowerment. The remaining four themes which constitute the framework for the 'transitional care progression' model include 'complications are mature when identified among older adults', 'medication knowledge is proportionate with its compliance', 'ignorance of supportive care increases caregiver burden' and 'deficient follow-up practices compromise health'. Transitional care for older adults with chronic illness is premature in developing countries. However, the needs of older adults with chronic disease and their caregivers evolved from the present study align with global perspectives. Themes generated from the current qualitative interview, blended with evidence-based interventions, yielded the transitional care progression model, which serves as the only available framework for implementing transitional care in the region. Future research to establish the feasibility and validity of the 'transitional care progression model' is forecasted. The model requires inclusion within the healthcare curriculum. Professional nurses prepared to implement coordinated transitional care pathways are recommended.

An evaluation of a transitional care programme for older adults in a general hospital in the Netherlands: Needs, preferences, and perspectives of the average old and the oldest old

Aim: This research aimed to evaluate a transitional care programme for older adults who were acutely admitted to a general hospital, with a special focus on health outcomes and healthcare utilisation for the oldest patients and to clarify patients’ and health care providers’ perspectives on the care provided.
 Background: Populations around the world are ageing, and many older adults have complex health problems owing to multimorbidity. Consequently, they experience many transitions in care. During the past decade, transitional care for older adults has become increasingly important in terms of safe transitions and prevention of adverse events during transitions.Research however, often leaves the oldest old and the most vulnerable out of scope.
 Methodology and methods: A mixed methods research design, based upon pragmatism and critical realism, was used in a parallel convergent design study. Measurements in the quantitative phase of the study were based on the The Older Persons and Informal Caregivers Survey Minimal Dataset (TOPICS-MDS). Data from the hospital registry and questionnaires were used. In the qualitative phase of the study reflexive thematic analysis was used on data gathered in interviews with patients, hospital nurses and community nurses and two focus group meetings with the geriatric team, and staff and managers from the home care organisations.
 Findings: The quantitative part of the study did not show any significant results of the effect of the Transitional Care Bridge (TCB) programme on the prevention of functional decline, health care utilisation and other health outcomes. However, the study revealed an increase in preventive care in the more frail TCB group. The qualitative part of the study reveals the programme was valued by patients, family members and professionals. The familiarity with the programme and personal attitudes of professionals may have influenced expectations and outcomes. Many patients enrolled in the programme were very frail and often unaware of the programme. As they often already received some kind of home care, patients were initially referred to the usual carers. The assessment of the care needs of the oldest patients to some extent fail to recognise what would contribute most to ageing well at home. Professionals in hospital as well as home care organisations struggled with motivation towards the programme and felt they still remained working within their silos. Professional roles were not always clearly defined, valued and reflected upon, and outcomes relating to collaboration reveal a gap between the different worlds of hospital and home.
 
 Discussion: Different contexts, organisational interests, personal attitudes and lack of reflection have influenced collaboration and the delivery of the programme. Transitional care interventions should be redeveloped for and with the oldest adults and their informal caregivers and address their needs during the period shortly after discharge, and help them build structure into their daily routines, and resume activities and exercise. Reflective practices on shared values, implications and outcomes should be developed as a competence within and between all involved organisations of transitional care. More reflective and emergent research approaches are needed to inform policies on ageing well in place and prevention.

Improving Transitional Care for Older Adults: Results of a Patient-Centred Quality Improvement Intervention.

The objective of this study was to evaluate the implementation and outcomes of a quality improvement intervention for older adults discharged from hospital to home, that used a patient-centred discharge education tool called the Patient-Centered Discharge Plan (PCAP). We conducted a pre-post evaluation of PCAP implementation among patients 65 years and older and discharged home from an acute medical or geriatric admission at two general hospitals. Two patient cohorts, PRE and POST, were analysed using administrative data (n = 3,309) and post-discharge structured interviews in a subset of patients (n = 326). Outcomes were 90-day readmissions and return emergency department (ED) visits, and transition experiences (10-item scale). The PCAP was provided to 20 per cent of 1,683 patients. Transition experience scores increased from PRE to POST at both hospitals (adjusted beta 1.3; 95% CI: 0.8, 1.7), and return ED visits declined in one of the two hospitals (adjusted decline 1.3%; 95% CI: -3.7, 6.2). In conclusion, dedicated resources are needed to support future PCAP implementation.

Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review.

To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity. Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions. Scoping review. Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies. Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences. The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.

TRANSITIONAL CARE FOR OLDER ADULTS WITH CHRONIC ILLNESS - AN INTEGRATED REVIEW

The increasing trend in the older adult population is proportionate to the burden of chronic illness among them, necessitating the need to move between varied care settings to relieve their pronounced discomforts. Literature reports a high incidence of potentially inappropriate medication, preventable complications, and caregiver burden during this phase. Transitional care plays a vital role in ensuring health care continuity, avoiding preventable poor outcomes among at-risk populations, and promoting the safe and timely transfer of patients from one level of care to another or from one type of setting to another. This review explores and crystallizes empirical literature on transitional care for older adults with an aim to comprehensively articulate its significance, components, interventions, and outcomes. The importance of coordinated and empowered transition between varied care settings is illuminated in this review. The components of transitional care from global evidence string together the staffing and competency requirements. The vastness of interventions employed within transitional care models provides the scope for practitioners to select feasible and affordable interventions within their practice settings. A glimpse into the outcomes of transitional care directs health and social care personnel to weigh outcomes greater than establishment investments.

Informal carers' support needs, facilitators and barriers in the transitional care of older adults: A qualitative study.

Inclusion of informal carers in transitional care is challenging because of fast throughput and service fragmentation. This study aimed to understand informal carers' needs during the care transitions of older adults from inpatient care to the community. A qualitative exploratory design was used with mixed-methods data collection. Seventeen semi-structured telephone interviews were conducted with family carers; one focus group was conducted by videoconference with two family carers and three community-based advocacy and aged care providers; and eight semi-structured telephone interviews were undertaken with healthcare practitioners from rehabilitation services. Data were thematically analysed. All carers described the main social challenge that they needed to address in transitional care as 'Needing to sustain family'. Carers reported their social needs across five solutions: 'Partnering with carers', 'Advocating for discharge', 'Accessing streamlined multidisciplinary care', 'Knowing how to care' and 'Accessing follow-up care in the community'. Focus group participants endorsed the findings from the carer interviews and added the theme 'Putting responsibility back onto carers'. All healthcare practitioners described the main social challenge that they needed to address as 'Needing to engage carers'. They reported their social solutions in three themes: 'Communicating with carers', 'Planning with carers' and 'Educating carers'. Findings highlight the importance of reconstructing the meaning of transitional care and relevant outcomes to be inclusive of carers' experiences and their focus on sustaining family. Transitional care that includes carers should commence at the time of hospital admission of the older adult. Future sustainable and high-quality health services for older adults will require transitional care that includes carers and older adults and efficient use of inpatient and community care resources. Healthcare professionals will require education and skills in the provision of transitional care that includes carers. To meet carers' support needs, models of transitional care inclusive of carers and older adults should be developed, implemented and evaluated. This study was conducted with the guidance of a Carer Advisory Group comprising informal carers with experience of care transitions of older adults they support and community-based organizations providing care and advocacy support to informal carers.

Toward Nurses’ Transformative Agency in Transitional Care for Older Adults: A Change-Laboratory Intervention

Mobilization of nurses’ agency across healthcare sectors is needed to counter challenges associated with older adults’ transitions between hospital and primary care. Based on Cultural Historical Activity theory and the Change Laboratory method, we developed a learning intervention with 16 nurses. The aim was to foster the nurses’ transformative agency to improve care. Video-recording of nine learning sessions were transcribed and analyzed. Results demonstrated that shared transformative agency exhibited as an emergent phenomenon crossing sectoral boundaries as a prerequisite for change in transitional care. The nurses progressed from acting as individuals criticizing the current conditions to collectively forming a vision around a transitional care model. This was nurtured through the nurses’ negotiations which included a recognition of sharing similar challenges deriving from the healthcare organization and related financial restrictions, and conflicting healthcare and nursing ideals across healthcare sectors. The evolution of transformative agency was grounded in a professional nursing identity.

Factors Associated With Informational Support in Transitional Care for Older Adults With Chronic Diseases: A Cross-Sectional Study.

To evaluate the current situation and associated factors of informational support for older adults with chronic diseases in transitional care. Study was conducted in five hospitals of five different cities in Jiangsu Province, China. A random cluster sample of 800 older adults with chronic diseases responded to the informational support questionnaire of transitional care survey. Descriptive analysis, t-tests, variance analysis, and stepwise multiple linear regression were used to analyze data. The STROBE statement for observational studies was applied. Total score of ISQTC for older adults with chronic diseases was (44.05 ± 17.21). Marital status, educational level, past occupation, close friends, medical insurance, complications, and exercise habits were significantly correlated with informational support. The level of informational support in transitional care for older adults with chronic diseases was low. Clinical staff should periodically and primarily assess their informational support, help find information resources for those who have low initial informational support, and identify which information they preferred to carry out accurate transitional care.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

BackgroundOlder adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities.MethodsParticipants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health and social service use and cost, from baseline to 6- and 12-months. Caregivers will be assessed for caregiver strain, depressive symptoms, anxiety, health-related quality of life, and health and social service use and costs. Descriptive and qualitative data from older adult and caregiver participants, and the nurse interventionists will be used to examine implementation of the intervention, how the intervention is adapted within each study region, and its potential for sustainability and scalability to other jurisdictions.DiscussionA nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population.Trial registration# NCT03157999.Registration Date: April 4, 2017.

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives.

Introduction:Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.Methods:The study used a qualitative design in two phases: 1) semi-structured interviews, 2) one focus group. The setting comprised one public health network and five community services in urban Australia. In Phase 1, health practitioners across settings were interviewed about their experience of transitional care. Phase 2 sought feedback about the Phase 1 findings from different practitioners. All data were thematically analysed.Findings:In Phase 1), 48 healthcare practitioners were interviewed across multiple settings. Few participants were aware of the introduction of consumer-directed care in community aged care. Four main themes were identified: ‘Rapid and safe care transition’, ‘Discussing as a team’, ‘Questioning the discharge’, and ‘Engaging patients and carers’. In Phase 2), seven participants from different settings reviewed and endorsed the findings from Phase 1.Discussion and conclusions:Findings indicate that healthcare practitioners use a range of communication and coordination processes in optimising integrated transitional care. Although participants involved their patients in transitional care planning, most participants were unaware of the recent implementation of consumer-directed care. In contexts of community-based care shaped by multidisciplinary, sub-acute and CDC models, care integration must focus on improved communication with patients and carers to ascertain their needs and to support their increased responsibility in their care transitions.

Evaluation of a transitional care programme for frail older adults and the effectiveness for the oldest old

Introduction: Older adults with multimorbidity, aged 70 years and older, experience a complex of both medical and social problems and frequently require continuous care in multiple settings. They move between acute and non-acute care settings, such as hospitals, home, intermediate care unit, primary care center, nursing home and hospice. It is within that context, that the transitional care programme for this group has been developed in the IJsselland hospital in the Netherlands, and will be evaluated. In this programme the Transmural Care Bridge is incorporated. The programme: The identification of seniors at risk starts at the Emergency Department with the ISAR- HP, the identification of seniors at risk- hospitalized. Patients at high risk for functional decline will fill out a triage questionnaire with their informal caregivers developed by the Geriatricians of the hospital. In all cases a registered nurse on the ward were the patient is admitted will start with screening on delirium, malnutrition, ADL functions, mobility and fall risk. If nessecary the geriatric consultation team will visit the patient and a systematic comprehensive geriatric assessment (CGA) will be done. The geriatrician will develop a care plan. In the programme one day before discharge from hospital a community nurse (CN) visits the patient inside the hospital and within 48 hours after discharge from hospital and after 2, 6, 12 and 24 weeks. Main issues during these visits are medication safety, appropriateness of care arranged during hospital admission resources, social network and support for the informal caregiver. The CN will discuss the care plan with the General Practitioner (GP) of the patient. In a prospective cohort study 100 older patients, 50 patients before and 50 patients a after the start of this programme, are asked to fill out a questionnaire at the start of the program in het hospital, and after one and three months after discharge from hospital, to measure morbidity, functional limitations, cognitive functioning, social functioning, self-perceived health, self-perceived quality of life, experiences, GP visits and admissions. Also the effectiveness of the program on self-management abilities will be measured by the CN through the Self Sufficiency Matrix. 30 professionals inside and outside the hospital who provide care for this group of older adults, specialist, nurses, general practitioners and community nurses will be asked to provide their perspectives on the programme and on inter-professional collaboration. Effectiveness for the oldest old: Because preliminary research findings showed that many people aged 85 years and older, who we consider in this study as the oldest old, said they felt lonely, useless, lost spouses, friends and sometimes children and sometimes were waiting to die, an additional question arose about how the oldest old would percieve this care programme and if this would meet their needs. This question will be adressed by in depth interviews with the oldest old. Aim: This research project aims to contribute to changes in transitional care for older adults who are admitted to the hospital and add to the current body of knowledge of the perspectives of the oldest old on their care.

Influence of Studies Published by the Journal of the American Geriatrics Society: Top 20 Articles from 2000-2015.

Influence of Studies Published by the Journal of the American Geriatrics Society: Top 20 Articles from 2000-2015.

Interprofessional simulation to improve patient participation in transitional care.

Educating and training healthcare professionals is known to improve the quality of transitional care for older adults. Arranging interprofessional meetings for healthcare professionals might be useful to improve patient participation skills in transitional care. To describe the learning activities used in The Meeting Point programme, focusing on patient participation in transitional care, and assess whether they increase healthcare professionals' awareness of and competencies relating to patient participation in the transitional care of older patients. Data were collected as part of an educational intervention programme, The Meeting Point, including three seminars on 'Patient participation in the transitional care of older patients' and four follow-up meetings. Participants were nurses, care assistants, doctors, physiotherapists, patient coordinators and administrative personnel from hospital, nursing homes and home-based care services. The Meeting Point was organised around four pillars: introduction, teaching session, group work activity and plenary discussion. Qualitative data included log reports, summaries of meetings, notes from group work activities, and reports from participants and from follow-up meetings. Feedback from participants shows that they were satisfied with meeting healthcare professionals from other units of care. A film scenario was perceived relevant for group work activity and useful in focusing participants' attention to patient participation. Follow-up meetings show that some nursing home wards, the emergency department and one medical ward at the hospital continued with ongoing work to improve quality of care. Efforts included implementation of an observational waiting room with comfortable chairs, planning for discharge in hospital admission, a daily patient flow registration system and motivational interviewing during admission to nursing home. The description of the learning activities used at The Meeting Point seminars shows that they were useful to increase awareness of and competencies on patient participation in transitional care.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

The Social Work Role in Reducing 30-Day Readmissions: The Effectiveness of the Bridge Model of Transitional Care

ABSTRACTThe hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. Novel approaches to addressing the complexities of transitional care are emerging as possible solutions. The Bridge Model is a person-centered, social work-led, interdisciplinary transitional care intervention that helps older adults safely transition from the hospital back to their homes and communities. The Bridge Model combines 3 key components—care coordination, case management, and patient engagement—which provide a seamless transition during this stressful time and improve the overall quality of transitional care for older adults, including reducing hospital readmissions. The post Affordable Care Act (ACA) and managed care environment’s emphasis on value and quality support further development and expansion of transitional care strategies, such as the Bridge Model, which offer promising avenues to fulfil the triple aim by improving the quality of individual patient care while also impacting population health and controlling per capita costs.

Intervention to Integrate Palliative Care into Transitional Care for Older Adults: Potential Challenges Identified by Clinicians (S798)

communication, bond, care access, competence, values, and beliefs. The presence of these elements influences the way parents perceive their role while they live the unexpected experience of losing a child, and they remain in their memories associated with the meanings attributed for the illness and the loss. Conclusion. These relationships serve as the basis to strengthen and support the parenting role, and they become a remarkable reminder that parents keep as a permanent connection to their deceased child. By revisiting these memories, meanings arise that contribute to their grieving process. Implications for Research, Policy or Practice. The quality of parents’ bond formed with the healthcare providers is a concrete reminder of the child’s last days and the illness trajectory, influencing the quality of their grieving process. Policies in pediatric palliative care must emphasize directives to enhance the practice of allowing families to maintain the secure bond after their child’s death, helping to prevent complicated grief.

Transitional care of older adults in skilled nursing facilities: A systematic review

Transitional care of older adults in skilled nursing facilities: A systematic review

Recovering from a stroke: A narrative review on post-stroke anxiety treatment and management

Recovering from a stroke: A narrative review on post-stroke anxiety treatment and management