Care Transition Process Research Articles

Transitional care of older ethnic minority patients: An integrative review.

To critically synthesize the empirical literature on practice in transitional care and how to meet the care needs of older ethnic minority populations who discharged from hospital to community. An integrative literature review integrating empirical studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Web of Science, PsycINFO, EBSCO (including CINAHL and MEDLINE) and Scopus were searched for papers published between 2012 and September 2022. Full-text papers were screened against inclusion and exclusion criteria subsequent to screening titles and abstracts. All included papers were evaluated for methodological quality using the Critical Appraisal Skills Programme Checklists. After extracting findings, themes were created by critically examining and synthesizing of findings. The search yielded a total of 1180 studies, 1153 after removing duplicates and 27 papers meeting the inclusion criteria and exclusion criteria were included in the review. The main findings were categorized into four themes: (i) intervention-related outcomes; (ii) unmet needs of older minority people; (iii) transitional care-related characteristics of older minority people and (iv) challenges for healthcare providers. Findings indicated that the transitional care experience of ethnic minority older populations differed from natives to some extent which revealed unmet needs addressing how to provide culturally appropriate transitional care for this population. This review gave insight into facilitators in the transitional care of ethnic minority older adults. Future transitional care interventions should incorporate needs of ethnic minority population. This review highlighted the defined gaps between existing transitional care programmes and transitional care needs of older ethnic minority. Increasing follow-up completion, evidence defining deeply of ethnic phenomenon in the transitional care process, developing interventions that meet transitional care needs and increasing healthcare providers' cultural competency were featured headlines. No Patient or Public Contribution.

The perspectives of older people living with dementia regarding a possible move to a nursing home

Background/Objectives Moving into a nursing home is often an unavoidable life event for older people living with dementia. It is associated with negative emotions and outcomes. Research capturing their perspectives is scarce. This study aims to identify how older people living with dementia perceive a potential life in a nursing home and to understand their (future) care wishes. Materials and methods This study is part of the European TRANS-SENIOR research network. The study followed a qualitative phenomenological methodology. Semi-structured interviews with 18 community-dwelling older people living with dementia were conducted between August 2018 and October 2019 (METCZ20180085). A stepwise interpretive phenomenological analysis was performed. Results The majority of community-dwelling older people feared the idea of potentially moving to a nursing home. The participants associated a possible move with negative perceptions and emotions. Additionally, this study emphasized the importance of knowledge of current and past experiences with care when identifying the participant’s wishes. They wanted to remain (a) individuals, who are (b) autonomous and have (c) social contacts if they would move to a nursing home. Discussion/Implications This study showed how past and current care experiences can educate/inform healthcare professionals on the future care wishes of older people living with dementia. The results indicated that listening to the wishes, and life stories of people living with dementia could be a way of identifying ‘a suitable time’ to suggest a move to a nursing home. This could improve the transitional care process and adjustment to living in a nursing home.

Stakeholders' perspectives on caregiver outcomes for health care transition for adolescents and young adults with special health care needs: A qualitative study.

Previous literature has explored parent/caregiver perspectives and satisfaction with the health care transition (HCT) process for their adolescents and young adults with special health care needs (AYASHCN). Limited research has explored the opinion of health care providers and researchers on parent/caregiver outcomes associated with a successful HCT for AYASHCN. A web-based survey was distributed through the international and interdisciplinary Health Care Transition Research Consortium listserv, which at the time of the survey was composed of 148 providers dedicated to optimizing the HCT of AYAHSCN. Participants responded to the open-ended question, 'What parent/caregiver-related outcome(s) would represent a successful healthcare transition?' Respondents included 109 providers (52 health care professionals, 38 social service professionals and 19 other). Responses were coded for emergent themes, and research suggestions were identified. Qualitative analyses identified two major themes: emotion- and behaviour-based outcomes. Emotion-based subthemes included relinquishing control of child's health management (n= 50, 45.9%) as well as parental satisfaction and confidence in their child's care and HCT (n= 42, 38.5%). Respondents also noted that parents/caregivers should experience an improved sense of well-being and decreased stress (n= 9, 8.2%) due to a successful HCT. Behaviour-based outcomes included early preparation and planning for HCT (n= 12, 11.0%) and parental instruction on the knowledge and skills necessary for their adolescent to independently manage their health (n= 10, 9.1%). Health care providers can assist parents/caregivers in learning strategies for instructing their AYASHCN about condition-related knowledge and skills as well as provide support for 'letting go' of the caregiver role during the HCT to adult-focused health services and adulthood. Communication between the AYASCH, their parents/caregivers and paediatric- and adult-focused providers needs to be consistent and comprehensive to ensure continuity of care and a successful HCT. We also offered strategies to address the outcomes suggested by the participants of this study.

Reducing risks in complex care transitions in rural areas: a grounded theory

ABSTRACT Purpose Although previous research indicates that care transitions differ between rural and urban areas, the knowledge of challenges related to care transitions in rural areas appears limited. This study aimed to provide a deeper understanding of what registered nurses’ perceive as the main concerns in care transitions from hospital care to home healthcare in rural areas, and how they handle these during the care transition process. Methods A Constructivist Grounded Theory method based on individual interviews with 21 registered nurses. Results The main concern in the transition process was “Care coordination in a complex context”. The complexity stemmed from several environmental and organizational factors, creating a messy and fragmented context for registered nurses to navigate. The core category “Actively communicating to reduce patient safety risks” was explained by the three categories– “Collaborating on expected care needs”, “Anticipating obstacles” and “Timing the departure”. Conclusions The study shows a very complex and stressed process that includes several organizations and actors. Reducing risks during the transition process can be facilitated by clear guidelines, tools for communication across organizations and sufficient staffing.

Provider-To-Provider Communication About Care Transitions: Considering Different Health Technology Tools.

Transitions in patient care require exchanges of information between providers. This period of transition presents a range of challenges, and inadequate transitions can have serious consequences for patients. Our objective was to understand providers' perspectives about patient care transitions, especially around communication between providers and the role of health information technology in provider-to-provider communication. Semi-structured interviews were conducted. Deductive-dominant thematic analysis was used to allow categorization of data based on general themes derived from the interview guides, as well as identification of emergent themes. We characterized three main themes involving providers' perspectives about care transitions. Themes included communication challenges, communication preferences, and suggestions for improving the care transition processes. With respect to challenges around communication, providers highlighted four main concerns. These concerns included the existence of too many methods of communication, high volume of communication, challenges with involvement of multiple providers delivering longitudinal care, and difficulty communicating with providers outside the health system. Providers noted opportunities to improve transitions including improving standardization, enhancing the specialty to primary care transition process, and increasing communication back to the referring provider. Implementation and evaluation of these improvements could be considered by health systems to enhance care transitions.

Adolescents' and Young Adults' Recommendations for Implementing Healthcare Transition in Rheumatology: A Mixed Methods Study.

The goal was to elicit adolescents' and young adults' (AYAs) perspectives about how to implement the Six Core Elements of Healthcare Transition within rheumatology care. AYAs (ages 16-28 years old) with self-reported rheumatic conditions were recruited through patient organizations and social media. In Phase One (qualitative [QUAL]), 90-minute focus groups were facilitated to elicit AYAs' reactions to Six Core Elements content. In Phase Two (quantitative; QUAN), a national survey was conducted to determine generalizability of recommendations extracted from Phase One. Mixed methods analyses were conducted by a multidisciplinary team of social science researchers, pediatric rheumatologists, and patients. Although focus group participants (n=39) were previously unfamiliar with the Six Core Elements, they reacted favorably to its format and content. Participants provided suggestions for how to logistically execute each component in the clinic. Additionally, 3 overarching recommendations emerged that focused on motivating AYAs to engage: 1) frame health care transition as an opportunity for empowerment; 2) implement a structured education plan; and 3) consider the role of parents. In line with qualitative findings, survey participants (n=137) reported that they would prefer to learn most transitional skills from and discuss developmentally specific topics with their rheumatology team. Participants reported they would likely complete programs to learn transitional skills from allied professionals, via patient portals, or in group settings. Incorporating patient perspectives into research and clinical practice is an opportunity to strengthen educational programs. AYAs emphasized the importance of gaining independence and becoming empowered through the health care transition process with structured support from their rheumatology teams.

Cross-sectional study and literature review on perceptions and attitudes of urology specialist providers toward transitional urologic care process

Cross-sectional study and literature review on perceptions and attitudes of urology specialist providers toward transitional urologic care process

Provider’s perspectives regarding transitional urologic care process: A scoping review

ObjectiveTo generate a scoping review that summarizes perceptions and attitudes of urology providers towards the transitional urologic care process. Likewise, summarize their identified barriers, facilitators, and ideal transition care for patients with genitourinary conditions. MethodA systematic literature search was performed in Oct 2021. Records were identified for studies relevant to assessing urology specialists' practice variation, perception of barriers, and attitudes toward transitional care of patients needing life-long urologic care. The methodological quality of the cross-sectional studies was assessed using AXIS. The information extracted was clustered according to identified themes from the included studies. This scoping review was part of a systematic review registered on PROSPERO-(CRD42022306229). ResultsA total of 641 records were retrieved from electronic medical databases and cross-referencing. Ultimately, ten studies were included in this scoping review, conducted in the USA (n = 7), Canada, United Kingdom, and Italy. There is a wide variation in transitional care practices and preferences. However, the common themes extracted were: appropriate age to start the transition, additional training of the providers involved in transitional care, common transition plans, and practices, characteristics of multidisciplinary teams, potential barriers, areas of improvement, or facilitators for a better transitional process. ConclusionCommon to all reports, multiple barriers are perceived. Areas that require improvement and multidisciplinary systems are needed to enhance urologic transition care. In addition, factors such as the age cut-off between pediatric and adult care or which specialist should handle specific procedures and conditions before, during, and after transition are still unclear and typically depend on the stakeholders.

CAN TRANSITIONAL CARE DECREASE READMISSION IN STROKE PATIENTS?

Background: One strategy to reduce the hospital readmission rate of stroke patients is to implement transitional care.
 Objective: The aim of this study was to identify the application of transitional care to the hospital readmission rate of stroke patients.
 Design: Design of this literature review was A Systematic review.
 Data Sources: We searched English articles in PubMed, CINAHL, SAGE, and Science Direct databases from January 2016 to September 28, 2021. Participants in the study were adults (17 years old or older) who had transitioned from hospital to home care. The included publications were mined for information on study features and research findings.
 Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was followed when conducting this review. The study question and search method were developed with the aid of the PICO framework, which provides descriptions of participants, interventions, comparisons, and results.
 Results: Eight articles were reviewed regarding the outcomes of implementing transitional care on readmission rates and satisfaction in stroke patients. All reviewed articles showed decreased readmission rates and increased patient satisfaction. There were some differences in the transitional care process, team coordinator, duration of transition care follow-up, and service satisfaction.
 Conclusion: Our findings show that the application of transitional care has a positive impact on decreasing readmission rates before 30 days and increasing patient satisfaction with nursing care. Transitional care policies need to be considered to reduce readmission rates in an effort to improve the quality of hospital services.

Effectiveness of transitional care interventions in patients with serious illness and their caregivers: a systematic review protocol.

The objective of this review is to evaluate the effectiveness of transitional care interventions for seriously ill patients and their caregivers. Seriously ill patients and their caregivers may have complex health and social care needs that require services from numerous providers across multiple sectors. Transitional care interventions have been designed to enhance a collaborative approach among providers to facilitate the care transition process. However, the effectiveness of transitional care interventions for seriously ill patients, their caregivers, and the effects of such interventions on their outcomes remain unclear. Randomized controlled trials with adult patients (≥18y old) with serious illness and their caregivers involved in transitional care programs will be considered for inclusion. The patients' outcomes will include mortality and/or survival, symptoms (eg, pain, nausea), and health-related quality of life. The caregivers' outcomes will include caregiver burden, preparedness, and well-being. The JBI methodology for systematic reviews of effectiveness evidence will be followed. The search strategy aims to locate published and unpublished studies. Electronic databases, including PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, will be systematically searched from 2003 to the present. Studies in English, Italian, Spanish, French, and German will be included. Critical appraisal and data extraction will be conducted using standardized tools. Quantitative data will be pooled in statistical meta-analysis or, if statistical pooling is not possible, the findings will be reported narratively. Certainty of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). PROSPERO CRD42022319848.

Implementation of Rheumatology Health Care Transition Processes and Adaptations to Systems Under Stress: A Mixed-Methods Study.

Despite poor health care transition outcomes among young adults with pediatric rheumatic diseases, adoption of transition best practices is low. We sought to understand how structured transition processes were operationalized within pediatric rheumatology practices and what factors were perceived to enable adaptations during a global pandemic. We conducted a mixed methods study of team leaders' experiences during an interim analysis of a pilot project to implement transition policy discussions at sites in the Childhood Arthritis and Rheumatology Research Alliance Transition Learning Collaborative. We combined quantitative assessments of organizational readiness for change (9 sites) and semistructured interviews of team leaders (8 sites) using determinants in the Exploration, Preparation, Implementation, Sustainment Framework. Engagement of nursing and institutional improvement efforts facilitated decisions to implement transition policies. Workflows incorporating educational processes by nonphysicians were perceived to be critical for success. When the pandemic disrupted contact with nonphysicians, capacity for automation using electronic medical record (EMR)-based tools was an important facilitator, but few sites could access these tools. Sites without EMR-based tools did not progress despite reporting high organizational readiness to implement change at the clinic level. Lastly, educational processes were often superseded by acute issues, such that youth with greater medical/psychosocial complexity may not receive the intervention. We generated several considerations to guide implementation of transition processes within pediatric rheumatology from the perspectives of team leaders. Careful assessment of institutional and nursing support is advisable before conducting complex transition interventions. Ideally, new strategies would ensure interventions reach youth with high complexity.

Effect of Pharmacist Interventions on Hospital Readmissions for Home-Based Primary Care Veterans

Several studies indicate that when patients transition from one level of care to another, errors may occur. Pharmacists can play an integral role in the transitions of care process. At Michael E. DeBakey Veteran Affairs Medical Center, the Home-Based Primary Care (HBPC) service has implemented a streamlined hospital discharge plan to improve 30-day readmission rates after 1 year of HBPC enrollment. Our aim was to identify specific pharmacist interventions to improve the HBPC discharge process and ultimately, improve hospital readmission rates. A Plan-Do-Study-Act quality improvement project was initiated. We conducted a review of veterans enrolled in HBPC from October 2019 to March 2020. Of 175 patients assessed postdischarge, a medication reconciliation was completed by an HBPC pharmacist in 118 (67.4%) patients. Of the 118 medication reconciliations completed, 92 (78%) interventions were made by HBPC pharmacists. During the 6-month study period, 30-day hospital readmission rates decreased from 19% to 13%. This study demonstrates several opportunities for interventions to lower readmission rates. Using the results from this study, education has been provided for the HBPC service and its readmission committee.

SWK-06. Structured transition from pediatric neuro-oncology to adult survivorship follow-up care - Can we close the gap?

PURPOSE: Advances in treatment have increased survival rates and quality of life of pediatric CNS tumor patients leading to a growing number of long-term survivors. However, there is sufficient clinical and scientific evidence for the need of a highly specialized lifelong follow-up care due to multidimensional late effects. Furthermore, adolescence and young adulthood are challenging age periods when patients frequently get lost to follow-up potentially having severe impact on health and well-being. Since 2020, we have established a structured transfer of long-term survivors older than 18 years to a newly founded highly specialized adult care follow-up setting for childhood cancer survivors (IONA). The aim of this study was to evaluate the current transition process. RESEARCH DESIGN: The standard of care transition process at the neuro-oncology unit of the MUV includes a joint appointment with the patient, a pediatric neuro-oncologist, psychologist and/or social worker and the team of the adult care facility (physician, psychologist). Different elements are used to end care safely in the pediatric structure and building trust in the upcoming out-patient-department at the same time. The transition process was evaluated statistically and analyzed qualitatively with regard to the factors that define a safe transition. RESULTS: After two years (01/2020-12/2021) 114 patients had a joint transition appointment, two patients contacted IONA directly. Shortly after the joint appointment all patients had a scheduled follow-up meeting at IONA. 102 patients (87.9%) showed up, seven patients (6%) already had a planned appointment, two patients (1.7%) were in contact with IONA but had no possibility to show up in person. Only five patients (4.3%) did not attend the appointment and were lost to follow-up. CONCLUSION: A structured interdisciplinary transition concept is a successful option to establish controlled and patient-safe transition from pediatric to adult care setting.

Patient Perspectives on Care Transitions From Hospital to Home

Understanding the patient's perspective of their care transition process from hospital or skilled nursing facility (SNF) to home may highlight gaps in care and inform system improvements. To gather data about patients' care transition experiences and factors associated with follow-up appointment completion. A survey tool was developed with input from patient advisors and organizations participating in a collaborative quality initiative. Seventeen hospitals, 12 practitioner organizations, and 6 SNFs in Michigan collaborated to identify shared patients who were aged 18 years and older, had a working telephone number, recently returned home or to an assisted living facility with a diagnosis of congestive heart failure or chronic obstructive pulmonary disease, or after an SNF stay. Using consecutive sampling, interviewers collected 5 telephone surveys per month. From October 2018 to December 2019, patients or caregivers were surveyed via telephone 8 to 12 days after discharge from a hospital or SNF. Data were analyzed from March 2020 to January 2022. Care transition experiences. The primary outcome was to identify patient-perceived gaps during care transition experiences, including postdischarge follow-up. On the basis of pilot data, the response rate was estimated at 34%, yielding 1257 surveys. Of 1257 survey respondents (mean [SD] age, 70 [12.94] years for 968 patients for whom age data was available), 654 (52%) were female; 829 (74%) were White, 250 (22%) were Black or African American, and 40 (4%) were another race. Eleven percent of patients reported not receiving a telephone number to call for postdischarge questions. Nearly 80% of patients (977 patients) received a follow-up telephone call, and most found it valuable. Twenty percent of patients (255 patients) reported at least 1 social determinant of health issue. Lack of transportation was associated with reduced likelihood of completing a follow-up visit, decreasing the odds of completing a follow-up by nearly 70% (odds ratio [OR], 0.31; 95% CI, 0.18-0.53; P < .001). Compared with other patient groups, Black patients were less likely to report completing a postdischarge follow-up visit (OR, 0.49; 95% CI, 0.36-0.67; P < .001) or to receive prescribed medical equipment (OR, 4.23; 95% CI, 1.30-13.83; P = .02). An examination of patient discharge experiences from a hospital or SNF identified inconsistencies in care transition processes, social determinants of health issues needing to be addressed after discharge, and racial disparities between patients who attend follow-up appointments. Physicians should be aware of these findings and their consequences for patient experiences.

Discrepancies occurred during multiple care transition process and their predictors in a tertiary care teaching hospital – a prospective observational study

Intense situations, shorter length of stay, miscommunication (verbally or written) amongst staff and patients, incomplete data sources, and conditions requiring immediate action create emergency department as hotspots for medication discrepancies. Despite the emphasis by international healthcare organizations, the transition of care remains unexplored in India. Hence, this study planned to assess and identify the discrepancies that occurred during multiple transitions care points and to estimate their predictors. Prospective observational study was conducted in patients admitted during October 2019–April 2020 in the emergency department and subsequently shifted to other wards until discharge. The medication reconciliation was performed at each transition level, and discrepancies were documented and analyzed to identify the predictors. A total of 165 patients were enrolled out of which 79 had discrepancies. The observed discrepancies were 159, of which 54 were intentional and 105 unintentional. Mean age of the patients was found to be 51.5 years, and the majority of the patients enrolled (38%) belonged to the middle age group, i.e., 38–58 years. Unintentional discrepancies (66.04%) due to reconciliation errors, dominated over intentional (33.96%). Omission (42.7%) followed by substitution (20.7%) was the most discrepancies observed. 47.2% of discrepancies occurred during the transition from intensive care unit to general wards, and 32.1% occurred at discharge. Binomial logistic regression showed that age, number of medications, and co-morbidities are predictive factors for discrepancies. The majority of unintentional discrepancies occurred due to reconciliation errors rather than erroneous history documentation. Most of the study in tertiary care settings showed similar discrepancies varying in their numbers. Emergency pharmacist-led reconciliation, especially during the transition from a special ward to a general ward and at discharge, will lead to early identification of discrepancies and prevent medication errors. Des situations graves, une durée de séjour plus courte, une mauvaise communication (verbale ou écrite) entre le personnel et les patients, des sources de données incomplètes et des conditions nécessitant une action immédiate font des services d’urgence des terrains favorables pour les erreurs médicamenteuses. Malgré l’accent mis par les organisations internationales de soins de santé, la transition des soins reste inexplorée en Inde. Par conséquent, cette étude a prévu d’évaluer et d’identifier les erreurs qui se produisent au niveau de plusieurs interfaces entre services de soins en enfin de rechercher les facteurs favorisants. Une étude observationnelle prospective a été menée chez des patients admis entre octobre 2019 et avril 2020 dans le service des urgences, puis transférés dans d’autres services jusqu’à leur sortie. Le bilan comparatif des médicaments a été effectué à chaque niveau de transition, et les écarts ont été documentés et analysés pour identifier les facteurs favorisants. Un total de 165 patients a été inclus et parmi ceux-ci, 79 ont connu des erreurs. Les écarts observés étaient de 159, dont 54 étaient intentionnels et 105 non intentionnels. L’âge moyen des patients était de 51,5 ans et la majorité des patients inclus (38 %) appartenaient au groupe d’âge moyen, c’est-à-dire 38–58 ans. Les erreurs non intentionnelles (66,04 %), dues à des écarts observés lors des conciliations, prédominaient sur les écarts intentionnels (33,96 %). L’omission (42,7 %) suivie de la substitution (20,7 %) concernait la plupart des erreurs observées. Au total, 47,2 % des erreurs sont survenues lors de la transition de l’unité de soins intensifs aux services généraux et 32,1 % sont survenues à la sortie. La régression logistique binomiale a montré que l’âge, le nombre de médicaments et les comorbidités sont des facteurs prédictifs d’erreurs. La majorité des divergences non intentionnelles sont dues à des erreurs de saisie plutôt qu’à des erreurs liées à une documentation historique erronée. La plupart des études menées dans les établissements de soins tertiaires ont montré des écarts similaires variant dans leur nombre. Les reprises de traitement dirigées par le pharmacien clinicien basé aux urgences, en particulier lors d’une interface service spécialisé – service général et à la sortie, permettrait d’identifier rapidement des écarts potentiels et d’éviter des erreurs médicamenteuses.

Paediatric transitional care process within a homecare parenteral nutrition service

Working in partnership with the NHS as a national homecare nursing service supporting both adult and paediatric patients at home receiving parenteral nutrition, we developed a transition training programme with a major centre for young adults between the ages of 13-15yrs on long term parenteral nutrition. The programme was coordinated jointly with nursing leads from the homecare nursing service and clinical nurse specialists for children with intestinal failure. Using the knowledge and guidance of both institutions we developed a transition programme that supports both the young adult and the parent or carers through the process of training and independence.

Patterns of Care for Adolescent With Schizophrenia: A Delphi-Based Consensus Study.

BackgroundThe current conceptualization of schizophrenia as neurodevelopmental disorder should lead to innovative public health policies in terms of a reorganization of the mental health care systems, particularly in the transition from adolescence to adulthood, to reduce personal, familiar, and social costs and burdens. The purpose of the project was to perform a survey among a panel of Italian schizophrenia experts, to share evidence-based information on adolescent schizophrenia and explore the degree of consensus among professionals in the following four macro-areas: early diagnosis; pharmacological treatment; health care system organization and transition process from adolescent to adulthood; and psychosocial interventions.MethodsThe consensus process consisted of a two-step web-based Delphi method, which took place between June and November 2021. The survey was developed by a panel of four psychiatrists and four child neuropsychiatrists, identified as key opinion leaders (KOLs). The KOLs identified 21 statements involving a total of 70 items with a major need of clarification on early-onset schizophrenia (EOS). The survey was distributed to 86 specialists in psychiatry and child neuropsychiatry.ResultsThe results revealed a large agreement among the expert group on all the investigated areas of adolescent schizophrenia patterns of care and management. Consensus was ultimately reached for 67 items of the Delphi survey (95.7%), while negative consensus was reached for 2 items and no consensus was reached for 1 item.ConclusionsOverall, results showed a significant gap between the acquired scientific knowledge and clinical practice. In this scenario, it should be necessary to plan specific initiatives at a multiple level, to edit recommendations on clinical decision-making, as well as to prompt changes at the political and organizational levels, also involving scientific societies, patients, and family associations, to overcome the barriers that delay the implementation process.

One-Bed-One-Team-Does an Integrated General Hospital Inpatient Model Improve Care Outcomes and Productivity: An Observational Study.

IntroductionWith the increasing complexity of healthcare problems worldwide, the demand for better-coordinated care delivery is on the rise. However, current hospital-based practices remain largely disease-centric and specialist-driven, resulting in fragmented care. This study aimed to evaluate the effectiveness and feasibility of an integrated general hospital (IGH) inpatient care model.MethodsRetrospective analysis of medical records between June 2018 and August 2019 compared patients admitted under the IGH model and patients receiving usual care in public hospitals. The IGH model managed patients from one location with a multidisciplinary team, performing needs-based care transition utilizing acuity tagging to match the intensity of care to illness acuity.Results5,000 episodes of IGH care entered analysis. In the absence of care transition in intervention and control, IGH average length of stay (ALOS) was 0.7 days shorter than control. In the group with care transition in intervention but not in control, IGH acute ALOS was 2 days shorter, whereas subacute ALOS was 4.8 days longer. In the presence of care transition in intervention and control, IGH acute ALOS was 6.4 and 10.2 days shorter and subacute ALOS was 15.8 and 26.9 days shorter compared with patients under usual care at acute hospitals with and without co-located community hospitals, respectively. The 30- and 60-days readmission rates of IGH patients were marginally higher than usual care, though not clinically significant.DiscussionsThe IGH care model maybe associated with shorter ALOS of inpatients and optimize resource allocation and service utilization. Patients with dynamic acuity transition benefited from a seamless care transition process.

Better understanding care transitions of adults with complex health and social care needs: a study protocol

BackgroundAdults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers.Methods/designWe will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged.DiscussionThis study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study’s findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.

A Quality Improvement Initiative: A Nurse Practitioner-Led Interdisciplinary Approach to Reducing Readmissions in the Subacute Population.

To decrease the 30-day Subacute Readmissions in an outpatient facility by using an Advanced Practice Nurse (APN) Project Leader while applying evidence based transitional care processes. Determine the effects of APN leadership within the Interdisciplinary Team in the subacute setting. Immersion of an APN as Project Leader over a 12-week period. Outcomes were divided into three groups. They were reorganized and analyzed. The new breakdown included patients readmitted plus hospice referrals (n = 5) and those not readmitted (n = 4). A significant difference in the 30-day outcomes as well as the LACE variable comorbidity scores t (4) = 2.95, p = 0.0418 were identified. The 30-day readmission rates were decreased using hospice as a referral source. Application of the Lippitt's Model of Planned Change and the use of the LACE Scoring Tool were instrumental to the success of this project. To improve optimal outcomes it is necessary for the APN/Doctor of Nursing Practice (DNP) and other healthcare professionals to engage in collaborative practices that result in effective policy changes. This quality improvement project restructured the existing Interdisciplinary Team processes to include the APN Project Leader with improved patient-centered outcomes.