Transitional Care Program Research Articles

Disparities After Discharge: The Association of Limited English Proficiency and Postdischarge Patient-Reported Issues.

The transition from hospital to home is a vulnerable period for all patients, particularly for those who have limited English proficiency (LEP). The research team retrospectively studied adults discharged home from a hospital in 2018-2019 to determine the association of LEP with (1) reach of a care transitions outreach program phone call (automated call within three days after discharge or a subsequent manual phone call) and (2) postdischarge issues reported on the phone calls. All results were adjusted for measured confounders; associations using predicted probabilities and average marginal effects were described. A total of 13,860 patients were included, and 11.3% had LEP. After adjustment, the program reached most patients regardless of LEP status; automated calls were more likely to reach English proficient patients (81.1% vs. 75.6%, p < 0.01), and when the automated call was unsuccessful, manual calls were more likely to reach LEP patients (47.8% vs. 28.3%, p<0.001). After adjustment, patients with LEP reported more difficulty with all measured issues: understanding discharge instructions (11.3% vs. 6.5%), obtaining prescriptions (8.3% vs. 5.5%), medication concerns (12.9% vs. 10.6%), follow-up questions (16.1% vs. 13.3%), new or worsening symptoms (15.1% vs. 11.9%), and any other clinical issues (16.6% vs. 13.0%); p<0.05 for all comparisons. Although reach was high for the care transitions program, among patients with LEP, important disparities exist in patient-reported postdischarge issues. These results indicate the need for better discharge processes that focus on communication quality and health equity.

Mediating effects of coping styles on the relationship between family resilience and self-care status of adolescents with epilepsy transitioning to adult healthcare: A cross-sectional study in China

PurposeThis study aimed to explore the relationship between family resilience, coping styles, and self-care among Chinese adolescents with epilepsy. Design and methodsA total of 1238 adolescents with epilepsy in nine tertiary hospitals in China participated in a cross-sectional survey conducted from May 2018 to March 2020. Structural equation modeling was used to analyze the mediating effect. ResultsThe total scores for family resilience and coping styles were positively correlated with the total self-care status score of adolescents with epilepsy during their transition (r = 0.209, 0.202, P < 0.01). Family resilience was positively correlated with coping style (r = 0.450, P < 0.01). The modified model’s fit index included χ2/df = 1.970, P = 0.001, RMSEA = 0.054, TLI = 0.973, CFI = 0.978, GFI = 0.941, AGFI = 0.917, NFI = 0.956, and IFI = 0.978. The confidence interval (CI) was 0.004–0.140 for the indirect effect and 0.033–0.306 for the direct effect. ConclusionsThe self-care status of adolescents with epilepsy during the transitional period is closely related to coping style and family resilience. Coping style mediates family resilience and self-care status. Practice implicationsHealthcare teams should pay attention to the coping ability of adolescents with epilepsy to help them transition smoothly and to improve family functioning. This study provides a theoretical basis for establishing transitional care programs for adolescents with chronic illnesses. The significant mediating effect of coping style should be emphasized in modalities of healthcare that include patient participation.

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

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

Health Concerns of Adolescents and Adults With Spina Bifida.

Due to advancements in medical care, people with spina bifida (SB) are surviving well into adulthood, resulting in a growing number of patients transitioning to an adult sector unequipped to care for people with chronic rehabilitative and medical needs. The Transitional and Lifelong Care (TLC) program is a multidisciplinary clinical service that compensates for this gap, providing comprehensive, coordinated care to adolescents, and adults with SB. As a relatively new clinical service, objective data about the patients using the service and their needs is scant. This study sought to identify the most common health concerns among TLC patients with SB at initial clinical consultation. A retrospective chart review of 94 patient charts was performed. Following data extraction, descriptive analyses were completed. The mean age of the sample was 29.04 ± 13.8 years. One hundred individual concerns and 18 concern categories were identified. On average, patients or care providers identified nine health concerns across various spheres of care, with care coordination being the most prevalent concern identified (86%). Patients also commonly had concerns regarding neurogenic bladder (70%), medications (66%), assistive devices (48%), and neurogenic bowel (42%). The numerous and wide-ranging health concerns identified support the need for individualised, coordinated care and a “medical home” for all adolescents and adults with SB during and following the transition to adult care. Health care providers caring for this population should continue to address well-documented health concerns and also consider raising discussion around topics such as sexual health, mental health, and bone health. Further research is required to understand how best to address the complex medical issues faced by adults with SB to maximise health and quality of life and improve access to healthcare.

Importance of telephone follow-up and combined home visit and telephone follow-up interventions in reducing acute healthcare utilization

PurposeTransitional care is increasingly important in reducing readmission rates and length of stay (LOS). Singapore is focusing on transitional care to address the evolving care needs of a multi-morbid ageing population. This study aims to investigate the impact of transitional care programs (TCPs) on acute healthcare utilization.Design/methodology/approachA retrospective, longitudinal, interventional study was conducted. High-risk patients were enrolled into a transitional care program of local tertiary hospital. Patients received either telephone follow-up (TFU) or home-based intervention (HBI) with TFU. Readmission rates and LOS were assessed for both groups.FindingsThere was no statistically significant difference in readmissions or LOS between TFU and HBI. After excluding demised patients, TFU had statistically significant lower LOS than HBI. Both interventions demonstrated statistically significant reductions in readmissions and LOS in pre–post analyses.Research limitations/implicationsTFU may be more effective than HBI in patients with lower clinical severity, despite both interventions showing statistically significant reductions in acute healthcare utilization. Study findings may be used to inform transitional care practices. Future studies should continue to examine the comparative effectiveness of transitional care interventions and the patient populations most likely to benefit.Originality/valuePrevious studies demonstrated promising outcomes for TFU and HBIs, but few have evaluated their comparative effectiveness on acute healthcare utilization and specific patient populations most likely to benefit. This study evaluated interventional effectiveness of both, which might be useful for informing allocation of resources based on clinical complexity and care needs.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial.

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge. We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group. For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (Pinteraction = .085). In total, 77.0% of the patients had at least one MRP post-discharge. Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Engagement of Older Adults in out-of-Home Occupations: Transitioning from Hospital to Home

Aims Transition Care Programs support older adults to return home post hospital admission. This study explored the experiences of older adults who identified therapy goals relating to out-of-home occupations. Methods In this convergent mixed methods study, we assessed 10 older adults using the Meaningful Activity Participation Assessment and the Life-space Questionnaire, followed by in-depth interviews to explore out-of-home occupational engagement. Results Participants described continued engagement in out-of-home occupations, albeit adapted due to their changing health. They reported experiencing an ongoing health and occupational journey which required them to actively consider barriers and enablers to their occupational engagement. These adults were skilled in analyzing their own performance and engagement in out-of-home occupations. Conclusion Older adults make progressive adaptations to maintain their occupational engagement. They are experts in analyzing enablers and barriers for out-of-home occupations and should be proactively invited to share their expertise during therapy.

Effects of a nurse-led transitional burns rehabilitation programme (4Cs-TBuRP) for adult burn survivors: protocol for a randomised controlled trial

BackgroundTransitioning from the burn unit to the home/community can be chaotic with limited professional support. Some adult burn survivors may face varied concerns leading to poor outcomes in the early post-discharge period with limited access to professional help. Based on these, a nurse-led transitional burns rehabilitation programme has been developed and the current trial aims to ascertain its effects as well as explore the implementation process.MethodsA single-centre, double-arm randomised controlled trial with a process evaluation phase will be utilised for this study. All adult burn survivors aged ≥ 18 years with burn size ≥ 10% total burn surface area at the site during the study period will be screened for eligibility at least 72 h to discharge. A sample size of 150 will be block randomised to treatment (receiving the nurse-led transitional care programme and routine post-discharge service) and control groups (receiving routine post-discharge service). The nurse-led transitional care programme comprises of predischarge and follow-up phases with the delivery of bundle of holistic interventions lasting for 8 weeks. There are three timelines for data collection: baseline, immediate post intervention, and 4 weeks post-intervention.DiscussionThe findings from this study can potentially inform the development and organisation of post-discharge care and affirm the need for ongoing comprehensive home-based care for burn survivors and their familiesTrial registrationClinicalTrials.govNCT04517721. Registered on 20 August 2020

Analysis of Readmissions in a Mobile Integrated Health Transitional Care Program Using Root Cause Analysis and Common Cause Analysis.

Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.

Diagnosis-group-specific transitional care program recommendations for 30-day rehospitalization reduction

Thirty-day rehospitalization rate is a well-studied and important measure reflecting the overall performance of health systems. Recently, transitional care (TC) programs have been initiated to reduce avoidable rehospitalizations. These programs typically ask nurses to follow-up with patients after the hospitalization to manage issues and reduce the risk of rehospitalizations during health care transitions. As rehospitalization is a complex process that depends on many factors, it is unlikely that these interventions are effective for all patients across a diverse population. In this paper we consider individualized intervention or treatment recommendation rules (ITRs) aimed at maximizing overall treatment effectiveness. We investigate our approach in a setting where patients are divided into two diagnosis related groups, medically complicated and uncomplicated. As the treatment effects can greatly vary between the two groups, we allow our recommendation rules to be group specific. In particular, our approach can accommodate scale differences in treatment effects and utilize a tuning parameter to drive the similarity of the estimated ITRs between groups. Computation is achieved by transforming our problem into a form solvable by existing software, and a wrapper R package is developed for our proposed treatment recommendation framework. We conduct extensive evaluation through both simulation studies and analysis of a TC program.

MP51-19 COMPLIANCE RATES AMONG PEDIATRIC CONGENITAL NEUROGENIC BLADDER PATIENTS PARTICIPATING IN A TRANSITIONAL CARE PROGRAM

You have accessJournal of UrologyPediatric Urology IV (MP51)1 Sep 2021MP51-19 COMPLIANCE RATES AMONG PEDIATRIC CONGENITAL NEUROGENIC BLADDER PATIENTS PARTICIPATING IN A TRANSITIONAL CARE PROGRAM Aleksandar Blubaum, Jennifer Lewis, Dominic Frimberger, and Gennady Slobodov Aleksandar BlubaumAleksandar Blubaum More articles by this author , Jennifer LewisJennifer Lewis More articles by this author , Dominic FrimbergerDominic Frimberger More articles by this author , and Gennady SlobodovGennady Slobodov More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002077.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Advancements in medical care have improved the prognosis of patients born with congenital urologic conditions. These patients have complex medical problems and often extensive surgical histories with altered anatomy, requiring specialized knowledge and close urologic follow-up. To assist these patients moving from pediatric to adult care, we developed a single specialty, urology-based transition clinic. Four readiness stages (T1-T4) that we have previously published about guide the transition. This study aims to update our experience with the transition clinic and report on its results. METHODS: We performed a retrospective chart review of all patients seen in the transition clinic since inception in 2014. We collected demographic and clinical data, including most recent T stage, appointment dates, transition time, as well as number of appointments and no show/cancellations. We analyzed this data to determine success rates and patient compliance with the transition process. RESULTS: 162 patients were seen in the transition clinic. 57/60 (95%) patients ready to transition to the adult clinic successfully completed this transition, with 3/60 (5%) failing to do so. The majority of inactive patients (last visit >365 days prior) were lost during pediatric stages with 34/60 (56.7%) at T1 and 13/60 (21.7%) at T2. Table 1 displays average transition time, average number of visits, and average number of no show/cancellations amongst active and inactive patients. 28 fully transitioned patients progressed per pathway, while 29 skipped from T2 to T4 due to losing their established pediatric provider. 7/29 (24.1%) expedited patients compared to 3/28 (10.7%) pathway patients were lost to follow-up (p=0.297). CONCLUSIONS: Patients with congenital urologic conditions who participated in a single specialty, urology-based transition clinic were successful completing the transition from pediatric to adult care. Active participation in a transition clinic was associated with increased clinic appointment attendance and fewer no show/cancellations. Non-compliance with pediatric provider visits predicted non-compliance with adult provider visits. Increased transition time and number of visits between stages were associated with increased transition completion rates. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e903-e904 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aleksandar Blubaum More articles by this author Jennifer Lewis More articles by this author Dominic Frimberger More articles by this author Gennady Slobodov More articles by this author Expand All Advertisement Loading ...

Bathing wipes, a valuable hygiene option for frail older persons at home: a proof of concept study

Objectives: To explore experiences and attitudes of frail older persons to using bathing wipes as a hygiene option at home. Methods: A descriptive, exploratory study was conducted with older clients who required hygiene assistance post hospital discharge and consented to trial bath wipes. Client participants or their carer completed a verbal questionnaire administered via telephone. Descriptive statistics summarised the quantitative data and closed-ended questions were analysed using content analysis. Results: Thirty-seven of the 49 consented participants used the bathing wipes at home. There was high level of agreement that bathing wipes were fit for purpose and participants indicated that they were suitable to use to supplement assisted showers. Conclusion: The use of bathing wipes provides an acceptable hygiene option and can support autonomy of frail, older persons, while reducing the risk of falls from wet floors. Bathing wipes are of use to persons who have not yet regained independence with showering and/or are awaiting bathroom modifications installed. What is already known about the topic? Wet floors associated with showering unassisted, can be a falls hazard to elderly persons attempting to regain independence. Transition care programs offered for elderly clients returning to their own home post hospital discharge are limited in scope and duration. Falls in frail, older people are common, with adverse consequences for the individual and the health system. What this paper adds Bath wipes were well accepted by elderly clients as an alternative to showering without assistance. Bath wipes can be used by the individual on a short-term basis while they regain independence with hygiene, while they wait for bathroom modifications, or they can be used longer term.

The effect of a mobile integrated health program on health care cost and utilization.

To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio=1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio=1.78, 95% CI=[1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial.

Backgroundafter hospitalisation for cardiac disease, older patients are at high risk of readmission and death.Objectivethe cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality.Designsingle-blind, randomised clinical trial.Settingthe trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge.Subjectscardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months.Methodsthe intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months.Resultsin total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care.Conclusionin high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.Trial registrationNetherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Cardiac Transitional Care Effectiveness: Does Overall Comorbidity Burden Matter?

BackgroundCardiovascular disease is the most common cause of mortality and hospitalization in the United States. Transitional care initiatives can improve outcomes for cardiac patients, but it is unclear whether patients with different baseline comorbidity burden benefit equally. We evaluated the effectiveness of the Bridging the Discharge Gap Effectively (BRIDGE) program, a nurse-practitioner-led transitional care clinic, in mitigating adverse clinical outcomes in cardiac patients with varying Charlson comorbidity index (CCI). MethodsWe studied patients referred to BRIDGE between 2008 and 2017 postdischarge for a cardiac condition. Using proportional hazards regression models, we evaluated associations between attendance at BRIDGE and hospital readmission, emergency department (ED) visit, and a composite outcome consisting of readmission, ED visit, or mortality, and assessed interaction between BRIDGE attendance and CCI. ResultsOf 4559 patients, 3256 (71.4%) attended BRIDGE. In patients with low CCI, attendance at BRIDGE was inversely associated with hospital readmission (adjusted hazard ratio = 0.82, 95% confidence interval [CI]: 0.69, 0.97, P = .02) and the composite endpoint (adjusted hazard ratio = 0.84, 95% CI: 0.72, 0.98, P = .02). Associations of BRIDGE attendance with both readmission and ED visit were significantly weaker in patients with high CCI (adjusted P, interaction = .007 and .03, respectively). Overall, BRIDGE attendance was associated with an 11% lower hazard of developing the composite endpoint (95% CI: 2%, 19%, P = .01). ConclusionsAttendance at a transitional care clinic is inversely associated with risk of readmission and a composite endpoint in cardiac patients with low CCI. Future research should investigate modified transitional care programs in patients with varying comorbidity burden.

Transitional Care Program for Enhancing Competence of Primary Care Givers in Home Care Management of Neonatal Intensive Care Unit Graduates

The discharge of a newborn who had been admitted in neonatal intensive care unit (NICU) for weeks or months after birth is both joy and worry for parents. A comprehensive plan is needed to prepare the parents so that they can take care of their baby by their own after discharge from NICU. The objective of the study was to assess the effectiveness of transitional care programmes on the competence of primary caregivers in home care management of NICU graduates. A Quasi-experimental design with a quantitative approach was adopted. The sample consisted of 80 primary caregivers selected by purposive sampling technique. Data were collected using the demographic profile, structured knowledge questionnaire and observation checklist. The findings showed that the mean knowledge score of mothers regarding home care of NICU graduates improved from 12.8 ± 3.93 in pretest to 27.55 ± 1.93 after the transitional care programme. There was a significant difference between pretest and posttest knowledge of mothers in the experimental group (P &lt; 0.001). The mean knowledge score of caregivers regarding homecare of NICU graduates improved from 12.7 ± 2.47 to 25.6 ± 3.25 after the transitional care programme. However, no significant difference was observed between the study participants of experimental and control groups (P &gt; 0.05). A randomised control trial with a large sample size is needed to find out the impact of transitional care programmes. This intervention can be incorporated into the discharge plan of NICU graduates to minimise the readmission to the hospital.

Identifying the Association Between Older Adults' Characteristics and Their Health-Related Outcomes in a Transition Care Setting: A Retrospective Audit.

Introduction: Continued evaluation of Transition Care Programs (TCP) is essential to improving older adults' outcomes and can guide which older adults may benefit from undertaking TCP. The aim of this study was to audit a transition care service to identify the association between the characteristics of older adults undertaking a facility-based TCP and (i) discharge destination and (ii) functional improvement.Materials and methods: An audit (n = 169) of older adults aged 60 years and above who completed a facility-based TCP in Australia was conducted. Outcomes audited were performance of activities of daily living (ADL) measured using the Modified Barthel Index (MBI) and discharge destination. Data were analyzed using logistic regression and linear mixed modeling.Results: Older adults [mean age 84.2 (±8.3) years] had a median TCP stay of 38 days. Fifty-four older adults (32.0%) were discharged home, 20 (11.8%) were readmitted to hospital and 93 (55%) were admitted to permanent residential aged care. Having no cognitive impairment [OR = 0.41 (95% CI 0.18-0.93)], being independent with ADL at admission [OR = 0.41 (95% CI 0.16-1.00)] and a pre-planned team goal of home discharge [OR = 24.98 (95% CI 5.47-114.15)] was significantly associated with discharge home. Cases discharged home showed greater improvement in functional ability [MBI 21.3 points (95% CI 17.0-25.6)] compared to cases discharged to other destinations [MBI 9.6 points (95% CI 6.5-12.7)].Conclusion: Auditing a facility-based TCP identified that older adults who were independent in ADL and had good cognitive levels were more likely to be discharged home. Older adults with cognitive impairment also made clinically significant functional improvements.

Provider Perspectives of Necessary Factors in Sickle Cell Disease Health Care Transition: Results from an Online Survey

Introduction: Survivorship of children with sickle cell disease (SCD) has substantially increased due to the advent of medical advances, such as sepsis prevention (prophylactic penicillin) and exposure to disease-modifying therapies (chronic transfusion and hydroxyurea). Despite greater longevity in SCD, the period surrounding the transition from pediatric to adult care has the highest prevalence of undesirable outcomes: youth aged 18-30 years are at high risk for mortality and high rates of healthcare utilization, resulting in increased healthcare costs. As such, health care transition programs have been created to prepare patients with SCD for adult-centered care and subsequently, improve health outcomes. However, few programs have been evaluated for effectiveness in achieving optimal health outcomes in SCD in part because of a lack of identifiable predictors and outcomes.Objective: To identify factors necessary for successful health care transition, as judged by pediatric and adult healthcare professionals involved with the SCD population.Method: Individuals who provide clinical care for or conduct clinical research with patients with SCD were eligible to participate in the survey and were collectively defined as providers. Providers were recruited online through nationally recognized professional societies, SCD provider contact lists and in person at a national SCD conference. Links to an online survey, administered via Qualtrics software, were distributed to potential participants. The survey included demographic questions and a list of 36 transition factors, including disease knowledge, self-management behaviors, and independent living skills. Participants were asked to rate the level of importance of each factor in helping a patient with SCD successfully transition from pediatric to adult care on a scale from 1 (not important) to 10 (very important). They were then asked to select five of the 36 factors they believed were most necessary for a successful transition, ranking them from 1 (highest) to 5 (lowest). Descriptive statistics were conducted to determine the top ratings and rankings. A two-way MANOVA was conducted to examine whether the top ratings were different according to provider gender and occupation.Results: The sample included 258 providers (74% female, 65% White). The majority were hematologists (41%); 38% were other medical staff (e.g., nurse, midlevel providers, other physicians) and 21% were non-medical staff (e.g., psychologist, social worker, researchers). The transition factor ratings (scale 1 to 10) ranged from 5.82-9.62 (M=8.05, SD=1.74). The factors with the highest ratings included: Knows how to take medications (M=9.62, SD=0.82), Explains/communicates medical needs to medical personnel (M=9.50, SD=0.93), Knows when to seek medical assistance if home management fails (M=9.32, SD=1.12), and Knows how to manage pain episodes (M=9.31, SD=1.18). These same four factors also were ranked as the top five most relevant factors: Knows how to manage pain episodes (N=138, 53%, M=2.59, SD=1.30), Explains/communicates medical needs to medical personnel (N=115, 45%, M=2.54, SD=1.38), Knows how to take medications (N=135, 52%, M=2.67, SD=1.31), Knows when to seek medical assistance if home management fails (N=102, 40%, M=2.97, SD=1.46). Knows medical history (N=100, 39%, M=2.57, SD=1.35) was the fifth most relevant factor. Multivariate results indicated a trend toward hematologists giving lower ratings compared to other medical and non-medical professionals, F (8, 486) = 1.91, p = .057.Conclusions: Our findings reveal the importance of attainment of disease knowledge and self-management skills for optimal transition from pediatric to adult care. Interventions and programming designed to prepare adolescents for transition should target these areas. Furthermore, disease knowledge and self-management skills may be meaningful predictors when evaluating transition outcomes and the effectiveness of transition programs during and after the health care transition process. Our data also indicated differences in provider ratings by profession, demonstrating the value of incorporating a variety of perspectives in assessing transitioning needs. Such efforts are essential to improve health outcomes and quality of care for patients with SCD transitioning to adult care. DisclosuresPorter:NHLBI: Research Funding.

454-P: Pharmacist-Led Diabetes Self-Management Education and Reduction of Readmission Rates at a County Hospital

Pharmacist-led Diabetes Self-Management Education and Reduction of Readmission Rates at a County Hospital With 10.5% of the US population or 34.2 million people affected by diabetes, education is greatly needed. The American Diabetes Association (ADA) and the Association for Diabetes Care and Education Specialists (ADCES) state that Diabetes Self-Management Education or Training (DSME/T) improves diabetes management, which can avoid hospital admissions and readmissions. Although DSME/T has traditionally been provided by nurses and dieticians, pharmacists can play a part, given their expertise in medication management, non-pharmacological therapies, and monitoring. The ADA and ADCES recommend that people with diabetes receive DSME/T at diagnosis, annually, when factors influence self-management, and at transitions of care. Therefore, a pharmacist-led transitions of care program was developed to reduce readmissions for patients with diabetes at Zuckerberg San Francisco General Hospital and Trauma Center. This hospital serves a diverse, low-income, and unhoused patient population, increasing the challenges of diabetes management. Pharmacists and pharmacy trainees were given a refresher course on DSME/T. Low-health literacy handouts in several languages, as well as demonstration kits, glucometers, insulin and insulin supplies, were all utilized for patient education. The objective of the study was to determine whether using pharmacists as educators, could reduce hospital readmissions. In 2017, provision of DSME/T at this institution was less than 5% and increased to 74% by December 2019, with the implementation of this program. The rate of readmission for patients with diabetes who received DSME/T was 11.7% compared to 19.2% for those who did not; an absolute risk reduction in readmission of 7.5%. Pharmacists and pharmacy trainees should use DMSE/T to help reduce readmissions, improve outcomes, and increase the national levels of patients with diabetes receiving DSME/T. Disclosure L. Mulala: None. T. Lenhoff: None.

Heart failure population health considerations.

The United States has an increasing number of patients with heart failure (HF) who experience significant disease burden as well as contribute to high economic healthcare costs and usage of healthcare resources. HFcosts are currently estimated at $30.7 billion. If no improvements are made to current treatment outcomes, it is expected to grow to $69.8 billion by the year 2030. Hospital admissions account for the driving factor of direct medical costs. There has been increased focus on decreasing HF-related hospital readmission rates in the United States for the past decade; however, few interventions have positively affected hospital readmission rates. Some transitional care programs have been successful at positively affecting readmissions, though not all programs have demonstrated improvement of end points. These mixed program outcomes show the importance of evaluating HF-related transitional care program components for future directions. Newly approved treatments for HF with preserved ejection fraction may improve clinical outcomes for these patients. Pharmacists and physicians can help improve access to HF medications by assisting patients on how to navigate manufacturer assistance programs, submitting complete and well-supported prior authorization forms when needed, and encouraging the use of pharmacy price matching and price checkers.