Patient Care Transitions Research Articles

Australian general practitioners' views on qualities that make effective discharge communication: a scoping review.

Transitions of patient care between hospital discharge and primary care are known to be an area of high-risk where communication is imperative for patient safety. Discharge summaries are known to often be incomplete, delayed and unhelpful for community healthcare providers. The aim of this review was to identify and map the literature which discusses Australian general practitioners' (GPs) views on the qualities that make up effective discharge communication. Medline, Scopus and the Cochrane register of controlled drug trails and systematic reviews were searched for publications until October 2021 that discussed Australian GPs' views on discharge communication from hospital to general practice. Of 1696 articles identified, 18 met inclusion and critical appraisal criteria. Five studies identified that GPs view timeliness of discharge summary receipt to be a problem. Communication of medication information in the discharge summary was discussed in six studies, with two reporting that GPs view reasons for medication changes to be essential. Five studies noted GPs would prefer to receive clinical discipline or diagnosis specific information. Four studies identified that GPs viewed the format and readability of discharge summaries to be problematic, with difficulties finding salient information. The findings of this scoping review indicate that GPs view timeliness, completeness, readability, medication related information and diagnosis/clinical discipline specific information to be qualities that make up effective discharge communication from hospital to the community. There are opportunities for further research in perspectives of effective discharge communication, and future studies on interventions to improve discharge communication, patient safety and policy in transfers of care.

Hospital discharge planning in care transition of patients with chronic noncommunicable diseases

RESUMO Objetivo: analisar a transição do cuidado no planejamento de alta hospitalar de pacientes com doenças crônicas não transmissíveis. Método: estudo qualitativo, fundamentado no modelo teórico Care Transitions Intervention, com quatro pilares de intervenção, para garantir uma transição segura. Participaram 12 profissionais, em hospital público, no interior paulista. Os dados foram coletados por meio de observação, análise documental e entrevistas semiestruturadas. Resultados: houve comprometimento da equipe multiprofissional para a integralidade da assistência e envolvimento de familiares nos cuidados ao paciente. Os documentos facilitaram a comunicação entre profissionais e/ou níveis de atenção. Todavia, a falta de tempo hábil para preparação da alta pode ocasionar um cuidado fragmentado, prejudicando a comunicação e colocando em risco a transição segura. Considerações finais: evidenciaram-se como elementos importantes na composição do planejamento de alta, visando garantir a transição do cuidado segura, participação da equipe com protagonismo do enfermeiro, planejamento precoce de alta e envolvimento da família.

Transition of care in post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil.

To analyze the transition of care for post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil. Quantitative, cross-sectional, descriptive, and analytical study carried out between 2020 and 2021. The sample had 78 patients. Data collection took place by telephone with the support of a sociodemographic questionnaire and the care transition assessment instrument (Care Transitions Measure). The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20). The average length of stay was 24.04 days. The average score for care transition was 71.68 (±11.71). "Self-management training" and "Understanding of medications" had higher averages, 75.15 (±13.76) and 74.10 (±16.20).

Transition of care in post-hospitalization patients due to covid-19 in a hospital in northeastern Brazil

RESUMO Objetivo: Analisar a transição do cuidado de pacientes pós-internação por covid-19 realizada em um hospital no Nordeste brasileiro. Métodos: Estudo quantitativo, transversal, descritivo e analítico realizado entre 2020 e 2021. A amostra contou com 78 pacientes. A coleta de dados ocorreu por telefone com apoio de um questionário sociodemográfico e do instrumento de avaliação da transição de cuidados (Care Transitions Measure). Resultados: O tempo médio de internação foi de 24,04 dias. A pontuação média para a transição do cuidado foi 71,68 (±11,71). O “Treinamento de autogestão” e o “Entendimento sobre medicações” obtiveram maiores médias, 75,15 (±13,76) e 74,10 (±16,20). Conclusões: A qualidade da transição do cuidado de pacientes da pós-internação por covid-19 foi satisfatória na instituição participante. Entretanto, a valorização das preferências do paciente e família para o autogerenciamento da doença bem como o plano de cuidados pós-alta precisam ser aprimorados.

Interprofessional actions in responsible discharge: contributions to transition and continuity of care.

To analyze the interprofessional team's perception of the actions carried out by means of responsible hospital discharge, and their contribution to improving the transition and continuity of patient care. A qualitative study was carried out in two hospitalization units, in October - November 2020, interviewing health professionals from a teaching hospital in the state of São Paulo. The reports were transcribed and subjected to thematic content analysis. Twelve professionals participated (doctor, nurse, physiotherapist, nutritionist, speech therapist and social worker) and three thematic categories emerged from the interviews: 1. informational continuity in responsible discharge; 2. interaction between professionals and services for the transition of care; and 3. workload management for better transition and continuity of care. The team recognized interprofessional advances and challenges in responsible discharge related to the informational and relational continuity of patient care and highlighted the (over)workload as an unfavorable aspect in the transition process, generating impacts for patients, professionals and health services.

Current practices of transition from pediatric to adult health care for patients with neurological disease: promote the cooperation between child and adult neurologists

The Special Committee for Measures Against Transition from Pediatric to Adult Health Care of the Japanese Society of Neurology, which consists of child and adult neurologists, started to tackle the issues of pediatric to adult health care transition for patients with neurological disease in July 2020. The Committee held a workshop with a theme of "cooperation between child and adult neurologists," which is a critical issue in the pediatric to adult health care transition. To solve the many problems in the pediatric to adult health care transition, it is crucial that child and adult neurologists and primary care physicians cooperate on the following issues: preparing child neurologists for the transition, encouraging adult neurologists to study child neurology, promoting the formation of multidisciplinary teams, improving the medical system and medical fees, appealing to governmental agencies for issues of community health care and welfare services.

Exploring the Evidence: Using Technology to Improve Integrated Care Coordination

A transition of care is defined as a change in level of health care services, as patient care needs change from one location to another during acute or chronic illness. The location of services can vary from the hospital, skilled nursing facility, an outpatient setting, a primary care provider's office, or home health. Care coordination gaps can occur due to a lack of information exchange through the electronic health record, a lack of evidence-based standards, and poor communication among providers. Often, clinicians work with a silo mentality, resulting in poor health outcomes and negatively impacting the patient care experience. Patients with chronic kidney disease (CKD) are vulnerable to suboptimal integrated care coordination during transitions of care, as individuals seek treatment from diverse practitioners within multiple settings to meet their medical needs. This article discusses methods to improve integrated care, emphasizing the use of technology-based interventions to facilitate care transitions for patients with CKD.

The Impact of Community Health Information Exchange Usage on Time to Reutilization of Hospital Services.

Few studies have determined whether clinician usage of a community health information exchange (HIE) directly improves patient care transitions. We hypothesized that lookup in the HIE by primary care physicians of patients recently released from the hospital would increase the time until hospital reuse. We identified a retrospective cohort of 8,216 hospital inpatients aged over 18 years that were discharged from January 1, 2021 through November 30, 2021 using the Paso del Norte Health Information Exchange, in El Paso County, Texas. All patients had a primary care physician visit within 30 days after hospital discharge, and we identified patients that were looked up in the HIE close to that visit. Of the cohort, 2,627 were rehospitalized and 3,809 visited an emergency department (ED) during the follow-up window. The remaining 1,780 patients were controls. We conducted survival analysis, censoring at the second ED or inpatient visit or end of the study window (January 31, 2022). The model was adjusted by ethnicity, gender, insurance, and age. Lookup in the HIE was significantly associated with reducing the likelihood of visiting the ED by 53% and being rehospitalized by 61%. Lookup in the HIE was associated with an increased median time to use of the ED after inpatient discharge from 99 to 238 patient days. Ethnicity, insurance, gender, and age were also significant predictors of hospital reuse. Increased utilization of community HIEs by primary care physicians on behalf of their recently discharged patients may dramatically increase the time until inpatient or ED reuse.

Quality of ICU Discharge Summaries Produced by Pediatric Residents: The Memorial Health University Medical Center Experience.

Discharging intensive care unit (ICU) patients directly home is becoming more common. High-quality ICU discharge summaries are crucial in the transition of patient care. Currently, at Memorial Health University Medical Center (MHUMC), there exists no standardized ICU discharge summary template or consistency when discharge documentation is completed. Investigators evaluated the timeliness and completeness of ICU discharge summaries at MHUMC produced by pediatric residents. A single-center retrospective chart review of pediatric patients discharged directly from a 10-bed Pediatric ICU to home was conducted. Charts were evaluated pre- and post-intervention. The intervention included the implementation of a standardized ICU discharge template, formal resident training in writing discharge summaries, and a new policy mandating documentation completion within 48 hours of patient discharge. Timeliness was based on documentation completion within 48 hours. Completeness was evaluated on the presence of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) recommendations of specific components that should be included in all discharge summaries. Results were reported as proportions, with differences calculated using Fisher's exact and chi-square tests. Patient descriptive characteristics were recorded. Thirty-nine total patients, 13 pre-intervention and 26 post-intervention were included in the study. In the pre-intervention group, 38.5% (5/13) had discharge summaries completed in less than 48 hours from patient discharge compared to 88.5% (23/26) in the post-intervention group (P=.002). Post-intervention discharge documentation was more likely than pre-intervention to contain the discharge diagnosis (100% vs. 69.2%, P=.009) and to provide follow-up care instructions for the outpatient physician (100% vs. 75%, P=.031). Standardizing discharge summary templates and encouraging stricter institutional policies regarding the timely completion of discharge summaries can improve the ICU discharge process. Formal resident training in medical documentation is important and should be incorporated into graduate medical education curricula.

Transition of care in patients with epidermolysis bullosa: A survey study.

There are little published data on the transition of care in EB. We conducted a survey study recruiting EB patients from the Dystrophic EB Research Association (debra) website and centers caring for high numbers of EB patients in the United States and internationally from Sept 17, 2019 to Nov 3, 2021. The majority of participants had not discussed the transition of care with their healthcare providers, nor the healthcare needs to be required as an adult. Ongoing pediatric subspecialty care was reported by 12% of adults, most commonly in pediatric dermatology. Identified barriers to transition included the perceived lack of adult providers' knowledge about EB patient healthcare needs. The results suggest the need for transition guidelines, early discussions with families about transition, and practical information for the adult providers accepting care.

Military Response to Medical Crises-Consensus Recommendations for Military-Civilian Transitions of Care.

The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an unprecedented response. The US military deployed active-duty medical professionals and equipment to NYC in a first of its kind response to a "medical" domestic disaster. Transitions of care for patients surfaced as a key challenge. Uniformed Services University and the Icahn School of Medicine at Mount Sinai hosted a consensus conference of civilian and military healthcare professionals to identify care transition best practices for future military-civilian responses. We performed individual interviews followed by a modified Delphi technique during a two-day virtual conference. Patient transitions of care emerged as a key theme from pre-conference interviews. Twelve participants attended the two-day virtual conference and generated best practice recommendations from an iterative process. Participants identified 19 recommendations in 10 "sub-themes" related to patient transitions of care: needs assessment and capability analysis; unified command; equipment; patient handoffs; role of in-person facilitation; dynamic updates; patient selection; patient tracking; daily operations; and resource typing. The COVID-19 pandemic resulted in an unprecedented military response. This study created 19 consensus recommendations for care transitions between military and civilian healthcare assets that may be useful in future military-civilian medical engagements.

Knowledge, Attitudes, and Practices of Allergists/Immunologists Regarding Transition of Care for Primary Immunodeficiency Patients.

Only some allergists/immunologists provide care throughout the lifespan despite their training. Although transition of care (TOC) guidelines exist, research on provider perspectives on TOC for pediatric primary immunodeficiency (PID) patients is lacking. We aimed to characterize knowledge, attitudes, and practices and establish clinician needs using a needs assessment survey. The 15-min online survey was adapted from an existing rheumatology TOC survey and was emailed to the American Academy of Allergy Asthma and Immunology (AAAAI) and Clinical Immunology Society (CIS) members. Our primary hypothesis was that both AAAAI and CIS providers report being underprepared for TOC and would express interest in TOC resources and consensus. Forty-nine of 1250 eligible AAAAI and 67 of 698 eligible CIS participants completed the survey (4.8% vs 11.3% participation rate). Many (53.1% vs 59.7%) respondents transition their own patients but also retain adult patients (59.2% vs 52.2%). Many accepted transition patients (85.7% vs 92.5%). In total, 24.1% of respondents did not have a TOC policy while 18.9% have an informal policy. Only 25.0% were satisfied with their current practices while 43.9% agreed that a consensus statement would be useful. Despite a small sample size and high rate of unanswered questions, our findings show that TOC remains overlooked in our specialty and that providers want and need additional training and resources. There is a clear need to develop and evaluate the effectiveness of evidence-based TOC guidelines, resources, and best practices for PID patients.

Transitional Care Models for Stroke Survivors to Improve Quality of Care through Bridging the Care Gap from Hospital to Home: A State of Art Review

Introduction : Stroke is a life threatening medical emergency that occurs suddenly and impact greatly in all aspect of an individual’s normal life since the early stage to long term. Various types of transitional care models are using by Health systems to improve care transition among stroke patients. Aims:
 This paper aims to explore the existing transitional care models used to improve the quality of care and patient’s outcome among stroke survivors.
 Methods: An Integrated review was conducted of empirical literature available in PubMed, Google Scholar, ProQuest, and NepJol by June 20, 2022 to identify studies of hospital to home care transitions of stroke patients with quality of care as the primary outcome.
 Results: There are 6 main types of transitional care model which focused on care transition for stroke survivors: 1) Naylor’s Transitional Care Model (TCM), 2) Coleman’s Care Transition Interventions (CTI), 3) Project Re-engineered Discharge (project RED), 4) Better Outcomes by Optimizing Safe Transition (Project Boost), 5) Enhanced Discharge Planning Program and 6) Comprehensive Post- Acute Stroke Services (COMPASS). Although, all models are differing by design, each of the models can provide a framework for managing health conditions from hospital to home settings in collaboration with the client and his/her family. Hence, the transitional care Models are effective in bridging the care gap between hospital to home and improve the quality of health care and patient outcomes among stroke survivors.

The Use of the Situation, Background, Assessment, and Recommendation (SBAR) Form as a Tool for Handoff Communication in the Pediatrics Department in a Sudanese Teaching Hospital.

Patient care transitions between healthcare providers are common in hospitals -- this project aimed to audit the use of Situation, Background, Assessment, and Recommendation (SBAR)-based handoff communication tool in the handoff process. This prospective audit was conducted at Ribat Teaching Hospital, Khartoum, Sudan. Allhandoffcommunicationsof pediatric inpatients who requiredclose monitoringduring the study period were included. Two cycles of data collection were conducted, each spanning a duration of two weeks. The data, whether in the first or second cycle, were collected using a checklist document containing theitems of the SBAR form.After the end of the first cycle, regular training sessions about the content and importance of the SBAR form were conducted for one week. Additionally, doctors' perception regarding the form was assessed. Some 48 doctors participated in this study, 29 females and 19 males. In the first cycle, the percentages of filled SBAR form components were as follows: Situation 7%, Background 0.00%, Assessment 0.00%, and Recommendation 0.00%. After conducting training sessions, the second cycle assessment was done and itshowed improvement in all form components: Situation 88.8%, Background 83.6%, Assessment 66.3%, and Recommendation 69.5%. Regarding the doctors' perception assessment, the majority reported the usefulness of the SBAR form in patients' safety, physicians' communication, and accountability. The SBAR form is a simple and effective tool for improving communication; it helps doctors capture all relevant patient information. Most importantly, the majority of doctors were satisfied with the use of this tool for handoff communication.

Medication safety for intensive care patients transferring to a hospital ward: A Hierarchical Task Analysis

Aims and objectivesTo identify the task steps involved in intensive care patients transferring to a hospital ward and their potential for human errors, and to prioritise areas to improve medication safety. BackgroundIntensive care patients recovering to transfer to a hospital ward experience challenges to care continuity and safety, including medication safety. Medication errors are common on this interface of patient care, contributing to the risk of adverse drug events on the hospital ward and beyond. Human factors are an important consideration in these transfer-related medication errors. MethodsA hierarchical task analysis, based on a goal of safe continuity of medication for intensive care patients on transfer to a hospital ward, was developed from local processes taken from four north of England hospital Trusts with electronic prescribing systems. The task analysis was developed and refined by the research team, incorporating documentary review of policies and procedures, and healthcare professional interviews. Failure modes for the key task steps impacting directly on patient medication safety were identified. Finally, ten intensive care healthcare professionals, individually graded each failure mode (1-5) in terms of the probability, criticality and detectability. Median grades for each parameter were used to determine an overall clinical risk score for each task step. ResultsTen task steps were identified (one conditional), comprising a total of 56 subordinate task steps (two conditional). Conditionality was based on integrated electronic prescribing system resource across the care interface. Thirty-four of the 56 (61%) subordinate task steps were considered by the research team to specifically involve medication continuity or safety aspects. Action omissions (operation, check, information communication) accounted for failure modes in twenty-four of the 34 (71%) task steps. Most task steps (25/34 (74%)) had one or more recovery steps, providing further safety opportunities. The medication review task for reviewing and re-introducing long-term medication had the highest cumulative risk score. The top six clinical risk scores for the failure modes involved task steps with some element of communication around medicines. ConclusionsThe safe continuity of medication for intensive care patients on transfer to a hospital ward is complex and prone to human error. Failure mode analysis indicated that medication review on intensive care prior to patient transfer, and communication around medication changes and plans, are particularly important risks that require addressing in any intervention developed to improve medication safety in this patient care transition.

Communication Strategies and Patient Care Transitions in the Early ICU Aftercare Period.

Danesh, Valerie PhD, RN, FCCM1,2; Hecht, Jonathan D. MSN, APRN, CCRN2; Sasangohar, Farzan PhD3,4 Author Information

Patient and provider perspectives on transition of care for patients with epilepsy

Patient and provider perspectives on transition of care for patients with epilepsy

Transitions in care for ER patients with a suspected cancer diagnosis.

117 Background: The oncology nurse navigators (ONNs) at Penn Medicine’s Abramson Cancer Center (ACC) observed that patients seen in the Emergency Room (ER) and found to have a suspicion of cancer were being told to call a medical oncologist. The oncologist in the ACC are highly specialized and since the patient has not had a confirmed cancer diagnosis, they were being told they couldn’t schedule an appointment. Some patients waited for the ACC to call them to schedule. When this didn’t happen they would call the ACC a week later. These barriers led to delays in care, poor patient experience, and a financial loss for the health system. The ONNs identified this as an opportunity to change the process to improve patient care. Methods: The initiative formally began in June 2021 when the ONNs reached out to the ER leadership to collaborate on a quality improvement project to streamline the process from ER visit to oncology work up and diagnosis. Direct referral to oncology nurse navigation from the ER facilitates timely navigation assessment and coordination of care. The Plan Do Study Act (PDSA) methodology was utilized. A “Consult to Nurse Navigation” order was built into the electronic medical record (EMR) for ER providers to directly refer patients to the navigation team. The ONNs contacted the patient within one business day to assess next steps. The ONNs scheduled the patient with the appropriate oncology specialist. The ONNs follows the patient through the diagnostic phase of care and assists with decreasing barriers to care. Data collection is ongoing to assess the impact of the interventions. Results: The EMR consult to ONNs went live April 2022. It includes 3 hospital ERs in the health system with diverse populations that often have limited access to health care. To date, 90% were appropriate referrals and triaged to cancer specialists for diagnostic workup and treatment. 90% had insurance accepted by the health system. Patients with unacceptable insurance plans were referred to ER social work and financial advocates. 70% were diagnosed with cancer and began treatment. Conclusions: ONNs are vital in identifying and removing barriers to care. The ONN team’s clinical knowledge, assessment skills, and expertise of the Penn health system have closed a gap in care while increasing patient satisfaction, patient retention, and downstream revenue. The ONNs leadership has directly enhanced the diagnostic process and timeliness to care for patients newly effected by cancer.

Prevalence and barriers to health care transition for adolescent patients with childhood-onset chronic diseases across Japan: A nation-wide cross-sectional survey.

Since the Japan Pediatric Society published its “Recommendations on Transitional Care for Patients with Childhood-Onset Chronic Diseases” in 2014, there has been an increased interest in the health care transition of adolescents with childhood-onset chronic diseases in Japan. However, the actual status of healthcare transition was not studied yet. The purpose of this study was to explore the prevalence of transitional support for adolescent patients with childhood-onset chronic disease and the factors hindering their transition. We conducted an anonymous questionnaire survey in August 2020, targeting physicians and nurses involved in health care transition at 494 pediatric facilities in Japan. Survey items included demographic data, health care systems related to transition to adult departments, health care transition programs based on Six Core Elements (establishing transition policy, tracking and monitoring transition progress, assessing patient readiness for transition, developing the transition plan with a medical summary, transferring the patient, completing the transfer/following up with the patient and family), barriers to transition (34-item, 4-point Likert scale), and expectations in supporting transition (multiple-choice responses), which consisted of five items (78 questions); all questions were structured. Descriptive statistics were used for analysis. Of the 225 responses collected (45.5% response rate), 88.0% were from pediatricians. More than 80% of respondents transferred patients of 20 years or older, but only about 15% had took a structured transition process of four or more based on the Six Core Elements. The top transition barriers were “intellectual disability/rare disease” and “dependence on pediatrics” as patient/family factors, and “lack of collaboration with adult healthcare (relationship, manpower/system, knowledge/understanding)” as medical/infrastructure factors. The study provides future considerations, including the promotion of structured health care transition programs, development of transitional support tailored to the characteristics of rare diseases and disorders, and establishment of a support system with adult departments.

Transition of care for stroke patients: an integrative review

Objective: to analyze, based on scientific evidence, how the transition of care for people with stroke occurs after hospital discharge. Methods: integrative literature review, conducted in the databases Scopus, Web of Science, Pubmed/MEDLINE, Latin American and Caribbean Literature on Health Sciences, Nursing Database and The Cumulative Index to Nursing and Allied Health Literature. A total of 21 articles were included in the final sample, which were then descriptively analyzed. Results: factors related to the adequate transition of care included: organizational barriers of the health services involved in the transition of care, the importance of health information, and the adequate coordination of care. Conclusion: the studies express limits experienced by individuals, family members and health professionals in systems that are fragmented and rule out the possibility of integral care in times of transition. Contributions to practice: the study reveals the necessary articulation of those who provide health care to people with this grievance and their families, to recognize points to be improved in their health practices and minimize complications arising from failures in care transitions.