Patient Care Transitions Research Articles

Palliative Social Worker Helps in Transitions of Care for Hospice-eligible Patients to Reduce Readmissions

Palliative Social Worker Helps in Transitions of Care for Hospice-eligible Patients to Reduce Readmissions

Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs.

The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs. An ethnographic design using multiple convergent data collection techniques. Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings. Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed 'safe care transition pathway' addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions. To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions. The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes. Findings are reported per the Consolidated Criteria for Reporting Qualitative research (COREQ). No patient or public contribution.

Predictors of follow-up care for critically-ill patients with seizures and epileptiform abnormalities on EEG monitoring

ObjectivePost-hospitalization follow-up visits are crucial for preventing long-term complications. Patients with electrographic epileptiform abnormalities (EA) including seizures and periodic and rhythmic patterns are especially in need of follow-up for long-term seizure risk stratification and medication management. We sought to identify predictors of follow-up. MethodsThis is a retrospective cohort study of all patients (age ≥ 18 years) admitted to intensive care units that underwent continuous EEG (cEEG) monitoring at a single center between 01/2016-12/2019. Patients with EAs were included. Clinical and demographic variables were recorded. Follow-up status was determined using visit records 6-month post discharge, and visits were stratified as outpatient follow-up, neurology follow-up, and inpatient readmission. Lasso feature selection analysis was performed. Results723 patients (53 % female, mean (std) age of 62.3 (16.4) years) were identified from cEEG records with 575 (79 %) surviving to discharge. Of those discharged, 450 (78 %) had outpatient follow-up, 316 (55 %) had a neurology follow-up, and 288 (50 %) were readmitted during the 6-month period. Discharge on antiseizure medications (ASM), younger age, admission to neurosurgery, and proximity to the hospital were predictors of neurology follow-up visits. Discharge on ASMs, along with longer length of stay, younger age, emergency admissions, and higher illness severity were predictors of readmission. SignificanceASMs at discharge, demographics (age, address), hospital care teams, and illness severity determine probability of follow-up. Parameters identified in this study may help healthcare systems develop interventions to improve care transitions for critically-ill patients with seizures and other EA.

Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial.

Disparities in posthospitalization outcomes for people with chronic medical conditions and insured by Medicaid are well documented, yet interventions that mitigate them are lacking. Prevailing transitional care interventions narrowly target people aged 65 years and older, with specific disease processes, or limitedly focus on individual-level behavioral change such as self-care or symptom management, thus failing to adequately provide a holistic approach to ensure an optimal posthospital care continuum. This study evaluates the implementation of THRIVE-an evidence-based, equity-focused clinical pathway that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home by focusing on the social determinants of health and systemic and structural barriers in health care delivery. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge. The study's objectives are to (1) examine referral patterns, 30-day readmission, and emergency department use for participants who receive THRIVE support services compared to those receiving usual care and (2) evaluate the implementation of the THRIVE clinical pathway, including fidelity, feasibility, appropriateness, and acceptability. We will perform a sequential randomized rollout of THRIVE to case managers at the study hospital in 3 steps (4 in the first group, 4 in the second, and 5 in the third), and data collection will occur over 18 months. Inclusion criteria for THRIVE participation include (1) being Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) residing in Philadelphia; (3) having experienced a hospitalization at the study hospital for more than 24 hours with a planned discharge to home; (4) agreeing to home care at partner home care settings; and (5) being aged 18 years or older. Qualitative data will include interviews with clinicians involved in THRIVE, and quantitative data on health service use (ie, 30-day readmission, emergency department use, and primary and specialty care) will be derived from the electronic health record. This project was funded in January 2023 and approved by the institutional review board on March 10, 2023. Data collection will occur from March 2023 to July 2024. Results are expected to be published in 2025. The THRIVE clinical pathway aims to reduce disparities and improve postdischarge care transitions for Medicaid-insured patients through a system-level intervention that is acceptable for THRIVE participants, clinicians, and their teams in hospitals and home care settings. By using our equity-focused case management services and leveraging the power of the electronic medical record, THRIVE creates efficiencies by identifying high-need patients, improving communication across acute and community-based sectors, and driving evidence-based care coordination. This study will add important findings about how the infusion of equity-focused principles in the design and evaluation of evidence-based interventions contributes to both implementation and effectiveness outcomes. DERR1-10.2196/54211. ClinicalTrials.gov NCT05714605; https://clinicaltrials.gov/ct2/show/NCT05714605.

Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data.

The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.

Hospitalists' Attitudes and Experiences With Posthospitalization Care Transitions for Patients With Substance Use Disorders: A Cross-sectional Analysis.

Medical hospitalizations are relatively common among individuals who have substance use disorders (SUDs) and represent opportunities for patient engagement and treatment. Posthospitalization transitions of care are an important element of providing full-spectrum inpatient SUD care; however, little is known about clinicians' experiences with postdischarge care transitions. We conducted a cross-sectional study surveying hospital-based medical clinicians (ie, "hospitalists") across 2 large health systems in the state of Utah to assess current practices, barriers, facilitators, and perceptions toward posthospitalization care transitions for patients with SUDs. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of hospitalists' attitudes toward providing SUD care on perceived barriers and facilitators. The survey was distributed to 429 individuals across 15 hospitals. Eighty-two hospitalists responded to the survey (response rate, 21.4%). Most respondents frequently cared for hospitalized patients with SUDs (n = 63, 77%) and prescribed medications for SUDs (n = 44, 56%). Four respondents (5%) felt that patients received adequate support during care transitions. Lack of social support ( P < 0.001) and social factors such as lack of transportation ( P < 0.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician ( P < 0.001) and outpatient-based care coordination ( P < 0.001) were perceived as the strongest facilitators. Respondents' attitudes toward people with SUDs had a modest effect on perceived barriers and facilitators. Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating posthospitalization care transitions for patients with SUDs.

A Hybrid Type 1 trial of a multi-component mHealth intervention to improve post-hospital transitions of care for patients with serious mental illness: Study protocol

BackgroundThe transition from acute (e.g., psychiatric hospitalization) to outpatient care is associated with increased risk for rehospitalization, treatment disengagement, and suicide among people with serious mental illness (SMI). Mobile interventions (i.e., mHealth) have the potential to increase monitoring and improve coping post-acute care for this population. This protocol paper describes a Hybrid Type 1 effectiveness-implementation study, in which a randomized controlled trial will be conducted to determine the effectiveness of a multi-component mHealth intervention (tFOCUS) for improving outcomes for adults with SMI transitioning from acute to outpatient care. MethodsAdults meeting criteria for schizophrenia-spectrum or major mood disorders (n = 180) will be recruited from a psychiatric hospital and randomized to treatment-as-usual (TAU) plus standard discharge planning and aftercare (CHECK-IN) or TAU plus tFOCUS. tFOCUS is a 12-week intervention, consisting of: (a) a patient-facing mHealth smartphone app with daily self-assessment prompts and targeted coping strategies; (b) a clinician-facing web dashboard; and, (c) mHealth aftercare advisors, who will conduct brief post-hospital clinical calls with patients (e.g., safety concerns, treatment engagement) and encourage app use. Follow-ups will be conducted at 6-, 12-, and 24-weeks post-discharge to assess primary and secondary outcomes, as well as target mechanisms. We also will assess barriers and facilitators to future implementation of tFOCUS via qualitative interviews of stakeholders and input from a Community Advisory Board throughout the project. ConclusionsInformation gathered during this project, in combination with successful study outcomes, will inform a potential tFOCUS intervention scale-up across a range of psychiatric hospitals and healthcare systems.Clinicaltrials.govregistration: NCT05703412

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

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

How SWAT Changed the Conversation: Implementation of a Discharge SWAT Team Improves Morale and Facilitates Communication During the COVID-19 Pandemic.

Hospital overcrowding and delays in discharge are serious issues in the modern health care landscape and can lead to poor patient outcomes and health care personnel (HCP) burnout. The goal of this project was to develop a collaborative forum where HCP representing the entire spectrum of the inpatient care team, including case management team members, could connect to discuss challenges and barriers to patient discharge. The following describes the development, implementation, and outcomes of the discharge SWAT (Solutions, Wins, Actions, and Tactics) team, which is a 30-min virtual daily meeting where discussion is primarily centered around challenges in discharging individual patients and addressing case manager needs. The primary aim of SWAT meetings is fostering a positive atmosphere to address barriers to discharge while prioritizing patient care and outcomes. This study was conducted in a 40-hospital academic health system in the United States. SWAT meetings were first implemented at a representative flagship facility in a health system. HCP at this first facility were surveyed to assess satisfaction with SWAT meetings. SWAT meetings then were implemented at the majority of facilities in a 40-hospital academic health system. During SWAT implementation, average inpatient length of stay (LOS) and patient care transitions were monitored for participating and nonparticipating service lines. Among surveyed HCP, the majority view SWAT meetings favorably and reported that it was a valuable use of their time and positively impacted their work in the patient discharge space. Nonprovider and case management staff in particular valued the SWAT meetings and found them beneficial. LOS remained stable for patients under the care of participating providers, despite the upheaval of the ongoing COVID-19 pandemic, and the research team also observed a positive impact of SWAT meetings on appropriate inpatient care transitions.

Care transition for patients admitted to hospital due to COVID-19 and its relationship with clinical characteristics

Objective To analyze care transition (CT) and its relationship with the clinical characteristics of patients admitted to hospital due to COVID-19. Methods This is a cross-sectional study, carried out in a general hospital, with 165 patients admitted to hospital due to COVID-19 and who were discharged home. Participants were those who had been admitted to hospital for at least 24 hours, over 18 years of age, with telephone access after discharge. Those who were discharged by transfer, who died or those without cognitive conditions were excluded. Data collected between March and July 2021, using a sociodemographic and clinical questionnaire as well as Care Transitions Measure-15. Descriptive and inferential statistical analysis was applied. Results The overall mean of Care Transitions Measure-15 was considered satisfactory (71.8±7.45). The Important preferences factor obtained the highest mean (80.5± 9.84) and the Care Plan factor the lowest (57.5± 11.4). Significant statistical differences were found when the CTM-15 factors were associated with the clinical variables: duration of chronic disease (p&lt;0.03); presence of clinical artifact (p&lt;0.040); use of continuous medication (p&lt;0.029). Readmission had a significant difference in the factors Health management preparation (p&lt;0.045), Important preferences (p&lt;0.027) and Care plan (p&lt;0.032). Conclusion Patients admitted to hospital due to COVID-19 assessed the general CT as satisfactory and the clinical variables, length of chronic illness, clinical artifact, continuous medication and readmission interfered in the CT of these patients.

Digitally Enabled Transitional Care Management in Oncology.

Improving care transitions for patients with cancer discharged from the hospital is considered an important component of quality care. Digital monitoring has the potential to better the delivery of transitional care through improved patient-provider communication and enhanced symptom management. However, remote patient monitoring (RPM) interventions have not been widely implemented for oncology patients after discharge, an innovative setting in which to apply this technology. We implemented a RPM intervention which identifies medical oncology patients at discharge, monitors their symptoms for 10 days, and intervenes as necessary to manage symptoms. We evaluated the feasibility (>50% patient engagement with symptom assessment), appropriateness (symptom alerts), and acceptability (net promoter score >0.7) of the intervention and the initial effect on acute care visits and return on investment. During the study period, January 1, 2021, to December 31, 2022, we evaluated 2,257 medical oncology discharges representing 1,857 unique patients. We found that 65.9% of patients discharged (N = 1,489) completed at least one symptom assessment postdischarge and of them, 45.5% (n = 678) generated a severe symptom alert that we helped to manage. Patients expressed high satisfaction with the intervention with a net promoter score of 84%. In preliminary analysis of patients with GI malignancies (n = 449), we found a nonsignificant decrease in 30-day readmissions for the intervention cohort (n = 269) by 5.8% as compared with the control (n = 180; from 33.3% to 27.5%; P = .22). Digital transitional care management was feasible and demonstrated that patients transitioning from the hospital to home have a substantial symptom burden. The intervention was associated with high patient satisfaction but will require further refinement and evaluation to increase its impact on 30-day readmission.

A92 THE CURRENT STATE OF PEDIATRIC TO ADULT TRANSITION OF CARE: A ROUND TABLE DISCUSSION WITH KEY STAKEHOLDER GROUPS

Abstract Background There is a severe paucity in available resources to facilitate a safe and effective pediatric to adult health care transition for patients with chronic disease. Aims This study aims to better understand the experiences of key stakeholder groups involved in pediatric to adult transition of care across various chronic disease specialties within a tertiary care urban environment. Methods A focus group was conducted on July 12th, 2018 at Women’s College Hospital with key stakeholder groups. Questions focused on the top issues related to pediatric to adult transition of care and an ideal transition model for their respective patient populations. The second part of this study included individual interviews with patients and carepartners. Focus group meetings and individual interviews were both audio-recorded and transcribed for qualitative thematic analysis. Results Seventeen pediatric and adult care physicians representing ten chronic disease specialties were represented. Seven patients and care partners were interviewed. Major focus group themes included: disproportionate access to resources between and within specialties (n=10), lack of mental health support in the adult setting (n=8), fragmentation of care due to multiple providers as a result of patients leaving for employment or education (n=6), patients feeling alienated due to decrease in allied health support or due to shorter appointment times (n=8), and difficulty retaining consistent care due to missed appointments as a result of inconsistent communications or change in location for education or employment (n=7). Ideal care models were suggested to include: centralized intake procedure to identify patients who may require extra support (n=9), education for scheduling administrators about second chances after a no-show (n=5), implementation of joint clinics with pediatric and adult care teams or back-and-forth clinic sessions to ensure bidirectional provider comfort before discharge to adult care system (n=4), and implementation of a dedicated transitions navigator or point of contact for patients (n=10). The individual patient and carepartner interviews emphasized the need for: centralized and comprehensive online resource (n=7), simple and clear educational content introducing the adult healthcare system (n=7), opportunities to meet and share information with other individuals in a similar position (n=3), and availability of a transitions navigator (n=4). Conclusions Current pediatric to adult transition of care resources are fragmented, allocated inefficiently, difficult to ascertain and often constrained to a specific condition or location. Future efforts should focus on improving the care transition process for high-risk patient populations by taking a comprehensive approach utilizing innovative, and multidisciplinary solutions. Funding Agencies None

Bowel Management Protocol: Impact on Care Transitions of Oncology Patients.

The project aimed to determine the impact of a standardized bowel regimen protocol for patients receiving opioids on the rate of stool softener prescription, occurrence of bowel movements of oncology patients, and improving the length of stay (LOS). Oncology unit in a community hospital. A posttest design was utilized, and a prospective medical record review of patients was completed after 8 weeks of the pilot study. The study sample (N = 164) included oncology patients admitted to a community hospital in the Southeast. The χ2 test was used to determine the impact of implementing a bowel panel order on the rate of stool softener prescriptions, the occurrence of bowel movements, and the LOS. Only 43% (n = 40) of the patients from the comparison group were ordered laxatives, and more patients from the intervention group (68%; n = 49) received the bowel regimen protocol, whereas 26% (n = 19) of the patients used a laxative or stool softener using providers' preference and demonstrated statistical significance (p = .001). In the intervention group, 93% of the patients (n = 67) reported having bowel movements compared with the comparison group, whereas only 32% (n = 32) demonstrated statistical significance (p = .001). The average LOS in the intervention group is less than 9 days compared with the comparison group, which was at 9 days (p = .001). Case managers play a critical role in coordinating care, improving transitions of care, and reducing LOS. Case managers can have a significant impact by monitoring and reminding nurses to report the gastrointestinal movements of oncology patients and then escalate opioid-induced constipation with the providers immediately. Case managers can facilitate the implementation of bowel regimen protocols, which may reduce hospitalizations and enhance patient outcomes, by taking this action.

Quality of Care Transition for COVID-19 Patients in a University Hospital in Southern Brazil.

To assess the quality of care transition from hospital to home for COVID-19 patients. A cross-sectional study conducted at a University Hospital in Southern Brazil, involving 78 patients discharged after COVID-19 hospitalization. Data collection was performed via telephone using the Brazilian version of the Care Transitions Measure (CTM-15). Data were analyzed using descriptive and analytical statistics. The mean quality of care transition was 70.8 on a scale ranging from zero to 100, indicating moderate quality of care transition. The highest score was attributed to factor 1, "Preparation for self-management," and the lowest to factor 4, "Care Plan." It is important to enhance communication and support provided to patients during the transition process, especially regarding understanding prescribed medications and the development of clear care plans.

Hand-off orientation in oral pathology: Bridging the gap for better patient care.

The practice of hand-off orientation in oral pathology plays a pivotal role in ensuring efficient and high-quality patient care. Given the intricate nature of oral health, the seamless transition of patient care from one healthcare provider to another is critical. Hand-off orientation in oral pathology begins with a comprehensive referral of oral biopsy specimens from a general dentist or clinical specialist to the oral pathology laboratory. Obtaining detailed information about oral biopsy tissue and complete patient information from clinicians is indeed crucial for a variety of reasons, including accurate diagnosis and treatment planning. This collaborative approach ensures that patients receive timely and accurate care, reducing the potential for misdiagnosis or treatment delays. In the field of oral pathology, effective hand-off orientation is a cornerstone of patient safety and positive outcomes.

Integrated care pathways between primary, secondary and tertiary health care for Aboriginal and Torres Strait Islander Australians

Empirical evidence and current policy documents strongly indicate a requirement for greater healthcare integration for Aboriginal and Torres Strait Islander people as an extension of the current coordinated care models. System fragmentation and the documented evidence of inadequate care transitions of many Aboriginal and Torres Strait Islander patients test the adequacy and flexibility of health systems to provide access and effective, efficient and appropriate care. Integration across organisations and sectors in the health system is necessary for coordinated patient-centred care that improves patient experiences and health outcomes and adds value to the system by delivering efficiencies. In this project, we aimed to better understand integrated care as a significant quality improvement approach in delivering care between the primary, secondary and tertiary care systems for Aboriginal and Torres Strait Islander people as the first step to real-world design and implementation. Firstly, we used a ‘participatory’ systematic review methodology to identify care processes and effective components needed to support integrated care models between primary, secondary and tertiary care. We focused on the processes involved in its implementation, delivery, and outcomes and impact to develop a conceptual model. Engagement with healthcare providers and community members grounded the theoretical model in real-world contexts. We then tested the model using a jury approach and wargaming, a soft simulation method. The structural reforms needed to ensure effective multistakeholder, multilevel integrated care implementation were identified and priority setting for implementation considered. We will present the developed integrated care model and discuss the inherent opportunities and challenges for implementation.

Collaborative inpatient and ambulatory care topic discussions in experiential education: An approach to assessing the Pharmacists' patient care process and transitions of care

IntroductionThe Pharmacists' Patient Care Process (PPCP) is woven throughout the doctor of pharmacy program; however, advanced pharmacy practice experiences (APPEs) are not structured in a specific order allowing students to apply the PPCP across the care continuum. Two faculty preceptors from two practice sites, inpatient family medicine and ambulatory care, joined to provide twice weekly, preceptor-led collaborative topic discussions to bridge this gap. This paper describes an approach to improve students' knowledge by incorporating progressive cases and assessments highlighting care across the continuum aligned with the PPCP. MethodsPreceptors developed topic discussions, progressive cases, and assessments to emphasize the PPCP and transitions of care (TOC) during month-long APPEs. Students' perceptions were assessed through an anonymous Likert-type item survey. To assess learning, students completed anonymous, preceptor-developed, multiple-choice pre- and post-assessments aligned with the different components of the PPCP and TOC. ResultsIn two academic years (2021−2023), 24 perception surveys were distributed and 21 were received from 19 unique students (87.5%). Compared to pre-implementation surveys, a significant increase was seen in the students strongly agreeing the incorporation of progressive cases improved their ability to apply the PPCP to patient care (48% vs. 76%, P value = .06). Twenty-four pre- and post-assessments (100%) were completed by 22 unique students, showing a statistically significant difference in students' understanding of content (71.8% vs. 81.6%, P value = .02). ConclusionsThe incorporation of collaborative topic discussions for APPE students between inpatient and ambulatory care preceptors increased students' knowledge to apply the PPCP during TOC.

Development of Discharge Planning for Stroke Patients

Highlights: 1. Given the frequent long-term complications of stroke, this study identified the ideal approach to discharge planning to improve the quality of life of patients and hospital care.2. This study provides evidence supporting the effectiveness of a conventional discharge planning approach that incorporates specific educational intervention with interactive learning through audiovisual media.3. The approaches presented in this study may offer valuable perspectives on enhancing health service provisions, particularly regarding the discharge planning process for nurses. Abstract The quality improvement of discharge planning is essential throughout the development of discharge planning, which guarantees a seamless transition of care for stroke patients and family preparedness. This systematic review aimed to analyze the development of discharge planning and its impact on stroke patients and their families. The research was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible pieces of literature were compiled from seven electronic databases, i.e., ScienceDirect, Scopus, PubMed, EBSCOhost, ProQuest, SAGE Journals, and Google Scholar. The literature search was performed using predetermined search terms, with specific criteria that included papers exclusively published in English and studies conducted in 2018–2022. The development of discharge planning showed a significant impact on stroke patients, as it could influence various aspects of their quality of life. This included improvements in physiological function, enhanced cognitive knowledge, increased satisfaction and self-efficacy, reduced stress levels and care burden, and the opportunity for families to adequately prepare for home-based patient care. This study concluded that integrating conventional with technology-based media is effective for developing discharge plans for stroke patients. The implementation of this novel approach in a health system can improve patient outcomes, family preparedness when providing care, and the quality of hospital care.

Improving caregiver preparedness in the care transition of stroke patients: a scoping review.

Stroke is a life-threatening condition caused by the rupture of a brain blood vessel, potentially causing brain damage within minutes, severe disability, and even death. After initial hospitalization and rehabilitation, most stroke survivors return home, relying on their family members as caregivers for activities of daily living and treatments. This scoping review aimed to evaluate caregivers' readiness for transitioning stroke patient care to a home environment. We conducted a comprehensive search on Scopus, PubMed, ScienceDirect, and Google Scholar databases, followed by a secondary search to identify articles based on predefined criteria. A total of 14 articles were synthesized, leading to a series of findings: (1) there is a need to assess and identify caregiver needs, (2) the process needs relevant information, (3) caregivers are involved in the care process until the patients are discharged from the hospital, and (4) there is a need to offer support to caregivers. These results indicate that implementing strategies to enhance caregiver preparedness is crucial for the effective home-based care of stroke survivors.

Hospital‐to‐home care transition for dementia patients and family care partners: communication, decision‐making, and support experience of a culturally diverse sample

AbstractBackgroundPersons living with dementia (PLWD) are twice as likely to be hospitalized than non‐dementia peers, and while hospitalized, more likely to suffer from delirium, falls, procedure‐related complications, and death. PLWDs and their care partners (CPs) need support and preparation for hospital‐to‐home transition to avoid unnecessary readmission to hospitals. The current study aims to identify and examine communication, decision‐making, and caregiver support experience of racially and financially diverse PLWDs/CP dyads during hospital‐to‐home care transition in the U.S.MethodWe analyzed preliminary data from an ongoing mixed methods study of care transition experience of hospitalized PLWD/CP dyads. We used survey and hospital case notes data from 22 dyads and in‐depth interviews with 12 CPs recruited from two urban hospitals. We conducted descriptive and content analysis with quantitative and qualitative data.ResultHalf of PLWDs were non‐white (50%), frail with recent history of fall (68%) or hospitalization (50%) in the last three months, lacked advance directives (46%), and received palliative care consult while hospitalized (77%). Majority of CPs were non‐White (68%), PLWD’s adult child/grandchild (64%), and reported knowing a little or not much at all about dementia (82%). Themes on CP communication, decision‐making and caregiving support emerged: CPs find surrogate decision‐making difficult; proactive palliative care prepares CPs for terminal trajectory of dementia; CPs need education and training on hands‐on caregiving tasks to keep PLWDs safe and comfortable at home; and CPs’ social needs need to be addressed to achieve goals of care for PLWDs.ConclusionPLWDs and CPs need education, training, coaching, and individualized support during care transitions in order to develop self‐efficacy and maintain resilience. Palliative care, currently offered in over 80% of U.S. hospitals, provides important education and support for PLWDs and CPs. However, palliative care support ends after discharge for most families. Findings from our study suggest that continuing comprehensive palliative care support after discharge may be needed, when PLWD and CPs may need support the most. Future studies should examine needs of PLWDs and CPs living in communities and the role of palliative care to address informational and support needs.