Transitional Care Program Research Articles

A Provider-Facing eHealth Tool for Transitioning Youth With Special Health Care Needs From Pediatric to Adult Care: Mixed Methods, User-Engaged Usability Study.

BackgroundThere is a need for medical education on health care transitions for youth with special health care needs. The Texas Transition Toolkit (the tool) supports providers through a one-stop shop for researching literature on care transitions, a catalog of care transition tools, and guides for developing care transition programs.ObjectiveThis study aims to assess the functionality and usability of the tool with providers working with transition-aged children and youth with special health care needs (representative users).MethodsThe tool was evaluated using a triangulated mixed methods case study approach consisting of a concurrent think-aloud phase, a satisfaction survey, and a survey of problem relevance and task performance to operationalize and capture functionality and usability. Our mixed methods deep dive into the functionality and usability of the tool focused on 10 representative users from one medical home in Texas and 5 website design experts.ResultsRepresentative users found the tool to be highly relevant, as demonstrated by the satisfaction score for relevance (138/150, 92%). According to the users, the tool provided comprehensive information related to health care transitions for youth with special health care needs, with a satisfaction score of 87.3% (131/150) for comprehensive. Overall satisfaction with the tool was high at 81.92% (1065/1300) with a cutoff score of 73.33% (953.4/1300) indicating high satisfaction, but users reported relatively lower satisfaction with search (114/150, 76%) and navigation (ease of use: 114/150, 76%; hyperlinks: 163/200, 81.5%; structure: 159/200, 79.5%). They experienced search- and navigation-related problems (total problems detected: 21/31, 68%) and, based on quality checks, had a relatively low task completion rate for tasks involving finding information (60/80, 75%), which required searching and navigation. The problems identified around search and navigation functionality were relevant (relevance scores ranging from 14.5 to 22, with a cutoff score of 11.7 indicating relevance).ConclusionsThe tool may help bridge the gaps in training on health care transitions for youth with special health care needs in US medical education. The tool can be used to create structured protocols to help improve provider knowledge, collaboration across pediatric and adult care providers, and the continuity of care as youth with special health care needs transition from pediatric to adult care. The results provided a road map for optimizing the tool and highlighted the importance of evaluating eHealth technologies with representative users.

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy

Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge. A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders. In total, 369 patients were included (control: n=195, intervention: n=174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, ORadj 0.70 [95% CI 0.38-1.31], university hospital: 63% vs 50%, OR adj 1.76 [95% CI 0.75-4.13]). The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.

The Effectiveness of the Transitional Care Program Among People Awaiting Coronary Artery Bypass Graft Surgery: A Randomized Control Trial.

This study examined the effectiveness of the Transitional Care Program (TCP) on the anxiety, depression, cardiac self-efficacy, number of hospitalizations, and satisfaction with care among people awaiting elective coronary artery bypass graft (CABG) surgery. The study design was a randomized controlled trial. The participants with coronary artery disease who met the study criteria (n = 104) were randomly assigned to the intervention group (n = 52) receiving the TCP plus routine care, or the control group (n = 52) receiving routine care only. The TCP, developed based on the Transitional Care Model, comprised hospital discharge planning and six weekly home telephone follow-ups to provide health education, counseling, monitoring, and emotional support tailored to the individual's needs. Data were collected at baseline, and then at weeks 1, 6, and 8 after program enrollment. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and the Z test. The intervention group had lower anxiety and depression than did the control group at weeks 1, 6, and 8 after program enrollment. At weeks 6 and 8, the intervention group exhibited higher cardiac self-efficacy and satisfaction with care than the control group. Further, the intervention group had a significantly lower number of hospitalizations than the control group at week 8. The TCP can reduce anxiety, depression, and number of hospitalizations, while increasing cardiac self-efficacy and satisfaction with care among people awaiting CABG. Nurses are in a pivotal position to make care transitions safer. Provision of discharge education and regular telephone contacts could enhance positive outcomes regarding patients awaiting elective cardiac surgery.

Outcomes of a Nursing Home-to-Community Care Transition Program

ObjectivesMost transitional care initiatives to reduce rehospitalization have focused on the transition that occurs between a patient's hospital discharge and return home. However, many patients are discharged from a skilled nursing facility (SNF) to their homes. The goal was to evaluate the effectiveness of the Mayo Clinic Care Transitions (MCCT) program (hereafter called program) among patients discharged from SNFs to their homes. DesignPropensity-matched control-intervention trial. InterventionPatients in the intervention group received care management following nursing stay (a home visit and nursing phone calls). Setting and ParticipantsPatients enrolled after discharge from an SNF to home were matched to patients who did not receive intervention because of refusal, program capacity, or distance. Patients were aged ≥60 years, at high risk for hospitalization, and discharged from an SNF. MethodsProgram enrollees were matched through propensity score to nonenrollees on the basis of age, sex, comorbid health burden, and mortality risk score. Conditional logistic regression analysis examined 30-day hospitalization and emergency department (ED) use; Cox proportional hazards analyses examined 180-day hospital stay and ED use. ResultsEach group comprised 160 patients [mean (standard deviation) age, 85.4 (7.4) years]. Thirty-day hospitalization and ED rates were 4.4% and 10.0% in the program group and 3.8% and 10.0% in the group with usual care (P = .76 for hospitalization; P > .99 for ED). At 180 days, hospitalization and ED rates were 30.6% and 46.3% for program patients compared with 11.3% and 25.0% in the comparison group (P < .001). Conclusions and ImplicationsWe found no evidence of reduced hospitalization or ED visits by program patients vs the comparison group. Such findings are crucial because they illustrate how aggressive stabilization care within the SNF may mitigate the program role. Furthermore, we found higher ED and hospitalization rates at 180 days in program patients than the comparison group.

Development of a community outreach project: An interprofessional partnership for thalassemia families guided by nursing students

Children with chronic illnesses have improved physiological and psychosocial outcomes when they are able to identify and converse with others who experience the same challenges. Support groups are one way to enhance this interaction. To facilitate this process, student nurses worked with an interprofessional healthcare team, thalassemia patients, and their families to determine their support needs. The purpose of this article is to describe the innovative development and outcomes of the Thalassemia Patient Support Project, a community engagement partnership. This partnership provided a unique educational clinical experience for nursing students where they had an opportunity to help develop a support group and a pediatric to adult transitional care program. The outcomes could be used as a guide for community nursing education, in US and international settings.

Effect of Dementia on Outcomes After Surgically Treated Hip Fracture in Older Adults

BackgroundHip fractures are associated with increased mortality and functional limitations. However, the effect that dementia has on these outcomes in individuals in aged care settings after fracture is not well established. This study examined the association of dementia with post-hip fracture mortality, permanent residential aged care entry, transition care use, and change in activities of daily living (ADL) needs. MethodsA retrospective cohort study using data from the Registry of Senior Australians (2003-2015) was conducted. Individuals with a hip fracture while receiving aged care services were included. Associations of dementia with mortality, risks of transition and permanent care use, and ADL needs progression were estimated using multivariable Cox, Fine-Gray, and logistic regression methods, respectively. ResultsOf 4771 individuals evaluated, 76% were women, the median age was 86 years (IQR 82-90), and 71% already lived in permanent residential aged care at the time of fracture. Within two years of their hip fracture, 50.4% (95% CI 48.9%-51.8%) of individuals died, 16.2% (95% CI 14.2%-18.2%) entered a transition care program, 59.1% (95% CI 56.5%-61.7%) entered permanent residential aged care, and 32% had greater ADL needs. Dementia was associated with higher risk of two-year mortality (HR = 1.19, 95% CI 1.09-1.30), 90-day entry into permanent care (sHR = 1.96, 95% CI 1.60-2.38), and increased likelihood of ADL limitations (OR = 1.36, 95% CI 1.00-1.85). Minor differences were seen in transition care use by dementia status. ConclusionDementia is a strong risk factor for mortality after hip fractures in individuals in aged care settings and associated with a high risk of entry into permanent care. Level of EvidencePrognostic level III.

Implementation of a Pharmacist-Managed Transitions of Care Tool.

To improve, expand, and sustain a pharmacist-based transitions of care (TOC) program and to assess interventions targeting veterans at high risk for adverse outcomes. A TOC program was developed and piloted at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC). Following success of the pilot project, targeted interventions were identified to improve and expand the program. Patients deemed high risk for readmission by an acute care pharmacist were identified and referred for continued postdischarge follow-up. The study population included patients discharged to the community with primary care established within the RLRVAMC system. Eligible patients were entered into a TOC database by the referring acute care pharmacist. A pharmacist in the primary care clinic reviewed then contacted the patient within 1 week of discharge. Appropriate documentation of each visit was completed in the electronic health record. Data collection included background information, time to follow-up, medication discrepancies, pharmacist interventions, emergency department visits, and hospital readmissions. A total of 139 patients were included, of which 99 patients were reached for pharmacist follow-up. There were 43 medication-related discrepancies among all patients. The most common discrepancy was taking the wrong dose of a prescribed medication. Additional counseling was provided to 75% of patients. The subset of patients who were reached by a pharmacist had decreased index (5.1% vs 15.0%; P = .049) and all-cause readmissions (8.1% vs 27.5%; P = .03) at 30 days compared with those who did not received pharmacist follow-up, respectively. This study demonstrated that implementation and expansion of a pharmacist-based TOC process is effective in communicating high-risk patients and intervening on medication-related issues postdischarge.

Stepping up: retention in HIV care within an integrated health care transition program

ABSTRACT Strategies are needed to optimize HIV health care transition (HCT). We describe HCT outcomes within the University of Maryland STEP Program, which is built upon integration of an adult HIV provider and navigator into the pediatric clinic, and coordinated collaboration between pediatric and adult HIV multi-disciplinary care teams. These outcomes were compared to a historical institutional HCT cohort (N = 50) which attempted transition in an earlier time period (2004–2012). Fifty-eight patients were enrolled during the study period, and 34 attempted HCT. In total, 84 patients underwent attempted HCT. In the STEP cohort, linkage to adult care was 94% and 12 month retention in adult care (95%) was statistically higher compared to the historical cohort. Rates of viral suppression did not differ pre- and post-HCT among STEP Program patients. These results support the concept of an integrated pediatric and adult HIV HCT model though the ability to achieve sustainable HCT success will require further study.

Transitional Cancer Care Program from Hospital to Home in the Health Care System of Iran.

Objectives:Transitional care program refers to the health care continuity during transferring from one health care setting to another or to home. This is an essential program for cancer patients and reduces the risk of unnecessary hospital admissions as well as the complications of the disease. The aim of this study was to develop a transitional cancer care program from hospital to home in the health care system of Iran. Methods:This study is a health policy and system research. It was conducted in four stages from October 2019 to January 2020. The first stage was a qualitative study. The qualitative data were collected through semi-structured interviews with 24 participants and a focus group with eight experts. In the second stage, a literature review of transitional care models was carried out. The initial version of the transitional cancer care program was developed based on the qualitative results and the literature review in the third stage. The validity and feasibility of the program were assessed using the Delphi study in the fourth stage. Results:Six major categories were extracted from the qualitative results, consisting of “integrated services for the continuity of care”, “holistic care”, “care standardization”, “the use of telemedicine”, “the transparency of rules” and “the care process provision”. Using these results and extracted the three common models of transitional care, the initial program was developed in three phases of pre-discharge, post-discharge, and transitional care with six protocols. The content validity of the program (98.7%) and its feasibility (95.8%) were approved by experts in the Delphi rounds. Conclusions:It is necessary to revise hospitals’ discharge program, and home health care center’s plan for admission and delivering health care services for cancer patients. Also, a pilot program is necessary to find the system advantages and disadvantages.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

BackgroundMany hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?MethodsThe six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.ResultsTCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.ConclusionTCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Adherence to care transitions recommendations among high-risk hospitalized older patients.

Evidence on the effectiveness of inpatient hospital geriatric consultation is scant, and it is unknown whether adherence to specific recommendations will improve care and patient outcomes. This study was conducted to provide insights from a quality improvement project that may help guide further improvements in the effectiveness of these consultations made as a component of a care transitions program (CTP). Secondary analysis of the implementation of a multicomponent CTP for high-risk hospitalized patients aged 75 and older. A 400-bed community teaching hospital. Two hundred and two patients admitted to non-ICU beds who met high-risk criteria. Inpatient comprehensive geriatric consultation including care transition recommendations, telephone and in-person follow-up weekly for 4 weeks after discharge, and collaboration with post-acute organizations and primary care and specialist physicians to implement recommendations. Primary outcomes for this analysis was 30-day hospital readmissions and adherence to transition of care recommendations. The 142 patients with at least one post-discharge visit received 936 care transition recommendations. Overall, 663 (71%) of the 936 care transition recommendations were adhered to (71%). The adherence rate was lower in the 22 patients who were readmitted to the hospital within 30 days (63%) compared to 72% adherence in the 120 patients who were not readmitted. This was not a statistically significant difference, and there were no significant differences in the number and percent adherence in any recommendation category between the two groups. We found adherence to just over two-thirds of care transition recommendations, similar to a small number of other studies. We did not find a relationship between the number of recommendations and adherence to them with 30-day readmissions to the hospital. Future studies of CTPs should consider several strategies may enhance geriatric consultation care transitions recommendations and adherence to them, and improve patient outcomes.

Effects of a nurse led web-based transitional care program on the glycemic control and quality of life post hospital discharge in patients with type 2 diabetes: A randomized controlled trial

BackgroundIndividuals with type 2 diabetes have a heightened risk of developing serious complications post hospital discharge. Web-based transitional care is a promising intervention to improve the glycemic control and quality of life of this patient group; however, whether web-based transitional care can improve the glycemic control and quality of life of this group remains unknown. Further, the mechanisms underlying the relationships between the intervention and both glycemic control and quality of life have not been fully explored. ObjectivesThe aims of this study were to develop a web-based transitional care program and evaluate its effects on the glycemic control and quality of life of Chinese patients with type 2 diabetes and to explore the mediating roles of self-efficacy and treatment adherence. DesignRandomized controlled trial. Settings and participantsThis study was conducted in a large regional hospital in Guangzhou City, China. Patients diagnosed with type 2 diabetes were included. MethodsA total of 116 eligible participants were randomly assigned to receive either the 3-month web-based transitional care program or usual care. Assessments of hemoglobin A1c (HbA1c), self-efficacy, treatment adherence, and quality of life were conducted at baseline and at 3 months. Analysis followed the intention-to-treat principle. A generalized estimating equation was used to determine intervention effects on HbA1c and quality of life. Path analysis was used to assess the mediation of these effects by changes in self-efficacy and treatment adherence during the intervention. ResultsParticipants in the intervention group had significantly greater improvements in HbA1c (β = 2.87; p < 0.01) and quality of life (β = 7.69; p < 0.01) compared with the control group. The relationships between the intervention and both glycemic control and quality of life were significantly mediated by improved self-efficacy (indirect effect: β = 0.18, p < 0.05) and improved treatment adherence (indirect effect: β = 0.17, p < 0.05); overall, the model explained 52.5% of the variance in HbA1c and 34.2% of the variance in quality of life. ConclusionsOur study identified beneficial effects of a web-based transitional care program on glycemic control and quality of life post hospital discharge in people with type 2 diabetes, and the underlying mediating mechanisms. The effectiveness and feasibility of this web-based intervention program suggests that its application should be promoted in community settings to reduce poor outcomes in people with type 2 diabetes.Tweetable abstract: The web-based transitional care program can improve patients’ glycemic control and quality of life.Registration number: ChiCTR2000035603

Impact of Adding Pharmacists and Comprehensive Medication Management to a Medical Group's Transition of Care Services.

Evaluate the impact of pharmacist-provided transition of care (TOC) services on hospital readmissions. Starting March 2014, TOC services were provided to all hospitalized patients from an at-risk medical group. Data covering all inpatient and outpatient services and prescription drugs were retrieved for all adult patients discharged between January 2010 and December 2018. The overall impact of TOC was estimated using a generalized estimating equation with logistic regression. Longitudinal TOC effects were estimated using generalized estimating equation in an interrupted time series model. Parallel analyses were conducted using data from an affiliated medical group in a neighboring county without access to the TOC intervention. The study included 13,256 hospital discharges for adult patients for the 30-day readmission analysis and 10,740 discharges for the 180 days analysis. The TOC program reduced 30-day readmission risk by 34.9% [odds ratio (OR)=0.651 (range, 0.590-0.719)] and 180-day readmissions by 33.4% [OR=0.666 (range, 0.604-0.735)]. The interrupted time series results found the 30-day readmission rate to be stable over the pre-TOC period (OR=0.00; not significant) then to decreased by 1.5% per month in the post-TOC period [OR=0.985 (range, 0.980-0.991)]. For 180-day readmissions, risk decreased by 1% per month after TOC implementation [OR=0.990 (range, 0.984-0.996)]. Referral to the medical group's pre-existing Priority Care clinic also reduced readmission risk. Results from the comparison medical group found 180-day readmission declined by 1% per month after March 2014 [OR=0.990 (0.891-1.00)]. Adding a pharmacist-led TOC program to the medical group's existing outpatient services reduced 30- and 180-day readmissions by "bending the curve" for readmission risk over time.

Utilizing the care coordination Atlas as a framework: An integrative review of transitional care models

Introduction Care coordination reduces care fragmentation and costs while improving health care quality. Transitional care programs, guided by tested models are an important component of effective care coordination, and have been found to reduce adverse events and prevent hospital readmissions. Using the Care Coordination Atlas as a framework, this article reports an integrative review of two transitional care models including analysis of model components, implementation factors, and associated 30-day all-cause hospital readmission rates. Methods Integrative review methodology. PubMed and Scopus databases were searched from January 2015 to July 2020. Fourteen studies set in 18 skilled nursing facilities and 50 hospitals were selected for data extraction and analysis. Results The ReEngineered Discharge model had five components and the Better Outcomes by Optimizing Safe Transitions model had eight components in the nine Care Coordination Atlas domains. Communication dominated activities in both models while neither addressed accountability/responsibility. Implementation was influenced by leadership commitment to understanding complexity of the models, culture change, integration of models into workflows, and associated labor costs. Model implementation studies consistently reported improvements in facilities’ 30-day all-cause hospital readmission rates. Discussion The Care Coordination Atlas was a useful framework to guide analysis of transitional care models. Leadership commitment to and participation in model implementation is vital. The models do not focus beyond the immediate post-discharge period limiting the impact on chronic disease management. Frameworks such as the Care Coordination Atlas are useful to help guide development of care coordination activities and associations with readmission rates.

Front-Line innovation: Rapid implementation of a nurse-driven protocol for care of outpatients with COVID-19.

Aims and objectivesOur objective was to rapidly adapt and scale a registered nurse‐driven Coordinated Transitional Care (C‐TraC) programme to provide intensive home monitoring and optimise care for outpatient Veterans with COVID‐19 in a large urban Unites States healthcare system.BackgroundOur diffuse primary care network had no existing model of care by which to provide coordinated result tracking and monitoring of outpatients with COVID‐19.DesignQuality improvement implementation project.MethodsWe used the Replicating Effective Programs model to guide implementation, iterative Plan‐Do‐Study‐Act cycles and SQUIRE reporting guidelines. Two transitional care registered nurses, and a geriatrician medical director developed a protocol that included detailed initial assessment, overnight delivery of monitoring equipment and phone‐based follow‐up tailored to risk level and symptom severity. We tripled programme capacity in time for the surge of cases by training Primary Care registered nurses.ResultsBetween 23 March and 15 May 2020, 120 Veterans with COVID‐19 were enrolled for outpatient monitoring; over one‐third were aged 65 years or older, and 70% had medical conditions associated with poor COVID‐19 outcomes. All Veterans received an initial call within a few hours of the laboratory reporting positive results. The mean length of follow‐up was 8.1 days, with an average of 4.2 nurse and 1.3 physician or advanced practice clinician contacts per patient. The majority (85%) were managed entirely in the outpatient setting. After the surge, the model was disseminated to individual primary care teams through educational sessions.ConclusionA model based on experienced registered nurses can provide comprehensive, effective and sustainable outpatient monitoring to high‐risk populations with COVID‐19.

A Qualitative Study of Older Patients' and Family Caregivers' Perspectives of Transitional Care From Hospital to Home.

The need for high-quality long-term healthcare services is increasing across the globe as the population ages. Strategies for improving transitional care from hospital to home are needed. This study aimed to explore the perspectives of patients aged 65 years and over and their family caregivers transitioning from hospital to home in an urban area of Turkey. Thematic analysis of in-depth semi-structured interviews was conducted with older patients (n = 14), with at least one chronic disease and admitted to the hospital for a minimum of 3 days, and family caregivers (n = 11) who voluntarily participated. Main themes were "confused feelings of safety and stress"; "worried about being left alone"; and "disrupted healthcare journey." The proactive rehabilitation model was used to elaborate on the study findings and interpret the perspectives and experiences of older patients and their family caregivers, which can be used for improving the quality of care after discharge from hospital. A high-quality transitional care program requires taking care of the feeling of safety in older patients and their family caregivers by the multidisciplinary team and their enhanced involvement in care initiatives after hospital discharge.

Hospital- and Patient-Level Characteristics Associated With Unplanned Readmissions and In-Patient Mortality in Men and Women With Alcoholic Cardiomyopathy

The aims of the study were to (a) determine rates of early, late, and overall 30-day all-cause readmission for women and men with the diagnosis of alcoholic cardiomyopathy (ACM), (b) examine hospital- and patient-level characteristics associated with the risk of readmission and how these factors differed by sex, and (c) examine the association between sex and in-patient mortality during readmission. We conducted a multi-year cross-sectional analysis of adult (≥18 years) inpatient hospitalizations in the United States. Descriptive statistics including frequencies and percentages were used to describe the study population, stratified by sex. We then used Poisson regression with robust error variance estimation to estimate risk ratios (RRs) and 95% confidence intervals (CIs) that represented the associations between sex and likelihood of 30-day all-cause readmission and inpatient mortality. Among more than 116 million hospitalizations, there were 53,207 ACM-related hospitalizations (45,573 men and 7,634 women). Thirty-day all-cause readmission rates following an ACM-related index hospitalization were similar between men (20.3%) and women (20.5%). For men and women, cancer, hepatitis, chronic renal failure, cirrhosis, asthma, and anemia were associated with a higher risk of readmission. Although crude in-hospital mortality rates were higher among women (6.6%) than men (4.3%), there were no sex differences in mortality after adjusting for confounders (RR = 1.26, 95% CI [0.88, 1.81]). Although men are more likely to be hospitalized for ACM, readmission risk is high (approximately 20%) and is similar in men and women following hospitalization for ACM. Hospital care transition programs that include a multidisciplinary approach are needed to help prevent these readmissions and associated morbidity and mortality.

Transition from hospital to home during COVID-19: A case report from an Australian transitional care program

Aim and Background: With the ongoing COVID-19 global pandemic, consideration for vulnerable groups, including our ageing population has been of great concern. Social isolation has been recommended to protect older adults with chronic diseases and reduce the spread of the virus, as well as to prevent healthcare services becoming overwhelmed. Yet social isolation presents its own health risks.&#x0D; Methods: In this paper, we provide commentary on the lived experience of returning home from hospital during the COVID-19 pandemic. This case report details the experience of an 83-year-old female, who was living and mobilising independently in her own home, prior to hospital admission following a fall and resultant head injury.&#x0D; Results: The participant returned home during the COVID-19 pandemic with a community transition care program which included assistance with cleaning tasks, shopping, and physiotherapy over a 45-day period.&#x0D; Conclusions: COVID-19 has illuminated the issue of social isolation and increased awareness of its negative health effects at a global level. As society eases restrictions and returns to a new ‘normal’, many older adults will remain socially isolated. Ongoing allied health intervention is required to ensure quality of life through the latter years and to support older adults through periods of social distancing.&#x0D; Keywords: transition care; COVID-19, social isolation, community participation&#x0D; &#x0D;

Causes and Predictors of Unplanned Readmission in Cranial Neurosurgery

A better understanding of the risks and reasons for unplanned readmission is an essential component in reducing costs in the health care system and in optimizing patient safety and satisfaction. The reasons for unplanned readmission vary between different disciplines and procedures. The aim of this study was to identify reasons for readmission in view of different diagnoses in cranial neurosurgery. In this single-center retrospective study, adult patients after neurosurgical treatment were analyzed and grouped according to the indication based on International Classification of Diseases and Related Health Problems, Tenth Revision, German Modification diagnosis codes. The main outcome measure was unplanned readmission within 30 days of discharge. Further logistic regression models were performed to identify factors associated with unplanned rehospitalization. Of the 2474 patients analyzed, 183 underwent unplanned rehospitalization. Readmission rates differed between the diagnosis groups, with 9.19% in neoplasm, 8.26% in hydrocephalus, 5.76% in vascular, 6.13% after trauma, and 8.05% in the functional group. Several causes were considered to be preventable, such as wound healing disorders, seizures, or social reasons. Younger age, length of first stay, surgical treatment, and side diagnoses were predictors for unplanned readmission. Diagnoses with an increased risk of readmission were glioblastoma, traumatic subdural hematoma, or chronic subdural hematoma. Reasons and predictors for an unplanned readmission differ considerably among the index diagnosis groups. In addition to well-known reasons for readmission, we identified social indication, meaning a lack of home care, which is particularly prevalent in oncologic and elderly patients. A transitional care program could benefit these vulnerable patients.

The Frailty In Residential Sector over Time (FIRST) study: methods and baseline cohort description

BackgroundThe Frailty In Residential Sector over Time (FIRST) Study is a 3-year prospective cohort study investigating the health of residents living in residential aged care services (RACS) in South Australia. The study aims to examine the change in frailty status and associated health outcomes.MethodsThis interim report presents data from March 2019–October 2020. The study setting is 12 RACS from one organisation across metropolitan and rural South Australia involving 1243 residents. All permanent (i.e. respite or transition care program excluded) residents living in the RACS for at least 8 weeks were invited to participate. Residents who were deemed to be medically unstable (e.g. experiencing delirium), have less than 3 months to live, or not fluent in English were excluded. Data collected included frailty status, medical diagnoses, medicines, pain, nutrition, sarcopenia, falls, dementia, anxiety and depression, sleep quality, quality of life, satisfaction with care, activities of daily living, and life space use at baseline and 12-months. Data Linkage will occur over the 3 years from baseline.ResultsA total of 561 permanent residents (mean age 87.69 ± 7.25) were included. The majority of residents were female (n = 411, 73.3%) with 95.3% (n = 527) being classified as either frail (n = 377, 68.2%) or most-frail (n = 150, 27.1%) according to the Frailty Index (FI). Most residents were severely impaired in their basic activities of daily living (n = 554, 98.8%), and were at-risk of malnutrition (n = 305, 55.0%) and at-risk of sarcopenia (n = 492, 89.5%). Most residents did not experience pain (n = 475, 85.4%), had normal daytime sleepiness (n = 385, 69.7%), and low anxiety and depression scores (n = 327, 58.9%).ConclusionThis study provides valuable information on the health and frailty levels of residents living in RACS in South Australia. The results will assist in developing interventions that can help to improve the health and wellbeing of residents in aged care services.Trial registrationProspectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000500156).