Transitional Care Research Articles

It’s More Complicated Than Interpreter Use: Improving Care for Non–English-Speaking Families

Mateo is a 2-week-old male who presented for evaluation of neonatal fever and whose parents speak Spanish. Workup revealed pyelonephritis, underlying renal anomalies, and vesicoureteral reflux. A complex interplay of individual and contextual factors contributed to Mateo not receiving prophylactic antibiotics, which ultimately led to a potentially preventable subsequent admission for sepsis secondary to Escherichia coli pyelonephritis with bacteremia. Further history revealed additional communication breakdown; despite multiple appointments between hospitalizations, systems issues led to Mateo’s primary care provider being unaware of Mateo’s admissions or urologic diagnoses. This case demonstrates challenges facing health care providers as we strive to provide equitable care to families speaking languages other than English (LOE). Although an in-person interpreter was used throughout Mateo’s hospitalization, there were still key areas of communication breakdown and opportunities for improvement. First, we describe characteristics of the growing population speaking LOE in the United States and discuss qualitative and quantitative disparities in health care encounters for this population. Through Mateo’s experience, we highlight the transition of care at discharge as being highly vulnerable to communication breakdown, particularly for patients speaking LOE, and emphasize the additional impact of low health literacy on these challenges. Finally, we outline potential strategies to reduce disparities and improve outcomes for pediatric patients and families speaking LOE, focusing on (1) consistent and evidence-based interpreter use, (2) incorporation of health literacy–informed communication strategies in the discharge process, (3) reducing barriers to follow-up appointments or diagnostic testing, and (4) closed-loop communication with the patient’s primary care provider.

An Integrated Review of Transitional Care for Families of Pre-Term Infants

This study was conducted to identify the key elements of transitional care for families with pre-term infants in South Korea. We used an integrative review methodology proposed by Whittemore and Knafle. During the problem identification step, the review question was constructed via the population, intervention, outcome, and timeframe (PIOT) format. During the literature search step, integrative reviews of the published literature from nine electronic databases were undertaken and a total of 14 studies were reviewed that met our inclusion criteria. During the data evaluation step, the quality of the literature was assessed using the Mixed Methods Appraisal Tool (MMAT) developed by Hong et al. We identified three domains and 10 key attributes of transitional care for families of pre-term infants. The parenting empowerment domain included growth and development, developmental promotion, nutrition, safe environment, general parenting, and parent–infant interaction. The emotional support domain included counseling, advocacy, and community network. The social support domain included professional collaboration. Efforts should continue to further develop programs and policies to enhance transitional care for families of pre-term infants that reflect South Korean nursing practices.

Bridging the continuity: Practice-enhancing publications about the ambulatory care medication-use process in 2022.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. This article identifies, summarizes, and prioritizes literature on the ambulatory care medication-use process (ACMUP) published in 2022 that can describe ambulatory pharmacy practice. The medication-use process (MUP) is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing, access, dispensing, adherence, and evaluating. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search for articles published in 2022 was conducted in January 2023 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 4,125 articles. A thorough review identified 49 potentially practice-enhancing articles: 6 for transitions of care, 9 for prescribing, 5 for access, 2 for dispensing, 6 for adherence, and 21 articles for evaluating. Trends from the impact articles are described. It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article continues a series of articles defining and evaluating the currently published literature around the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Characteristics and Trajectory of Older Adults Supported by a Patient Navigator Program in a Hospital Setting: A Cohort Observational Study.

To improve transitions in care, a new patient navigation (PN) program was introduced to support older adults with complex care needs transition from hospital to home. The patient navigator is a community social worker embedded in the hospital's care teams. A cohort observational design was used to conduct the study by analysing the patient navigator's clinical notes and hospital's administrative data to describe the characteristics of patients, scope of the patient navigator's activities, and patient outcomes. Ninety patients were assigned to the patient navigator's caseload (November 2019-November 2021) in which the average age was 78.9 (range 55-95). The most frequent PN intervention types were referrals to community services (66%, n = 59) and discharge planning (61%, n = 55). The patient navigator supported 66% patients (n = 59) in returning home and provided follow-up care for 74 days (average). This study provides important insights into the patient navigator's role to guide decision makers in implementing PN programs for older adults in a hospital setting.

Exploring genetic counselors' interest and role in transitional care discussions for pediatric patients with neurodevelopmental conditions.

Previous studies have examined the perspectives of healthcare providers regarding their role in the transition process of pediatric patients with neurodevelopmental conditions (NDCs), but the perspective of a genetic counselor has yet to be considered. This study explored genetic counselors' current practices and attitudes regarding care for pediatric patients with NDCs as they transition into adult care. Genetic counselors (GCs) currently seeing patients with NDCs were recruited through a cross-sectional online survey. Questions included demographics, current practices with patients aged 0-15 years vs. patients 16-22 years, self-confidence, attitudes, and barriers regarding a genetic counselor's role in medical transition. A total of 51 surveys were included in the analysis. The majority (76.7%) of GCs were interested in playing a role in the transition process. Furthermore, all participants perceived transition planning for pediatric genetic patients with NDCs as somewhat important or important. Most GCs (70.0%) discussed topics of transition with patients over 18 years of age. These results demonstrate GCs' interest in assisting patients and families with the transition of individuals. Incorporating a genetic counselor skill set into transition discussions with patients with NDCs could improve the transition process and help to meet the standards of care called for by the American Academy of Pediatrics.

Update on Diagnosis and Management of Kawasaki Disease: A Scientific Statement From the American Heart Association.

Kawasaki disease (KD), an acute self-limited febrile illness that primarily affects children <5 years old, is the leading cause of acquired heart disease in developed countries, with the potential of leading to coronary artery dilation and coronary artery aneurysms in 25% of untreated patients. This update summarizes relevant clinical data published since the 2017 American Heart Association scientific statement on KD related to diagnosis, cardiac imaging in acute KD treatment, and long-term management. Criteria defining North American patients at high risk for developing coronary artery aneurysms who may benefit from more intensive initial treatment have been published. Advances in cardiovascular imaging have improved the ability to identify coronary artery stenosis in patients with KD, yet knowledge gaps remain regarding optimal frequency of serial imaging and the best imaging modality to identify those at risk for inducible myocardial ischemia. Recent data have advanced the understanding of safety and dosing for several anti-inflammatory therapies in KD. New anticoagulation medication, myocardial infarction management, transition of health care for patients with KD, and future directions in research are discussed.

Adapting to Adulthood: A Review of Transition Strategies for Osteogenesis Imperfecta.

Osteogenesis Imperfecta (OI), known as "brittle bone disease," presents a rare genetic disorder characterized by bone fragility, often accompanied by skeletal deformities and extraskeletal complications. OI is primarily associated with collagen type I defects, responsible for the syndromic nature of the disease affecting a broad range of tissues. As such, its multisystemic complexity necessitates multidisciplinary care approaches in all patient life stages. OI treatment remains largely supportive, commonly including bisphosphonates and orthopedic surgeries, which show promise in children. Although rehabilitation programs for children exist, guidelines for adult care and especially the transition from pediatric to adult care, are lagging behind in OI care and research. The current systematic review summarizes the literature on OI patient pediatric to adult care transition experiences and compares OI transition approaches to other chronic diseases. The review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Systematic searches were conducted across multiple databases. Search terms encompassed synonyms and closely related phrases relevant to "OI" and "Transition to adult care". The initial screening involved the evaluation of article titles, followed by a thorough review of abstracts to assess relevance for the purpose of the current review. Programs aimed at easing the transition from pediatric to adult OI care necessitate a multifaceted approach. Collaborative efforts between different medical disciplines including pediatricians, endocrinologists, orthopedics, cardiology, pulmonology, ophthalmology, otolaryngologists, maxillofacial specialists, psychologists and medical genetics, are crucial for addressing the diverse needs of OI patients during this critical life phase. Comprehensive education, readiness assessments, personalized transition plans, and further follow-up are essential components of a structured transition framework. Further research is warranted to evaluate the feasibility and efficacy of sequential stepwise transition systems tailored to individuals with OI.

Abstract 4136911: Daily Dyadic Symptom Appraisal Dynamics During Care Transitions in Persons with Heart Failure and Their Care Partners

Background: Symptom monitoring after heart failure (HF) hospitalization is a central aspect of patient education. However, appraising symptoms can be difficult for persons with HF (PWHFs), and studies suggest family care partners (CPs) play a key supportive role. The purpose of this study is to examine dyadic HF symptom appraisal dynamics in PWHF-CP dyads during hospital-to-home transitions. Methods: We conducted a daily diary study of dyadic symptom appraisal in which PWHFs and CPs were enrolled during a HF hospitalization. Over 5 weeks, both completed daily assessments of the PWHF’s symptoms (HF Somatic Perception Scale, PROMIS Fatigue 4a). Each dyad’s appraisal dynamics were quantified using a set of N of 1 dyadic autoregressive time series models examining total symptoms, hallmark symptoms (dyspnea, edema) and nonspecific symptoms (early/subtle cluster, fatigue). Models were examined for within-dyad dynamics (within-dyad associations on the same day or on a 1-day lag). Patterns in significant dynamics across dyads were narratively described. Results: This analysis includes n=14 cohabitating dyads, all partnered. On average, PWHFs and CPs were 69.6±5.4 and 67.4±8.0 years of age. The sample was relatively gender balanced (43% of PWHFs and 64% of CPs identified as female), and primarily identified as non-Hispanic (86% of PWHFs, 93% of CPs) and White (93% of PWHFs, 86% of CPs). Most PWHFs had non-ischemic cardiomyopathy (64%) and were NYHA Class III/IV (86%), with 57% HFrEF (mean EF 37%±17%). Symptom appraisals were highly variable within and across dyads (Fig 1). Most (n=11, 79%) had significant dyadic dynamics, but dynamics across dyads varied by symptom type and time structure (Fig 2). Conclusions: The types of symptoms that HF care dyads are able to appraise together and the time structure of appraisals are variable during care transitions. Precision approaches tailored to individual dyads are needed to optimize inclusion of CPs in symptom monitoring interventions.

Transitional Care Support for Medicaid-Insured Patients With Serious Mental Illness: Protocol for a Type I Hybrid Effectiveness-Implementation Stepped-Wedge Cluster Randomized Controlled Trial.

People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization. This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI. This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments. This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027. We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders. ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509. DERR1-10.2196/64575.

Impact of a Transitional Care Workshop for Medical Students and Residents

Impact of a Transitional Care Workshop for Medical Students and Residents

Abstract 4136566: Primary Pericardial Mesothelioma: Diagnostic dilemma and rapid decline

Description of case: A 33-year-old man with no medical history or environment exposures, presented with dyspnea, nausea, and vomiting. He was tachycardic, with jugular venous distension, pulsus paradoxus, low voltage QRS and echocardiogram (TTE) showed a large pericardial effusion with ventricular interdependence. He underwent pericardiocentesis with negative fluid studies, including cytology. Two months later he represented with dyspnea and pleuritic chest pain, was diagnosed with pericarditis, and found to have recurrent pericardial effusion without tamponade. He was treated with aspirin and colchicine and discharged, with surveillance TTE showing a stable pericardial effusion but with significant adhesions and constrictive physiology (confirmed on right heart catheterization). Negative QuantiFERON was obtained and Anakinra started. Two months later he remained symptomatic with new pleural effusions and was sent for positron emission tomography scan which revealed diffuse intensely hypermetabolic pericardial thickening/fluid, up to 3.8 cm in maximal thickness and increased uptake in mediastinal nodes. Next, a cardiac MRI showed extensive circumferential thickening of the pericardial space approximately 2.5 cm in thickness. Both the visceral and parietal pericardium exhibited extensive scattered delayed hyperenhancement. Subsequent pericardial biopsy showed markedly fibrotic pericardium and pathology showed biphasic malignant pericardial mesothelioma. Immunosuppressive medications were stopped, and he underwent thoracentesis. After multidisciplinary discussions, he was started on nivolumab every two weeks and ipilimumab with a plan for surgery based on response to therapy. However, progressive symptoms and worsening constriction physiology led to palliative consultation and comfort care transition, with him dying shortly after. Discussion: Recurrent pericarditis and pericardial effusion, along with negative typical pericardial fluid studies, raised suspicion for a non-benign etiology. Multimodality imaging was employed and led to a pericardial biopsy. Constrictive pericarditis is an uncommon presentation of primary pericardial mesothelioma. Biphasic mesotheliomas from pleural or peritoneal origins are normally treated with systemic therapy with preference for combined immunotherapy. Primary pericardial mesothelioma is associated with a late presentation and high mortality rate, with surgery, if able to be done early appearing to be the recommended approach.

Improving Patient Handoffs and Transitions in Care Among Residents: A Chief Resident-Led Initiative

Improving Patient Handoffs and Transitions in Care Among Residents: A Chief Resident-Led Initiative

Association Between an Enhanced Clinical Pharmacy Service and Patient Experience in Hospitalized Adults: A Cohort Study.

Purpose. To determine if implementation of an enhanced clinical pharmacy service (ECPS) at a community hospital could improve patient experience as measured by medication-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Methods. A cohort study of 260 patients at a community hospital was conducted. Patients in the intervention group received additional pharmacy services from the standard of care (SOC) group, including daily medication counseling, pharmacist-driven medication administration, discharge medication reconciliation and education, consistent offers to enroll in a bedside medication delivery program (BMDP), and a telephone call following discharge. The primary outcome of patient experience was assessed through patients' responses to a care transitions HCAHPS survey question regarding understanding of the purpose of taking medications following discharge. Results. Among patients in the ECPS cohort, 75.8% had a top-box response to the care transitions HCAHPS question, compared to 63.3% of patients in the SOC cohort (OR = 1.81; 95% CI [0.61-5.37]). Top-box responses increased for all assessed HCAHPS questions but were not statistically significant. The HCAHPS survey response rate was 29.3% in the SOC cohort and 29.9% in the ECPS cohort. Conclusion. Following an ECPS intervention, patient experience as determined by HCAHPS scores increased, but the results did not reach statistical significance. Further, larger studies are needed on this topic.

Cost-effectiveness and cost-utility analysis of a nurse-led, transitional care model to improve care coordination for patients with cardiovascular diseases: results from the "Cardiolotse" study.

To assess the 12-month cost-effectiveness of the nurse-led transitional care program "Cardiolotse" (CL) for patients with cardiovascular diseases compared to usual care (UC). A cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) were conducted from the perspective of statutory health insurance (SHI), covering a time horizon of 12 months. Analyzed outcomes included the number of rehospitalizations and health-related quality of life (HRQoL). Total costs comprised program costs and the utilization of healthcare resources. Point estimates are presented as incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs). Sensitivity and subgroup analyses were conducted to illustrate uncertainty and provide insights into the impact mechanisms of the CL program. The study population consisted of 2550 patients, with 1256 allocated to the intervention group and 1294 to the control group. Patients who received support from CLs experienced fewer rehospitalizations and lower inpatient costs from an SHI perspective, compared to the UC group. HRQoL assessments indicated higher utility values for CL patients at the 12-month follow-up. Total program costs amounted to €1454.65 per patient. The CEA and CUA demonstrate that the CL program is dominant compared to UC from the SHI perspective. Our study shows that the CL program not only reduces the number of rehospitalizations and costs but increases HRQoL, resulting in a dominant ICER and ICUR. Further research is necessary to evaluate longer periods of time, different levels of care intensity, and perspectives of different healthcare stakeholders. German Clinical Trial Register DRKS00020424, 2020-06-18, retrospectively registered.

The mobile seniors’ clinic - an innovative transition of care for frail older adults

BackgroundThis study aims to evaluate the impact of Quebec’s first hospital-at-home-inspired mobile Seniors’ Clinic, the “Clinique des Ainés (CDA)”, on frail older adults’ returns to the Emergency Department (ED), mortality, and hospital Length Of Stay (LOS) and rehospitalizations.MethodsDesign: Quasi-experimental pre-post implementation cohort study. Population: Patients aged ≥ 75 years admitted to the short-term geriatric unit after an ED consultation (control) or included by the CDA (intervention). Outcomes: return to ED (RtoED), mortality, ED & hospital LOS, and rehospitalizations. Statistical analyses: Multivariable regression modelling.ResultsOverall, 891 patients were included. At the intervention site (CDA) (n = 437), RtoED were similar at 30 (17.5% & 19.5%, p = 0.58), 90 (34.4% & 37.3%, p = 0.46) and 180 days (47.2% & 54.0%, p = 0.07) in the pre and post-implementation phases. No mortality differences were found. The hospitalization LOS was significantly shorter (28.26 and 14.22 days, p < 0.01). At 90 days, rehospitalization LOS was decreased by 8.51 days (p = 0.02) and by 6.48 days at 180 days (p = 0.03). Compared to the control site (n = 454) in the post-implementation phase, RtoED was 54% at the intervention site compared to 44.1% (p = 0.02) at 180 days. The CDA had a lower adjusted probability of mortality at 90 days compared to the control site (4.8% VS 11.7%, p = 0.03). No rehospitalization LOS differences were noted.ConclusionsThe Clinique des Ainés showed effectiveness in caring for frail older patients in their homes by decreasing their hospital LOS by half and 90 days mortality risk. It was a safe care trajectory without a clinically significant increase in ED returns or mortality.

Coping difficulties after inpatient hospital treatment: validity and reliability of the German version of the post-discharge coping difficulty scale.

Patients transitioning between different care contexts are at increased risk of experiencing adverse events. In particular, being discharged to home after inpatient treatment involves significant risks. However, there is a lack of valid and internationally comparable assessment tools on patients' experiences of difficulties following hospital discharge. Therefore, this study aimed to adapt and validate the German version of the post-discharge coping difficulty scale (PDCDS-G). Patients were recruited at a German university hospital. 815 adult patients participated in a self-report survey following an inpatient stay of at least three days. Factorial validity of the PDCDS-G was evaluated via factor analyses. Further, examination of measurement invariance was performed. To establish criterion validity, associations with patients' self-reported health status and occurrence of patient safety were determined. Further, group differences regarding patient characteristics, hospitalization factors, and survey-related variables were examined. Factorial validity of the PDCDS-G was confirmed by a two-factorial model with good model fit. Both factors showed good to excellent reliability. The two-factor model achieved measurement invariance across all patient characteristics, hospitalization factors, and survey-related variables. Significant relationships with patients' health status and the occurrence of patient safety incidents corroborate criterion validity of the PDCDS-G. Differential associations of the two PDCDS-G factors regarding patient characteristics, hospitalization, and survey-related variables were found. Construct and criterion validity, as well as the reliability of the PDCDS-G, were verified. Further, instrument's measurement invariance was confirmed allowing use of the scale for the interpretation of group differences and comparisons between studies. The PDCDS-G provides a validated and comparable patient-reported outcomes measure for patient experiences after hospital discharge to home. The PDCDS-G can be used for patient surveys in quality or patient safety improvement in care transition processes.

Long-term clinical outcomes and healthcare resource utilization in male and female patients following hospitalization for heart failure.

Heart failure (HF) is a leading cause of hospitalization, and sex differences in care have been described. We assessed sex-specific clinical outcomes and healthcare resource utilization following hospitalization for HF. This was an exploratory analysis of patients hospitalized for HF across 10 Canadian hospitals in the Patient-Centered Care Transitions in HF (PACT-HF) cluster-randomized trial. The primary outcome was all-cause mortality. Secondary outcomes included all-cause readmissions, HF readmissions, emergency department (ED) visits, and healthcare resource utilization. Outcomes were obtained via linkages with administrative datasets. Among 4441 patients discharged alive, 50.7% were female. By 5 years, 63.6% and 65.5% of male and female patients, respectively, had died (p = 0.19); 85.4% and 84.4%, respectively, were readmitted (p = 0.35); and 72.2% and 70.9%, respectively, received ED care without hospitalization (p = 0.34). There were no sex differences in mean [SD] number of all-cause readmissions (males, 2.8 [7.8] and females, 3.0 [8.4], p = 0.54), HF readmissions (males, 0.9 [3.6] and females, 0.9 [4.5], p = 0.80), or ED visits (males, 1.8 [11.3] and females, 1.5 [6.0], p = 0.24) per person. There were no sex differences in mean [SD] annual direct healthcare cost per patient (males, $80 334 [116 762] versus females, $81 010 [112 625], p = 0.90), but males received more specialist, multidisciplinary HF clinic, haemodialysis, and day surgical care, and females received more home visits, continuing/convalescent care, and long-term care. Annualized clinical events were highest in first year following index discharge in both males and females. Among people discharged alive after hospitalization for HF, there were no sex differences in total and annual deaths, readmissions, and ED visits, or in total direct healthcare costs. Despite similar risk profiles, males received relatively more specialist care and day surgical procedures, and females received more supportive care. ClinicalTrials.gov NCT02112227.

Association of physical function with hospital readmissions among older adults: A systematic review.

Hospital readmissions pose significant burdens on healthcare systems, particularly among older adults. While efforts to reduce readmissions have historically focused on medical management, emerging evidence suggests physical function may also play a role in successful care transitions. However, there is a limited understanding of the relationship between functional measures and readmission risk. This systematic review aims to assess the association between physical function impairments and hospital readmissions. This systematic review aims to assess the association between physical function impairments and hospital readmissions. A systematic review was conducted following PRISMA guidelines, with studies identified through databases including PubMed, CINAHL, Embase, and others published January 1, 2010-December 31, 2022. Inclusion criteria encompassed observational studies of adults aged 50 and older in the United States, reporting readmissions within 90 days of discharge and assessing physical function across domains of the International Classification of Function model. Data extraction and risk of bias assessment were independently conducted by two authors using theScottish Intercollegiate Guidelines Network (SIGN) tool. Seventeen studies, representing 80,008 participants, were included in this systematic review. Patient populations included a wide array of medical populations, including general medical inpatients and those undergoing cardiac surgery. Across various functional measures assessed before or during admission, impairments were consistently associated with increased risk for hospital readmissions up to 90 days after admission. Measures of participation, including life-space mobility, were also associated with increased readmission risk. Functional impairments are robust predictors of hospital readmissions in older adults. Routine assessment of physical function during hospitalization can improve risk stratification and may support successful care transitions, particularly in older adults.

Effectiveness of transitional care in Inflammatory Bowel Disease; Development, Validation, and Initial outcomes of a Transition Success Score.

The effectiveness of transition programs from paediatric to adult healthcare in adolescents with inflammatory bowel disease is not clear, as prospective studies using validated outcome measures for transition are lacking. This study aimed to develop and validate a quantitative Transition Success Score, and to apply it in a multicenter setting to assess the effectiveness of transitional care. The Top 10 outcome items related to successful transition, identified through an international Delphi study with IBD stakeholders, were integrated into a generic questionnaire, the Transition Success Score. In a prospective, multicenter study, Transition Success Score was scored by adult healthcare providers, young adult patients and caregivers, 9-15 months after transfer of care. In seven Dutch hospitals, 160 patients completed the Transition Success Score. The mean score was 25 (range 17-27), 25.6% of patients achieving maximum score. Hypothesis testing for construct validity revealed significant associations with characteristics related to transitional care, such as knowledge, independence, and quality of life (p <0.005). Structural validation indicated the score was most effective at discerning lower levels of transition success. Internal consistency was acceptable (0.64). High disease burden, exacerbation during or after transfer, and certain personality profiles were associated with lower scores. The Transition Success Score serves as a quantitative tool to evaluate the effectiveness of transitional care interventions and to identify inflammatory bowel disease patients at risk of encountering challenges during the transition to adult healthcare.

Addressing Hypoglycemia Risk During Care Transitions

Addressing Hypoglycemia Risk During Care Transitions