Transitional Care Research Articles

Enhancing care coordination through transitional care management.

232 Background: West Cancer Center and Research Institute (WCCRI) serves Memphis and the Arkansas, Mississippi, and Tennessee tri-state region as the comprehensive care leader in adult cancer care and research, amounting to over 260,000 visits across 57,000 unique patients in 2023. Cancer patients are predisposed for higher risk of hospital admissions, making uniform care coordination between the discharging hospital and their outpatient oncology care home essential to care continuity. While WCCRI attempted to mitigate readmissions, there was no formalized managed care approach for capturing and responding to unplanned patient hospital visits to prevent readmission. Auditing of claims data suggested nearly 500 patient care opportunities within a four-month period. Methods: To improve continuity of care and decrease preventable readmissions, WCCRI implemented a care transitions process based on the Centers for Medicare and Medicaid's Transitional Care Management (TCM). This required a repeatable approach of proactive outreach to patient upon discharge, a clinical assessment of patient need, and an office visit within fourteen days of discharge. To maximize impact, this project was scoped to patients with unplanned hospital admissions who are at moderate to high risk for readmission. Results: Twelve months after implementation, WCCRI has proactively identified 974 patients qualifying for TCM and successfully scheduled 91.48% for a hospital follow-up appointment with their oncologist. Proactive outreach to patients has led to a 35% increase in office visits within fourteen days of discharge, a key measure of care continuity. Conclusions: Learnings from this implementation project have been spread to formalize hospital follow-up approaches across WCCRI. By aligning policies, engaging stakeholders, and fostering a culture of collaboration and accountability, WCCRI has delivered high-quality, coordinated care, and achieved better patient outcomes.

Hospital stays and probable dementia as predictors of relocation to long-term care facilities.

This study aims to investigate the relocation of older adults in the US from community living to long-term care facilities (LTCFs). Specifically, it examines the predictive roles of possible and probable dementia and hospital stays in this complex health care transition. Utilizing data from the National Health and Aging Trends Study, a longitudinal cohort study (2011-2019), we employed a panel data approach, which consists of multiple observations over time for the same participants, allowing us to account for both cross-sectional variations (differences between participants) and time-series variations (changes in the same participant over time). The analysis involved longitudinal logistic regression models. Using the AD8 dementia screening interview, clock drawing test, immediate and delayed word recall test, orientation, and history of dementia diagnosis, we placed participants into categories of having no dementia, possible dementia, and probable dementia. A survey asked about hospital stays in the past year. Relocation to LTCFs was examined based on the changes to the living location. The proportion of individuals transitioning to LTCFs tripled between 2011 and 2019, emphasizing the need to understand and manage this health care transition. Hospital stays significantly increased the probability of moving to LTCFs, especially nursing homes. Probable dementia demonstrated a 3-fold increase, aligning with the rising prevalence of Alzheimer disease. Difficulty walking and climbing stairs significantly increased relocation probabilities. The study findings emphasize complexity in late-life relocations influenced by dementia and hospital stays. Screening for cognitive function among community-dwelling older adults, particularly those with a history of hospital stays and mobility difficulties, can inform interventions and policies. Implications extend to health care policy, geriatric care, and the imperative for targeted interventions considering demographic variations. Future research should explore additional variables and address limitations to refine our understanding of the relocation process.

Impact of a Health Care Transition (HCT) Clinic on Health Outcomes in Patients with Kidney Diseases: A Single-Center Experience

Impact of a Health Care Transition (HCT) Clinic on Health Outcomes in Patients with Kidney Diseases: A Single-Center Experience

STARx Health Care Transition Readiness Scores among Arabic-Speaking Youth with Chronic Conditions

STARx Health Care Transition Readiness Scores among Arabic-Speaking Youth with Chronic Conditions

Responses from Arabic-Speaking Caregivers of Youth with Chronic Conditions to the Health Care Transition Readiness Starx Questionnaire

Responses from Arabic-Speaking Caregivers of Youth with Chronic Conditions to the Health Care Transition Readiness Starx Questionnaire

Allied rehabilitation using caregiver-mediated exercises combined with telerehabilitation for stroke (ARMed4Stroke): A randomised controlled trial

Objective To assess the added value of caregiver-mediated exercises combined with telerehabilitation in addition to usual care compared to usual care alone on the self-reported mobility outcome after subacute stroke. Design Multicentre, observer-blinded, parallel randomised controlled trial. An off-site researcher allocated treatments using minimisation. Setting Four rehabilitation centres in the Netherlands. Participants Forty-one patient–caregiver dyads within 3 months poststroke. Intervention Eight-week blended care program with caregiver-mediated mobility exercises for 2.5 h per week supported by telerehabilitation and four face-to-face sessions in addition to usual care. Main measures Self-reported mobility domain of the Stroke Impact Scale postintervention. Secondary outcomes were functional outcome, dyads’ psychosocial wellbeing, care transition to the community postintervention and after 6 months. Results Forty-one dyads (21 intervention, 20 control) were randomised, and 37 (N = 18; N = 19) were analysed following intention-to-treat. The Stroke Impact Scale mobility was not significantly different between groups postintervention (B 0.8, 95% CI –6.8–8.5, p = 0.826). The secondary outcomes, namely, (a) caregivers’ quality of life postintervention (p = 0.013), (b) caregivers’ symptoms of depression postintervention (p = 0.025), and (c) independence in leisurely activities at 6 months (p = 0.024), showed significant benefits in favour of caregiver-mediated exercises with telerehabilitation. A significant difference favouring controls was found in self-reported muscle strength at 6 months (p = 0.002). Conclusions Caregiver-mediated exercises combined with telerehabilitation yielded no differential effect on our primary outcome self-reported mobility. Although the trial is underpowered, current findings are in line with previous trials. Future studies should further explore beneficial effects of caregiver involvement in stroke rehabilitation targeting psychosocial wellbeing.

Cancer care delivery in prisons: From barriers to best practices.

49 Background: Cancer is the leading cause of death in US prisons. Incarcerated patients with cancer have 92% higher 5-year mortality than the general population with cancer, but little is known about how to improve cancer screening, diagnosis and treatment in this high-risk population. Methods: We conducted interviews with state prison medical directors and primary care clinicians, and medical, radiation and gynecologic oncologists who coordinate or provide cancer care for individuals incarcerated in prison. Participants were recruited via 1) email invitation to participants at a correctional health conference, 2) purposeful sampling using targeted emails to clinicians in prison systems selected for diversity in size, geography and correctional health model (e.g., contracted care), and 3) snowball sampling of individuals from research and participant networks. Participants were interviewed about 1) logistics of cancer care delivery from screening and treatment through end-of-life care, 2) barriers and facilitators to cancer care delivery, and 3) evidence-based strategies to facilitate cancer care in prisons, including best practices. Interview transcripts were analyzed using mixed inductive/deductive thematic content analysis to identify emerging themes. Results: 34 participants from 16 prison systems were interviewed (10 medical directors, 6 PCPs, 14 oncologists, 4 other). Participants reported prison clinicians coordinate most cancer care (e.g., screening, diagnosis and symptom management), while cancer treatment largely occurs in community or academic facilities outside of prison. Common barriers identified included underscreening / delays in diagnosis, complex logistical coordination, poor communication (between patients and oncologists, and prison clinicians and oncologists), inadequate symptom management, dehumanizing practices, loss-to-follow-up after release and that patients often come from marginalized populations. Common facilitators were better access to insurance, cancer screening, and general medical and cancer care than incarcerated patients might receive before/after incarceration. Participants identified multiple ways to improve cancer screening (creating enforceable standards, increasing continuing medical education, implementing electronic medical record reminders, reducing logistical barriers), cancer treatment (implementing navigators within prisons and cancer centers, prioritizing care with oncologist input, keeping care in prisons, decarceration), and transitions to the community (Medicaid activation prior to release, community partnerships to facilitate care transitions). Conclusions: Incarceration imposes multiple barriers to cancer care delivery, but clinicians identified numerous tools to improve cancer care in prison. Future studies should test and optimize these strategies to improve cancer outcomes for incarcerated patients.

Intra- and inter-facility experiences of coordinating care for patients with lung cancer in KwaZulu-Natal public health facilities: a qualitative study

Aim Despite evidence that effective cancer care coordination has yielded positive results in facilitating and supporting high-quality care, it remains a complex and challenging system to implement. South Africa’s mortality of lung cancer is reported at 13.4%, ranking highest among all cancers. Coordinating the care of cancer patients is complex and can last several months or years, with multiple consultations, rounds of treatment, and follow-up in various settings. With so many health professionals, services, and settings involved, the care of these patients can become fragmented and uncoordinated. This interface between primary and specialty care offers a valuable opportunity to appreciate the challenges of delivering well-coordinated cancer care. Consequently, this paper explores healthcare professionals’ perspectives on coordinating lung cancer care within and between healthcare services. Methods This study was conducted through virtual, telephonic, and face-to-face in-depth interviews with 26 purposively selected participants from primary to tertiary health professionals, using a semi-structured tool and drawing from grounded theory design. Data generation and analysis were conducted iteratively, followed by systematic thematic analysis to organise data, review, and interpret the findings. Findings The overall public health system challenges reported by participants involved service fragmentation, staff shortages, and communication problems. Drivers of lack of care coordination varied widely across healthcare professionals, with interoperability and communication challenges standing out as the most prominent themes. Consequently, better communication, interoperability, and improved care transitions between providers and health systems were proposed. This study provides pertinent information for policymakers and healthcare professionals to develop appropriate strategies for improving cancer care coordination interventions. Conclusions A fundamental change is required to shift the direction of the KwaZulu-Natal public health system towards responsive, patient-centred, comprehensive, and coordinated care. Enabling the primary healthcare level to play a substantial role in care coordination may provide a plausible intervention to circumvent healthcare complexities.

Self-Advocacy and Care Transition Readiness Among Adolescents With Chronic and End-Stage Kidney Diseases

Self-Advocacy and Care Transition Readiness Among Adolescents With Chronic and End-Stage Kidney Diseases

Transition of care from pediatric to adult nephrology post-renal transplant: a review.

Pediatric renal transplant recipients (RTRs) face heightened risks when they transition from a childhood nephrologist to an adult-centered one. The transition of care usually occurs when an individual is between ages 18 and 21 years, although some change providers earlier or later depending on varying circumstances. Turbulence during this shift can significantly impact daily life and, in severe cases, lead to graft loss. Several modern studies have explored the transition from pediatric to adult-centered nephrology care post-renal transplant. In this review, we first provide an overview of the differences between pediatric and adult renal transplant, highlighting unique challenges faced by pediatric patients such as donor-recipient size disparity, growth impairment, and need for additional immunizations. We then emphasize the criticality of a well-planned transition process, identifying factors that can hinder a smooth transition-such as medical and medication nonadherence, lack of health literacy, patient psychosocial challenges, and systemic shortcomings in coordination between care teams. Furthermore, this review outlines existing protocols and risk assessment tools, in addition to highlighting recent advancements aimed at facilitating smoother transitions such as the RISE protocol, readiness assessment, and the use of multidisciplinary teams. Proper implementation of coordinated, evidence-based transition protocols can improve patient outcomes, promote medication and appointment adherence, and reduce graft rejection rates. Efforts from multidisciplinary teams utilizing technology, risk stratification tools, and open communication between providers and patients are key to optimizing the transition process for pediatric RTRs as they transfer to adult-centered care.

Identification of interventions to improve patient experienced quality of care in transitions between healthcare settings: a scoping review

BackgroundTransitions in healthcare settings can be a challenge for patients and they express a need for guidance and support to cope with these transitions. The aim of this scoping review was to investigate if interventions can improve patients’ experiences when transitioning between healthcare settings.MethodsThis review was conducted following the Johanna Briggs Institute’s methods and reported according to the PRISMA-ScR Checklist. Included articles were published and peer-reviewed, and reported qualitative and quantitative findings on patient experiences with interventions when transitioning between healthcare settings. The search was conducted in May 2024 in Medline Ovid, Embase Ovid, and Cinahl.ResultsTwenty-three studies were included. Factors extracted from the studies were: author(s), year of publication, country of origin, study design, theoretical methods, population description, intervention, phenomena of interest(s), and key findings. There has been an increase in published studies on the subject in the last few years, and most of the included studies originated from Western countries. Most studies were quantitative, primarily RCTs, and the theoretical methods were thus mainly statistical analysis. The study populations were found to be heterogeneous. The interventions were categorized: care coordinator, program, integrated care, online communication platform, coaching, discharge care plan, and miscellaneous interventions.ConclusionsOverall, interventions were found to improve the patient experience. Centralization of healthcare has increased the number of transitions, and patients express that the coordination of healthcare transitions can be improved. This review’s findings should be used alongside other research on interventions’ effect on factors like hospital readmissions and mortality to determine the optimal intervention to implement.

Improvements in Transitional Care Among Medicaid-Insured Patients With Serious Mental Illness.

The Thrive program is an evidenced-based care model for Medicaid-insured adults in the hospital-to-home transition. A substantial portion of Thrive participants live with serious mental illness (SMI), yet Thrive's efficacy has not been tested among these patients. To compare 30-day postdischarge outcomes between Thrive participants with and without SMI and explore Thrive's appropriateness and acceptability among participants with SMI. We conducted a sequential explanatory mixed-methods study of 252 (62 with SMI) Thrive participants discharged from an academic medical center from February 2021 to August 2023. Interviews of participants with SMI were analyzed using rapid qualitative analysis. Participants with and without SMI experienced similar rates of 30-day readmissions, emergency room visits, and postdischarge follow-up visits, with these differences being nonsignificant. Participants with SMI were highly satisfied with Thrive's care coordination and attention to social needs, yet participants suggested stronger connections to behavioral health care. Participants with and without SMI benefit equitably from Thrive.

“Into the Abyss” – Exploring Healthcare Professionals Experience of Transitions of Care from Stroke Early Supported Discharge Services in Ireland

Abstract Background Early Supported Discharge (ESD) is a key component of the stroke rehabilitation pathway. Evidence suggests that ongoing needs persist for people with stroke at the end of ESD, however little is known about the transition from ESD to other services. As such, the aim of this study was to explore healthcare professionals’ (HCPs) experiences of transitions of care from ESD services, in the Republic of Ireland. This was achieved through the following objectives: 1) Discussion of HCPs experience of transition from ESD, including ongoing needs of people with stroke and referral pathway utilisation; 2) Exploration of barriers and facilitators to ESD transition; 3) Discussion of potential solutions to barriers experienced. Methods A qualitative descriptive design was implemented using semi-structured interviews with HCPs working in ESD. Interviews took place online from November 2023 to January 2024 and were audio and video recorded and transcribed, via Microsoft Teams. Analysis of interview transcripts utilised an inductive coding approach through implementation of Braun and Clarke’s six step approach to thematic analysis. Results Nine HCPs took part in this study. A variety of ongoing needs and current referral pathways were described. Three key themes were identified: 1) “Into the Abyss”: Lack of a coordinated care pathway after ESD, 2) Role of communication and integrated information sharing in transition of care from ESD and 3) Facilitating care transition from ESD: current practices and future solutions. Conclusion This study highlights that at present, services in Ireland appear insufficient to cater to the ongoing needs of people with stroke after ESD. The roll out of community neurorehabilitation teams nationally and developing integrated communication systems are key areas for development, which warrant consideration by relevant stakeholders in order to optimise patient-centred care for this cohort.

Unexpected Journeys: Investigating Urgent and Emergency Care Trends of Patients Attending a Community Specialist Team for Older Adults

Abstract Background Transitions of care for older people via ICPOP and Urgent and Emergency Care (UEC) pathways are becoming more complex. Demand for unscheduled care for older adults with complex care needs will increase with an ageing society, requiring proactive case management and practical realisation of integrated care pathways. Methods Retrospective analysis of UEC presentations of older patients attending a community specialist team (CST) who underwent Comprehensive Geriatric Assessment (CGA) between January-July 2023. Demographics and functional status [Clinical Frailty Score (CFS), Barthel Index (BI), Lawton-Brody Score (IADL), Montreal Cognitive Assessment (MOCA)] were extracted, along with UEC presentations post-CGA until March 2024. Results 356 patients underwent CGA and 42% (n=148) had subsequent unscheduled care attendance(s). Of those with an UEC attendance 36% (n=54) lived alone. Median functional scores were: CFS 5, BI 17, IADL 3, MOCA 17. Median time to UEC presentation was 100 days since CGA. There were 283 UEC interactions in total. 39% (n=58) had >1 interaction. 73% (n=206) of interactions resulted in acute hospital admissions, 21% (n=58) were ED visits, and 6% (n=19) were Pathfinder interactions. Falls (31%) and infection (19%) were the leading causes for presentation. Of 206 admissions, 61% were admitted under medical specialties, 26% under Geriatric Medicine, and 13% under Surgery. Average hospital stay was 13 days. 65% (n=134), were discharged home, 11% (n=22) to transitional care beds, 7% (n=15) to rehabilitation, 7% (n=14) to nursing home, 3% (n=5) transferred to other hospitals, 7%(n=15) died. Conclusion Over half of patients attending a CST had an UEC presentation, reflecting the complexity of this cohort and their level of healthcare utilisation. Case management roles that complement and pull together existing elements of the older persons pathway are lacking across healthcare settings and are fundamental to successful implementation of a patient-centred age friendly health system.

Bouncing Back: Hospital Reliance On Transitional Care Beds – A Disservice To Patients? A Review Of Readmission Rates

Abstract Background The Health Service Executive (HSE) developed an Urgent and Emergency Care (UEC) Operational Plan in 2023. One UEC action was an aim to transfer “clinically appropriate” patients to alternative care settings e.g. Transitional Care Beds (TCBs) to relieve pressure caused by high occupancy rates in acute hospitals. Inclusion criteria for TCB use is ill defined and we sought to evaluate their usage. Methods Retrospective analysis of characteristics and readmission rates (RAR) of patients discharged from a tertiary hospital to TCB from Oct 1st, 2023 - Jan 1st, 2024. Results 158 patients were discharged from hospital to TCBs. 49% (n=77) were female, mean [SD] age 77.82 [10.09] years. The median length of stay (LOS) was 15 days. 50% (n=79) were discharged from surgical services, 40.5% (n=64) from medical teams, 8% (n=13) from oncology services, 7% (n=11) from geriatric medicine and 1% (n=2) from ED. 27% (n=43) had a “fall” documented as their discharge diagnosis. 32% (n=51) of patients were readmitted within 90 days, 11% (n=18) within 30 days and 4% (n=6) within 14 days. 30% (n=15) were readmitted directly from TCB. Average time between discharge and readmission was 44.7 days. Median LOS on readmission was 10 (IQR 15.5 days). 9% (n=14) had an eventual discharge to long term care (LTC) either from a subsequent admission or transitioned directly from TCB. 6% (n=10) of patients died. Conclusion Of those readmitted, one third were directly from TCBs suggesting discharge to TCB may have been premature and patient selection inappropriate subsequently resulting costly readmissions. Although interventions are needed to relieve capacity pressure in hospitals, greater emphasis needs to be placed on access for patients to designated rehabilitation programmes. We should aim to support older adults following acute hospital admissions by carrying out comprehensive geriatric assessment to maximise independence and reduce likelihood of hospital readmission or transition to LTC.

Caregivers' burden of care during emergency department care transitions among older adults: a mixed methods cohort study.

Improving care transitions for older adults can reduce emergency department (ED) revisits, and the strain placed upon caregivers. We analyzed whether caregivers felt a change in burden following a care transition, and what may be improved to reduce it. This mixed-methods observational study nested within LEARNING WISDOM included caregivers of older patients who experienced an ED care transition. Burden was collected with the brief Zarit Burden Interview (ZBI-12), and caregivers also commented on the care transition. A qualitative coding scheme of patient care transitions was created to reflect themes important to caregivers. Comments were randomly analyzed until saturation and themes were extracted from the data. We followed both the SRQR and STROBE checklists. Comments from 581 caregivers (mean age (SD) 64.5 (12.3), 68% women) caring for patients (mean age (SD) 77.2 (7.54), 48% women) were analyzed. Caregivers overwhelmingly reported dissatisfaction and unmet service expectations, particularly with home care and domestic help. Communication and follow-up from the ED emerged as an area for improvement. Caregivers who reported an increased level of burden following a patient's care transition had significantly higher ZBI scores than caregivers who self-reported stable burden levels. Caregivers with increasing, stable, and improved levels of subjective burden all reported areas for improvement in the care transition process. Themes centering on the capacity to live at home and inadequate communication were most frequently mentioned and may represent serious challenges to caregivers. Addressing these challenges could improve both caregiver burden and ED care transitions.

Caring for terminally Ill patients: the impact on oncologists

BackgroundJourneying with patients throughout their cancer trajectory and caring for them at the end of life can lead to emotional and moral distress in oncologists, negatively impacting their personal and professional identities. A better understanding of how transitions in care goals affect oncologists can shed light on the challenges faced and the support required. This study explored the impact of care transitions on oncologists’ professional identity formation (PIF).MethodsFrom September to December 2023, semi-structured interviews were conducted with oncologists in a palliative care center in Singapore. The Ring Theory of Personhood (RToP) was used as a framework to capture the effects of experiences with patients transitioning from curative to palliative care on the oncologists’ sense of self and identity. Data were analyzed using both inductive and deductive qualitative analysis.ResultsParticipants included six female and six male physicians, aged 30 to 53 years (mean 38 years), with an average of 9.75 years of experience as oncologists. The main domains identified were 1) challenges faced in transitioning patients to palliative care, 2) the impact of dealing with dying patients on oncologists, and 3) coping mechanisms.ConclusionOncologists experience self-doubt and moral distress as they manage transitions in care. The PIF of oncologists can be supported through reflection and introspection, peer support, and interventions to promote self-care — ultimately enabling them to make meaning of their experiences, renew family ties, and reaffirm their commitment to the profession.

A pilot study testing a new transition of care model from hospital to the community for Hispanic/Latino adults with diabetes to reduce emergency department visits and hospital re-admissions

BackgroundHispanic/Latino populations have the second highest prevalence of diabetes (12.5%) among ethnic minority groups in the USA. They also have higher rates of uncontrolled diabetes and diabetes-related complications. Approximately 29% of diabetes care costs are attributed to inpatient hospital care. To reduce hospital length of stay and re-admission rates for diabetes, the American Diabetes Association (ADA) recommends a “structured discharge plan tailored to the individual patient with diabetes.” However, limited research exists on the feasibility and applicability of a transition of care model specifically tailored for the Hispanic/Latino population.MethodsWe conducted a 2-year pilot study to develop a practical, patient-centered, and culturally competent transition of care (TOC) model for Hispanic/Latino adults with diabetes discharged from the hospital to the community. Feasibility outcomes included recruitment rates, questionnaire completion rates, adherence to a 30-day post-discharge phone call, and resource needs and utilization for study implementation. Participant-centered outcomes included 30-day post-discharge emergency department (ED) visits, 30-day post-discharge unplanned re-admissions, follow-up visits within 2 weeks of discharge, and patient satisfaction with the TOC model.ResultsTwelve participants were enrolled over the study period, with weekly enrollment ranging from 0 to 4 participants. Participants’ average age in years was 47 (± 11.6); the majority were male (85%), and 75% had type 2 diabetes. Recruitment involved the support of 4 bilingual staff. The estimated time to review the chart, approach participants, obtain informed consent, complete questionnaires, and provide discharge instructions was approximately 2.5 h. Of the 10 participants who completed the 30-day post-discharge phone call, none had ED visits or unplanned hospital re-admissions within 30 days post-discharge, and all had a follow-up with a medical provider within 2 weeks.ConclusionsImplementing a patient-centered and culturally competent TOC model for Hispanic/Latino adults with diabetes discharged from the hospital to the community is feasible when considering key resources for success. These include a bilingual team with dedicated and funded time, alignment with existing discharge process and integration into the Electronic Medical Record (EMR) systems.

The Transition of Care Between Emergency Department and Primary Care: An Integrative Systematic Review.

To identify the barriers and enablers of effective transitions of care between the emergency department and primary care providers. Successful patient care transitions from the emergency department to primary care providers are important because this process has implications for the quality, patient safety, and cost of patient care. Failure in follow-up consultations with primary care can result in representations to the emergency department, which can impact negative emergency department operational issues throughout the entire hospital. An integrative systematic review was reported according to PRISMA guidelines. The reviewers followed a systematic review protocol registered with PROSPERO (CRD42022316165). A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, PsycINFO, Scopus, ProQuest Nursing and Allied Health databases. Articles were assessed using a predetermined eligibility criterion. Quality assessment and a narrative synthesis were conducted. Of the 1200 articles screened, 25 studies were included. Four additional articles were identified from reference lists. The range of study designs included: four qualitative, three mixed methods and 22 quantitative studies. A total of 291,012 patients were represented. Successful care transition was enhanced by access to insurance, ease of payment methods, effective communication, prior booked primary care provider appointments and access to transportation. Many patients experienced financial toxicity, and the shortfall between fees charged and rebates provided was found to influence primary care provider follow-up compliance. Future recommendations to provide safe and effective transitions of care would be to optimise supported self-management for patients and deliver timely and clear communication with standardised discharge documentation to be shared between the emergency department and primary care providers. There is no one-size-fits-all approach to delivering safe care transitions between emergency department and primary care providers, and future research should target high-risk groups. Prospero: CRD42022316165.

OPTimising MEDicine information handover after Discharge (OPTMED-D): protocol for development of a multifaceted intervention and stepped wedge cluster randomised controlled trial

BackgroundGeneral practitioners (GP) and community pharmacists need information about hospital discharge patients’ medicines to continue their management in the community. This necessitates effective communication, collaboration, and reliable information-sharing. However, such handover is inconsistent, and whilst digital systems are in place to transfer information at transitions of care, these systems are passive and clinicians are not prompted about patients’ transitions. There are also gaps in communication between community pharmacists and GPs. These issues impact patient safety, leading to hospital readmissions and increased healthcare costs.MethodsA three-phased, multi-method study design is planned to trial a multifaceted intervention to reduce 30-day hospital readmissions. Phase 1 is the co-design of the intervention with stakeholders and end-users; phase 2 is the development of the intervention; phase 3 is a stepped wedge cluster randomised controlled trial with 20 clusters (community pharmacies). Expected intervention components will be a hospital pharmacist navigator, primary care medication management review services, and a digital solution for information sharing. Phase 3 will recruit 10 patients per pharmacy cluster/month to achieve a sample size of 2200 patients powered to detect a 5% absolute reduction in unplanned readmissions from 10% in the control group to 5% in the intervention at 30 days. The randomisation and intervention will occur at the level of the patient’s nominated community pharmacy. Primary analysis will be a comparison of 30-day medication-related hospital readmissions between intervention and control clusters using a mixed effects Poisson regression model with a random effect for cluster (pharmacy) and a fixed effect for each step to account for secular trends.Trial registrationThis trial is registered with the Australian New Zealand Clinical Trials Registry: ACTRN12624000480583p, registered 19 April 2024.