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"Transitions of care"

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https://www.readbyqxmd.com/read/28530068/-newborn-discharge-letter-as-a-communication-document-for-continuity-of-care
#1
Jacob Urkin, Zachi Grossman, Gil Chapnick, Daniella Landau
AIMS: To check information items in newborn discharge letters from various delivery rooms and compare them to the expectations of community pediatricians. BACKGROUND: The newborn discharge letter is the document that supports the transition of care from the hospital stay to life at home and in the community. It usually summarizes medical information related to the baby's family, maternal pregnancies, delivery and the stay in hospital until discharge. It is primarily a communication tool between healthcare professionals...
November 2016: Harefuah
https://www.readbyqxmd.com/read/28530039/transition-from-paediatric-to-adult-care-of-adolescents-living-with-hiv-in-sub-saharan-africa-challenges-youth-friendly-models-and-outcomes
#2
Désiré Lucien Dahourou, Chloé Gautier-Lafaye, Chloe A Teasdale, Lorna Renner, Marcel Yotebieng, Sophie Desmonde, Samuel Ayaya, Mary-Ann Davies, Valériane Leroy
INTRODUCTION: The number of adolescents with perinatally or behaviourally acquired HIV is increasing in low-income countries, and especially in sub-Saharan Africa where HIV prevalence and incidence are the highest. As they survive into adulthood in the era of antiretroviral therapy, there is a pressing need to transfer them from paediatric to adult care, known as the transition of care. We conducted a narrative review of recent evidence on their transition outcomes in Africa, highlighting the specific needs and challenges in these populations and settings, and the different models of care for transition...
May 16, 2017: Journal of the International AIDS Society
https://www.readbyqxmd.com/read/28506976/implementation-of-postdischarge-follow-up-telephone-calls-at-a-comprehensive-cancer-center
#3
Shrina D Patel, Phuoc Anh Anne Nguyen, Melissa Bachler, Bradley Atkinson
PURPOSE: The development and implementation of a pharmacy-driven, postdischarge follow-up telephone call program to assess medication adherence, provide education, and address medication-related concerns are discussed. SUMMARY: Many readmissions are avoidable through effective discharge planning and patient follow-up after hospitalization. However, there is limited information on how to effectuate this process. To address this barrier, a team consisting of a clinical pharmacy specialist, a clinical pharmacy manager, a postgraduate year 1 pharmacy resident, and an education specialist at The University of Texas MD Anderson Cancer Center collaborated to create a postdischarge telephone call program within a transitions-of-care (TOC) pilot program...
June 1, 2017: American Journal of Health-system Pharmacy: AJHP
https://www.readbyqxmd.com/read/28497759/long-term-challenges-and-perspectives-of-pre-adolescent-liver-disease
#4
REVIEW
Nedim Hadžić, Ulrich Baumann, Pat McKiernan, Valerie McLin, Valerio Nobili
Chronic liver disease is a growing problem that has substantial effects on public health. Many paediatric liver conditions are precursors of adult chronic liver disease, cirrhosis, and hepatocellular carcinoma. Clinical management of Wilson's disease, autoimmune liver disease, and chronic biliary disorders, such as biliary atresia, which remains the most common paediatric chronic liver disease and indication for liver transplantation, is similar in children and adults. In the past 10 or so years, paediatric hepatology has expanded into neighbouring clinical areas, such as metabolic liver diseases and systemic conditions with liver involvement...
June 2017: Lancet. Gastroenterology & Hepatology
https://www.readbyqxmd.com/read/28491911/navigating-long-term-care
#5
James D Holt
Americans over age 65 constitute a larger percentage of the population each year: from 14% in 2010 (40 million elderly) to possibly 20% in 2030 (70 million elderly). In 2015, an estimated 66 million people provided care to the ill, disabled, and elderly in the United States. In 2000, according to the Centers for Disease Control and Prevention (CDC), 15 million Americans used some form of long-term care: adult day care, home health, nursing home, or hospice. In all, 13% of people over 85 years old, compared with 1% of those ages 65 to 74, live in nursing homes in the United States...
January 2017: Gerontology & Geriatric Medicine
https://www.readbyqxmd.com/read/28489226/transition-of-care-for-youth-with-hiv
#6
Mary Ellen Acree
Remarkable advances have been made in the treatment of HIV. Despite progress in reducing perinatal HIV transmission, there is a growing number of adolescents and emerging adults with HIV who will require transfer of care from pediatric to adult providers. Adolescents with HIV have poorer retention in care and viral suppression compared to other age groups with HIV. Barriers to successful care of youth with HIV include mental health disorders, poor medication adherence, socioeconomic instability, and HIV-related stigma...
May 1, 2017: Pediatric Annals
https://www.readbyqxmd.com/read/28489224/current-concepts-of-transition-of-care-in-cystic-fibrosis
#7
Ajanta Patel, Maria Dowell, B Louise Giles
Over the past 6 decades, advances in cystic fibrosis (CF) diagnosis and management have extended the life expectancy of patients far beyond childhood; therefore, all pediatric CF patients must prepare for transition to adult care. Readiness assessment, knowledge and skill education, and support structures are all elements of ideal transition. Transition should begin early in life with teaching skills and knowledge for disease care, and in adolescence the readiness to transition should be addressed. Transition is a gradual process of increasing responsibilities in self-care and disease management, an improvement in the understanding of CF, and an iterative process of self-assessment with knowledge acquisition...
May 1, 2017: Pediatric Annals
https://www.readbyqxmd.com/read/28477319/transition-of-care-in-congenital-heart-disease-ensuring-the-proper-handoff
#8
REVIEW
Angela Lee, Barbara Bailey, Geraldine Cullen-Dean, Sandra Aiello, Joanne Morin, Erwin Oechslin
BACKGROUND: With great advances in medical and surgical care, most congenital heart disease patients are living in to adulthood and require lifelong surveillance and expert care for adult onset complications. Care lapse and lack of successful transfer from pediatric to adult care put young adults at risk for increased morbidity and premature death. Hence, transition and transfer from pediatric to adult care is a crucial and critical process to provide access to specialized care and lifelong surveillance...
June 2017: Current Cardiology Reports
https://www.readbyqxmd.com/read/28470134/standardized-icu-to-or-handoff-increases-communication-without-delaying-surgery
#9
Thomas J Caruso, Juan Luis Sandin Marquez, Melanie S Gipp, Stephen P Kelleher, Paul J Sharek
Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format...
May 8, 2017: International Journal of Health Care Quality Assurance
https://www.readbyqxmd.com/read/28469903/transitional-care-management-in-the-outpatient-setting
#10
Analiza Baldonado, Ofelia Hawk, Thomas Ormiston, Danielle Nelson
Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum...
2017: BMJ Quality Improvement Reports
https://www.readbyqxmd.com/read/28468724/in-search-of-a-resident-centered-handoff-tool-discovering-the-complexity-of-transitions-of-care
#11
Meredith Barrett, David Turer, Hadley Stoll, David T Hughes, Gurjit Sandhu
INTRODUCTION: Transfer of a patient's care between providers is a significant potential for medical errors. Given the potential for patient safety breeches we sought to investigate residents' perceptions of handoffs at our institution. METHODS: Residents completed an online survey assessing the effectiveness of handoffs and what they thought was necessary for safe and informative transition communication. Thematic analysis was used to identify critical themes. RESULTS: 78% of residents reported formal training in handoff delivery...
April 25, 2017: American Journal of Surgery
https://www.readbyqxmd.com/read/28455194/improving-medication-information-transfer-between-hospitals-skilled-nursing-facilities-and-long-term-care-pharmacies-for-hospital-discharge-transitions-of-care-a-targeted-needs-assessment-using-the-intervention-mapping-framework
#12
Luiza Kerstenetzky, Matthew J Birschbach, Katherine F Beach, David R Hager, Korey A Kennelty
INTRODUCTION: Patients transitioning from the hospital to a skilled nursing home (SNF) are susceptible to medication-related errors resulting from fragmented communication between facilities. Through continuous process improvement efforts at the hospital, a targeted needs assessment was performed to understand the extent of medication-related issues when patients transition from the hospital into a SNF, and the gaps between the hospital's discharge process, and the needs of the SNF and long-term care (LTC) pharmacy...
April 7, 2017: Research in Social & Administrative Pharmacy: RSAP
https://www.readbyqxmd.com/read/28448780/integration-strategies-of-pharmacists-in-primary-care-based-accountable-care-organizations-a-report-from-the-accountable-care-organization-research-network-services-and-education
#13
Tina Joseph, Genevieve M Hale, Sara M Eltaki, Yesenia Prados, Renee Jones, Matthew J Seamon, Cynthia Moreau, Stephanie A Gernant
BACKGROUND: The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. PROGRAM DESCRIPTION: As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care...
May 2017: Journal of Managed Care & Specialty Pharmacy
https://www.readbyqxmd.com/read/28439351/residents-exposure-to-educational-experiences-in-facilitating-hospital-discharges
#14
Eric Young, Chad Stickrath, Monica McNulty, Aaron J Calderon, Elizabeth Chapman, Jed D Gonzalo, Ethan F Kuperman, Max Lopez, Christopher J Smith, Joseph R Sweigart, Cecelia N Theobald, Robert E Burke
BACKGROUND: There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. OBJECTIVE: We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. METHODS: A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility...
April 2017: Journal of Graduate Medical Education
https://www.readbyqxmd.com/read/28421638/renal-replacement-therapy-and-incremental-hemodialysis-for-veterans-with-advanced-chronic-kidney-disease
#15
Kamyar Kalantar-Zadeh, Susan T Crowley, Srinivasan Beddhu, Joline L T Chen, John T Daugirdas, David S Goldfarb, Anna Jin, Csaba P Kovesdy, David J Leehey, Hamid Moradi, Sankar D Navaneethan, Keith C Norris, Yoshitsugu Obi, Ann O'Hare, Tariq Shafi, Elani Streja, Mark L Unruh, Tushar J Vachharajani, Steven Weisbord, Connie M Rhee
Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources...
May 2017: Seminars in Dialysis
https://www.readbyqxmd.com/read/28412054/community-pharmacy-transition-of-care-services-and-rural-hospital-readmissions-a-case-study
#16
Allison P Patton, Yifei Liu, D Matthew Hartwig, Justin R May, Jessica Moon, Steven C Stoner, Kendall D Guthrie
OBJECTIVES: To explore community pharmacist involvement in the transition of care (TOC) process for patients discharged with acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), or elective total hip or knee arthroplasty (THA/TKA). SETTING: Patients discharged from a 60-bed acute care hospital located in rural Missouri were seen by a community pharmacist in 2 independent community pharmacy chain locations...
April 12, 2017: Journal of the American Pharmacists Association: JAPhA
https://www.readbyqxmd.com/read/28396033/improving-transitions-of-care-across-the-spectrum-of-healthcare-delivery-a-multidisciplinary-approach-to-understanding-variability-in-outcomes-across-hospitals-and-skilled-nursing-facilities
#17
Giana H Davidson, Elizabeth Austin, Lucas Thornblade, Louise Simpson, Thuan D Ong, Hanh Pan, David R Flum
INTRODUCTION: Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission. METHODS: Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions...
April 5, 2017: American Journal of Surgery
https://www.readbyqxmd.com/read/28385023/impact-of-a-pharmacy-based-transitional-care-program-on-hospital-readmissions
#18
Weiyi Ni, Danielle Colayco, Jonathan Hashimoto, Kevin Komoto, Chandrakala Gowda, Bruce Wearda, Jeffrey McCombs
OBJECTIVES: Avoidable readmissions of patients discharged from hospitals are a major concern. This study evaluates the impact of pharmacist-provided postdischarge services on hospital readmissions for members of a US managed Medicaid health plan. STUDY DESIGN: Prospective cohort study. METHODS: Synergy Pharmacy Solutions (SPS) initiated a transition of care (TOC) service for high-risk members of the Kern Health Systems (KHS) managed Medicaid plan...
March 2017: American Journal of Managed Care
https://www.readbyqxmd.com/read/28375954/optimizing-the-care-coordinator-role-in-primary-care-a-qualitative-case-study
#19
Elizabeth C Clark, Jenna Howard, Jeanne Ferrante, Cathryn Heath, Kang Li, Susan Albin, Shawna V Hudson
BACKGROUND: Care coordinators (CCs) are increasingly employed in primary care as a means to improve health care quality, but little research examines the process by which CCs are integrated into practices. This case study provides an in-depth examination of this process and efforts to optimize the role. METHODS: Two CCs' work was observed and assessed, and attempts were made to optimize the role using workflow modeling and "Plan-Do-Study-Act" cycles. Rolling qualitative analyses of field notes from key informant interviews and team meetings were conducted using iterative cycles of "immersion/crystallization" to identify emerging themes...
April 2017: Quality Management in Health Care
https://www.readbyqxmd.com/read/28364994/can-managed-care-manage-polypharmacy
#20
REVIEW
Richard G Stefanacci, Taha Khan
Polypharmacy has come to mean the inappropriate use of multiple medications. Polypharmacy can occur as a result of a range of situations, including the excessive application of clinical guidelines, lack of coordination among multiple prescribers, treating adverse drug events, misaligned medications across transitions of care, patient self-treatment, and inappropriate overtreatment. Polypharmacy is a problem because the benefits of a specific medication at the dose and frequency that an individual patient is taking are often outweighed by the costs...
May 2017: Clinics in Geriatric Medicine
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