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"Care transitions"

Ryan J Coller, Thomas S Klitzner, Carlos F Lerner, Bergen B Nelson, Lindsey R Thompson, Qianqian Zhao, Adrianna A Saenz, Siem Ia, Jessica Flores-Vazquez, Paul J Chung
OBJECTIVES: We sought to examine the effect of a caregiver coaching intervention, Plans for Action and Care Transitions (PACT), on hospital use among children with medical complexity (CMC) within a complex care medical home at an urban tertiary medical center. METHODS: PACT was an 18-month caregiver coaching intervention designed to influence key drivers of hospitalizations: (1) recognizing critical symptoms and conducting crisis plans and (2) supporting comprehensive hospital transitions...
July 11, 2018: Pediatrics
Robin L Black, Courtney Duval
BACKGROUND: Diabetes is a growing problem in the United States. Increasing hospital admissions for diabetes patients demonstrate the need for evidence based care of diabetes patients by inpatient providers, as well as the importance of continuity of care when transitioning patients from inpatient to outpatient providers. METHOD: A focused literature review of discharge planning and transitions of care in diabetes, conducted in PubMed is presented. Studies were selected for inclusion based on content focusing on transitions of care in diabetes, risk factors for readmission, impact of inpatient diabetes education on patient outcomes, and optimal medication management of diabetes during care transitions...
July 11, 2018: Current Diabetes Reviews
John Sather, Craig Rothenberg, Emily B Finn, Kevin N Sheth, Charles Matouk, Laura Pham, Vivek Parwani, Andrew Ulrich, Arjun K Venkatesh
Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate...
July 1, 2018: American Journal of Medical Quality: the Official Journal of the American College of Medical Quality
N C Oguego, O Okoye, A Aghaji, F C Maduka-Okafor, O I Okoye, I R Ezegwui
Background: Discharge summaries are important components of hospital-care transitions in ensuring continuity of care. Aim: We assessed the adequacy and accuracy of discharge summaries written by junior doctors. Methods: An instrument, adapted largely from the current hospital discharge summary template and recommendations regarding content from the Joint Commission International, was used to study 420 discharge summaries written in 2012 from the ophthalmology service of a Rural Teaching Hospital in Nigeria...
July 2018: Nigerian Journal of Clinical Practice
Anne Black, Tamsin McGlinchey, Maureen Gambles, John Ellershaw, Catriona Rachel Mayland
BACKGROUND: There is limited understanding of the 'lived experience' of palliative care patient within the acute care setting. Failing to engage with and understand the views of patients and those close to them, has fundamental consequences for future health delivery. Understanding 'patient experience' can enable care providers to ensure services are responsive and adaptive to individual patient need. METHODS: The aim of this study was to explore the 'lived experience' of a group of patients with palliative care needs who had recently been in-patients in one acute hospital trust in the north-west of England...
July 6, 2018: BMC Palliative Care
Margory A Molloy, Michael P Cary, Jill Brennan-Cook, Danett S Cantey, Christine Tocchi, Donald E Bailey, Marilyn H Oermann
Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients' cognitive decline as well as learn how to communicate with patients, family members, and the healthcare team...
July 2018: Home Healthcare Now
Gregory Kennedy, Valerie A Lewis, Souma Kundu, Julien Mousqués, Carrie H Colla
Due to high magnitude and variation in spending on, accountable care organizations (ACOs) are focusing on transforming management of hospital discharge through relationships with preferred skilled nursing facilities (SNFs). Using a mixed-methods design, we examined survey data from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs who performed well on cost and quality measures. Survey data revealed that over half of ACOs had no formal relationship with SNFs; however, the majority of ACO interviewees had formed preferred SNF networks...
July 1, 2018: Medical Care Research and Review: MCRR
Sean Marks, Alexis Williams, Wendy Peltier, Ann Helms, Chad Carlson
Status epilepticus is a common and under-recognized cause of unconsciousness among hospitalized patients. It can clinically mimic delirium and other causes of acute mental status change, especially when clinically relevant seizure activity is not appreciated on physical examination. While the successful treatment of status epilepticus may require anesthetic dosing of antiepileptics such as barbiturates, these seemingly drastic therapeutic measures are justified when goals of care are life prolonging as they may allow a patient to regain consciousness and meaningfully interact with loved ones...
June 29, 2018: Journal of Palliative Medicine
Joan M Teno, Pedro Gozalo, Amal N Trivedi, Jennifer Bunker, Julie Lima, Jessica Ogarek, Vincent Mor
Importance: End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care. Objective: To describe changes in site of death and patterns of care among Medicare decedents. Design, Setting, and Participants: Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home...
June 25, 2018: JAMA: the Journal of the American Medical Association
Rozalina G McCoy, Stephanie M Peterson, Lynn S Borkenhagen, Paul Y Takahashi, Bjorg Thorsteinsdottir, Anupam Chandra, James M Naessens
BACKGROUND: Care transitions programs have been shown to reduce hospital readmissions. OBJECTIVES: The main objective of this study was to evaluate effects of the Mayo Clinic Care Transitions (MCCTs) Program on potentially preventable and nonpreventable 30-day unplanned readmissions among high-risk elders. RESEARCH DESIGN: This was a retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care...
June 22, 2018: Medical Care
Sarah L Martin, Nancy Connelly, Cassandra Parsons, Katlyn Blackstone
Western medicine is undergoing a transition toward transparency of quality and costs, and healthcare systems are striving to achieve the Triple Aim, a framework for improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare. Meanwhile, there is growing recognition of the impact of social determinants of health and a new federal requirement for nonprofit hospitals to implement prevention strategies. A specialized meal delivery program called Simply Delivered for ME (SDM) was formed in an effort to improve care and reduce 30-day hospital readmission rates...
June 2018: American Journal of Managed Care
Kim J Verhaegh, Patricia Jepma, Suzanne E Geerlings, Sophia E de Rooij, Bianca M Buurman
Quality problem: Unplanned hospital readmissions frequently occur and have profound implications for patients. This study explores chronically ill patients' experiences and perceptions of being discharged to home and then acutely readmitted to the hospital to identify the potential impact on future care transition interventions. Initial assessment and implementation: Twenty-three semistructured interviews were conducted with chronically ill patients who had an unplanned 30-day hospital readmission at a university teaching hospital in the Netherlands...
June 25, 2018: International Journal for Quality in Health Care
Mark E Patterson, Janice B Foust, Sandra Bollinger, Chandler Coleman, Diepngan Nguyen
BACKGROUND: Medication discrepancies occurring during transitions of care between hospitals and nursing homes increase the risk of adverse events for patients. Resolving mismatched information between hospitals and nursing homes adds additional burden to nursing home staff. OBJECTIVE: The aim of this study was to characterize challenges facing nursing home staff in receiving and resolving medication discrepancies during resident intake. METHODS: This study used one focus group comprised of five nurses, one pharmacist and two administrators from four nursing homes to explore the staffs' experiences resolving medication discrepancies at resident intake...
June 8, 2018: Research in Social & Administrative Pharmacy: RSAP
Sharon Hewner, Sabrina Casucci, Suzanne Sullivan, Francine Mistretta, Yuqing Xue, Barbara Johnson, Rebekah Pratt, Li Lin, Chester Fox
Context: Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. Case Description: The coordinating transitions intervention uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach...
July 4, 2017: EGEMS
Gina Dimitropoulos, Ashley L Landers, Victoria E Freeman, Jason Novick, Olivia Cullen, Marla Engelberg, Cathleen Steinegger, Daniel Le Grange
Background: Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment. Methods: The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN...
2018: Journal of Eating Disorders
Chantal Backman, Dawn Stacey, Michelle Crick, Danielle Cho-Young, Patricia B Marck
BACKGROUND: Older adults with multiple chronic conditions typically have more complex care needs that require multiple transitions between healthcare settings. Poor care transitions often lead to fragmentation in care, decreased quality of care, and increased adverse events. Emerging research recommends the strong need to engage patients and families to improve the quality of their care. However, there are gaps in evidence on the most effective approaches for fully engaging patients/clients and families in their transitional care...
June 20, 2018: BMC Health Services Research
Sara L Ackerman, Nathaniel Gleason
Growing demand for specialty care has resulted in longer wait times for appointments, particularly at US academic referral centers. A proportion of specialty visits are for routine follow-up care of stable problems, and there is evidence that primary care providers are willing and able to take responsibility for a significant proportion of these patients. However, little is known about how to transition care back to a referring primary care clinician in a manner that is acceptable to everyone involved. In this article, we describe social, legal, and financial barriers to effective care transition and propose communication strategies to overcome them...
June 19, 2018: Journal of Ambulatory Care Management
Stephanie K Mueller, Evan Shannon, Anuj Dalal, Jeffrey L Schnipper, Patricia Dykes
OBJECTIVES: Although existing data suggest marked variability in interhospital transfer (IHT), little is known about specific factors that may impact the quality and safety of this care transition. We aimed to explore transferred patients' and involved physicians' experience with IHT to better understand the components of the transfer continuum and identify potential targets for improvement. METHODS: We performed a qualitative study using individual interviews of adult patients recently transferred to cardiology, general medicine, and oncology services at a tertiary care academic medical center, as well as their transferring physician, accepting attending physician, and accepting/admitting resident physician...
June 12, 2018: Journal of Patient Safety
Wataru Kubota, Masataka Honda, Hirokazu Okada, Motoshi Hattori, Masayuki Iwano, Yuko Akioka, Akira Ashida, Yukihiko Kawasaki, Hideyasu Kiyomoto, Mayumi Sako, Yoshio Terada, Daishi Hirano, Mikiya Fujieda, Shouichi Fujimoto, Takao Masaki, Shuichi Ito, Osamu Uemura, Yoshimitsu Gotoh, Yasuhiro Komatsu, Shinichi Nishi, Mitsue Maru, Ichiei Narita, Shoichi Maruyama
No abstract text is available yet for this article.
August 2018: Clinical and Experimental Nephrology
Marije A van Melle, Henk F van Stel, Judith M Poldervaart, Niek J de Wit, Dorien L M Zwart
BACKGROUND: Patients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed. AIM AND METHODS: To identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection...
2018: PloS One
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