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"Care transitions"

Katerina Petrov, Ranjani Varadarajan, Martha Healy, Elmira Darvish, Cathleen Cowden
Background: Because of the frequency of medication errors related to care transitions, patient-safety initiatives have recently focused on improving the patient medication list. Pharmacy student and technician participation in the medication-history process has been shown to improve the quality of medication histories. To improve patient care, a pharmacy-driven medication-history service utilizing a unique hybrid team of pharmacy students and technicians was launched at Inova Loudoun Hospital (ILH)...
November 2018: P & T: a Peer-reviewed Journal for Formulary Management
Shelly R Welch, Ann K Carruth, Ralph Wood, Bobijo Bode, Amy Babineaux-Jones, Cortney Mitchell, Gina Burdett, Brandy Davis, Charles Ducombs
To avoid penalty through the Hospital Readmission Reduction Program, an academic practice partnership, Health Transitions Alliance, was formed with the local university, resulting in adoption of an innovative transitional care model. Key to the model was a health coach who operationalized transition care to the home setting. Health coaches, interns in their last semester of college, used motivational interviewing to help patients set disease management goals. As a result of this model, the readmission rate for program participants in the initial 7 months was reduced by 72%...
November 7, 2018: Journal of Nursing Administration
Hawa O Abu, Milena D Anatchkova, Nathaniel A Erskine, Joanne Lewis, David D McManus, Catarina I Kiefe, Heena P Santry
BACKGROUND: Healthcare providers play a critical role in the care transitions. Therefore, efforts to improve this process should be informed by their perspectives. AIM: The study objective was to explore the factors that negatively/positively influence care transitions following an unplanned hospitalization from the perspective of healthcare providers. METHODS: A qualitative study using semi-structured interviews conducted between February and September of 2016 at a single academic medical center...
December 2018: Applied Nursing Research: ANR
Patrick M Zueger, Holly M Holmes, Dima M Qato, A Simon Pickard, Gregory S Calip, Todd A Lee
BACKGROUND: Limited benefit medications (LBMs), those medications with questionable benefit at the end of life, are often recommended for discontinuation in hospice patients. Transitions in care are associated with inappropriate prescribing in older and terminally ill populations. OBJECTIVES: To evaluate the association between burdensome health care transitions and subsequent receipt of LBMs in older hospice patients. METHODS: We conducted a matched cohort analysis of patients admitted to hospice between 2008 and 2013 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database...
October 22, 2018: Medical Care
Corbin Pagano, Ana Cios, Stefan David
Cutaneous angiosarcoma (CA) is a rare form of cancer with limited treatment options and has a very severe prognosis. In this case report, a differential diagnosis, ranging from infection and neoplasia to autoimmune disease, was attributed to recurrent cellulitis centered on a purple lesion. The continuous pursuit of a diagnosis and treatment plan had to be tailored in accordance with patient goals of care. Careful anticipation of disease progression and complications was required following the diagnosis of CA and involved careful transition from palliation to hospice care...
2018: Journal of Community Hospital Internal Medicine Perspectives
Patience H White, W Carl Cooley
Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home," are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults...
November 2018: Pediatrics
Karen Pellegrin, Alicia Lozano, Jill Miyamura, Joanne Lynn, Les Krenk, Sheena Jolson-Oakes, Anita Ciarleglio, Terry McInnis, Alistair Bairos, Lara Gomez, Mercedes Benitez-McCrary, Alexandra Hanlon
BACKGROUND: We previously reported reduction in the rate of hospitalisations with medication harm among older adults with our 'Pharm2Pharm' intervention, a pharmacist-led care transition and care coordination model focused on best practices in medication management. The objectives of the current study are to determine the extent to which medication harm among older inpatients is 'community acquired' versus 'hospital acquired' and to assess the effectiveness of the Pharm2Pharm model with each type...
October 18, 2018: BMJ Quality & Safety
Monica Mazzucato, Laura Visonà Dalla Pozza, Cinzia Minichiello, Silvia Manea, Sara Barbieri, Ema Toto, Andrea Vianello, Paola Facchin
Background : Despite the fact that a considerable number of patients diagnosed with childhood-onset rare diseases (RD) survive into adulthood, limited information is available on the epidemiology of this phenomenon, which has a considerable impact both on patients' care and on the health services. This study describes the epidemiology of transition in a population of RD patients, using data from the Veneto Region Rare Diseases Registry (VRRDR), a web-based registry monitoring since 2002 a consistent number of RD in a defined area (4...
October 10, 2018: International Journal of Environmental Research and Public Health
Gabriella Caleres, Åsa Bondesson, Patrik Midlöv, Sara Modig
BACKGROUND: Discharge summary with medication report effectively counteracts drug-related problems among elderly patients due to insufficient information transfer in care transitions. However, this requires optimal transfer and use of the discharge summaries. This study aimed to examine information transfer with discharge summaries from hospital to primary care. METHODS: A descriptive study with data consisting of discharge summaries of 115 patients, 75 years or older, using five or more drugs, collected during one week from 28 different hospital wards in Skåne county, Sweden...
October 11, 2018: BMC Health Services Research
Jocelyn Carter, Anne Walton, Karen Donelan, Anne Thorndike
BACKGROUND: In 2011, there were approximately 3.3 million adult 30-day all-cause hospital readmissions in the US generating $41.3 billion in hospital costs. Community health worker (CHW) care delivery is one of very few interventions demonstrated to reduce health care utilization among populations with chronic disease. While there are a number of studies demonstrating improved disease-specific outcomes with CHW interventions, studies examining the effect of CHW care delivery on 30-day readmission rates are rare...
November 2018: Contemporary Clinical Trials
Franz H Vergara, Nancy J Sullivan, Daniel J Sheridan, Jean E Davis
PURPOSE OF STUDY: Many hospitals established telephone follow-up (TFU) programs to improve care transitions and reduce hospital readmissions. However, there is a lack of knowledge on how to increase the outreach of TFU programs. This integrative review aims to answer the clinical practice question, "What is the best practice for increasing telephone follow-up reach rates post-hospital discharge?" PRIMARY PRACTICE SETTING: The primary setting evaluated in this review was hospital-based phone call programs that are conducting post-hospital discharge TFU...
November 2018: Professional Case Management
Nayoung Han, Seung Hee Han, Hyuneun Chu, Jaehyun Kim, Ki Yon Rhew, Jeong-Hyun Yoon, Nam Kyung Je, Sandy Jeong Rhie, Eunhee Ji, Euni Lee, Yon Su Kim, Jung Mi Oh
Our goal was to help prevent drug-related morbidity and mortality by developing a collaborative multidisciplinary team care (MTC) service model using a service design framework that addressed the unmet needs and perspectives of diverse stakeholders. Our service model was based on a "4D" framework that included Discover, Define, Design, and Develop phases. In the "discover" phase, we conducted desk research and field research of stakeholders to identify the unmet needs in existing patient care services...
2018: PloS One
Ivy Benjenk, Jie Chen
OBJECTIVE: Early follow-up after inpatient psychiatric hospitalization is a key part of the care transition process and has been found to reduce the risk of readmission and emergency department utilization. Our objective was to determine the extent to which hospital performance on measures of 7- and 30-day mental health follow-up after hospitalization for Medicare beneficiaries varies by hospital characteristics and hospital neighborhood socioeconomic characteristics. METHODS: We linked 2015 hospital-level follow-up rates from the Centers for Medicare and Medicaid Services' Hospital Compare website to hospital characteristics obtained from the American Hospital Association Annual Survey and characteristics of the community within a 5-mile radius of the hospital obtained from the American Community Survey...
August 25, 2018: American Journal of Geriatric Psychiatry
Stephanie Mueller, Jie Zheng, Endel John Orav, Jeffrey L Schnipper
BACKGROUND: Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied. OBJECTIVE: To evaluate the association between IHT and healthcare utilisation and clinical outcomes. DESIGN: Retrospective cohort. SETTING: CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data...
September 26, 2018: BMJ Quality & Safety
Amber K Sabbatini, Fiona Gallahue, Joshua Newson, Stephanie White, Thomas Gallagher
BACKGROUND: Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure - 3 (CTM-3) in the ED setting and its association with outcomes of care after ED discharge. METHODS: Telephone survey of a convenience sample of patients 14 days after discharge from 2 emergency departments in an academic health system. Patients responded to 3 statements using a 4-point agreement scale (Strongly Disagree, Disagree, Agree, Strongly Agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my healthcare needs would be" 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health, and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications...
September 26, 2018: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
Amy K Rosen, Todd H Wagner, Warren B P Pettey, Michael Shwartz, Qi Chen, Jeanie Lo, William J O'Brien, Megan E Vanneman
OBJECTIVE: To assess differences in risk (measured by expected costs associated with sociodemographic and clinical profiles) between Veterans receiving outpatient services through two community care (CC) programs: the Fee program ("Fee") and the Veterans Choice Program ("Choice"). DATA SOURCES/STUDY SETTING: Administrative data from VHA's Corporate Data Warehouse in fiscal years (FY) 2014-2015. STUDY DESIGN: We compared the clinical characteristics of Veterans across three groups (Fee only, Choice only, and Fee & Choice)...
September 24, 2018: Health Services Research
Chantal Backman, Anne Harley, Liam Peyton, Craig Kuziemsky, Jay Mercer, Mary Anne Monahan, Sandra Schmidt, Harvinder Singh, Deborah Gravelle
BACKGROUND: As the population ages, the need for appropriate geriatric rehabilitation services will also increase. Pressures faced by hospitals to reduce length of stay and reduce costs have driven the need for more complex care being delivered in the home or community setting. As a result, a multifaceted approach that can provide geriatric rehabilitation patients with safe and effective person- and family-centered care during transitions from hospital to home is required. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to safely manage their personalized needs during care transitions from hospital to home...
September 24, 2018: JMIR Research Protocols
Sangchoon Jeon, Dena Schulman-Green, Ruth McCorkle, Jane K Dixon
BACKGROUND: We created the Measurement of Transitions in Cancer Scale to assess patients' perceptions of the extent of change they experience with cancer-related transitions, and how well they feel they are managing these transitions. For some transitions, we found that the more change that was reported, the worse management was reported; however, the benchmark by which patients assess how well they have managed may vary with the extent of change. OBJECTIVES: To identify approaches to combine reports of extent and management of change...
September 20, 2018: Nursing Research
R Voumard, E Rubli Truchard, L Benaroyo, G D Borasio, C Büla, R J Jox
In aging societies, the last phase of people's lives changes profoundly, challenging traditional care provision in geriatric medicine and palliative care. Both specialties have to collaborate closely and geriatric palliative care (GPC) should be conceptualized as an interdisciplinary field of care and research based on the synergies of the two and an ethics of care.Major challenges characterizing the emerging field of GPC concern (1) the development of methodologically creative and ethically sound research to promote evidence-based care and teaching; (2) the promotion of responsible care and treatment decision making in the face of multiple complicating factors related to decisional capacity, communication and behavioural problems, extended disease trajectories and complex social contexts; (3) the implementation of coordinated, continuous care despite the increasing fragmentation, sectorization and specialization in health care...
September 20, 2018: BMC Geriatrics
Ruth Baxter, Jane O'Hara, Jenni Murray, Laura Sheard, Alison Cracknell, Robbie Foy, John Wright, Rebecca Lawton
INTRODUCTION: Hospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes...
September 19, 2018: BMJ Open
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