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"Care transitions"

Iulia D Ursan, Jerry A Krishnan, A Simon Pickard, Elizabeth Calhoun, Robert DiDomenico, Valentin Prieto-Centurion, Jamie B Sullivan, Lauren Valentino, Mark V Williams, Min Joo
Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient-level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. We sought to understand the perspectives of patients and their caregivers about hospital to home transitions from an MSI, as well as their attitudes about patient navigators to facilitate care transitions. We conducted qualitative research using focus groups (FGs)-five disease-specific patient FGs and two caregiver FGs, including 23 patients and 10 caregivers...
2016: Journal of Health Care for the Poor and Underserved
Ying P Tabak, Xiaowu Sun, Carlos M Nunez, Vikas Gupta, Richard S Johannes
BACKGROUND: Identifying patients at high risk for readmission early during hospitalization may aid efforts in reducing readmissions. We sought to develop an early readmission risk predictive model using automated clinical data available at hospital admission. METHODS: We developed an early readmission risk model using a derivation cohort and validated the model with a validation cohort. We used a published Acute Laboratory Risk of Mortality Score as an aggregated measure of clinical severity at admission and the number of hospital discharges in the previous 90 days as a measure of disease progression...
October 14, 2016: Medical Care
Juliessa M Pavon, Sandro O Pinheiro, Gwendolen T Buhr
OBJECTIVE: We developed a Transitions of Care (TOC) curriculum to teach and measure learner competence in performing TOC tasks for older adults. DESIGN: Internal medicine interns at an academic residency program received the curriculum, which consisted of experiential learning, self-study, and small group discussion. Interns completed retrospective pre/post surveys rating their confidence in performing five TOC tasks, qualitative open-ended survey questions, and a self-reflection essay...
October 18, 2016: Gerontology & Geriatrics Education
A M Acosta, M A D S Lima, G Q Marques, P F Levandovski, L A F Weber
AIM: To translate, adapt and evaluate psychometric properties of the complete (15 items) and reduced (three items) versions of the Care Transitions Measure into Brazilian Portuguese. INTRODUCTION: The Care Transitions Measure assesses the quality of care transitions, from the perspective of patients. As accomplishing effective transitions is a challenge to healthcare systems, the instrument provides an opportunity to assess care transitions and improve quality initiatives...
October 18, 2016: International Nursing Review
Brent C Pottenger, Richard O Davis, Joanne Miller, Lisa Allen, Melinda Sawyer, Peter J Pronovost
OBJECTIVE: To determine whether Comprehensive Unit-based Safety Program (CUSP) teams could be used to enhance patient experience by improving care transitions and discharge processes in a 318-bed community hospital. METHODS: In 2015, CUSP teams produced feasible solutions by participating in a design-thinking initiative, coupled with performance improvement tools involving data analytics and peer-learning communities. Teams completed a 90-day sprint challenge, involving weekly meetings, monthly department leader meetings, and progress trackers...
October 2016: Quality Management in Health Care
Derenda Lovelace, Diane Hancock, Sabrina S Hughes, Phyllis R Wyche, Claire Jenkins, Cindy Logan
BACKGROUND: In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%...
November 2016: Professional Case Management
Dan Wood
PURPOSE OF REVIEW: There is increasing recognition of the need for life-long care in patients who have congenital urological anomalies. This study looks at the factors surrounding transition and suggests those, which may improve the success. RECENT FINDINGS: One of the most challenging phases in this care is adolescence. There are the physical and psychological changes that all adolescents go through. Patients need medical surveillance through this time in order to ensure good care and patient safety...
October 5, 2016: Current Opinion in Urology
E Chapman, A Eastman, A Gilmore-Bykovskyi, B Vogelman, A J Kind
Older adults often face poor outcomes when transitioning from hospital to home. Although physicians play a key role in overseeing transitions, there is a lack of practice-based educational programs that prepare resident physicians to manage care transitions of older adults. An educational intervention to provide residents with real-life transitional care practice was therefore developed-Resident-coordinated Transitional Care (RC-TraC). RC-TraC adapted the evidence-based Coordinated-Transitional Care (C-TraC) nurse role for residents, providing opportunities to follow patients during the peri-hospital period without additional costs to the residency program...
October 17, 2016: Gerontology & Geriatrics Education
M Amber Sajjad, Kara L Holloway, Mark A Kotowicz, Patricia M Livingston, Mustafa Khasraw, Sharon Hakkennes, Trisha L Dunning, Susan Brumby, Richard S Page, Daryl Pedler, Alasdair Sutherland, Svetha Venkatesh, Sharon L Brennan-Olsen, Lana J Williams, Julie A Pasco
Background: An increasing burden of chronic disease and associated health service delivery is expected due to the ageing Australian population. Injuries also affect health and wellbeing and have a long-term impact on health service utilisation. There is a lack of comprehensive data on disease and injury in rural and regional areas of Australia. The aim of the Ageing, Chronic Disease and Injury study is to compile data from various sources to better describe the patterns of chronic disease and injury across western Victoria...
August 19, 2016: Journal of Public Health Research
Thomas E Smith, Maria Abraham, Michael Bivona, Myles J Brakman, Isaac S Brown, Gita Enders, Sara Goodman, Liam McNabb, Joseph W Swinford
Objective: The study aimed to clarify the potential role and impact of behavioral health peer support providers on community hospital acute inpatient psychiatric units. Method: Qualitative interviews were conducted to examine perspectives of peer support providers (peers) and individuals who initially received peer services (recipients) during an inpatient stay on a community hospital psychiatric unit. Interviews elicited perspectives on interactions between peers and recipients, the role of peers vis-à-vis the clinical treatment team, and involvement of peers in discharge planning and transitions to community-based care...
October 13, 2016: Psychiatric Rehabilitation Journal
Carolyn Wong, David B Hogan
BACKGROUND: A common scenario that may pose challenges to primary care providers is when an older patient has been discharged from hospital. The aim of this pilot project is to examine the experiences of patients' admission to hospital through to discharge back home, using analysis of patient narratives to inform the strengths and weaknesses of the process. METHODS: For this qualitative study, we interviewed eight subjects from the Sheldon M. Chumir Central Teaching Clinic (CTC)...
September 2016: Canadian Geriatrics Journal: CGJ
Satya Surbhi, Kiraat D Munshi, Paula C Bell, James E Bailey
OBJECTIVES: First, to investigate the prevalence and types of drug therapy problems and medication discrepancies among super-utilizers, and associated patient characteristics. Second, to examine the outcomes of pharmacist recommendations and estimated cost avoidance through care transitions support focused on medication management. DESIGN: Retrospective analysis of the pharmacist-led interventions as part of the SafeMed Program. SETTING: A large nonprofit health care system serving the major medically underserved areas in Memphis, Tennessee...
October 6, 2016: Journal of the American Pharmacists Association: JAPhA
Parag Goyal, Madeline R Sterling, Ashley N Beecy, John T Ruffino, Sonal S Mehta, Erica C Jones, Mark S Lachs, Evelyn M Horn
OBJECTIVES: Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge. PATIENTS AND METHODS: This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014...
2016: Clinical Interventions in Aging
Ann Malley, Gary J Young
AIMS: To explore the issues and challenges of care transitions in the preoperative environment. BACKGROUND: Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there. DESIGN: Qualitative descriptive design was used. METHODS: Semi-structured interviews were conducted in a 975 bed academic medical center...
October 5, 2016: Journal of Clinical Nursing
David McNeil, Roger Strasser, Nancy Lightfoot, Raymond Pong
The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a community-based rapid response nurse...
2016: Healthcare Quarterly
Rachel J Le, Michael W Cullen, Brian D Lahr, R Scott Wright, Stephen L Kopecky
BACKGROUND: Patients hospitalized for first acute coronary syndrome (ACS) are frequently discharged on multiple new medications. The short-term tolerability of these medications is unknown. METHODS: This single-center cohort study assessed 30-day health-care utilization and how it may be impacted by medication prescribing trends. We included Olmsted County patients presenting with ACS and previously undiagnosed coronary artery disease in 2008 to 2009. All health-care contacts were reviewed 30 days after index hospital discharge for potential adverse medication effects including documented hypotension or bradycardia, or symptoms likely attributed to the medications...
October 2, 2016: Journal of Cardiovascular Pharmacology and Therapeutics
Gregory M Garrison, Paul M Robelia, Jennifer L Pecina, Nancy L Dawson
RATIONALE, AIMS AND OBJECTIVES: Hospital readmission within 30 days of discharge occurs in almost 20% of US Medicare patients and may be a marker of poor quality inpatient care, ineffective hospital to home transitions, or disease severity. Within a patient centered medical home, care transition interventions may only be practical from cost and staffing perspectives if targeted at patients with the greatest risk of readmission. Various scoring algorithms attempt to predict patients at risk for 30-day readmission, but head-to-head comparison of performance is lacking...
October 3, 2016: Journal of Evaluation in Clinical Practice
Jeanne M Little, Janice A Odiaga, Carla Z Minutti
For adolescents with diabetes, ineffective health care transition to adult health services may result in suboptimal adherence to medical supervision, leading to poor glycemic control, increased diabetes complications, and hospitalization. Despite national recommendations, few youth receive the needed preparation to transition to adult health services. A data transition registry was created at a large Midwest urban academic medical center to identify patients 14 years and older with Type 1 diabetes. Thirty-nine patients with Type 1 diabetes were identified, and 33 were eligible to begin transition planning...
September 29, 2016: Journal of Pediatric Health Care
Mariela Acuña Mora, Philip Moons, Carina Sparud-Lundin, Ewa-Lena Bratt, Eva Goossens
BACKGROUND: Life-long specialized care is of the utmost importance to safeguard longevity as well as the quality of life in children diagnosed with a chronic condition (CC). Provision of life-long care, however, infers transfers to different settings in line with person's development status. Young people with CC (10-25 years) will transfer care from a pediatric towards an adult-oriented care setting. As a transfer of care is associated with a change of care context, healthcare team, responsibilities, expectations, and roles, patients need to be prepared for this alteration...
September 29, 2016: Systematic Reviews
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October 2016: Nursing Management
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