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"Transitional care"

M Colinart-Thomas, V Noël, G Roques, S Gordes-Grosjean, M Abely, C Pluchart
Sickle cell disease, a hemoglobin disorder with autosomal recessive transmission, is one of the most common genetic diseases screened in France. Thanks to early management, 95% of sickle cell patients reach adulthood and require transition from pediatric care to adult care. Through a retrospective study of records from serious sickle cell patients over 17 years old, followed in the hematology-oncology pediatric unit of Reims University Hospital Center in France, we analyzed transition conditions, compared pediatric and adult management, and proposed a plan for transition care...
March 9, 2018: Archives de Pédiatrie: Organe Officiel de la Sociéte Française de Pédiatrie
Katherine Schultz, Leanne Carroll, Kristin Mainey, Elsa Dent
BACKGROUND: Transition care programs (TCPs) are designed to optimise functional recovery and independence in older adults post-hospitalisation. These programs are under high demand, and understanding inefficiencies in patient flow are a key step towards service improvement. AIMS: To identify service improvement opportunities in an Australian community TCP service. METHODS: An in-depth retrospective study of 113 community TCP clients. RESULTS: TCP occupancy was high (94%) and client functional level improved across the program...
March 10, 2018: Aging Clinical and Experimental Research
Brendan Bowman, Sijie Zheng, Alex Yang, Brigitte Schiller, José A Morfín, Melvin Seek, Robert S Lockridge
Dialysis care in the United States continues to move toward an emphasis on continuous quality improvement and performance benchmarking. Government- and industry-sponsored programs have evolved to assess and incentivize outcomes for many components of end-stage renal disease care. One aspect that remains largely unaddressed at a systemic level is the high-risk transition period from chronic kidney disease and acute kidney injury to permanent dialysis dependence. Incident dialysis patients experience disproportionately high mortality and hospitalization rates coupled with high costs...
March 3, 2018: American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation
A Dang, S Miller, D Horvat, T Klassen-Ross, M Graveline, R Collins, R Olson
Background: Across our province, post-radiotherapy (rt) handover notes are sent to family physicians (fps) after rt. Based on previous fp feedback, we created a revised post-radiotherapy handover note with more information requested by fps. The purpose of this study was to determine whether the revised handover note improved the note as a communication aid. Methods: Potential common and rare treatment side effects, oncologist contact information, and treatment intent were added to the revised handover note...
February 2018: Current Oncology
Christina R Whitehouse, Nancy C Sharts-Hopko, Suzanne C Smeltzer, David A Horowitz
The aim of the current study was to compare outcomes for older adults with type 2 diabetes mellitus and obesity following participation in a transitional care intervention that included diabetes self-management education (DSME) and homecare. The three groups analyzed comprised an inpatient DSME plus homecare group (n = 35); an inpatient DSME only group (n = 100); and a group who received usual care (n = 45). Outcomes of interest included rehospitalization rates and hemoglobin A1C (A1C) for up to 1-year post hospital discharge...
March 1, 2018: Research in Gerontological Nursing
Xiaoling Xiang, Sheria G Robinson-Lane, Walter Rosenberg, Renae Alvarez
This qualitative study analyzed the experience of community-based organizations (CBOs) implementing and sustaining the Bridge Model of Transitional Care, a social work-based health service intervention for reducing hospital readmissions. We conducted semi-structured interviews with clinical supervisors from 13 CBOs that received Bridge Model training between 2012 and 2015. CBOs faced significant challenges implementing and sustaining transitional care programs, particularly related to building effective and sustainable partnerships with hospitals...
February 28, 2018: Journal of Gerontological Social Work
Gregory Maniatopoulos, Ann Le Couteur, Luke Vale, Allan Colver
Objectives To explore the role of integrated commissioning in improving the transition of young people with long-term conditions from child to adult services. We aimed to identify organizational and policy gaps around transition services and provide recommendations for integrated commissioning practice. Methods Semi-structured in-depth interviews were conducted with two groups of participants: (1) twenty-four stakeholders involved in the commissioning and provision of transition services for young people with long-term conditions in two regions in England; (2) five professionals with national roles in relation to planning for transition...
January 1, 2018: Journal of Health Services Research & Policy
Linda L Costa, Ha Do Byon
The purpose of this study was to evaluate the occurrence of medication discrepancies during transitional care home visits and the association with emergency department (ED) visits. Using secondary data analysis, the relationships between in-home medication discrepancies and 30- and 90-day ED utilization were examined. For every in-home medication discrepancy, the odds of being admitted to the ED within 90 days increased by 31%. This brief intervention could add a valuable component to post-hospital transition management...
April 2018: Journal of Nursing Care Quality
Michele H Talley, Shea Polancich, Jason B Williamson, Jennifer S Frank, William Curry, John F Russell, Cynthia Selleck
Diabetes is a leading cause of morbidity and mortality; prevalence of diabetes is especially high in the southeastern United States among minority populations and those from lower socioeconomic sectors without access to health care services. The purpose of this project was to evaluate the clinical and financial outcomes of a nurse-led, interprofessional collaborative practice model that provides care coordination and transitional care for uninsured patients with diabetes. Data for this study were collected and evaluated from medical records of patients seen at the Providing Access to Health Care (PATH) Clinic between August 1, 2015, through May 30, 2017...
February 13, 2018: Population Health Management
Mary Rose Naugler, Kristine DiCarlo
The purpose of this integrative review was to identify interventions that increase compliance of nurses and of parents with safe sleep recommendations for premature infants. Ten studies were included in the final sample, including three studies with a prospective descriptive design, five quality improvement initiatives with an interventional research design, one secondary analysis, and one retrospective medical chart review. Study samples included neonatal nurses and parents of premature infants in NICUs and transitional care nurseries in Massachusetts, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Texas...
February 2018: Nursing for Women's Health
Sarah B Cairo, Indrajit Majumdar, Aurora Pryor, Alan Posner, Carroll M Harmon, David H Rothstein
Obesity in pediatric patients is rising with nearly one third of children in the USA classified as overweight and up to 16-18% of the adolescent population obese with at least one comorbid condition. Consequently, bariatric procedures in this population have increased without consistent recommendations for follow-up and transition to adult providers. This review describes the known and potential long-term consequences of bariatric surgery in pediatric patients, reviews the current literature on transitions of care for adolescent patients with chronic illnesses...
February 9, 2018: Obesity Surgery
Ponrathi Athilingam, Bradlee A Jenkins, Heather Zumpano, Miguel A Labrador
BACKGROUND: Heart failure (HF) causes significant symptom burden and human suffering with considerable economic burden due to hospital readmissions. Targeted interventions to encourage and support self-management behavior is warranted. AIM: To test the proof of concept of a mobile application (HeartMapp) in improving self-care management of patients with heart failure. METHOD: An exploratory inquiry used a field study strategy with purposeful sampling and constant comparative analysis to test the proof of concept of HeartMapp using The Business Model Canvas framework...
February 2018: Applied Nursing Research: ANR
Sarah B Cairo, Alessandra Gasior, Michael D Rollins, David H Rothstein
BACKGROUND: Anorectal malformations are one of the most common congenital intestinal anomalies affecting newborns. Despite advances in neonatal care and surgical techniques, many patients with a history of anorectal malformations are affected by long-term challenges involving bowel and bladder dysfunction, sexual dysfunction, and psychosocial issues. These outcomes or challenges are additionally exacerbated by the lack of a structured transition of care from the pediatric to the adult setting...
March 2018: Diseases of the Colon and Rectum
Lori E Weeks, Marilyn Macdonald, Ruth Martin-Misener, Melissa Helwig, Andrea Bishop, Damilola F Iduye, Elaine Moody
OBJECTIVE: The objective was to identify and synthesize the best available evidence on the impact of transitional care programs on various forms of health services utilization in community-dwelling older adults. INTRODUCTION: There is growing evidence that transitional care programs can help address important challenges facing health care systems and our increasing older adult population in many countries by reducing unnecessary health service utilization. There is a need for a systematic review of the research evaluating the impact of transitional care programs on hospital and other health service usage...
February 2018: JBI Database of Systematic Reviews and Implementation Reports
Charmaine Wright, Caren Steinway, Sophia Jan
PURPOSE OF REVIEW: Transitioning adolescents and young adults with chronic conditions can be complex. Expert recommendations support a transition process that starts in early adolescence, provides continuous guidance and support and allows for care opportunities with patients and caregivers, with the patient alone and between paediatric and adult providers. As most of the guidance is focused on individual patients, providers and clinical programmes, much less is known about how health systems as a whole might support effective transitions of care...
February 5, 2018: Current Opinion in Pediatrics
Yu-Huan Chao, Tzu-I Lee, Shuh-Jen Sheu
Breast cancer significantly threatens the life of women, while the adverse effects of cancer treatment degrade quality of life and psychological well-being. The quality of transitional care following the completion of treatment significantly affects the ability of breast cancer patients to transition successfully into survivorship. This paper introduces multiple theoretical perspectives and provides an overview of the tenets of each in order to identify the positions of breast cancer survivors and to highlight the factors and strategies that influence their transitional care...
February 2018: Hu Li za Zhi the Journal of Nursing
Jeffrey Wang, Shahida Khan, Paige Wyer, Jessica Vanderwilp, Justin Reynolds, Bruce Bethancourt, Ken S Ota
BACKGROUND: Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. METHODS: We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic...
January 1, 2018: American Journal of Hospice & Palliative Care
Heather Margonary, Margaret S Hannan, Elizabeth A Schlenk
Pain treatment begins with a nurse’s assessment, which relies on effective assessment skills. Hospital settings have implemented pain assessment education, but there is limited evidence in pediatric transitional care settings. The purpose of this quality improvement (QI) initiative was to develop, implement, and evaluate an evidence-based pain education session with 20 nurses in a pediatric specialty hospital that provides transitional care. Specific aims were to assess nurses’ knowledge and attitudes of pain, and evaluate assessment skills based on nurses’ documentation...
March 2017: Pediatric Nursing
Marianne Storm, Jörn Schulz, Karina Aase
OBJECTIVE: The study objective was to assess the effects of an interorganisational educational intervention called the 'Meeting Point' on patient safety culture among staff in hospital and nursing home wards. DESIGN: The study employs a quasi-experimental, non-randomised design with a hospital and nursing home intervention group and a hospital and nursing home control group. The study uses one preintervention and two postintervention survey measurements. The intervention group participated in an educational programme 'The Meeting Point' including interorganisational staff meetings combining educational sessions with a discussion platform focusing on quality and safety in transitional care of the elderly...
January 31, 2018: BMJ Open
Insa Koné, Bettina Zimmermann, Tenzin Wangmo, Silvia Richner, Markus Weber, Bernice Elger
AIM OF THE STUDY: Switzerland introduced the SwissDRG in 2012. The goal of this reimbursement system was to promote cost containment and efficiency in hospital care. To ensure that patients with care needs are not released prematurely because of constraints under the new hospital financing system, the Swiss law on Acute and Transitional Care (ATC) was introduced one year earlier. The objective of the present study was to investigate the impact of ATC and its effects on discharge of patients with persisting care needs after hospitalisation...
January 29, 2018: Swiss Medical Weekly
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