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"Transitional care"

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https://www.readbyqxmd.com/read/28815552/connect-home-transitional-care-of-skilled-nursing-facility-patients-and-their-caregivers
#1
Mark Toles, Cathleen Colón-Emeric, Mary D Naylor, Josephine Asafu-Adjei, Laura C Hanson
BACKGROUND: Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood. OBJECTIVE: To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. DESIGN: A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers...
August 16, 2017: Journal of the American Geriatrics Society
https://www.readbyqxmd.com/read/28800938/using-hospital-use-trends-to-improve-transitional-care
#2
Joe Feinglass, Celeste A Mallama, Angela Rogers, Caroline Teter, Courtney Hurt, Christine Schaeffer
BACKGROUND: This study evaluates the Northwestern Medicine Group Transitional Care clinic (NMG-TC), which transitions patients from an urban hospital to primary care at partner community clinics. We evaluate change over the 55 month study period in emergency department, observation or inpatient use within 90 days of an initial NMG-TC visit. METHODS: Electronic health records were used to determine patient demographic, insurance and clinical characteristics, including inflation-adjusted total hospital charges in the 90 days prior and the 90 days after an initial NMG-TC visit...
August 8, 2017: Healthcare
https://www.readbyqxmd.com/read/28796810/the-association-of-post-discharge-adverse-events-with-timely-follow-up-visits-after-hospital-discharge
#3
Dennis Tsilimingras, Samiran Ghosh, Ashley Duke, Liying Zhang, Henry Carretta, Jeffrey Schnipper
OBJECTIVE: There has been little research to examine the association of post-discharge adverse events (AEs) with timely follow-up visits after hospital discharge. We aimed to examine whether having a timely follow-up outpatient visit would reduce the risk for post-discharge AEs. METHODS: This was a methods study of patients at risk for post-discharge AEs from December 2011 through October 2012. Five hundred and forty-five patients who were under the care of hospitalist physicians and were discharged home from a community hospital, spoke English, and could be contacted after discharge were evaluated...
2017: PloS One
https://www.readbyqxmd.com/read/28793893/the-role-of-hospitals-in-bridging-the-care-continuum-a-systematic-review-of-coordination-of-care-and-follow-up-for-adults-with-chronic-conditions
#4
Melissa De Regge, Kaat De Pourcq, Bert Meijboom, Jeroen Trybou, Eric Mortier, Kristof Eeckloo
BACKGROUND: Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies...
August 9, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/28761657/improving-the-transition-from-pediatric-to-adult-diabetes-care-the-pediatric-care-provider-s-perspective-in-quebec-canada
#5
Meranda Nakhla, Lorraine E Bell, Sarah Wafa, Kaberi Dasgupta
OBJECTIVES: The transition from pediatric to adult care is a high-risk period for the emerging adult with diabetes. We aimed to determine adequacy of pediatric transition care structures and explore the pediatric diabetes care provider's perceptions of transition care. RESEARCH DESIGN AND METHODS: In-depth interviews with pediatric diabetes care providers from 12 diabetes centers in Quebec were conducted. We queried alignment with Got Transition's six core elements of healthcare transition, experiences, and barriers to transition care...
2017: BMJ Open Diabetes Research & Care
https://www.readbyqxmd.com/read/28760316/developing-a-transition-care-coordination-program-for-youth-with-spina-bifida
#6
Amanda Seeley, Linda Lindeke
INTRODUCTION: This quality improvement pilot study focused on developing and facilitating readiness for transition in youth with spina bifida. The results contribute to a broader institution-wide initiative at a subspecialty pediatric organization. METHODS: The clinical roles of six nurse care coordinators were restructured to add responsibility for transition care coordination. Together, parents, youth, and nurse transition care coordinators created and implemented individualized family-centered care plans focused on improving self-management and readiness for transition to adulthood...
July 28, 2017: Journal of Pediatric Health Care
https://www.readbyqxmd.com/read/28740335/challenges-of-modern-day-transition-care-in-inflammatory-bowel-disease-from-inflammatory-bowel-disease-to-biosimilars
#7
EDITORIAL
Ali Hakizimana, Iftikhar Ahmed, Rachel Russell, Mark Wright, Nadeem A Afzal
In this article we discuss the challenges of delivering a high quality Transition care. A good understanding of the adolescent needs with good communication between Transition care physicians and the patient is essential for good continuity of care. Despite availability of several guidelines, one model doesn't fit all and any transition service development should be determined by the local need and available healthcare facilities.
July 7, 2017: World Journal of Gastroenterology: WJG
https://www.readbyqxmd.com/read/28739647/compensatory-distal-reabsorption-drives-diuretic-resistance-in-human-heart-failure
#8
Veena S Rao, Noah Planavsky, Jennifer S Hanberg, Tariq Ahmad, Meredith A Brisco-Bacik, Francis P Wilson, Daniel Jacoby, Michael Chen, W H Wilson Tang, David Z I Cherney, David H Ellison, Jeffrey M Testani
Understanding the tubular location of diuretic resistance (DR) in heart failure (HF) is critical to developing targeted treatment strategies. Rodents chronically administered loop diuretics develop DR due to compensatory distal tubular sodium reabsorption, but whether this translates to human DR is unknown. We studied consecutive patients with HF (n=128) receiving treatment with loop diuretics at the Yale Transitional Care Center. We measured the fractional excretion of lithium (FELi), the gold standard for in vivo assessment of proximal tubular and loop of Henle sodium handling, to assess sodium exit after loop diuretic administration and FENa to assess the net sodium excreted into the urine...
July 24, 2017: Journal of the American Society of Nephrology: JASN
https://www.readbyqxmd.com/read/28739535/importance-and-feasibility-of-transitional-care-for-children-with-medical-complexity-results-of-a-multi-stakeholder-delphi-process
#9
JoAnna K Leyenaar, Paul A Rizzo, Dmitry Khodyakov, Laurel K Leslie, Peter K Lindenauer, Rita Mangione-Smith
BACKGROUND: Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes following discharge, and several gaps exist regarding the quality of hospital-to-home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital-to-home transitional care interventions for CMC from the perspectives of parents and healthcare professionals. METHODS: We conducted a two-round electronic Delphi process to identify important and feasible transitional care interventions...
July 21, 2017: Academic Pediatrics
https://www.readbyqxmd.com/read/28737412/integrated-care-clinic-creating-enhanced-clinical-pathways-for-integrated-behavioral-health-care-in-a-family-medicine-residency-clinic-serving-a-low-income-minority-population
#10
Jerica M Berge, Lisa Trump, Stephanie Trudeau, Damir S Utržan, Michele Mandrich, Andrew Slattengren, Tanner Nissly, Laura Miller, Macaran Baird, Eli Coleman, Michael Wootten
INTRODUCTION: Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic's transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs)...
July 24, 2017: Families, Systems & Health: the Journal of Collaborative Family Healthcare
https://www.readbyqxmd.com/read/28733155/implementation-of-a-health-information-exchange-into-community-pharmacy-workflow
#11
Kenneth C Hohmeier, Christina A Spivey, Samantha Boldin, Tara B Moore, Marie Chisholm-Burns
OBJECTIVES: To explore the feasibility and report preliminary outcomes of the integration of a health information exchange (HIE) into community pharmacy workflow clinical service delivery. SETTING: Independent pharmacy in eastern Tennessee. PRACTICE DESCRIPTION: The pharmacy offers medication reconciliation services via HIE access, as well as other clinical pharmacy services. The average number of prescriptions filled weekly is 1900, and staffing included 3...
July 18, 2017: Journal of the American Pharmacists Association: JAPhA
https://www.readbyqxmd.com/read/28728555/medical-homelessness-and-candidacy-women-transiting-between-prison-and-community-health-care
#12
Penelope Abbott, Parker Magin, Joyce Davison, Wendy Hu
BACKGROUND: Women in contact with the prison system have high health needs. Short periods in prison and serial incarcerations are common. Examination of their experiences of health care both in prison and in the community may assist in better supporting their wellbeing and, ultimately, decrease their risk of returning to prison. METHODS: We interviewed women in prisons in Sydney, Australia, using pre-release and post-release interviews. We undertook thematic analysis of the combined interviews, considering them as continuing narratives of their healthcare experiences...
July 20, 2017: International Journal for Equity in Health
https://www.readbyqxmd.com/read/28727619/an-innovative-transitional-care-program-improves-community-health
#13
Barbara M Richardson
In this month's Magnet® Perspectives column, Barbara Richardson, MSN, RN-BC, CCRN, clinical nurse specialist at the Southwestern Vermont Medical Center, examines the ways in which a robust transitional care program improves community health, reduces readmissions and emergency department visits, and provides valuable social support for even the most complex patients. Richardson shares critical factors that impacted the program's success, including a Magnet® environment of innovation, a visionary hospital leadership team, strong community alliances, and collaborative solutions to previously intractable problems...
July 2017: Journal of Nursing Administration
https://www.readbyqxmd.com/read/28716014/the-comprehensive-post-acute-stroke-services-compass-study-design-and-methods-for-a-cluster-randomized-pragmatic-trial
#14
Pamela W Duncan, Cheryl D Bushnell, Wayne D Rosamond, Sara B Jones Berkeley, Sabina B Gesell, Ralph B D'Agostino, Walter T Ambrosius, Blair Barton-Percival, Janet Prvu Bettger, Sylvia W Coleman, Doyle M Cummings, Janet K Freburger, Jacqueline Halladay, Anna M Johnson, Anna M Kucharska-Newton, Gladys Lundy-Lamm, Barbara J Lutz, Laurie H Mettam, Amy M Pastva, Mysha E Sissine, Betsy Vetter
BACKGROUND: Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes...
July 17, 2017: BMC Neurology
https://www.readbyqxmd.com/read/28709380/the-clinical-quality-fellowship-program-developing-clinical-quality-leadership-in-the-greater-new-york-region
#15
Rohit Bhalla, Hillary S Jalon, Lorraine Ryan
The Institute of Medicine has noted that a key factor underlying patient safety problems in the United States is a paucity of quality and safety training programs for clinicians. The Greater New York Hospital Association and United Hospital Fund created the Clinical Quality Fellowship Program (CQFP) to develop quality improvement leaders in the New York region. The goals of this article are to describe the CQFP's structure and curriculum, program participants' perceived value, improvement projects, and career paths...
July 1, 2017: American Journal of Medical Quality: the Official Journal of the American College of Medical Quality
https://www.readbyqxmd.com/read/28707992/transitional-care-services-a-quality-and-safety-process-improvement-program-in-neurosurgery
#16
Faith C Robertson, Jessica L Logsdon, Hormuzdiyar H Dasenbrock, Sandra C Yan, Siobhan M Raftery, Timothy R Smith, William B Gormley
OBJECTIVE Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance...
July 14, 2017: Journal of Neurosurgery
https://www.readbyqxmd.com/read/28706095/elucidating-the-information-exchange-during-interfacility-care-transitions-insights-from-a-qualitative-study
#17
Lianne Jeffs, Marianne Saragosa, Madelyn Law, Kerry Kuluski, Sherry Espin, Jane Merkley, Chaim M Bell
OBJECTIVE: To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital. DESIGN: An exploratory qualitative study using semi-structured interviews and observation. PARTICIPANTS AND SETTING: Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care...
July 12, 2017: BMJ Open
https://www.readbyqxmd.com/read/28676290/completion-of-an-outpatient-visit-after-skilled-nursing-facility-discharge-and-readmission-risk
#18
Ernest Shen, Angelika Alem, Peter Khang, Heather L Watson, Jing Li, Huong Q Nguyen
OBJECTIVES: Examine the association between completion of an outpatient visit with a physician or advanced practice provider (PCP) within 7 days of discharge from a short skilled nursing facility (SNF) stay and 30-day readmission and determine if functional status at discharge moderates visit effectiveness. DESIGN: Retrospective cohort study. SETTING: Large integrated health care system. PARTICIPANTS: Adults 65 years and older, discharged home from a short SNF stay (n = 4073)...
July 1, 2017: Journal of the American Medical Directors Association
https://www.readbyqxmd.com/read/28674948/transitional-health-care-for-patients-with-hirschsprung-disease-and-anorectal-malformations
#19
M J Witvliet, N Petersen, E Ekkerman, C Sleeboom, E van Heurn, A F W van der Steeg
BACKGROUND: Hirschsprung disease (HD) and anorectal malformations (ARM) are congenital disorders with potentially lifelong consequences. Although follow-up is performed in most pediatric patients, transfer to adult health care is often problematic. This study assesses transitional care with the help of questionnaires in consultation with adult patients. METHODS: This study was conducted in an outpatient clinic of a pediatric surgical center in the Netherlands. All patients born and treated for ARM or HD before 1992 were invited to visit our clinic...
July 3, 2017: Techniques in Coloproctology
https://www.readbyqxmd.com/read/28674136/a-systematic-review-of-the-cost-and-cost-effectiveness-of-electronic-discharge-communications
#20
Laura K Sevick, Rosmin Esmail, Karen Tang, Diane L Lorenzetti, Paul Ronksley, Matthew James, Maria Santana, William A Ghali, Fiona Clement
BACKGROUND: The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered...
July 2, 2017: BMJ Open
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