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https://www.readbyqxmd.com/read/28727619/an-innovative-transitional-care-program-improves-community-health
#1
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
#2
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
#3
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
#4
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
#5
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
#6
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
#7
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
#8
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
https://www.readbyqxmd.com/read/28661842/innovative-care-model-to-improve-clinical-quality-and-safety-of-transitional-care-early-outcomes
#9
Brooke Roeper, Eric Beck, Daniel Castillo, J Brent Myers, Brandy Sparkman, Jonathan Cox, Scott Bourn
One in five elderly patients returns to the hospital within 30 days of leaving. These rehospitalizations are a common and costly occurrence. A program developed to address problems in post-acute transitional care seems to be effective in reducing 30-day readmission rates for some Medicare fee-for-service beneficiaries.
June 2017: Managed Care
https://www.readbyqxmd.com/read/28657408/shared-care-of-childhood-cancer-survivors-a-telemedicine-feasibility-study
#10
Aimee G Costello, Bethany D Nugent, Noelle Conover, Amanda Moore, Kathleen Dempsey, Jean M Tersak
PURPOSE: With an increasing number of childhood cancer survivors (CCSs), determining the best model of survivorship transition care is becoming a growing priority. Shared care between pediatric oncology and adult primary care is often necessary, making survivorship a time of transition, but effective standard models are lacking. We sought to provide a more integrated approach to transition using telemedicine. METHODS: Recruited primary care provider/CCS dyads were instructed to log-in to a password-protected virtual meeting room using telemedicine equipment at the time or a regularly scheduled office visit...
June 28, 2017: Journal of Adolescent and Young Adult Oncology
https://www.readbyqxmd.com/read/28649454/methods-guiding-stakeholder-engagement-in-planning-a-pragmatic-study-on-changing-stroke-systems-of-care
#11
Sabina B Gesell, Karen Potvin Klein, Jacqueline Halladay, Janet Prvu Bettger, Janet Freburger, Doyle M Cummings, Barbara J Lutz, Sylvia Coleman, Cheryl Bushnell, Wayne Rosamond, Pamela W Duncan
BACKGROUND: The Comprehensive Post-Acute Stroke Services (COMPASS) Study is one of the first large pragmatic randomized-controlled clinical trials using comparative effectiveness research methods, funded by the Patient-Centered Outcomes Research Institute. In the COMPASS Study, we compare the effectiveness of a patient-centered, transitional care intervention versus usual care for stroke patients discharged home from acute care. Outcomes include stroke patient post-discharge functional status and caregiver strain 90 days after discharge, and hospital readmissions...
April 2017: Journal of clinical and translational science
https://www.readbyqxmd.com/read/28647948/gender-creative-or-transgender-youth-and-advanced-nursing-practice
#12
Nicole Kirouac, Mabel Tan
The World Professional Association for Transgender Health (WPATH) defines gender dysphoria as "Discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)" (WPATH, 2016). Gender creative (GC) and transgender (TG) youth are at high risk for severe mental health disparities if they don't receive competent and timely gender transitioning care. Although awareness and early care of TG youth in specialty clinics is improving and increasing, there is still much effort that is required to eliminate barriers to care at many levels and thus improve outcomes...
June 2017: Pediatric Endocrinology Reviews: PER
https://www.readbyqxmd.com/read/28634181/outcomes-after-observation-stays-among-older-adult-medicare-beneficiaries-in-the-usa-retrospective-cohort-study
#13
Kumar Dharmarajan, Li Qin, Maggie Bierlein, Jennie E S Choi, Zhenqiu Lin, Nihar R Desai, Erica S Spatz, Harlan M Krumholz, Arjun K Venkatesh
Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays.Design Retrospective cohort study.Setting 4750 hospitals in the USA.Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363 037 index observation stays, 2 540 000 index emergency department treatment-and-discharge stays, and 2 667 525 index inpatient stays from 2006-11...
June 20, 2017: BMJ: British Medical Journal
https://www.readbyqxmd.com/read/28622983/the-effect-of-a-comprehensive-care-transition-model-on-cost-and-utilization-for-medically-complex-children-with-cerebral-palsy
#14
Steven W Howard, Zidong Zhang, Paula Buchanan, Eric Armbrecht, Christine Williams, Geneva Wilson, Janna Hutchinson, Lindsey Pearson, Samantha Ellsworth, Caitlin M Byler, Travis Loux, Jing Wang, Steph Bernell, Nicholas Holekamp
INTRODUCTION: Our aim was to evaluate cost and acute care utilization related to an organized approach to care coordination and transitional care after major acute care hospitalization for children with medical complexities, including cerebral palsy. METHODS: A retrospective cohort of 32 patients from Ranken Jordan Pediatric Bridge Hospital (RJPBH) who received the Care Beyond the Bedside model was compared with 151 patients receiving standard care elsewhere across Missouri...
June 13, 2017: Journal of Pediatric Health Care
https://www.readbyqxmd.com/read/28622972/a-patient-led-international-study-of-long-term-outcomes-of-esophageal-atresia-eat-1
#15
Evelyn Svoboda, JoAnne Fruithof, Anke Widenmann-Grolig, Graham Slater, Frederic Armand, Bernhard Warner, Simon Eaton, Paolo De Coppi, Edward Hannon
INTRODUCTION: Long term outcomes of esophageal atresia (OA) are poorly understood. The Federation of Esophageal Atresia and Tracheo-Esophageal Fistula support groups (EAT), a collaboration of patient support groups aimed to define patient reported long term outcomes and quality of life (QoL) in a large international cohort of OA patients. METHODS: Questionnaires were designed focusing on patient/parent reported outcomes including surgical history, current symptomatology and quality of life...
June 9, 2017: Journal of Pediatric Surgery
https://www.readbyqxmd.com/read/28618896/managing-risk-during-care-transitions-when-approaching-end-of-life-a-qualitative-study-of-patients-and-health-care-professionals-decision-making
#16
Maureen A Coombs, Roses Parker, Kay de Vries
BACKGROUND: Increasing importance is being placed on the coordination of services at the end of life. AIM: To describe decision-making processes that influence transitions in care when approaching the end of life. DESIGN: Qualitative study using field observations and longitudinal semi-structured interviews. SETTING/PARTICIPANTS: Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand...
July 2017: Palliative Medicine
https://www.readbyqxmd.com/read/28606904/transition-structures-and-timing-of-transfer-from-paediatric-to-adult-based-care-after-kidney-transplantation-in-germany-a-qualitative-study
#17
Jenny Prüfe, Marie-Luise Dierks, Dirk Bethe, Martina Oldhafer, Silvia Müther, Julia Thumfart, Markus Feldkötter, Anja Büscher, Katja Sauerstein, Matthias Hansen, Martin Pohl, Jens Drube, Florian Thiel, Susanne Rieger, Ulrike John, Christina Taylan, Katalin Dittrich, Sabine Hollenbach, Günter Klaus, Henry Fehrenbach, Birgitta Kranz, Carmen Montoya, Bärbel Lange-Sperandio, Bettina Ruckenbrod, Heiko Billing, Hagen Staude, Reinhard Brunkhorst, Krisztina Rusai, Lars Pape, Martin Kreuzer
OBJECTIVES: It is known that transition, as a shift of care, marks a vulnerable phase in the adolescents' lives with an increased risk for non-adherence and allograft failure. Still, the transition process of adolescents and young adults living with a kidney transplant in Germany is not well defined. The present research aims to assess transition-relevant structures for this group of young people. Special attention is paid to the timing of the process. SETTING: In an observational study, we visited 21 departments of paediatric nephrology in Germany...
June 12, 2017: BMJ Open
https://www.readbyqxmd.com/read/28601691/effects-of-a-nurse-led-transitional-care-program-on-clinical-outcomes-health-related-knowledge-physical-and-mental-health-status-among-chinese-patients-with-coronary-artery-disease-a-randomized-controlled-trial
#18
Pan Zhang, Yu-Ding Hu, Feng-Mei Xing, Chang-Zai Li, Wang-Feng Lan, Xiao-Li Zhang
BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality among adults worldwide, including China. After a hospital stay, transitional care could help to ensure improved patient care and outcomes, and reduce Medicare costs. Nevertheless, the results of the existing transitional care are not always satisfactory and our knowledge of how to perform effective transitional care for patients with coronary artery disease is limited in mainland China. OBJECTIVES: To examine the effectiveness of a nurse-led transitional care program on clinical outcomes, health-related knowledge, and physical and mental health status among Chinese patients with coronary artery disease...
April 14, 2017: International Journal of Nursing Studies
https://www.readbyqxmd.com/read/28599656/transitional-care-for-rheumatic-conditions-in-europe-current-clinical-practice-and-available-resources
#19
Daniel Clemente, Leticia Leon, Helen Foster, Loreto Carmona, Kirsten Minden
OBJECTIVE: To assess European pediatric rheumatology providers' current clinical practices and resources used in the transition from child-centered to adult-oriented care. METHODS: European pediatric rheumatologists were invited to complete a 17-item anonymized e-survey assessing current transition practices, transition policy awareness, and needs in advance of the publication of EULAR/PReS recommendations on transition. RESULTS: The response rate was 121/276 (44%), including responses from 115 centers in 22 European Union countries...
June 9, 2017: Pediatric Rheumatology Online Journal
https://www.readbyqxmd.com/read/28599139/risk-factors-associated-with-residential-aged-care-respite-and-transitional-aged-care-admission-for-older-people-following-an-injury-related-hospitalisation
#20
Rebecca Mitchell, Lara Harvey, Brian Draper, Henry Brodaty, Jacqueline Close
OBJECTIVES: To identify factors associated with admission to residential aged care (RAC), respite RAC and transitional care (TC) for older individuals following an injury hospitalisation. METHOD: A retrospective analysis was conducted of individuals aged ≥65 years who had an injury hospitalisation and who were admitted to RAC during 1 July 2008 and 30 June 2013 in New South Wales, Australia. Multinominal logistic regression was used to examine the factors associated with admissions to aged care services compared to returning to the community...
June 4, 2017: Archives of Gerontology and Geriatrics
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