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Care transitions

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25 papers 0 to 25 followers
By Jamie Jarmul Md / PhD student at UNC - Chapel Hill, PhD in Health Policy and Management
https://www.readbyqxmd.com/read/27397857/a-conceptual-model-for-episodes-of-acute-unscheduled-care
#1
Jesse M Pines, Gaetano R Lotrecchiano, Mark S Zocchi, Danielle Lazar, Jacob B Leedekerken, Gregg S Margolis, Brendan G Carr
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care...
October 2016: Annals of Emergency Medicine
https://www.readbyqxmd.com/read/27512721/factors-associated-with-emergency-department-visits-a-multistate-analysis-of-adult-fee-for-service-medicaid-beneficiaries
#2
Parul Agarwal, Thomas K Bias, Suresh Madhavan, Nethra Sambamoorthi, Stephanie Frisbee, Usha Sambamoorthi
OBJECTIVE: The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. METHODS: A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid Analytic eXtract files. Information on county-level health-care resources was obtained from the Area Health Resource file and County Health Rankings file...
January 2016: Health Services Research and Managerial Epidemiology
https://www.readbyqxmd.com/read/27724889/roles-of-disease-severity-and-post-discharge-outpatient-visits-as-predictors-of-hospital-readmissions
#3
Hao Wang, Carol Johnson, Richard D Robinson, Vicki A Nejtek, Chet D Schrader, JoAnna Leuck, Johnbosco Umejiego, Allison Trop, Kathleen A Delaney, Nestor R Zenarosa
BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission...
October 10, 2016: BMC Health Services Research
https://www.readbyqxmd.com/read/27881054/transition-of-care-for-patients-with-diabetes
#4
Patricia Garnica
BACKGROUND: Diabetes is a common chronic condition among adults that can complicate the transition from the hospital to the community. Hospital readmission is an important contributor to total medical expenditures and is an emerging indicator of quality of care. Failure to acknowledge diabetes transition of care is associated with increased emergency department visits and 30-day readmissions. METHODS: Literature review of transition of care models, sample tools and processes are presented...
November 22, 2016: Current Diabetes Reviews
https://www.readbyqxmd.com/read/27877025/medication-knowledge-of-patients-hospitalized-for-heart-failure-at-admission-and-after-discharge
#5
Florian Custodis, Franziska Rohlehr, Angelika Wachter, Michael Böhm, Martin Schulz, Ulrich Laufs
BACKGROUND: A substantial aspect of health literacy is the knowledge of prescribed medication. In chronic heart failure, incomplete intake of prescribed drugs (medication non-adherence) is inversely associated with clinical prognosis. Therefore, we assessed medication knowledge in a cohort of patients with decompensated heart failure at hospital admission and after discharge in a prospective, cross-sectional study. METHODS: One hundred and eleven patients presenting at the emergency department with acute decompensated heart failure were included (mean age 78...
2016: Patient Preference and Adherence
https://www.readbyqxmd.com/read/27856087/hemodialysis-hospitalizations-and-readmissions-the-effects-of-payment-reform
#6
Kevin F Erickson, Wolfgang C Winkelmayer, Glenn M Chertow, Jay Bhattacharya
BACKGROUND: In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits...
November 14, 2016: American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation
https://www.readbyqxmd.com/read/27865022/exploring-the-experiences-of-patients-attending-day-hospitals-in-the-rural-scotland-capturing-the-patient-s-voice
#7
Elizabeth Adamson, Janette Pow, Fiona Houston, Pamela Redpath
AIM: The aim of the study was to understand the meaning of person-centred compassionate care for people attending Day Hospitals in rural Scotland BACKGROUND: Increasing numbers of older people are living with chronic conditions and require support to live at home. Intermediate care services such as Day Hospitals can enable this. Much previous research about Day Hospitals focused on organizational aspects of care. This study set out to capture the voice of the patient using this service...
November 16, 2016: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/23804841/enhancing-quality-of-primary-care-using-an-ambulatory-icu-to-achieve-a-patient-centered-medical-home
#8
Joy Lewis, Alex Hoyt, Rose M Kakoza
RESEARCH OBJECTIVE: The Patient-Centered Medical Home (PCMH) has been advocated as a model to address the lack of coordination and continuity in the health system. However, implementation in practice has been slow and incompletely described. STUDY DESIGN: Patients referred into the program received intensive nurse follow-up focused on medication adherence, care coordination, and education. Patients graduate from the program when treatment goals are met. POPULATION STUDIED: The first 100 patients enrolled into the PCMH focused program of a primary care clinic in an urban, academic medical center...
October 1, 2011: Journal of Primary Care & Community Health
https://www.readbyqxmd.com/read/27864915/identification-of-emergency-department-visits-in-medicare-administrative-claims-approaches-and-implications
#9
Arjun K Venkatesh, Hao Mei, Keith Kocher, Mike Granovsky, Ziad Obermeyer, Erica Spatz, Craig Rothenberg, Harlan Krumholz, Zhenqui Lin
OBJECTIVES: Administrative claims datasets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare dataset and to compare this definition to existing operational definitions used by researchers and policymakers...
November 19, 2016: Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine
https://www.readbyqxmd.com/read/27373194/improving-pancreas-surgery-over-time-performance-factors-related-to-transition-of-care-and-patient-volume
#10
Jon Arne Søreide, Oddvar M Sandvik, Kjetil Søreide
BACKGROUND: Pancreas surgery has evolved with better diagnostic imaging, changing indications, and improved patient selection. Outside high-volume tertiary centers, the documented effect of evolution in care and volumes are limited. Thus, we aimed to review indications and outcomes in pancreas surgery during the transition from community-based hospital to a university hospital. METHODS: All pancreatic surgeries performed between 1986 and 2012 within a well-defined Norwegian population were identified from the hospital's database...
August 2016: International Journal of Surgery
https://www.readbyqxmd.com/read/27355263/postoperative-30-day-readmission-time-to-focus-on-what-happens-outside-the-hospital
#11
Melanie S Morris, Laura A Graham, Joshua S Richman, Robert H Hollis, Caroline E Jones, Tyler Wahl, Kamal M F Itani, Hillary J Mull, Amy K Rosen, Laurel Copeland, Edith Burns, Gordon Telford, Jeffery Whittle, Mark Wilson, Sara J Knight, Mary T Hawn
OBJECTIVE: The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions. BACKGROUND: Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk. METHODS: National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data...
October 2016: Annals of Surgery
https://www.readbyqxmd.com/read/27106509/care-coordination-gaps-due-to-lack-of-interoperability-in-the-united-states-a-qualitative-study-and-literature-review
#12
Lipika Samal, Patricia C Dykes, Jeffrey O Greenberg, Omar Hasan, Arjun K Venkatesh, Lynn A Volk, David W Bates
BACKGROUND: Health information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States...
2016: BMC Health Services Research
https://www.readbyqxmd.com/read/27129914/treatment-considerations-and-the-role-of-the-clinical-pharmacist-throughout-transitions-of-care-for-patients-with-acute-heart-failure
#13
Elizabeth B McNeely
Heart failure is associated with increased risk of morbidity and mortality, resulting in substantial health-care costs. Clinical pharmacists have an opportunity to reduce health-care costs and improve disease management as patients transition from inpatient to outpatient care by leading interventions to develop patient care plans, educate patients and clinicians, prevent adverse drug reactions, reconcile medications, monitor drug levels, and improve medication access and adherence. Through these methods, clinical pharmacists are able to reduce rates of hospitalization, readmission, and mortality...
April 28, 2016: Journal of Pharmacy Practice
https://www.readbyqxmd.com/read/27150224/design-and-implementation-of-a-targeted-approach-for-pharmacist-mediated-medication-management-at-care-transitions
#14
Chris Ploenzke, Tessa Kemp, Todd Naidl, Rebecca Marraffa, Jennifer Bolduc
OBJECTIVES: To improve patient care through the development of a clinical risk stratification tool to identify high-risk patients and implementation of pharmacist-mediated medication management after patient care transitions. SETTING: Minneapolis Veterans Affairs (VA) Health Care System from December 1, 2014, to April 1, 2015. PRACTICE DESCRIPTION: A composite care transition score was developed based on risk factors obtained from a literature review and combined with a national stratification tool unique to the Veterans Health Administration (VHA) primary care population, the Care Assessment Need (CAN) score...
May 2016: Journal of the American Pharmacists Association: JAPhA
https://www.readbyqxmd.com/read/27156945/-pitching-pharmacists-as-improvers-of-transition-of-care-outcomes
#15
Patrick G Clay
No abstract text is available yet for this article.
May 2016: Journal of the American Pharmacists Association: JAPhA
https://www.readbyqxmd.com/read/27206289/improving-transitions-of-care-with-an-advanced-practice-nurse-a-pilot-study
#16
Martha Hsueh, Kathleen Dorcy
Gaps in complex oncology care coordination between inpatient and outpatient settings can result in treatment and monitoring delays and omissions, which can negatively affect patient outcomes. Gaps also exist for patients facing complex treatment modalities and collaborations between multiple care teams working at geographically distant sites. A pilot advanced practice nurse care coordinator 
(APNCC) role to coordinate these complex care transitions and implement processes for safer and more efficient care has shown promise...
June 1, 2016: Clinical Journal of Oncology Nursing
https://www.readbyqxmd.com/read/27243428/integrating-a-student-pharmacist-into-the-home-healthcare-setting
#17
Fredrick OʼNeal, Tracy R Frame, Julia Triplett
Patients in a transition of care are highly susceptible to health and medication errors. In many situations, patients are eager to go home and providers are expected to discharge quickly. It is in this time of documented vulnerability that an increase in adverse effects related to poor health literacy, medication usage, and a lack of documentation occurs. Through the collaboration of Vanderbilt Home Care Services, Inc., and Belmont University College of Pharmacy, pharmacy students are utilized in a capacity that integrates pharmacy students into the home healthcare team to ease transitions of care and reduce medication-related problems in patients...
June 2016: Home Healthcare Now
https://www.readbyqxmd.com/read/27248789/transitions-of-care-in-the-management-of-acute-bacterial-skin-and-skin-structure-infections-a-paradigm-shift
#18
Jaime E Verastegui, Yukihiro Hamada, David P Nicolau
Acute bacterial skin and skin structure infections (ABSSSI) have evolved over a relatively short period of time to become one of the most challenging medical problems encountered in clinical practice. Notably the high incidence of methicillin-resistant S. aureus (MRSA) across the continuum of care has coincided with increased outpatient failures and higher rates of hospital admissions for parental antibiotic therapy. Consequently the management of ABSSSI constitutes a tremendous burden to the healthcare system in terms of cost of care and consumption of institutional and clinical resources...
August 2016: Expert Review of Clinical Pharmacology
https://www.readbyqxmd.com/read/27273678/pharmacist-provided-medication-management-in-interdisciplinary-transitions-in-a-community-hospital-pmit
#19
Aubrie Rafferty, Sheri Denslow, Elizabeth Landrum Michalets
BACKGROUND: Medication management during transitions of care (TOC) impacts clinical outcomes. Published literature on TOC implementation is increasing, but data remains limited regarding the optimal role for the inpatient pharmacist, particularly in the community health setting. OBJECTIVE: To evaluate the impact of a dedicated inpatient TOC pharmacist on re-presentations following discharge. METHODS: This is a prospective study with historical control...
August 2016: Annals of Pharmacotherapy
https://www.readbyqxmd.com/read/27280035/mind-how-you-cross-the-gap-outcomes-for-young-people-who-failed-to-make-the-transition-from-child-to-adult-services-the-track-study
#20
Zoebia Islam, Tamsin Ford, Tami Kramer, Moli Paul, Helen Parsons, Katherine Harley, Tim Weaver, Susan McLaren, Swaran P Singh
Aims and method The Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK) study was a multistage, multicentre study of adolescents' transitions between child and adult mental health services undertaken in England. We conducted a secondary analysis of the TRACK study data to investigate healthcare provision for young people (n = 64) with ongoing mental health needs, who were not transferred from child and adolescent mental health services (CAMHS) to adult mental health services mental health services (AMHS)...
June 2016: BJPsych Bulletin
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