Enhanced Care Program for Transitional Care to Home Upon Acute Care or SNF Discharge: A Quality Improvement Study

Abstract Purpose Recent evidence suggests that improving the transitional care process may reduce 30-day readmissions and hospital length of stay (LOS). The objective of this study was to evaluate the impact of a pharmacist-led transitions-of-care (TOC) program on 30- and 90-day all-cause readmissions and LOS for patients discharged from the hospital acute care setting. Methods A retrospective cohort study was conducted using a difference-in-difference (DID) approach. Patients who were at least 18 years old with any of the following primary diagnoses were included: acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), and pneumonia. Outcome measures were all-cause 30- and 90-day readmission and LOS for the index admission. Results From October 2013 through September 2017, 1,776 patients were discharged from the intervention site, and 2,969 patients were discharged from 3 control sites. Only 33.3% of eligible patients at the intervention site actually received the intervention. The DID analysis showed that the odds ratio (OR) for 30-day readmission was 0.65 [P = 0.035] at the intervention site following TOC program initiation. The OR for 90-day readmission was 0.75 [P = 0.070]. Among all diagnosis groups, the CHF subgroup had the highest proportion of patients who actually received the TOC intervention (57.2%). Within that CHF subgroup, the ORs for 30- and 90-day readmissions were 0.52 [P = 0.056] and 0.47 [P = 0.005], respectively. The mean LOS did not change significantly in either analysis. Conclusion This pharmacist-led transitional care intervention was associated with significantly decreased inpatient readmissions. The analysis indicates that pharmacist interventions can significantly reduce 30-day readmissions for high-risk populations and 90-day readmissions in patients with CHF.

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Quality Improvement: Developing and Implementing a Quality Improvement Plan in an Acute Care Hospital Setting

Perspectives on Administration and Supervision ◽

10.1044/aas9.3.7 ◽

1999 ◽

Vol 9 (3) ◽

pp. 7-11

Author(s):

Carole R. Roth

Keyword(s):

Quality Improvement ◽

Acute Care ◽

Hospital Setting ◽

Acute Care Hospital ◽

Care Hospital ◽

Improvement Plan

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Progressive Mobility As a Team Effort in Transitional Care

Critical Care Nurse ◽

10.4037/ccn2015622 ◽

2015 ◽

Vol 35 (3) ◽

pp. 62-68 ◽

Cited By ~ 2

Author(s):

Margaret M. Ecklund ◽

Jill W. Bloss

Keyword(s):

Hospital Readmission ◽

Transitional Care ◽

Interdisciplinary Collaboration ◽

Skilled Nursing Facility ◽

Care Program ◽

Care Needs ◽

Nursing Facility ◽

Skilled Nursing ◽

Core Culture ◽

The Continuum

With changing health care, progressive care nurses are working in diverse practice settings to meet patient care needs. Progressive care is practiced along the continuum from the intensive care unit to home. The benefits of early progressive mobility are examined with a focus on the interdisciplinary collaboration for care in a transitional care program of a skilled nursing facility. The program’s goals are improved functional status, self-care management, and home discharge with reduced risk for hospital readmission. The core culture of the program is interdisciplinary collaboration and team partnership for care of patients and their families.

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Quality improvement in hospitals: barriers and facilitators

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-12-2015-0144 ◽

2017 ◽

Vol 30 (1) ◽

pp. 16-24 ◽

Cited By ~ 14

Author(s):

Dick E. Zoutman ◽

B. Douglas Ford

Keyword(s):

Patient Safety ◽

Quality Improvement ◽

Patient Care ◽

Acute Care ◽

Medical Staff ◽

Acute Care Hospitals ◽

Content Type ◽

Active Involvement ◽

Staff Engagement ◽

Positive Impacts

Purpose The purpose of this paper is to examine quality improvement (QI) initiatives in acute care hospitals, the factors associated with success, and the impacts on patient care and safety. Design/methodology/approach An extensive online survey was completed by senior managers responsible for QI. The survey assessed QI project types, QI methods, staff engagement, and barriers and factors in the success of QI initiatives. Findings The response rate was 37 percent, 46 surveys were completed from 125 acute care hospitals. QI initiatives had positive impacts on patient safety and care. Staff in all hospitals reported conducting past or present hand-hygiene QI projects and C. difficile and surgical site infection were the next most frequent foci. Hospital staff not having time and problems with staff prioritizing QI with other duties were identified as important QI barriers. All respondents reported hospital leadership support, data utilization and internal champions as important QI facilitators. Multiple regression models identified nurses’ active involvement and medical staff engagement in QI with improved patient care and physicians’ active involvement and medical staff engagement with greater patient safety. Practical implications There is the need to study how best to support and encourage physicians and nurses to become more engaged in QI. Originality/value QI initiatives were shown to have positive impacts on patient safety and patient care and barriers and facilitating factors were identified. The results indicated patient care and safety would benefit from increased physician and nurse engagement in QI initiatives.

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Abstract 256: Readmission Avoidability in Acute Coronary Syndrome Patients

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.256 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Maria Souphis ◽

Rachel Sylvester ◽

Alison Wiles ◽

Meghana Subramanian ◽

William Froehlich ◽

...

Keyword(s):

Transitional Care ◽

Drug Effects ◽

Care Program ◽

Readmission Rates ◽

Coronary Syndrome ◽

History Of ◽

Definition Of ◽

Avoidable Readmission ◽

Cancer Complications ◽

Avoidable Readmissions

Background: Readmissions for ACS are common, costly, and potentially preventable. According to Medicare 13.4% of AMI admissions were followed by a rehospitalization within 15 days. A 2007 MedPAC report declared 76% of 30-day readmissions preventable. These rates are used as quality indicators despite lack of consensus on the definition of avoidable and unavoidable readmissions. We sought to define these terms and to analyze the effect of these definitions on 30-day outcomes. Methods: BRIDGE (Bridging the Discharge Gap Effectively) is an NP-led transitional care program for cardiac patients within 14 days of discharge. Retrospective data were abstracted on ACS patients readmitted before their appointments between 2008-2010. All readmissions were characterized as avoidable or unavoidable. Definitions were developed from the literature and in concert with senior cardiologists. Avoidable readmission was defined as being the result of a patient or provider issue that if managed may have prevented the admission. Unavoidable readmissions were defined as a patient in need of acute care. Avoidability status was further divided as related or unrelated to the index diagnosis. Results: Of 1188 BRIDGE referrals 304 (25.6%) experienced ACS events. In comparison to the total ACS population, patients readmitted before their BRIDGE clinic appointment (BC) (n=21, 6.9%) tended to be older, female, and were less likely to have a history of a cath or AMI (Table 1). In this study, 81% (n=17) of early readmissions were deemed unavoidable and most (n=14, 66.7%) were attributed to non-ACS issues or disease progression. These unavoidable readmissions included patients with cancer complications, chest pain, or other non-related diagnoses. Only 19% (n=4) of the readmissions were declared avoidable as a result of patient lack of adherence or provider issues such as adverse drug effects. Conclusion: The majority of early (before BC) readmissions following an index hospitalization for ACS patients referred to BRIDGE were unavoidable and unrelated to ACS. A clear discrepancy is seen between the 76% preventable readmissions in the MedPAC report and the 19% preventable readmissions in this study. Distinctions between unavoidable and avoidable readmissions should inform the utility of 30-day readmission rates as quality metrics.

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Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement

Journal of the American Medical Directors Association ◽

10.1016/j.jamda.2016.09.009 ◽

2017 ◽

Vol 18 (1) ◽

pp. 70-73 ◽

Cited By ~ 17

Author(s):

Christine D. Jones ◽

Ethan Cumbler ◽

Benjamin Honigman ◽

Robert E. Burke ◽

Rebecca S. Boxer ◽

...

Keyword(s):

Quality Improvement ◽

Acute Care ◽

Information Exchange ◽

Care Facility ◽

Acute Care Facility ◽

Post Acute Care

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Crossing Knowledge Boundaries: Health Care Providers’ Perceptions and Experiences of What is Important to Achieve More Person-Centered Patient Pathways For Older People

10.21203/rs.3.rs-145825/v1 ◽

2021 ◽

Author(s):

Cecilie Olsen ◽

Astrid Bergland ◽

Asta Bye ◽

Jonas Debesay ◽

Anne Langaas

Keyword(s):

Health Care ◽

Quality Improvement ◽

Older People ◽

Health Care Providers ◽

Transitional Care ◽

Care Providers ◽

Quality Improvement Collaborative ◽

Patient Journey ◽

Patient Pathways

Abstract Background: Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Older people’s patient pathways may be unpredictable and complex, posing significant challenges for health care providers (HCPs). In particular, appropriate follow-up in primary care after discharge is key. Current research in the field endorses person-centered care as crucial to improving the patient pathways of older people. The aim of this study was to explore HCPs’ perceptions and experiences of what is important to achieve more person-centered patient pathways for older people.Methods: This was a qualitative study. We performed individual semistructured interviews with 20 HCPs and three key persons who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed. Results: A thematic analysis resulted in five themes: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathways of older people; and 5) ambiguity toward checklists and practice implementation. Conclusion: To understand the findings, it proved useful to see them in light of knowledge sharing and boundary crossing, which are central concepts in the literature on transitional care. HCPs in the collaborative shared and coproduced new knowledge of the patient pathways of older people based on a patient journey perspective. Mapping the patient journey and asking, “What matters to you?” facilitated the crossing of knowledge boundaries between the HCPs; hence, a new and more holistic view of the patient pathways of older people in the current context emerged. The centrality of getting to know the patient and the special role of providers working in home care services was a central finding. The study adds to existing knowledge by suggesting that the achievement of person-centered patient pathways for older people does not only depend on the crossing of knowledge boundaries among HCPs, but also between HCPs and older persons.

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Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.097 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Caitlin Fette ◽

Rachel Krallman ◽

Colin McMahon ◽

Daniel Montgomery ◽

Jennifer Wang ◽

...

Keyword(s):

Transitional Care ◽

Care Program ◽

Primary Diagnosis ◽

Lower Mortality ◽

Diabetic Patients ◽

Post Discharge ◽

Readmission Rates ◽

Coronary Syndrome ◽

Increased Risk ◽

Discharge Outcomes

Background: Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE. Methods: Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients. Results: Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees. Conclusions: Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.

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