Improving the Quality of Transitional Care for Persons with Complex Care Needs

2003 ◽  
Vol 51 (4) ◽  
pp. 556-557 ◽  
Author(s):  
Eric A. Coleman ◽  
Chad Boult
Keyword(s):  
Transitional Care ◽  
Complex Care ◽  
Care Needs ◽  
Complex Care Needs

scholarly journals Programmes to support transitions in care for children and youth with complex care needs and their families: a scoping review protocol

BMJ Open ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. e033978
Author(s):  
Shelley Doucet ◽  
Janet A Curran ◽  
Sydney Breneol ◽  
Alison Luke ◽  
Emilie Dionne ◽  
...  
Keyword(s):  
Scoping Review ◽  
Transitional Care ◽  
Research Policy ◽  
Children And Youth ◽  
Advisory Council ◽  
Complex Care ◽  
Care Needs ◽  
Transitions In Care ◽  
Scoping Reviews ◽  
Complex Care Needs

IntroductionChildren and youth with complex care needs (CCNs) and their families experience many care transitions over their lifespan and are consequently vulnerable to the discontinuity or gaps in care that can occur during these transitions. Transitional care programmes, broadly defined as one or more intervention(s) or service(s) that aim to improve continuity of care, are increasingly being developed to address transitions in care for children and youth with CCNs. However, this literature has not yet been systematically examined at a comprehensive level. The purpose of this scoping review is to map the range of programmes that support transitions in care for children and youth with CCNs and their families during two phases of their lifespan: (1) up to the age of 19 years (not including their transition to adult healthcare) and (2) when transitioning from paediatric to adult healthcare.Methods and analysisThe Joanna Briggs Institute methodology for scoping reviews (ScR) will be used for the proposed scoping review. ScR are a type of knowledge synthesis that are useful for addressing exploratory research questions that aim to map key concepts and types of evidence on a topic and can be used to organise what is known about the phenomena. A preliminary search of PubMed was conducted in December 2018.Ethics and disseminationEthical approval is not required where this study is a review of the published and publicly reported literature. The research team’s advisory council will develop a research dissemination strategy with goals, target audiences, expertise/leadership, resources and deadlines to maximise project outputs. The end-of-grant activities will be used to raise awareness, promote action and inform future research, policy and practice on this topic.

scholarly journals A Transitional Care Model for Veterans With Complex Needs During COVID: The Behavioral Recovery Outreach (BRO) Team

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 46-46
Author(s):  
Kathleen Matthews ◽  
Latrice Vinson
Keyword(s):  
Transitional Care ◽  
Lessons Learned ◽  
Future Research ◽  
Complex Care ◽  
Veterans Health ◽  
Behavioral Recovery ◽  
Care Needs ◽  
Program Outcomes ◽  
Complex Care Needs ◽  
Team Model

Abstract The Veterans Health Administration’s Care for Patients with Complex Problems (CP)2 Program developed a national infrastructure to disseminate promising practice models to improve care for Veterans with complex medical, mental health, and/or neurocognitive conditions, who may also have behaviors disruptive to care. A strategic priority is improving safe and effective transitions to community care for Veterans with complex care needs, many of whom have historically been limited to VA settings as a result of behavioral concerns. The Behavioral Recovery Outreach (BRO) Team was the first model identified for national dissemination and evaluation at partner sites. Developed at VA Central Iowa, BRO is an interdisciplinary team model that identifies Veterans in long-term VA care settings with complex care needs to engage in individualized behavioral programing to manage/stabilize behaviors and safely transition them to more appropriate and less costly community settings. This symposium will describe the BRO team model, highlight the facilitators and barriers to nationally disseminating the BRO model with VA partner facilities, discuss adaptations in continuing community transitions following the COVID-19 pandemic, and describe program outcomes. The first speaker will discuss development of the BRO model and outcomes of a regional dissemination. The second speaker will present results from the program evaluation of the national dissemination. The final speaker will describe BRO Team expansion and lessons learned from the perspective of a VA partner facility. The (CP)2 Program Director will integrate findings and highlight implications for scaling and evaluating promising models for national dissemination for policy, practice, and future research.

ASSOCIATIONS BETWEEN FRAILTY, COMPLEX CARE NEEDS AND QUALITY OF LIFE IN MULTI-MORBID OLDER PEOPLE

2014 ◽  
pp. 1-6
Author(s):  
N. BLEIJENBERG ◽  
V.H. TEN DAM ◽  
I. DRUBBEL ◽  
M.E. NUMANS ◽  
N.J. DE WIT ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Older People ◽  
The Elderly ◽  
Complex Care ◽  
Care Needs ◽  
Self Assessment ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Relationship

Background:Little is known regarding the complex care needs, level of frailty or quality of life ofmulti-morbid older patients. Objectives:The objective of this study was to determine the relationship betweenfrailty, complexity of care and quality of life in multi-morbid older people. Design:Cross-sectional study.Setting: Thirteen primary care practices in the Netherlands. Participants:1,150 multi-morbid older people livingin the community. Measurements:The level of frailty was assessed with the Groningen Frailty Indicator.Complexity of care needs was measured with the Intermed for the Elderly Self-Assessment. Quality of life (QoL)was measured with two items of the RAND-36. Results:In total, 758 out of 1,150 (65.9%) patients were frail,8.3% had complex care needs, and the mean QoL score was 7.1 (standard deviation 1.2). Correlations betweenfrailty and complexity, frailty and QoL, and complexity of care and QoL were 0.67, -0.51 and -0.52 (all p<0.001)respectively. All patients with complex care needs were frail, but, only 12.5% of the frail patients had complexcare needs. Problems at climbing up stairs was associated with higher levels of frailty and complexity of care butwith a lower QoL. Conclusions:Higher levels of frailty and complexity of care are associated with a lower QoLin multi-morbid older people. The results of this study contribute to a better understanding these concepts and arevaluable for the development of tailored interventions for older persons in the future.

scholarly journals The Behavioral Recovery Outreach (BRO) Team: A Transitional Care Model for Veterans With Complex Care Needs

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 46-46
Author(s):  
Kathleen Matthews ◽  
Grant Bauste ◽  
Emily Luitjens
Keyword(s):  
Transitional Care ◽  
Policy Implications ◽  
Behavioral Recovery ◽  
Care Needs ◽  
Post Discharge ◽  
Community Based ◽  
Delivery Of Care ◽  
Program Fidelity ◽  
Complex Care Needs

Abstract In 2012, VA Central Iowa developed a novel program known as the Behavioral Recovery Outreach (BRO) Team to address unmet needs of our aging Veteran population with complex medical, psychological, neurocognitive and behavioral concerns. BRO Teams provide evidence-informed treatments in inpatient VA settings, and transitional care/support post-discharge to ensure successful placement and stability in the community. We will discuss how implementation science informed the expansion of this model from a local pilot to a nationally disseminated program. We will explore the challenges of ensuring program fidelity while fostering innovation and adaptation. Given the challenges of national dissemination, we will highlight the predicted and unforeseen aspects of program evaluation and policy implications. Finally, we will discuss the impacts of the COVID-19 pandemic on delivery of care methods and community-based interactions, as well as how this program has improved the lives and quality of care for this high-risk Veteran population.

Health Status Transitions in Community-Living Elderly with Complex Care Needs

2011 ◽  
pp. 223-247
Author(s):  
Louise Lafortune ◽  
François Béland ◽  
Howard Bergman ◽  
Joël Ankri
Keyword(s):  
Health Status ◽  
Community Living ◽  
Complex Care ◽  
Care Needs ◽  
Complex Care Needs

scholarly journals People with an intellectual disability in the discourse of chronic and complex conditions: an invisible group?

2008 ◽  
Vol 32 (3) ◽  
pp. 405 ◽  
Author(s):  
Linda Goddard ◽  
Patricia M Davidson ◽  
John Daly ◽  
Sandra Mackey
Keyword(s):  
Health Care ◽  
Intellectual Disability ◽  
Chronic Conditions ◽  
Health Professions ◽  
Disability Services ◽  
Complex Care ◽  
Competency Development ◽  
Care Needs ◽  
Complex Care Needs ◽  
Respiratory Conditions

People with an intellectual disability and their families experience poorer health care compared with the general population. Living with an intellectual disability is often challenged by coexisting complex and chronic conditions, such as gastrointestinal and respiratory conditions. A literature review was undertaken to document the needs of this vulnerable population, and consultation was undertaken with mothers of children with disabilities and with professionals working within disability services for people with an intellectual disability and their families. Based on this review, there is a need to increase the profile of people with an intellectual disability in the discourse surrounding chronic and complex conditions. Strategies such as guideline and competency development may better prepare health professions to care for people with disabilities and chronic and complex care needs and their families.

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