THE CARE TRANSITIONS SENIOR EMPOWERMENT PROGRAM; PROMOTING PATIENT PARTICIPATION TO IMPROVE SAFETY IN TRANSITIONS OF CARE

Care transitions are a hot topic in healthcare delivery, research, and policy today because national patient quality and safety data have identified transition of care as a critical time during a patient’s care continuum when both quality and safety are potentially compromised. Poorly executed transitions of care are associated with preventable adverse events and hospital readmissions that are burdensome to patients and their caregivers, correlating to suboptimal outcomes and exorbitant costs. Therefore, reducing both adverse events during a care transition and hospital readmission rates is a matter of clinical and policy priority. High-risk surgical patients are particularly vulnerable to preventable adverse events and readmissions during care transitions because of the complexity of their care needs. To address this problem, governmental and other healthcare organizations are allocating resources and investing in research initiatives to improve, refine, and standardize the transition-of-care process in order to optimize quality of care throughout a patient’s care continuum.

Download Full-text

Interdisciplinary partnerships for rural older adults’ transitions of care

Quality in Ageing and Older Adults ◽

10.1108/qaoa-12-2017-0050 ◽

2018 ◽

Vol 19 (4) ◽

pp. 232-241

Author(s):

Joyce Weil ◽

Gwyneth Milbrath ◽

Teresa Sharp ◽

Jeanette McNeill ◽

Elizabeth Gilbert ◽

...

Keyword(s):

Public Health ◽

Rural Areas ◽

Older Persons ◽

Health Care Services ◽

Team Building ◽

Knowledge Exchange ◽

Care Transitions ◽

Transitions Of Care ◽

Content Type ◽

The Creation

Purpose Integrated transitions of care for rural older persons are key issues in policy and practice. Interdisciplinary partnerships are suggested as ways to improve rural-care transitions by blending complementary skills of disciplines to increase care’s holistic nature. Yet, only multidisciplinary efforts are frequently used in practice and often lack synergy and collaboration. The purpose of this paper is to present a case of a partnership model using nursing, gerontology and public health integration to support rural-residing elders as a part of building an Adult-Gerontology Acute Care Nurse Practitioner program. Design/methodology/approach This paper uses the Centre for Ageing Research and Development in Ireland/O’Sullivan framework to examine the creation of an interdisciplinary team. Two examples of interdisciplinary work are discussed. They are the creation of an interdisciplinary public health course and its team-based on-campus live simulations with a panel and site visit. Findings With team-building successes and challenges, outcomes show the need for knowledge exchange among practitioners to enhance population-centered and person-centered care to improve health care services to older persons in rural areas. Practical implications There is a need to educate providers about the importance of developing interdisciplinary partnerships. Educational programming illustrates ways to move team building through the interdisciplinary continuum. Dependent upon the needs of the community, other similarly integrated partnership models can be developed. Originality/value Transitions of care work for older people tends to be multi- or cross-disciplinary. A model for interdisciplinary training of gerontological practitioners in rural and frontier settings broadens the scope of care and improves the health of the rural older persons served.

Download Full-text

A Call to Action: The Role of Antiretroviral Stewardship in Inpatient Practice, a Joint Policy Paper of the Infectious Diseases Society of America, HIV Medicine Association, and American Academy of HIV Medicine

Clinical Infectious Diseases ◽

10.1093/cid/ciz792 ◽

2019 ◽

Vol 70 (11) ◽

pp. 2241-2246 ◽

Cited By ~ 1

Author(s):

David E Koren ◽

Kimberly K Scarsi ◽

Eric K Farmer ◽

Agnes Cha ◽

Jessica L Adams ◽

...

Keyword(s):

Infectious Diseases ◽

American Academy ◽

Medication Errors ◽

Treatment Options ◽

Care Transitions ◽

Transitions Of Care ◽

Healthcare Facilities ◽

Call To Action ◽

Policy Paper ◽

Enhance Patient Safety

Abstract Persons living with human immunodeficiency virus (HIV) and others receiving antiretrovirals are at risk for medication errors during hospitalization and at transitions of care. These errors may result in adverse effects or viral resistance, limiting future treatment options. A range of interventions is described in the literature to decrease the occurrence or duration of medication errors, including review of electronic health records, clinical checklists at care transitions, and daily review of medication lists. To reduce the risk of medication-related errors, antiretroviral stewardship programs (ARVSPs) are needed to enhance patient safety. This call to action, endorsed by the Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine, is modeled upon the success of antimicrobial stewardship programs now mandated by the Joint Commission. Herein, we propose definitions of ARVSPs, suggest resources for ARVSP leadership, and provide a summary of published, successful strategies for ARVSP that healthcare facilities may use to develop locally appropriate programs.

Download Full-text

Incorporating Oral Health Considerations for Medication Management in Care Transitions

Pharmacy ◽

10.3390/pharmacy8020067 ◽

2020 ◽

Vol 8 (2) ◽

pp. 67

Author(s):

Kimberly A. Sanders ◽

Christine L. Downey ◽

Anita Yang ◽

Brooke K. Baker

Keyword(s):

Oral Health ◽

Patient Outcomes ◽

Hospital Readmission ◽

Medication Management ◽

Care Transitions ◽

Transitions Of Care ◽

Consult Service ◽

Health Factors ◽

Clinic Practice ◽

Successes And Challenges

Transitions of care involve multifaceted considerations for patients, which can pose significant challenges if factors like oral health are overlooked when evaluating medication management. This article examines how oral health factors should be considered in medication management of patients who may be at risk for hospital readmission. This article also explores successes and challenges of a pharmacy consult service integrated into a dental clinic practice, and the opportunities within that setting to improve overall patient outcomes including those related to care transitions.

Download Full-text

Effects of pharmacy interventions at transitions of care on patient outcomes

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa081 ◽

2020 ◽

Vol 77 (12) ◽

pp. 943-949

Author(s):

Susan Fosnight ◽

Philip King ◽

Jacqueline Ewald ◽

John Feucht ◽

Angela Lamtman ◽

...

Keyword(s):

Length Of Stay ◽

Readmission Rate ◽

Average Length ◽

Care Transitions ◽

Outcome Data ◽

Transitions Of Care ◽

Readmission Rates ◽

Average Length Of Stay ◽

Pharmacy Intervention ◽

Surgical Unit

Abstract Purpose An interdisciplinary group developed a care transitions process with a prominent pharmacist role. Methods The new transitions process was initiated on a 32-bed medical/surgical unit. Demographics, reconciliation data, information on medication adherence barriers, medication recommendations, and time spent performing interventions were prospectively collected for 284 consecutive patients over 54 days after the pharmacy participation was completely implemented. Outcome data, including 30-day readmission rates and length of stay, were retrospectively collected. Results When comparing metrics for all intervention patients to baseline metrics from the same months of the previous year, the readmission rate was decreased from 21.0% to 15.3% and mean length of stay decreased from 5.3 days to 4.4 days. Further improvement to a 10.2% readmission rate and a 3.6-day average length of stay were observed in the subgroup of intervention patients who received all components of the pharmacy intervention. Additionally, greater improvements were observed in intervention-period patients who received the full pharmacy intervention, as compared to those receiving only parts of the pharmacy intervention, with a 10.2-percentage-point lower readmission rate (10.2% vs 20.4%, P = 0.016) and a 1.7-day shorter length of stay (3.6 days vs 5.3 days; 95% confidence interval, 0.814-2.68 days; P = 0.0003). For patients receiving any component of the pharmacy intervention, an average of 9.56 medication recommendations were made, with a mean of 0.89 change per patient deemed to be required to avoid harm and/or increased length of stay. Conclusion A comprehensive pharmacy intervention added to a transitions intervention resulted in an average of nearly 10 medication recommendations per patient, improved length of stay, and reduced readmission rates.

Download Full-text

Patient Perspectives on Transitions of Surgical Care: Examining the Complexities and Interdependencies of Care

Qualitative Health Research ◽

10.1177/1049732317704406 ◽

2017 ◽

Vol 27 (12) ◽

pp. 1856-1869 ◽

Cited By ~ 2

Author(s):

Maynor G. González ◽

Kristin N. Kelly ◽

Ann M. Dozier ◽

Fergal Fleming ◽

John R. T. Monson ◽

...

Keyword(s):

Care Transitions ◽

Hybrid Approach ◽

Surgical Care ◽

Transitions Of Care ◽

Major Surgery ◽

Discharge Process ◽

Patient Centered ◽

Outcomes Of Care ◽

Anxiety Patient ◽

Medical Histories

This study examined a thematic network aimed at identifying experiences that influence patients’ outcomes (e.g., patients’ satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantly influenced by two cascades identified as patients’ medical histories and home circumstances. Patients who reported previous medical or surgical histories also experienced less distress during the discharge process, whereas patients with no prior experiences reported more concerns and greater anxiety. Patient dissatisfactions and challenges were due in large part to the contrasts between hospital and home experiences. Our hybrid approach may inform patient-centered guidelines aimed at improving transitions of care among patients undergoing major surgery.

Download Full-text

How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol

BMJ Open ◽

10.1136/bmjopen-2020-045596 ◽

2021 ◽

Vol 11 (2) ◽

pp. e045596

Author(s):

Hardeep Singh ◽

Alana Armas ◽

Susan Law ◽

Terence Tang ◽

Carolyn Steele Gray ◽

...

Keyword(s):

Older Adults ◽

Human Subjects ◽

Digital Health ◽

Phase 1 ◽

Care Transitions ◽

Health Interventions ◽

Transitions Of Care ◽

Rapid Review ◽

Two Phase ◽

Hospital To Home

IntroductionOlder adults may experience challenges during the hospital to home transitions that could be mitigated by digital health solutions. However, to promote adoption in practice and realise benefits, there is a need to specify how digital health solutions contribute to hospital to home transitions, particularly pertinent in this era of social distancing. This rapid review will: (1) elucidate the various roles and functions that have been developed to support hospital to home transitions of care, (2) identify existing digital health solutions that support hospital to home transitions of care, (3) identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions for older adults (eg, the pre-trial results of the Digital Bridge intervention; ClinicalTrials.gov Identifier: NCT04287192).Methods and analysisA two-phase rapid review will be conducted to meet identified aims. In phase 1, a selective literature review will be used to generate a conceptual map of the roles and functions of individuals that support hospital to home transitions for older adults. In phase 2, a search on MEDLINE, EMBASE and CINAHL will identify literature on digital health solutions that support hospital to home transitions. The ways in which digital health solutions can support the roles and functions that facilitate these transitions will then be mapped in the analysis and generation of findings.Ethics and disseminationThis protocol is a review of the literature and does not involve human subjects, and therefore, does not require ethics approval. This review will permit the identification of gaps and new opportunities for digital processes and platforms that enable care transitions and can help inform the design and implementation of future digital health interventions. Review findings will be disseminated through publications and presentations to key stakeholders.

Download Full-text

Identifying roles in older adults’ emergency department transitions

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/1071181320641159 ◽

2020 ◽

Vol 64 (1) ◽

pp. 685-689

Author(s):

Megan E. Salwei ◽

Hanna Barton ◽

Nicole E. Werner ◽

Rachel Rutkowski ◽

Peter L.T. Hoonakker ◽

...

Keyword(s):

Older Adults ◽

Emergency Department ◽

Older Adult ◽

Error Detection ◽

Care Transitions ◽

Care Facility ◽

Transitions Of Care ◽

Adult Care ◽

Term Care ◽

Long Term Care Facility

Older adults frequently visit the emergency department (ED) and participate in multiple transitions of care following an ED visit. These transitions of care, e.g. to hospital, long-term care facility or home, represent patient safety risks because of communication and coordination failures between the various roles involved, but also provide opportunities for error detection and recovery and, therefore, resilience. The objective of this study was to identify and describe the multiple roles involved in older adult care transitions during an ED visit. As part of a large research project, we conducted patient-centered observations and interviewed ED clinicians and hospital administrators. We identified 16 ED roles involved in older adult care transitions out of the ED, including 4 roles solely focused on coordinating transitions. By better understanding the roles involved in ED care transitions, we can improve the design of team processes and technologies to support care of older adults throughout their care transitions.

Download Full-text

The SAFEDC Model for Improving Transitions of Care: Lessons Learned from a Participatory Design Workshop (Preprint)

10.2196/preprints.31277 ◽

2021 ◽

Author(s):

Ji Youn Shin ◽

Nkiru Okammor ◽

Karly Hendee ◽

Amber Pawlikowski ◽

Grace Jenq ◽

...

Keyword(s):

Participatory Design ◽

Transitional Care ◽

Care Transitions ◽

Patient Discharge ◽

Lessons Learned ◽

Transitions Of Care ◽

Care Transition ◽

Patient Centered ◽

Patient Journey ◽

Design Workshop

BACKGROUND Transition home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require healthcare professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions. OBJECTIVE This study aims to understand the effectiveness of the Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT) design model of bringing together stakeholders of the healthcare system and providing them with a novel tool that captures the patient perspective (patient journey map). METHODS We chose a mixed method of direct patient observations and a participatory design workshop to develop transitional care interventions that serve each hospital’s unique situation and contexts. By applying thematic analysis methods, we analyzed problem statements and proposed interventions collected from the participatory design workshops. Findings showed the patterns of major discussion during the workshop. RESULTS Based on workshop results, we formalized the I-MPACT transition of care model, SAFEDC (socioeconomic, active engagement, follow-up, education, discharge readiness tool, consistency), which other organizations can apply to improve patient experiences in care transition. CONCLUSIONS Our study demonstrates the benefits of the participatory design approach in defining challenges associated with transitions of care related to patient discharge and generating sustainable interventions to improve care transitions.

Download Full-text

Application of a Participatory Ergonomic Approach for Scaling Handoff Redesign: A Pilot Feasibility Study

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care ◽

10.1177/2327857920091016 ◽

2020 ◽

Vol 9 (1) ◽

pp. 283-288

Author(s):

Louise Gliga ◽

Isaac Lynch ◽

Richard Preble ◽

Philip Greilich

Keyword(s):

Participatory Design ◽

Best Practice ◽

Medical Center ◽

Academic Medical Center ◽

Care Transitions ◽

Implementation Process ◽

Scaling Up ◽

Transitions Of Care ◽

Modified Delphi ◽

Best Practice Guidelines

Transitions of care between clinical areas are potentially dangerous events in healthcare. This is especially true in high risk areas, such as between the operating room (OR) and the intensive care unit (ICU). Despite the existence of best practice guidelines for perioperative handoffs, scaling up successful pilots remains a challenge. To more effectively address this limitation, we tested the feasibility of using a participatory ergonomic approach for scaling handoff redesign and implementation in an academic medical center. A multidisciplinary unit-based change team of representatives and influencers was supported by a guidance team of leaders, coaches and subject matter experts through a structured implementation process (plan, engage, execute, reflect). The participatory design incorporated a modified Delphi technique, simulation, and facilitated debriefing to elicit feedback in multiple iterative cycles. The redesigned handoff became the preferred approach by frontline clinicians across the involved disciplines and resulted in a sustained improvement in conformance to unit-determined handoff best practices. The success of this feasibility pilot has led to the support of a diffusion pilot for scaling up handoff redesign within the health system. The study supports further investigation of using a participatory ergonomics approach to engage frontline clinicians and executive leadership to scale complex sociotechnical change, like handoffs and care transitions.

Download Full-text