Abstract W P349: Bridging the Gap: Discharge to Follow-up: A Qualitative Review

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Anh Juntura ◽  
Linda Shields ◽  
Fern Cudlip
Keyword(s):  
Patient Compliance ◽  
Assessment Tool ◽  
Discharge Planning ◽  
Signs And Symptoms ◽  
Well Being ◽  
Qualitative Assessment ◽  
Phone Call ◽  
Discharge Process ◽  
Post Discharge

Background: Discharging patients from the hospital is complex and challenging. The discharge process includes discharge planning, medication reconciliation, discharge summation, and patient instruction. The enormity of information and complexity of the process directly impacts patient compliance and re-admission. Given the extent of this process, efforts toward assuring clarity of knowledge have the potential to improve patient compliance. We sought to identify and address gaps in post discharge patient awareness. Methods: A follow-up phone interview was conducted 1 week post discharge, with 26 stroke patients. All patients had received verbal and written stroke education prior to discharge. The qualitative assessment tool included 10 questions regarding general wellbeing, follow-up appointment compliance, medication utilization, and stroke knowledge. The patient responses were categorized accordingly. A copy of the patient’s discharge instructions was utilized during the interview for verification and clarification of discharge information. Results: Regarding wellbeing, 77% of the patients reported a reasonable sense of well being. The majority (77%) had scheduled follow-up appointments with the remaining 23% requiring clarification. Concerning medication compliance, 92% of the patients were able to obtain and comprehend use of their new medications. Review of stroke type confirmed 54% with understanding, whereas, 44% expressed lack of clarity regarding the subject. The same was true in regards to comprehension of stroke risk factors (56% verbalized understanding and 44% lacked awareness). Lastly, 54% of respondents were unable to identify the signs and symptoms of stroke despite the majority (60%) verbalizing a correct use of the 9-1-1 system Conclusion: Our findings imply that a post discharge phone call practice serves to identify information gaps and provide opportunity to clarify stroke awareness, thus, “bridging the gap” of understanding and compliance regarding stroke management and prevention

Transitions in care and reduction in discharge errors.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 77-77
Author(s):  
Mary Anne Fenton ◽  
Tara Szyamnski ◽  
Megan Begnoche ◽  
Carol Chase ◽  
Michelle Moreau ◽  
...  
Keyword(s):  
Financial Distress ◽  
Multidisciplinary Care ◽  
Care Plan ◽  
Phone Call ◽  
Discharge Process ◽  
Post Discharge ◽  
Oncology Nurse ◽  
Ambulatory Oncology ◽  
Discharge Transition

77 Background: Patients are often overwhelmed at the time of hospital discharge and focus on home rather than the discharge process. Fragmented communication and lack of planning between the hospital team, patient, family and primary oncologist can lead to frustration and delays in implementation of palliative or curative therapies and potential hospital readmission when the plan of care is not followed in a timely manner. Our goal is to avoid medication errors, delays in implementation of a care plan and reemergence of symptoms or new symptoms as a result of a suboptimal discharge transition. Methods: A multidisciplinary care transition team including phone nurses, social workers, pharmacists, physicians, nursing leadership and a palliative care practitioner meet monthly to review and refine discharge transitions. Our intervention is a proactive phone call, by specially trained ambulatory oncology nurses, to patients within 1-2 business days after discharge from the inpatient Hematology Oncology service. The nurse asks consistent questions to address common issues in the discharge transition including review of symptoms, understanding of discharge medications, confirmation of new medication initiation, side effects, coping, and next appointment with the oncologist. The nurse reinforces the ambulatory nurse phone line and availability of same day sick visits. Results: Preliminary discharge phone call results from the nurses’ interventions include clarification of discharge medications, interventions when a patient had not obtained the ordered medication including antibiotics, referrals for same day sick visits, referrals to social work for emotional and financial distress, education on medications or side effect management, and follow-up appointments. The average time for the post discharge call is 13 minutes. Conclusions: Our follow up discharge intervention by the oncology nurse has shown many patients are uncertain of medications and follow-up even when provided with detailed discharge paperwork and medication reconciliation. A proactive discharge phone call may help resolve these issues and prevent future readmissions. A six month summary of our intervention will be presented.

Abstract T MP103: Effect of Follow-up Phone Calls on 30-day Readmission Rates for Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Kelly Anderson
Keyword(s):  
Intervention Group ◽  
Signs And Symptoms ◽  
Lifestyle Changes ◽  
Phone Call ◽  
Control Group ◽  
Readmission Rates ◽  
Convenience Sample ◽  
Phone Calls ◽  
Number Of Patients

Background and Purpose: Patients who are hospitalized for a stroke or TIA go home with a great deal of information about risk factors, medications, diet and exercise, signs and symptoms of stroke and follow-up care. This information may be difficult for the patient or caregiver to understand and can be overwhelming in the face of a new life-changing event. In addition, The Centers for Medicare and Medicaid Services will start publicly reporting 30-day readmission rates beginning in 2016. The purpose of this study is to determine if follow-up phone calls with a nurse help to reduce 30 day readmission rates for patients with stroke and TIA. Methods: This study utilized a convenience sample of adult patients who were admitted for ischemic stroke, ICH, SAH or TIA from March 2013 to February 2014. Patients in the intervention group participated in a phone call seven days after discharge to assess their compliance with medications, physician appointments and lifestyle changes. The proportion of readmissions between the groups was compared with Fisher’s exact test. Results: The total number of patients enrolled in the study was 586 and there were no significant differences in demographics between the control and intervention groups. Of the 533 patients in the control group, 54 (10%) of them were readmitted, including 11 patients readmitted for elective surgical procedures. Of the 52 patients in the intervention group, 3 (5.7%) of them were readmitted before the 7-day phone call. Of the 49 patients who participated in the 7-day phone call, none of them were readmitted ( p =0.0098). Conclusions: Patients who participate in a 7-day phone call appear to benefit and are less likely to be readmitted to the hospital. Other strategies may need to be considered for patients who are at higher risk, and thus more likely to be readmitted within seven days of discharge. In addition, some providers may wish to reconsider how they schedule elective procedures for secondary stroke prevention.

scholarly journals 49. Effects of Maternal SARS-CoV-2 Infection on Neonatal Discharge Planning and Care: Exacerbation of Racial and Ethnic Healthcare Disparities

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S35-S35
Author(s):  
Jennifer Jubulis ◽  
Amanda Goddard ◽  
Sarah Dibrigida ◽  
Carol A McCarthy
Keyword(s):  
Healthcare Disparities ◽  
Discharge Planning ◽  
Medical Center ◽  
Newborn Care ◽  
Well Being ◽  
Racial Minorities ◽  
Foreign Born ◽  
Factors Affecting ◽  
Exposed Infant

Abstract Background SARS-CoV-2 has exacerbated healthcare disparities. Maine’s population of 1.3 million is comprised of only 6% Black, Indigenous, People of Color (BIPOC); however, statewide 18% of SARS-CoV-2 infections have occurred in this group. This study examines newborn care inequities for infants born to mothers with SARS-CoV-2. Methods This study was conducted at Maine Medical Center in Portland, the largest hospital in Maine. Maternal SARS-CoV-2 infections from March 15, 2020 through April 1, 2021 were identified by PCR near time of delivery. Cases were matched to uninfected women by date of delivery. Chart review was conducted assessing demographic and clinical characteristics, comparing SARS-CoV-2 exposed and unexposed infants. The subset of SARS-CoV-2 exposed infants was further analyzed for trends in care by race. Protocol was exempt by MaineHealth IRB. Results Twenty four women and their infants were identified with maternal positive SARS-CoV-2 PCR just prior to delivery. An additional 24 unexposed infants were enrolled. When compared to unexposed infants, SARS-CoV-2 exposed were more likely to be racial minorities (63% vs 21%, p = 0.003), to have foreign-born mothers (58% vs 0.4%, p< 0.05) or to receive health care in a language other than English (29% vs 0.4%, p =0.02). For infants born to SARS-CoV-2 infected mothers, only 29% had initial follow up visit in person with their primary care provider (13% of BIPOC infants vs 56% of non-BIPOC infants, p = 0.03). Time to in-person follow up for exposed infants varied by race, with median time of 21 days (range 2-53 days) for racial minorities and 7.5 days (range 2-30 days) for non minorities. All families were discharged with a thermometer and scale for home management. No infants required re-admission during the month after discharge. One exposed infant tested positive for SARS-CoV-2. Conclusion The American Academy of Pediatrics recommends evaluation of newborns 3-5 days after discharge to identify maternal and child health factors affecting newborn well-being. The SARS-CoV-2 pandemic has made this challenging for patients, particularly for racial minorities. BIPOC pediatric patients were disproportionately affected by the pandemic in Maine, and were disproportionately affected by care discrepancies even when the infant was uninfected. Disclosures All Authors: No reported disclosures

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Sara Jones ◽  
Anna Kucharska-Newton ◽  
Janet Freburger ◽  
Walter Ambrosius ◽  
...  
Keyword(s):  
Transitional Care ◽  
Discharge Planning ◽  
Care Transitions ◽  
Cluster Randomized Trial ◽  
Stroke Patients ◽  
Care Needs ◽  
Post Discharge ◽  
Exact Test ◽  
Chi Squared

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Abstract TP288: Overcoming Obstacles Making People Healthy (OOMPH): A Patient Centered Post Discharge Follow-up Program for Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jonathan Muller ◽  
Barbara Gatton ◽  
Linda Fox ◽  
Joseph A Bove ◽  
Johanna Donovan Turner ◽  
...  
Keyword(s):  
Support Groups ◽  
Medical Information ◽  
Patient Adherence ◽  
Hospital Readmissions ◽  
Phone Call ◽  
Stroke Patients ◽  
Post Discharge ◽  
Phone Calls ◽  
Stroke Support Groups

Background and Purpose: At least 12% of stroke patients are readmitted to a hospital within 30 days of discharge. We know that patients hospitalized for other conditions are less likely to be readmitted within 30 days if they are seen by their PCP shortly after discharge. However, less than a third of patients in the New York metropolitan area admitted for heart failure, heart attacks, and pneumonia see their PCP within 14 days after discharge and nearly 40% of patients do not adhere to their prescribed regimen. In the case of cerebrovascular diseases, outpatient follow-up may prevent the majority of avoidable readmissions. The purpose of this project is to identify and reduce unnecessary, unplanned hospital readmissions after stroke. Our goal is to encourage patient adherence to prescribed medication and other therapies, as well as to ensure timely follow-up with their PCP. Methods: Stroke and transient ischemic attack (TIA) patients with a disposition of either home or short-term rehabilitation are visited and offered enrollment. Participants are given a kit which includes a personalized binder (to manage essential medical information) and a 28-slot pill box. Each patient then receives 3 phone call interviews at 7, 21 and 32 days after discharge. The aim of the phone calls is to identify obstacles to compliance with treatment regimen and follow-up care. Results: From January 2015 to June 2016, 247 patients were enrolled and followed up. Within 30 days of discharge, 10% were readmitted and 50% of all readmissions occurred within the first 7 days. Of those readmitted, 19% were due to an injury from physical therapy. Data from follow-up phone calls revealed that 83% were taking all prescribed medications, 89% had completed a follow-up with any physician, 69% were using the binder, and 61% had done all three. Conclusions: While we have not enrolled enough patients to see a statistically significant reduction in readmissions, our interviews showed that weather, depression, as well as a lack of insurance, family support, and a home health aide are all determinants on how patients will follow their prescribed regimen. The results of this study have allowed us to begin implementing stroke support groups and pre-discharge follow-up appointment scheduling.

OP39 Evaluation Of Discharge Planning And Transitional Care For The Elderly

2018 ◽  
Vol 34 (S1) ◽  
pp. 15-15
Author(s):  
Maggy Wassef ◽  
Marc-Olivier Trepanier ◽  
Sylvie Beauchamp
Keyword(s):  
Readmission Rate ◽  
Transitional Care ◽  
Discharge Planning ◽  
Grey Literature ◽  
The Elderly ◽  
Narrative Synthesis ◽  
Local Data ◽  
Post Discharge ◽  
Level Of Evidence

Introduction:According to our local data, elderly patients accounted for 14 percent of the population yet, represent 58 percent of hospitalization and, they are more likely to return after discharge. These patients are more likely to return to the hospital following discharge. In order to meet ministerial target for length of stay of patient on a stretcher, the UETMIS-SS was requested to evaluate interventions aiming to improve the fluidity of patient trajectories in the acute care services. The objective of this health technology assessment is to evaluate the effectiveness of discharge planning and transitional care interventions aiming at reducing the readmission rate of the elderly.Methods:An umbrella review was conducted following the PRISMA statement to summarize the scientific evidence. The search was conducted in five databases along with the grey literature search. Two reviewers independently performed the study selection, the quality assessment and the data extraction. To better illustrate the activities and the healthcare professionals (HCP) involved in the interventions, an analytical framework was developed. Results were summarized in a narrative synthesis. The contextual and experiential data were collected through interviews with HCP and directorates from different settings. The level of evidence was and a committee was then held to elaborate the recommendations.Results:In the nine systematic reviews included in the narrative synthesis, three models were identified: Post-discharge planning and follow-up by the same HCP was established to be effective in reducing the readmission rate. Discharge planning interventions with follow-up by non-specific HCP have been shown to be promising, while discharge planning without follow-up after the hospital discharge has shown to be ineffective in reducing the readmission rate.Conclusions:An individualized discharge plan, coordination of services and follow-up performed by the same HCP is established to be effective in reducing readmission rate.

P0560POST-DISCHARGE FOLLOW UP AFTER AKI. AN EXTERNAL VALIDATION AND DECISION CURVE ANALYSIS OF TWO RISK MODELS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Simon Sawhney ◽  
Zhi Tan ◽  
Corri Black ◽  
Brenda Hemmelgarn ◽  
Angharad Marks ◽  
...  
Keyword(s):  
Risk Model ◽  
Discharge Planning ◽  
External Validation ◽  
Curve Analysis ◽  
Net Benefit ◽  
Post Discharge ◽  
Decision Curve Analysis ◽  
One Year ◽  
Unplanned Admissions

Abstract Background and Aims There is limited evidence to inform which people should receive follow up after AKI and for what reasons. Here we report the external validation (geographical and temporal) and potential clinical utility of two complementary models for predicting different post-discharge outcomes after AKI. We used decision curve analysis, a technique that enables visualisation of the trade-off (net benefit) between identifying true positives and avoiding false positives across a range of potential risk thresholds for a risk model. Based on decision curve analysis we compared model guided approaches to follow up after AKI with alternative strategies of standardised follow up – e.g. follow up of all people with AKI, severe AKI, or a discharge eGFR<30. Method The Alberta AKI risk model predicts the risk of stage G4 CKD at one year after AKI among those with a baseline GFR>=45 and at least 90 days survival (2004-2014, n=9973). A trial is now underway using this tool at a 10% threshold to identify high risk people who may benefit from specialist nephrology follow up. The Aberdeen AKI risk model provides complementary predictions of early mortality or unplanned readmissions within 90 days of discharge (2003, n=16453), aimed at supporting non-specialists in discharge planning, with a threshold of 20-40% considered clinically appropriate in the study. For the Alberta model we externally validated using Grampian residents with hospital AKI in 2011-2013 (n=9382). For the Aberdeen model we externally validated using all people admitted to hospital in Grampian in 2012 (n=26575). Analysis code was shared between the sites to maximise reproducibility. Results Both models discriminated well in the external validation cohorts (AUC 0.855 for CKD G4, and AUC 0.774 for death and readmissions model), but as both models overpredicted risks, recalibration was performed. For both models, decision curve analysis showed that prioritisation of patients based on the presence or severity of AKI would be inferior to a model guided approach. For predicting CKD G4 progression at one year, a strategy guided by discharge eGFR<30 was similar to a model guided approach at the prespecified 10% threshold (figure 1). In contrast for early unplanned admissions and mortality, model guided approaches were superior at the prespecified 20-40% threshold (figure 2). Conclusion In conclusion, prioritising AKI follow up is complex and standardised recommendations for all people may be an inefficient and inadequate way of guiding clinical follow-up. Guidelines for AKI follow up should consider suggesting an individualised approach both with respect to purpose and prioritisation.

Impact of Visual-Spatial Neglect on Stroke Functional Outcomes, Discharge Destination and Maintenance of Improvement Post-Discharge

2009 ◽  
Vol 72 (5) ◽  
pp. 219-225 ◽  
Author(s):  
Maria Stella Stein ◽  
David Maskill ◽  
Louise Marston
Keyword(s):  
Occupational Therapy ◽  
Functional Outcomes ◽  
Discharge Planning ◽  
Inpatient Rehabilitation ◽  
Functional Mobility ◽  
Spatial Neglect ◽  
Discharge Destination ◽  
Post Discharge ◽  
Visual Spatial

This study evaluated basic functional mobility in 25 patients with stroke and visual-spatial neglect during inpatient rehabilitation and early follow-up. Seven patients with neglect and 12 patients without neglect were discharged home and the rest to institutions. Patients without neglect achieved higher outcomes in a shorter time (mean 52 and 79 days respectively). All patients discharged home continued to improve at least up to 5 weeks post-discharge. The patients discharged to institutions achieved lower outcomes overall and quickly deteriorated to admission levels post-discharge. The results inform occupational therapy practice in the areas of assessment, discharge planning, destination and expected functional mobility outcomes in the community.

Observational study of ifosfamide (Ifos) neurotoxicity (N): The prospective use of a nursing assessment tool.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. e19580-e19580
Author(s):  
Jeanne Held-Warmkessel ◽  
Monica Davey ◽  
Samuel Litwin ◽  
John Lee ◽  
Mitchell Reed Smith ◽  
...  
Keyword(s):  
Risk Factors ◽  
Assessment Tool ◽  
Signs And Symptoms ◽  
Well Being ◽  
Prior History ◽  
Low Grade ◽  
Nursing Assessment ◽  
History Of ◽  
Hand Writing ◽  
Writing Sample

e19580 Background: Ifos chemotherapy is known to cause central nervous system toxicity. Risk factors have not been well identified in the literature, with limited information on the onset, duration, and severity of this toxicity. No clinical tools are available to assess and document N. Methods: We developed a clinical nursing assessment tool based upon review of the literature. Patients initiating inpatient Ifos chemotherapy, after informed consent was obtained under an IRB approved protocol, were prospectively monitored for signs and symptoms of N during 1 cycle of therapy. A full neurologic nursing assessment of 24 signs and symptoms including a hand writing sample was done at baseline and a basic assessment evaluating alertness, orientation, sense of well being and a hand writing sample was repeated every 12 hours. In the event N was identified, a full assessment was repeated; observed N was graded using the NCI CTC, version 3. Other variables collected were demographic traits, dose per day, hydration, and potential risk factors for N: renal function, albumin, largest pelvic tumor dimension, prior Ifos or cisplatin, use of other medications with potential for N, and alcohol use history. Individual factors were analyzed using Fisher’s exact test or the Wilcoxon two-sample test. Results: Eighty patients were accrued from 5/09-1/12. Median age was 54.5 (range: 21-85), 51% were males, PS 0 in 26.3%, 1 in 65%, 2 in 6.3% and 3 or 4 in 1.3% each. Diagnosis was sarcoma in 73.75%, lymphoma 22.5%, or germ cell tumor 3.75%. N was observed in 47.5% of patients. Toxicities in >15% of patients were sleepiness (25%), lethargy and restlessness (16.25% for each), and dizziness (15%). The majority were grade 1-2 (89.6%). Factors associated with N included generic versus brand formulation of Ifos (p=0.041) and prior history of a drug related neurotoxicity (p=0.047). BSA, performance status, gender, age, dose per m2, total planned dose, pretreatment Cr, and pretreatment albumin were not associated. Conclusions: The incidence of Ifos N is common using this nursing assessment tool, although usually low grade. We identified the formulation of Ifos and a prior history of drug related N as statistically correlated with developing N.

scholarly journals Decisions to Enter and Leave Skilled Nursing Facilities for Post-Acute Rehabilitation: A Qualitative Study

2020 ◽  
Vol 3 ◽  
Author(s):  
Daniel Chimitt ◽  
Jennifer Carnahan
Keyword(s):  
Older Adults ◽  
Qualitative Study ◽  
Comparative Method ◽  
Skilled Nursing Facilities ◽  
Phone Call ◽  
Healthcare Team ◽  
Discharge Process ◽  
Nursing Facilities ◽  
Skilled Nursing

Background and Hypothesis:   Approximately 40% of patients aged 80+ enter a Skilled Nursing Facility (SNF) following a hospitalization. SNFs can be used as “safety nets” to expedite the discharge process of older adults and it can be difficult to pinpoint how and who made the decision for a hospitalized older adult to discharge to a SNF.   This project examines the factors that drive older adults to enter and leave a SNF for their rehabilitation care.    Project Methods:   Interview transcripts from a qualitative study with patients and their caregivers were used to examine factors influencing admission to and discharge from SNFs. Baseline interviews were conducted within two to seven days after returning home from a SNF stay followed by a follow up phone call one to two weeks after the initial interview. Transcripts and audio files were coded (using NVivo version 12+) for major themes. Interviews were analyzed using a constant comparative method to elicit themes of interest to interviewees.    Results:   There were 24 baseline interviews and X follow up interviews performed with a total of 24 patients and 15 caregivers. The primary theme identified was that patients perceived a loss of autonomy when considering the decision-making process. 75% (18/24) patients or their caregivers felt the healthcare team told them they must go to a SNF for their rehabilitation. 38% (9/24) patients or caregivers felt they had no choice but to leave due to insurance coverage and 50% (12/24) stated that they needed more time.    Potential Impact:   To achieve better patient outcomes, one must understand both the purpose of skilled nursing facilities and also how patients and their families are feeling as they transition through this uncertain period of their lives. Restoring a patient’s sense of autonomy will foster better patient-healthcare relationships and improve trust in the system. 

Sign in / Sign up

Export Citation Format

Share Document