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

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.

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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.

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Intern Transitions of Care Curriculum Through Posthospital Home and Skilled Nursing Facility Visits

Journal of Graduate Medical Education ◽

10.4300/jgme-17-00499.1 ◽

2018 ◽

Vol 10 (4) ◽

pp. 442-448 ◽

Cited By ~ 1

Author(s):

Rachel K. Miller ◽

Shimrit Keddem ◽

Samuel Katz ◽

Zachary Smith ◽

Christina R. Whitehouse ◽

...

Keyword(s):

Home Visit ◽

Skilled Nursing Facility ◽

Transitions Of Care ◽

Discharge Process ◽

Nursing Facility ◽

Skilled Nursing ◽

Team Members ◽

Care Experience ◽

Home Care Nurse ◽

Medical Histories

ABSTRACT Background Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care. Objective We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum. Methods The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011–2012; cohort 2: 2012–2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed. Results Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofessional team members' roles and the discharge process for patients with complex medical histories. Seventy-nine percent (26 of 33) reported continued use of medication reconciliation at discharge, and 64% (21 of 33) reported the experience enhanced their ability to identify threats to transitions. Of cohort 2 interns, 88% (42 of 48) participated in the home visit and 69% (33 of 48) in the skilled nursing facility visit. Intern reflections revealed insights gained, incomprehensive discharge plans, posthospital health care teams, and patients' postdischarge experience. Conclusions An experiential transitions of care curriculum is feasible and acceptable. Residents reported using the curriculum 18 to 20 months after exposure.

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Diabetes Discharge Planning and Transitions of Care: A Focused Review

Current Diabetes Reviews ◽

10.2174/1573399814666180711120830 ◽

2019 ◽

Vol 15 (2) ◽

pp. 111-117 ◽

Cited By ~ 9

Author(s):

Robin L. Black ◽

Courtney Duval

Keyword(s):

Patient Outcomes ◽

Hospital Admissions ◽

Discharge Planning ◽

Medication Management ◽

Hospital Readmissions ◽

The United States ◽

Transitions Of Care ◽

Discharge Process ◽

The Impact ◽

Diabetes Patients

Background: Diabetes is a growing problem in the United States. Increasing hospital admissions for diabetes patients demonstrate the need for evidence-based care of diabetes patients by inpatient providers, as well as the importance of continuity of care when transitioning patients from inpatient to outpatient providers. Methods: A focused literature review of discharge planning and transitions of care in diabetes, conducted in PubMed is presented. Studies were selected for inclusion based on content focusing on transitions of care in diabetes, risk factors for readmission, the impact of inpatient diabetes education on patient outcomes, and optimal medication management of diabetes during care transitions. American Diabetes Association (ADA) guidelines for care of patients during the discharge process are presented, as well as considerations for designing treatment regimens for a hospitalized patient transitioning to various care settings. Results: Multiple factors may make transitions of care difficult, including poor communication, poor patient education, inappropriate follow-up, and clinically complex patients. ADA recommendations provide guidance, but an individualized approach for medication management is needed. Use of scoring systems may help identify patients at higher risk for readmission. Good communication with patients and outpatient providers is needed to prevent patient harm. A team-based approach is needed, utilizing the skills of inpatient and outpatient providers, diabetes educators, nurses, and pharmacists. Conclusion: Structured discharge planning per guideline recommendations can help improve transitions in care for patients with diabetes. A team based, patient-centered approach can help improve patient outcomes by reducing medication errors, delay of care, and hospital readmissions.

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Surgical Interventions in Patients Hospitalised with COVID-19. A Review of Seven Months of Experience Working in a COVID-19 Dedicated Centre

Journal of Clinical Medicine ◽

10.3390/jcm10030395 ◽

2021 ◽

Vol 10 (3) ◽

pp. 395

Author(s):

Justyna Rymarowicz ◽

Michał Pędziwiatr ◽

Piotr Major ◽

Bryan Donohue ◽

Karol Ciszek ◽

...

Keyword(s):

Emergency Surgery ◽

Surgical Procedure ◽

Surgical Care ◽

Major Surgery ◽

Surgical Specialty ◽

Surgical Interventions ◽

Face To Face ◽

Overall Mortality

The Coronavirus Disease 2019 (COVID-19) pandemic has made changes to the traditional way of performing surgical consultations. The aim of the present study was to assess the need for surgical care performed by various surgical specialties among patients infected with COVID-19 hospitalized in a COVID-19 dedicated hospital. All surgical consultations performed for patients infected with COVID-19 in a COVID dedicated hospital in a seven month period were evaluated. Data on demographics, surgical specialty, consult reason, procedure performed, and whether it was a standard face to face or teleconsultation were gathered. Out of 2359 COVID-19 patients admitted to the hospital in the seven month period, 229 (9.7%) required surgical care. Out of those 108 consultations that did not lead to surgery, 71% were managed by telemedicine. A total of 36 patients were operated on while suffering from COVID-19. Out of them, only three patients admitted primarily for COVID-19 pneumonia underwent emergency surgery. The overall mortality among those operated on was 16.7%. Conclusions: Patients hospitalised with COVID-19 may require surgical care from various surgical specialties, especially during peaks of the pandemic. However, they rarely require a surgical procedure and only occasionally require major surgery. A significant portion of potentially surgical problems could be managed by teleconsultations.

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Robotics and Reproductive Surgery

Seminars in Reproductive Medicine ◽

10.1055/s-0037-1602594 ◽

2017 ◽

Vol 35 (04) ◽

pp. 364-377 ◽

Cited By ~ 1

Author(s):

Ian Waldman ◽

Antonio Gargiulo ◽

Stephanie Estes

Keyword(s):

Surgical Care ◽

Postoperative Recovery ◽

Natural Orifice ◽

Robotic Technology ◽

Patient Centered ◽

Patient Acceptability ◽

Conscious Patient ◽

Recovery Pathways ◽

Sterilization Reversal ◽

Improve Patient

AbstractRobotic technology applied to laparoscopy augments the armamentarium of the reproductive specialist. Uterine leiomyomas, adenomyosis, endometriosis, adnexal masses, sterilization reversal, and fertility preservation techniques can all be addressed with a robotic surgery skill set. Additionally, new approaches with single site and natural orifice surgery will continue to maximize advanced opportunities for safe, effective, and cosmetically conscious (patient-centered) approaches to surgical care. Enhanced postoperative recovery pathways are fully adaptable to these robotic procedures and improve patient acceptability while controlling costs.

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Preventing Breakdowns in Communication: Teaching Patient-Centered Posthospital Care Transitions to Medical Students

MedEdPORTAL ◽

10.15766/mep_2374-8265.10435 ◽

2016 ◽

Vol 12 (1) ◽

Cited By ~ 1

Author(s):

Maureen D. Lyons ◽

D. Bailey Miles ◽

Andrew M. Davis ◽

Mark B. Saathoff ◽

Amber T. Pincavage

Keyword(s):

Medical Students ◽

Care Transitions ◽

Patient Centered

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A patient-centered system in a provider-centered world: challenges of incorporating post-discharge wound data into practice

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocv183 ◽

2016 ◽

Vol 23 (3) ◽

pp. 514-525 ◽

Cited By ~ 32

Author(s):

Patrick C Sanger ◽

Andrea Hartzler ◽

Ross J Lordon ◽

Cheryl AL Armstrong ◽

William B Lober ◽

...

Keyword(s):

Design Process ◽

Data Transfer ◽

Clinical Care ◽

Healthcare Providers ◽

Surgical Patients ◽

Discharge Process ◽

Post Discharge ◽

Patient Centered ◽

Semistructured Interviews ◽

Present Design

Objective The proposed Meaningful Use Stage 3 recommendations require healthcare providers to accept patient-generated health data (PGHD) by 2017. Yet, we know little about the tensions that arise in supporting the needs of both patients and providers in this context. We sought to examine these tensions when designing a novel, patient-centered technology – mobile Post-Operative Wound Evaluator (mPOWEr) – that uses PGHD for post-discharge surgical wound monitoring. Materials and Methods As part of the iterative design process of mPOWEr, we conducted semistructured interviews and think-aloud sessions using mockups with surgical patients and providers. We asked participants how mPOWEr could enhance the current post-discharge process for surgical patients, then used grounded theory to develop themes related to conflicts and agreements between patients and providers. Results We identified four areas of agreement: providing contextual metadata, accessible and actionable data presentation, building on existing sociotechnical systems, and process transparency. We identified six areas of conflict, with patients preferring: more flexibility in data input, frequent data transfer, text-based communication, patient input in provider response prioritization, timely and reliable provider responses, and definitive diagnoses. Discussion We present design implications and potential solutions to the identified conflicts for each theme, illustrated using our work on mPOWEr. Our experience highlights the importance of bringing a variety of stakeholders, including patients, into the design process for PGHD applications. Conclusion We have identified critical barriers to integrating PGHD into clinical care and describe design implications to help address these barriers. Our work informs future efforts to ensure the smooth integration of essential PGHD into clinical practice.

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Facilitating Home Hospice Transitions of Care in Oncology: Evaluation of Clinical Pharmacists’ Interventions, Hospice Program Satisfaction, and Patient Representation Rates

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909118765944 ◽

2018 ◽

Vol 35 (9) ◽

pp. 1181-1187 ◽

Cited By ~ 2

Author(s):

Alison P. Duffy ◽

Nina M. Bemben ◽

Jueli Li ◽

James Trovato

Keyword(s):

Medication Reconciliation ◽

Transitions Of Care ◽

Cancer Center ◽

Discharge Process ◽

Program Satisfaction ◽

Discharge Medication ◽

Pharmacist Interventions ◽

Center Care ◽

Discharge Readiness

Background: The importance of medication reconciliation and the pharmacist’s role within the interdisciplinary team at the point of transition to home hospice is understudied. A transitions of care pilot initiative was developed to streamline the transition for patients at end of life from inpatient cancer center care to home hospice. The initiative consisted of using a hospice discharge checklist, pharmacist-led discharge medication reconciliation in consultation with the primary team responsible for inpatient care, review of discharge prescriptions, and facilitation of bedside delivery of discharge medications. Methods: This was a single-center, prospective, pilot initiative. The objectives of this study were to characterize pharmacist interventions at the time of transition, to assess changes in hospice organizations’ perceptions of discharge readiness, and to evaluate differences in representation rates with the implementation of the pilot discharge process. Results: Fifteen patients in the preimplementation period and 12 patients in the postimplementation period were included. One hundred eleven pharmacist interventions were captured, an average of 9.3 interventions per patient, with an acceptance rate of 82.9% by providers. There was a statistically significant ( P = .035) improvement in hospice organizations’ perceptions of discharge readiness. There was no difference in 30-day representation rates postdischarge ( P = 1). Conclusion: This well-received pilot initiative demonstrated an improvement in local hospice’s perception of patient readiness for discharge and a high percentage of accepted pharmacist interventions during discharge medication reconciliation. A larger sample size of patients and longer follow-up period may be needed to demonstrate statistically significant improvements in representation rates postintervention.

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Teaching a DISCHARGE Framework to Hospital Teams to Improve Transitions of Care

10.21203/rs.2.23445/v1 ◽

2020 ◽

Author(s):

Shreya P. Trivedi ◽

Mack Lipkin ◽

Mark D. Schwartz

Keyword(s):

Ad Hoc ◽

Discharge Planning ◽

Transitions Of Care ◽

Hospital Discharges ◽

Patient Centered ◽

Team Members ◽

Informal Curriculum ◽

Discharge Plan ◽

Perceived Change ◽

Hospital Teams

Abstract Background: Residents typically learn about managing transitions of care as part of the informal curriculum in an ad-hoc, reactive manner. Learning may be enhanced by using a framework to proactively practice addressing key domains for a patient soon-to-be-discharged from the hospital. We developed such an evidence-based framework, DISCHARGE , as a cognitive aid. Using this framework, we implemented and evaluated a workshop designed for hospital teams to learn addressing key components of discharging a patient.Methods: All members of 8 Internal Medicine teams across 4 rotations were invited to attend an hour-long workshop ranging from September 2017 - February 2018. Participants completed a retrospective, pre-post survey on their perceived change in discharge-related behaviors. We evaluated the perceived effectiveness of the workshop with a retrospective pre-post questionnaire. We used Wilcoxon signed-rank tests for pairwise comparisons to access perceived changes in discharge behaviors.Results: A total of 90 of 140 team members (64%) attended the workshop and 79 of the 90 (87%) completed the questionnaire. The session was effective in increasing the likelihood of addressing patient-centered behaviors at discharge (mean 1.4 improvement on a 5-point scale, P<0.001, R>0.5). In addition, senior residents and attendings projected they were more likely to discuss the importance of discharge planning with the team early in a rotation. Interns noted they were more comfortable asking the team for help in carrying out a discharge plan (p<0.001, R>0.5).Conclusions: Teaching teams a cognitive aid to practice managing hospital discharges may increase the likelihood of addressing important domains for their patients. Incorporating the team allows for explicit alignment for priorities and communication. Further study is needed to document how such learning is translated into discharge practice.

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Abstract 17161: Type and Intensity of Strategies to Reduce Readmissions Under the Hospital Readmissions Reduction Were Not Associated With Improvements in Readmission Rates

Circulation ◽

10.1161/circ.142.suppl_3.17161 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

J Gmerice Hammond ◽

Jonathan Yu ◽

Jose Figueroa ◽

Karen E Joynt Maddox

Keyword(s):

Acute Care ◽

High Intensity ◽

Hospital Readmissions ◽

Acute Care Hospitals ◽

Transitions Of Care ◽

Patient Centered ◽

Readmission Rates ◽

Hospital Size ◽

Reduction Strategies ◽

Individual Strategies

Background: Little is known about what strategies are associated with improvements in hospital readmissions under the Hospital Readmissions Reduction Program. Objective: To determine whether the type or intensity of readmission reduction strategies were associated with changes in readmission rates for heart failure, acute myocardial infarction, and pneumonia among acute care hospitals participating in the HRRP. Methods: We surveyed leaders of 1,600 U.S. acute care hospitals participating in the HRRP about their use of 13 specific strategies to reduce readmissions. Strategies were grouped into three domains: transitions of care (TOC, e.g. discharge checklist), quality improvement (QLT, e.g. medication reconciliation), and patient-centered (PC, e.g. patient engagement programs). Intensity of each domain was scored as high or low according to how many strategies were implemented. We calculated hospital-level readmission rates prior to (2011-12) and following (2014-15) HRRP implementation. We used linear regression to determine if there were associations between individual strategies, domains, or overall scope of strategies and a reduction in readmission rates. Results: Of the 1,600 hospitals surveyed, 926 participated (58% response rate). Hospitals reported using 6.1 (SD 2.5) strategies on average. TOC was the most commonly used domain: 69% of hospitals scored high intensity in TOC, compared to only 22% and 14% of hospitals scoring high intensity in QLT and PC domains, respectively. After adjusting for hospital size, type, teaching status, and location, there were no statistically significant associations between any individual strategy and changes in readmission rates, nor between domain intensity and changes in readmission rates. Nearly half of all hospitals, 49%, scored high in only one domain; only 22% scored high in two domains and 5% scored high in all three domains. In fully adjusted models, there was no association between scoring high in multiple domains and reducing readmission rates. Conclusions: Under the HRRP, hospitals focused most on transitions of care strategies. There was no evidence that any of the most commonly employed strategies for reducing readmissions were associated with differential changes in readmission rates.

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