scholarly journals CARE TRANSTION IN HOSPITAL DISCHARGE FOR ADULT PATIENTS: INTEGRATIVE LITERATURE REVIEW

2021 ◽  
Vol 30 ◽  
Author(s):  
Jociele Gheno ◽  
Alísia Helena Weis
Keyword(s):  
Hospital Discharge ◽  
Continuity Of Care ◽  
Care Transitions ◽  
Hospital Costs ◽  
Experimental Studies ◽  
Adult Patients ◽  
Care Transition ◽  
Discharge Process ◽  
Post Discharge ◽  
Discharge Care

ABSTRACT Objective: to summarize and analyze the scientific production on care transition in the hospital discharge of adult patients. Method: integrative review, conducted from May to July 2020, in four relevant databases in the health area: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus and Virtual Health Library (VHL). The analysis of the results occurred descriptively and was organized into thematic categories that emerged according to the similarity of the contents extracted from the articles. Results: 46 articles from national and international journals, with a predominance of descriptive/non-experimental studies or qualitative studies, met the inclusion criteria. Five categories were identified: discharge and post-discharge process; Continuity of post-discharge care; Benefits of care transition; Role of nurses in care transition and Experiences of patients on care transition. Hospital discharge and care transitions are interconnected processes as transitions qualify the dehospitalization process. Different strategies for continuity of care should be adopted, as they offer greater safety to the patient. Studies have shown that nurses play a fundamental role in transitions and, in Brazil, this activity still needs to gain more space. Reduced hospitalizations, mortality, hospital costs and patient satisfaction are benefits of transitions. Conclusion: care transition is an effective strategy for the care provided to the patient being discharged. It points out the need for integration between the care network and assists services in decision-making about the continuity of care on discharge.

Optimization of Provider Ecosystem Through Actor-Resource Integration

2020 ◽  
pp. 103-115
Author(s):  
Mohan Tanniru
Keyword(s):  
Information Technology ◽  
Social Media ◽  
Continuity Of Care ◽  
Healthcare Providers ◽  
Care Transition ◽  
The Internet ◽  
Post Discharge ◽  
Discharge Care ◽  
Internal Operations ◽  
Insight Into

Information technology has enabled healthcare providers such as hospitals to extend their internal operations into external facilities such as urgent and ambulatory care centers and optimizeresources in support of patient care. With the development of the internet, social media, wearables, and telehealth technologies, the potential for patient engagement in preventive and post-discharge care transition has increased. Unlike other organizations where the provider has limited insight into the customer ecosystem, hospitals, for example, have an opportunity to gain insight into the patient ecosystem and influence patient behavior while the patients are within the provider ecosystem. This chapter looks at hospital engagement with patients in two settings—the emergency room (ER) and the patient room (PR)—to illustrate both the opportunities and the strategies that can help hospitals use patient touchpoints to improve continuity of care inside and outside hospital walls.

scholarly journals Association of continuity of care with readmission, mortality and suicide after hospital discharge among psychiatric patients

2020 ◽  
Vol 32 (9) ◽  
pp. 569-576
Author(s):  
Young Choi ◽  
Chung Mo Nam ◽  
Sang Gyu Lee ◽  
Sohee Park ◽  
Hwang-Gun Ryu ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Continuity Of Care ◽  
Psychiatric Patients ◽  
Psychiatric Inpatients ◽  
Post Discharge ◽  
Increased Risk ◽  
All Cause Mortality ◽  
Nested Case Control ◽  
Control Study

Abstract Objectives The objective of this study was to identify the association between continuity of ambulatory psychiatric care after hospital discharge among psychiatric patients and readmission, mortality and suicide. Design Nationwide nested case-control study. Settings South Korea. Participants Psychiatric inpatients. Interventions Continuity of psychiatric outpatient care was measured from the time of hospital discharge until readmission or death occurred, using the continuity of care index. Main Outcome Measures Readmission, all-cause mortality and suicides within 1-year post-discharge. Results Of 18 702 psychiatric inpatients in the study, 8022 (42.9%) were readmitted, 355 (1.9%) died, and 108 (0.6%) died by suicide within 1 year after discharge. Compared with the psychiatric inpatients with a high continuity-of-care score, a significant increase in the readmission risk within 1 year after discharge was found in those with medium and low continuity of care scores. An increased risk of all-cause mortality within 1 year after hospital discharge was shown in the patients in the low continuity group, relative to those in the high-continuity group. The risk of suicide within 1 year after hospital discharge was higher in those with medium and low continuity of care than those with high continuity of care. Conclusion The results of this study provide empirical evidence of the importance of continuity of care when designing policies to improve the quality of mental health care, such as increasing patient awareness of the importance of continuity and implementation of policies to promote continuity.

scholarly journals ROLE OF NURSES FOR CONTINUITY OF CARE AFTER HOSPITAL DISCHARGE

2020 ◽  
Vol 29 (spe) ◽  
Author(s):  
Magaly Del Carmen Gallardo Guzmán ◽  
Alexandra Ferreira ◽  
Selma Regina de Andrade
Keyword(s):  
Hospital Discharge ◽  
Continuity Of Care ◽  
Patient Discharge ◽  
Hospital Nursing ◽  
Healthcare Transition ◽  
Discharge Care ◽  
Nursing Services ◽  
Analysis Technique ◽  
Discharge From Hospital

ABSTRACT Objective: to recognize the role of nurses to maintain continuity of care for users after hospital discharge. Method: an exploratory, descriptive study with a qualitative approach. The study was applied at hospital discharge originating from the most complex health center in Magallanes, the Hospital Clinico Magallanes, Chile. Data were collected through interviews with nurses, carried out between May and August 2018. To analyze the material, the content analysis technique was used. Results: three categories emerged, which bring together what nurses mention in their discourse: How they see the implementation of hospital nursing services, which facilitate continuity of care in the healthcare network of discharged patients (known as care networks); Who they identify in the nursing service for continuity of care after discharge (care networks), which these nursing professionals make and suggestions for their performance; and How care networks affect users in continuity of care after discharge. Conclusion: the role of nurses is key in patient discharge from hospital. With autonomy and competencies for comprehensive care, professionals facilitate the healthcare transition; manage hospital discharge, convening the institutional nursing network and the emerging networks with primary health care; aspire to develop strategies for an inter-level care network, with systematic participation.

scholarly journals Receipt of Training Among Family Caregivers Assisting With a Post-Hospital Care Transition

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 92-92
Author(s):  
Julia Burgdorf ◽  
Chanee Fabius ◽  
Catherine Riffin ◽  
Jennifer Wolff
Keyword(s):  
Older Adults ◽  
Family Caregivers ◽  
Hospital Care ◽  
Transitional Care ◽  
Care Plan ◽  
National Study ◽  
Care Transition ◽  
Discharge Process ◽  
Post Discharge ◽  
Care Training

Abstract Medicare Conditions of Participation require hospitals to provide training to family and unpaid caregivers when their support is necessary to enact the post-discharge care plan. However, caregivers often report feeling unprepared for this role. We perform a cross-sectional analysis of the 2017 National Health and Aging Trends Study and its linked National Study of Caregiving (nationally representative surveys of older adults and their family and unpaid caregivers, respectively) to assess the prevalence of, and factors associated with, caregiver receipt of adequate transitional care training. Our analytic sample includes 795 (weighted n=7,083,222) family caregivers who assisted an older adult during a post-hospital care transition in the past year. The outcome of interest caregiver-reported receipt of the training needed to manage this transition (“adequate transitional care training”) from hospital staff. Six in ten (59.1%) caregivers who assisted during a post-hospital care transition reported receiving adequate transitional care training. In weighted, multivariable logistic regression models, caregivers were half as likely to report receiving adequate transitional care training if they were black compared to white (Adjusted Odds Ratio (aOR): 0.52; 95% CI: 0.31-0.89) or experienced financial difficulty (aOR: 0.50; 95% CI: 0.31-0.81). Findings suggest that socially vulnerable family caregivers of older adults are less likely to report receiving adequate transitional care training. Changes to the discharge process, such as using standardized caregiver assessments, may be necessary to ensure equitable support of family caregivers.

Abstract TP379: The Impact of a Nurse Navigator-Centered Discharge Plan on Care Transitions for Patients Discharged From a Comprehensive Stroke Center

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Frances Jaime ◽  
Cristina Carillo-Gutierrez ◽  
Kim Smith ◽  
Marwah Elsehety ◽  
Peri Smith ◽  
...  
Keyword(s):  
Clinical Symptoms ◽  
Care Transition ◽  
Discharge Process ◽  
Stroke Patients ◽  
Post Discharge ◽  
Home Discharge ◽  
Nurse Navigator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Background: An effective care transition plan at the time of a stroke discharge impacts risk factor control, readmissions, and patient satisfaction. In our Comprehensive Stroke Center (CSC), we assigned a registered nurse to be our Stroke Nurse Navigator (SNN). The SNN meets with patients and caregivers prior to discharge to address care transition needs and answers the Stroke Nurse Helpline to provide assistance after discharge. Purpose: To assess the impact of the SNN in meeting care transition needs of patients discharged home from a CSC Methods: Stroke patients in our CSC are called within 72 hours after home discharge, and a standard questionnaire is used to assess satisfaction with the discharge process. We compared post-discharge callback data from stroke patients during a 6-month period before (1/1/18 to 6/30/18) and after (7/1/18 to 12/31/18) designation of the SNN. Results: Among 413 stroke patients who completed questionnaires, 207 were pre-SNN and 206 were post-SNN, representing 55% and 47% of home discharges respectively. There was a 46% decrease in all concerns: 74% in non-clinical concerns, 70% in complaints about hospital experience, and 45% in reported early admissions (Table 1). There were fewer reported concerns about activity restrictions and assistive devices (100% decrease), outpatient therapy (76% decrease), prescriptions (75% decrease), outpatient testing (60% decrease), and other discharge information (29%). There were more concerns related to clinical symptoms after hospitalization (36% increase), establishing care with primary provider or neurologist (36% increase), and understanding home medications. Conclusion: SNNs may play a role in meeting care transition needs of stroke patients by providing assistance before and early after a home discharge. SNNs may foster heightened awareness among stroke patients and caregivers about following through on recommended post-hospital care for better recovery outcomes.

Capturing rich person-centred discharge information: exploring the challenges in developing a new model

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Nyree J. Taylor ◽  
Reeva Lederman ◽  
Rachelle Bosua ◽  
Marcello La Rosa
Keyword(s):  
Patient Care ◽  
Hospital Discharge ◽  
Process Mining ◽  
Specific Information ◽  
Discharge Process ◽  
Post Discharge ◽  
Patient Journey ◽  
Discharge Data ◽  
Content Type ◽  
Coronary Syndrome

PurposeCapture, consumption and use of person-centred information presents challenges for hospitals when operating within the scope of limited resources and the push for organisational routines and efficiencies. This paper explores these challenges for patients with Acute Coronary Syndrome (ACS) and the examination of information that supports successful hospital discharge. It aims to determine how the likelihood of readmission may be prevented through the capturing of rich, person-specific information during in-patient care to improve the process for discharge to home.Design/methodology/approachThe authors combine four research data collection and analysis techniques: one, an analysis of the patient record; two, semi-structured longitudinal interviews; three, an analysis of the patient's journey using process mining to provide analytics about the discharge process, and four, a focus group with nurses to validate and confirm our findings.FindingsThe authors’ contribution is to show that information systems which support discharge need to consider models focused on individual patient stressors. The authors find that current discharge information capture does not provide the required person-centred information to support a successful discharge. Data indicate that rich, detailed information about the person acquired through additional nursing assessments are required to complement data provided about the patient's journey in order to support the patients’ post-discharge recovery at home.Originality/valuePrior research has focused on information collection constrained by pre-determined limitations and barriers of system design. This work has not considered the information provided by multiple sources during the whole patient journey as a mechanism to reshape the discharge process to become more person-centred. Using a novel combination of research techniques and theory, the authors have shown that patient information collected through multiple channels across the patient care journey may significantly extend the quality of patient care beyond hospital discharge. Although not assessed in this study, rich, person-centred discharge information may also decrease the likelihood of patient readmission.

scholarly journals The Health Department of Sicily “Regional recommendations for hospital discharge and communication with patients after admission due to a cardiologic event” Decree

2015 ◽  
Vol 82 (2) ◽  
Author(s):  
Maurizio Giuseppe Abrignani ◽  
Giovanni De Luca ◽  
Michele Gabriele ◽  
Nidal Tourkmani
Keyword(s):  
Primary Care ◽  
Hospital Discharge ◽  
Task Force ◽  
Care Transitions ◽  
Treatment Compliance ◽  
Health Department ◽  
Discharge Process ◽  
Scientific Societies ◽  
Thrombotic Risk ◽  
Discharge Letter

Mortality and rehospitalizations still remain high after discharge for an acute cardiologic event. In this context, hospital discharge represents a potential pitfall for heart disease patients. In the setting of care transitions, the discharge letter is the main instrument of communication between hospital and primary care. Communication, besides, is an integral part of high-quality, patient-centered interventions aimed at improving the discharge process. Inadequate information at discharge significantly affects the quality of treatment compliance and the adoption of lifestyle modifications for an effective secondary prevention. The Health Department of Sicily, in 2013, established a task force with the aim to elaborate “Regional recommendations for hospital discharge and communication with patients after admission due to a cardiologic event”, inviting to participate GICR-IACPR and many other scientific societies of cardiology and primary care, as discharge letter and communication are fundamental junctions of care transitions in cardiology. These recommendations have been published as a specific decree and contain: – a structured model of discharge letter, which includes all of the parameters characterizing patients at high clinical risk, high thrombotic risk and low risk according to the Consensus document ANMCO/GICR-IACPR/GISE; is thus possible to identify these patients, choosing consequently the most appropriate follow-up pathways. A particular attention has been given to the “Medication Reconciliation” and to the identification of therapeutic targets; – an educational Kit, with different forms on cardiac diseases, risk factors, drugs and lifestyle; – a check-list about information given to the patient and caregivers. The “Recommendations” represent, in conclusion, the practical realization of the fruitful cooperation between scientific societies and political-administrative institutions that has been realized in Sicily in the last years.

scholarly journals Care transition of patients with chronic diseases from the discharge of the emergency service to their homes

2020 ◽  
Vol 41 (spe) ◽  
Author(s):  
Aline Marques Acosta ◽  
Maria Alice Dias da Silva Lima ◽  
Ione Carvalho Pinto ◽  
Luciana Andressa Feil Weber
Keyword(s):  
Emergency Department ◽  
Chronic Diseases ◽  
Care Transitions ◽  
Management Training ◽  
Care Transition ◽  
Discharge Process ◽  
Cross Sectional ◽  
South Of Brazil ◽  
Emergency Department Discharge

ABSTRACT Objective: To evaluate the quality of the care transition for patients with chronic non-communicable diseases discharged from the emergency department to home. Method: A cross-sectional observational and epidemiological study conducted at an emergency department in the South of Brazil with 117 patients and 81 caregivers. The Care Transitions Measure was applied by phone to collect data. A descriptive and analytical statistical analysis was performed. Results: The quality of the care transition’s total score was close to satisfactory (69.5). The “Self-Management Training” factor had the highest score (70.6), while “Understanding medications” had the lowest (68.3). Items related to understanding medications and confidence in carrying out care after discharge obtained lower scores. Conclusions: A moderate quality of the care transition was evidenced, as well as the need to adopt strategies to improve the emergency department discharge process and the continuity of the care of patients with chronic diseases.

scholarly journals CONTINUITY OF HOSPITAL DISCHARGE CARE FOR PRIMARY HEALTH CARE: SPANISH PRACTICE

2020 ◽  
Vol 29 ◽  
Author(s):  
Maria Fernanda Baeta Neves Alonso da Costa ◽  
Suely Itsuko Ciosak ◽  
Selma Regina de Andrade ◽  
Cilene Fernandes Soares ◽  
Esperanza I. Ballesteros Pérez ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Primary Health Care ◽  
Hospital Discharge ◽  
Continuity Of Care ◽  
University Hospitals ◽  
Online Questionnaire ◽  
Primary Health ◽  
Discharge Care ◽  
Discharge Plan

ABSTRACT Objective: to understand discharge plan and the facilities and difficulties for continuity of care in Primary Health Care. Method: a qualitative and exploratory study carried out in Madrid, Barcelona, Murcia, Seville and Granada, with 29 hospital liaison nurses working in university hospitals, between 2016 and 2018. For data collection, an online questionnaire was used with open and closed questions about the profile of nurses; work context; hospital discharge plan; communication between hospital nurses and primary care. All were analyzed based on Thematic Analysis. Results: hospital liaison nurses from Spain draw up a discharge plan at least 48 hours in advance. They offer a Continuity of Care Report, guide patients, families and caregivers to the necessary care after hospital discharge, coordinate consultations and referrals and carry out home visits. Communication with primary care occurs through the computerized system and telephone. Monitoring takes place using indicators and statistical reports. In cases of readmission, nurses are requested and contacted by nurses in primary care. Communication with primary care is among the facilities. Lack of liaison nurses is among the difficulties. Conclusion: hospital liaison nurses from Spain carry out a discharge plan and communicate with primary care. When patients are hospitalized, they are called when there is a need for continuity of care for primary care.

scholarly journals PRACTICES OF HOSPITAL NURSES FOR CONTINUITY OF CARE IN PRIMARY CARE: AN EXPLORATORY STUDY

2021 ◽  
Vol 30 ◽  
Author(s):  
Maria Fernanda Baeta Neves Alonso da Costa ◽  
Esperanza I. Ballesteros Perez ◽  
Suely Itsuko Ciosak
Keyword(s):  
Primary Care ◽  
Continuity Of Care ◽  
Structured Interview ◽  
Hospital Nurses ◽  
Management Service ◽  
University Hospitals ◽  
Care Needs ◽  
Post Discharge ◽  
Discharge Care ◽  
Director Of Nursing

ABSTRACT Objective: to know the practices developed by hospital nurses for continuity of care for Primary Care. Method: this is an exploratory, qualitative research conducted in university hospitals in São Paulo and Curitiba, Brazil. For data collection, a semi-structured interview was conducted with the Director of Nursing and an online questionnaire through open-ended and closed-ended questions, with nurses between August 2018 and July 2019. The analyzes of the interviews were carried out as proposed by Minayo based on in the theoretical framework of continuity of care. Results: the research was conducted at three university hospitals, and one Director of Nursing and 48 nurses participated. From analysis of nurses’ answers, two categories of analysis emerged: identification of post-discharge patients’ care needs and the necessary competencies for continuity of care. Where it was perceived since patients’ admission, nurses’ concern for continuity of post-hospital discharge care, establishing flows together with nurses of the Internal Center for Regulation/Discharge Management Service for the Health Department of the municipality, which forwards to patients’ reference health unit. Conclusion: although nurses are professionals who actively participates in care at various points in the health care network and recognizes the importance of continuing post-discharge care, they remain a fragile point in the care chain, and it is necessary to strengthen this mechanism with Primary Care, optimize home care and avoid hospitalizations.

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