scholarly journals Lessons Learned by Medical Students about Systems-Based Practice as Patients Transition their Care

2021 ◽  
Author(s):  
Eduard Pey ◽  
Diego Sierra ◽  
Sydney Katz ◽  
Laura Greisman ◽  
Deanna Jannat-Khah ◽  
...  
Keyword(s):  
Medical Students ◽  
Care Coordination ◽  
Care Transitions ◽  
Transitions Of Care ◽  
Phone Call ◽  
Post Discharge ◽  
Medicine Clerkship ◽  
Practice Improvement ◽  
Phone Calls

Abstract Background: One in five patients suffer an adverse event within two weeks of discharge as they transition from one healthcare setting to another. Systems-based practice is a core competency of physicians and seeks to minimize these events; however, education of trainees is inconsistent. We asked whether structured post-discharge phone calls and reflections on barriers to discharge and practice improvement can enhance students’ understanding of systems-based practice. Method: Medical students in the Internal Medicine Clerkship were assigned to perform a structured post-discharge phone call on hospitalized patients as part of a “Transitions of Care” assignment. Students reflected on issues occurring at the transition from hospitalization to discharge. We performed qualitative analysis of 90 medical student responses and identified themes and sub-themes addressing issues with care transitions. Results: Students consistently identified barriers to safe discharge including issues scheduling follow-up care, poor care coordination, and inadequate social support. The post-discharge phone calls revealed problems with patients’ understanding of their discharge diagnosis, medication-related issues and patients’ failure to attend scheduled follow-up. Common student-proposed practice improvement interventions included: enhanced provider-patient communication and education, improved interdisciplinary collaboration and care coordination, and greater attention to patient’s psychosocial and financial status. Conclusions: Medical students learned about systems-based practice from a transitions of care assignment involving a post-discharge phone call, identifying critical events in over half of patients identified. Self-reflective practice within the context of direct patient care offers insights into practice improvement in care transitions.

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.

Expansion of an oncology care coordination nurse model to reduce hospitalizations and emergency department utilization.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 82-82
Author(s):  
Georgina T. Rodgers ◽  
Michelle Brusio ◽  
Jacob Lindberg ◽  
Craig Savage ◽  
Joseph Hooley ◽  
...  
Keyword(s):  
Patient Education ◽  
Care Coordination ◽  
Hospital Admissions ◽  
Care Transitions ◽  
Phone Call ◽  
Emergency Department Utilization ◽  
Coordinated Care ◽  
Care Coordinator ◽  
Oncology Care

82 Background: Comprehensive, coordinated care is a key driver of care transformation within the Oncology Care Model. Care coordination provides deliberate, organized, patient centered care initiatives aimed to improve care transitions, patient education, patient engagement and quality of care throughout the care continuum. Methods: Specialty care coordinator nurses were a part of our heath system’s model of care but over the course of our participation in the OCM we have implemented care coordination in our regional locations across 15 additional sites of care. Standardized templates for initial and follow up education were created for oral and parenteral therapies with an emphasis on symptom management education. A patient education tool was developed through a partnership with nursing, pharmacy and physicians across disease groups to outline when a patient should contact their physician or RN care coordinator with symptom issues. Targeted outreach calls and associated documentation templates were created for symptom assessment and adequate follow up. Templates include a pre-chemo orientation call, post treatment follow up phone call within seven days, and post hospital discharge/ED treat and release follow up calls. A team based huddle guideline was developed to provide a means for interdisciplinary communication to assess patients for high risk based upon medical, functional, social, cognitive and behavioral factors that might lead to a hospitalization. Results: Our teams worked closely with EMR specialists and internal data analysts to build appropriate templates and subsequent reports to monitor compliance with documentation, evaluate the number of outreach touch points and effectiveness of interventions on a reduction of hospitalizations and ED utilization. We have noted an a modest decrease in hospitalizations and ED utilization through OCM feedback reports and reconciliation reports. Conclusions: We continue to monitor our monthly hospital admissions and ED utilization across the health system and drill down into the data to determine if there are any opportunities where care coordination outreach and incoming telephone triage could have prevented the admission.

Abstract 360: A Simplified Post-Discharge Telephone Intervention To Reduce Hospital Readmission for Patients with Cardiovascular Disease.

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Gene F Kwan ◽  
Lana Kwong ◽  
Yun Hong ◽  
Abhishek Khemka ◽  
Gary Huang ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Statistical Significance ◽  
Hospital Readmissions ◽  
Intervention Group ◽  
Phone Call ◽  
Post Discharge ◽  
Coronary Syndrome ◽  
Phone Calls ◽  
Administrative Assistants

Background: Readmission rates are high for patients with cardiovascular disease, particularly heart failure (HF) and acute coronary syndrome (ACS). Telephone calls by clinical staff have had mixed effects. We aim to evaluate the degree of implementation and the effect of a quality improvement initiative using a simplified post-discharge phone call by administrative assistants. Methods: Clinical data were retrospectively reviewed at a single urban public hospital. From January through October 2012 all patient discharged home from inpatient cardiology services (intervention group, n=1034 discharges) were identified. Within 7 days, administrative assistants contacted patients via telephone and queried regarding (1) medication compliance, (2) awareness of follow-up appointments and (3) if clinician contact is requested. Outcome events were defined as readmissions (for any cause) within 30 days to the same hospital and are reported as patients experiencing readmission, and total readmissions. A comparison group of all patients discharged home from inpatient cardiology services from January through October 2010 (n=746) were selected as controls (no phone calls). Categorical data were compared in a univariate fashion using the Chi Square test. Statistical significance is defined as p<.05. Results: Of the 1034 discharge events in the intervention group, 620 (60.0%) had phone calls attempted. Of those, 419 (67.6%) were directly contacted. Patients were statistically different with respect to language, ethnicity and insurance status. Of the patients called, 48 (7.7%) reported medication abnormalities, 13 (2.1%) did not understand their follow-up and 38 (6.1%) had a question for a clinician. The rates of patients experiencing events was not statistically different (132 [17.7%] vs. 156 [15.1%], OR 0.85, p=.14). Total readmissions were significantly reduced (157[21.0%] vs. 179 [17.3%], OR 0.82, p=.047). Pre-specified subgroups of ACS and HF patients showed a trend towards decreased re-admissions but were not statistically significant. Conclusion: A simplified post-discharge telephone call strategy is associated with a trend towards reduced hospital readmissions for cardiology patients. Further refinements are needed to improve program implementation.

scholarly journals Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses’ and patients’ perspectives

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jinying Chen ◽  
Jessica G. Wijesundara ◽  
Angela Patterson ◽  
Sarah L. Cutrona ◽  
Sandra Aiello ◽  
...  
Keyword(s):  
Primary Care ◽  
Care Coordination ◽  
Pain Assessment ◽  
Transitional Care ◽  
Symptom Assessment ◽  
Medical Attention ◽  
Post Discharge ◽  
Phone Calls ◽  
Facilitators And Barriers

Abstract Background After hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients’ post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers. Methods Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model. Results Participants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI). Conclusions Strategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.

Abstract WP384: Feasibility Of Systematic Assessment Of 30-day Functional Outcomes After Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Irene L Katzan ◽  
Alice M Liskay ◽  
Siobhan Martin ◽  
Charles Thomas ◽  
Thomas E Love ◽  
...  
Keyword(s):  
Functional Status ◽  
Hospice Care ◽  
Multivariable Analysis ◽  
Policy Implications ◽  
Phone Call ◽  
Post Discharge ◽  
Systematic Assessment ◽  
Phone Calls ◽  
Significant Difference

Although functional status after stroke is widely considered important to measure, the feasibility of systematic assessment of functional status after stroke is unknown. Objective: To determine the feasibility of obtaining 30 day functional status via phone call follow-up by a central group of nurses spanning multiple hospitals. Methods: Prospective cohort study of patients admitted for stroke at 6 hospitals participating in the Ohio Coverdell Outcomes Evaluation Project. At 5 of these sites, patients were contacted by a central nurse 30-51days post discharge using a standardized protocol. In the remaining hospital, outpatient appointments were arranged for 30 days postdischarge. Patients who died inhouse or had hospice care were excluded from the follow-up protocol. Results: Of the 699 patients in this cohort, 53.1% were female and 76.4% were white. Mean age was 68.5 yrs and mean admission NIHSS was 6.0. Phonecalls were successfully completed in 65.8% of the 486 eligible patients. There was no significant difference in completion rates among the 5 hospitals. Most common reasons for unsuccessful phone followup were: patient/family never reached 22.8% (111/486) and patient opted-out 6.4% (31/486). Factors associated with unsuccessful phone call included: DNR order (15.7% vs 8.7%, p=0.021), longer lengths of stay (median days 4 vs 3, p=0.015), higher discharge Rankin (2.9 vs 2.6, p=0.06), and IV tPA use (6.6 vs 2.8, p=0.05). There was no association between completed phone calls and discharge destination. In multivariable analysis, only age (OR 1.02, 95% CI 1.00 - 1.04) and no DNR (OR 1.96, 95% CI 1.00 - 3.83) were independently associated with successful phone follow-up. Post discharge clinic visits were completed in 52.9% (46/87) patients at the remaining site, and there were similar clinical associations with a completed visit. Conclusion: Success of obtaining 30day phone follow-up is modest, occurring in 65.8% in 5 hospitals of varied types and patient populations. This has important policy implications for measuring stroke outcomes; systematic assessment of functional status post-discharge may require a combination of different methods to achieve high assessment rates.

Post-Hospital Syndrome (PHS) and Potentially Preventable Hospitalizations(PPH) in Adults. MonashWatch adult cohort patient telehealth journeys (Preprint)

2018 ◽  
Author(s):  
Associate Professor Martin ◽  
Narelle Hinckley ◽  
Keith Stockman ◽  
Donadl Campbell
Keyword(s):  
Adverse Outcomes ◽  
Phone Call ◽  
Post Discharge ◽  
Patient Journey ◽  
Preventable Hospitalizations ◽  
Acute Admission ◽  
Avoidable Hospitalizations ◽  
Self Rated Health ◽  
Phone Calls ◽  
Potentially Preventable Hospitalizations

BACKGROUND Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘threshold’ identified by HealthLinks Chronic Care (HLCC) algorithms using personal, diagnostic, and service data, excluding surgical and psychiatric admissions. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of health perceptions with more alerts per call indicating greater risk of Potentially Preventable Hospitalizations (PPH) and Post Hospital Syndrome (PHS). Most knowledge of PPH and PHS occurs at a macro-level with little understanding of fine-grained dynamics. OBJECTIVE To describe patterns of self-reported concerns and self-rated health 10 days before and after acute hospital admission in the telehealth intervention cohort of MonashWatch in the context of addressing PPH and PHS. METHODS Participants: 173 who had an acute admission of the of the 232 HLCC cohort with predicted 3+ admissions/year, in MW service arm for >40 days. Measures: Self-reported health and health care status in 764 MW phone call records which were classified into Total Alerts (all concerns - self-reported) and Red Alerts (concerns judged to be higher risk of adverse outcomes/admissions -acute medical and illness symptoms). Acute (non-surgical) admissions from Victorian Admitted Episode database. Analysis: Descriptive Timeseries homogeneity metrics using XLSTAT. RESULTS Self-reported problems (Total Alerts) statistically shifted to a higher level 3 days before an acute admission and stayed at a high level for the 10 days post discharge; reported acute medical and illness symptoms (Red Alerts) increased 1 day prior to admission and but remained at a higher level than before admission. Symptoms of concern did not change before admission or after discharge. Self-rated health and feeling depressed were reported to worsen 5 days post discharge. Patients reported more medication changes up to 2 days before acute admission. CONCLUSIONS These descriptive findings in a cohort of high risk individuals suggest a prehospital phase of what is termed PHS, which persisted on discharge and possibly worsened 5 days after discharge with worse self-rated health and depressive symptoms. Further research is needed. The role and place of community and hospital in such a cohort needs further investigation and research into PPH and PHS.

scholarly journals Impact of pharmacist-conducted anticoagulation patient education and telephone follow-up on transitions of care: a randomized controlled trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Lamis R. Karaoui ◽  
Elsy Ramia ◽  
Hanine Mansour ◽  
Nisrine Haddad ◽  
Nibal Chamoun
Keyword(s):  
Tertiary Care ◽  
Intervention Group ◽  
Bleeding Event ◽  
Transitions Of Care ◽  
Control Group ◽  
Published Data ◽  
Post Discharge ◽  
Readmission Rates ◽  
The Impact

Abstract Background There is limited published data in Lebanon evaluating the impact of supplemental education for anticoagulants use, especially DOACs, on clinical outcomes such as bleeding. The study aims to assess the impact of pharmacist-conducted anticoagulation education and follow-up on bleeding and readmission rates. Methods This study was a randomized, non-blinded interventional study conducted between August 2017 and July 2019 in a tertiary care teaching Lebanese hospital. Participants were inpatients ≥18 years discharged on an oral anticoagulant for treatment. Block randomization was used. The control group received the standard nursing counseling while the intervention group additionally received pharmacy counseling. Phone call follow-ups were done on day 3 and 30 post-discharge. Primary outcomes included readmission rates and any bleeding event at day 3 and 30 post-discharge. Secondary outcomes included documented elements of education in the medical records and reported mortality upon day 30 post-discharge. Results Two hundred patients were recruited in the study (100 patients in each study arm) with a mean age of 73.9 years. In the pharmacist-counseled group, more patients contacted their physician within 3 days (14% versus 4%; p = 0.010), received explicit elements of education (p < 0.001) and documentation in the chart was better (p < 0.05). In the standard of care group, patients were more aware of their next physician appointment date (52% versus 31%, p < 0.001). No difference in bleeding rates at day 3 and 30 post-discharge was observed between the groups. Conclusions Although pharmacist-conducted anticoagulation education did not appear to reduce bleeding or readmission rates at day 30, pharmacist education significantly increased patient communication with their providers in the early days post-discharge. Trial registration Lebanon Clinical Trial Registry LBCTR2020033424. Retrospectively registered. Date of registration: 06/03/2020.

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.

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.

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