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

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.

scholarly journals EMERGING MODELS OF CARE: THE IMPACT OF PHARMACIST-LED MEDICATION MANAGEMENT IN A TRANSITIONAL CARE PROGRAM

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S708-S708
Author(s):  
Ebony Andrews ◽  
Travonia Brown-Hughes ◽  
Ronald Lyon ◽  
Shanea D Parker ◽  
Brad Lazernick
Keyword(s):  
Transitional Care ◽  
Medication Management ◽  
Hospital Readmissions ◽  
Care Transitions ◽  
Patient Activation ◽  
Care Program ◽  
Transition Process ◽  
Models Of Care ◽  
Care Transition ◽  
The Impact

Abstract Transitional care programs have emerged as successful models of care in which to reduce cost and improve health outcomes. However, few transitional care models have directly incorporated the expertise of the pharmacist as an integral member of the care coordination team. Therein lies an inherent limitation of many community-based transitional care programs, the underutilization of pharmacist during all stages of the care transition process. In 2013, the Hampton Roads Care Transitions Project (HRCTP), a partnership between Senior Services of Southeastern Virginia Area Agency on Aging in Norfolk, VA and Hampton University School of Pharmacy, was established. The goal of the HRCTP is to provide medication management services to reduce preventable hospital readmissions for adults 60 years of age and older with targeted diagnoses. Pharmacists work in collaboration with social workers who act as HRCTP care transition coaches. Between May 2017- October 2018, 678 patients were enrolled in the HRCTP. The hospital readmission rate among patients with targeted diagnoses was reduced by 55.3% with an absolute percentage point reduction of 9.9% and estimated savings amount per avoided readmission of $14,400. Patients who participated in the HRCTP showed a 14% increase in the Patient Activation Assessment indicating an improvement in self-managing efficacy. 93% of patients/caregivers indicated they felt more confident in their ability to manage their health, and 91% expressed satisfaction with the program. The program has proven effective in assisting seniors to remain in their home, reducing hospitalizations, promoting health, increasing patient satisfaction, and reducing healthcare cost.

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

2017 ◽  
Vol 27 (12) ◽  
pp. 1856-1869 ◽  
Author(s):  
Maynor G. González ◽  
Kristin N. Kelly ◽  
Ann M. Dozier ◽  
Fergal Fleming ◽  
John R. T. Monson ◽  
...  
Keyword(s):  
Care Transitions ◽  
Hybrid Approach ◽  
Surgical Care ◽  
Transitions Of Care ◽  
Major Surgery ◽  
Discharge Process ◽  
Patient Centered ◽  
Outcomes Of Care ◽  
Anxiety Patient ◽  
Medical Histories

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

A patient-centered digital cost simulator based on Time-Driven Based-Activity Costing: a proof-of-concept study of knee replacement in two private Portuguese hospitals (Preprint)

2021 ◽  
Author(s):  
Salomé Azevedo ◽  
Francisco von Hafe ◽  
Carolina Ramos ◽  
João Leal ◽  
Ana Rita Londral
Keyword(s):  
Knee Replacement ◽  
Care Delivery ◽  
Unit Cost ◽  
Cost Of Care ◽  
Lessons Learned ◽  
Accurate Information ◽  
Proof Of Concept ◽  
Patient Centered ◽  
Patient Journey ◽  
Concept Study

BACKGROUND The number of knee replacement surgeries in OECD countries will continue rising due to the prevalence of osteoarthritis caused by aging and obesity. It is a cost-effective but expensive procedure. Consequently, decision-makers need accurate information on intervention outcomes and costs to manage the healthcare system efficiently. Literature proposed Time-Driven Based-Activity Costing (TDABC) as a cost measurement model that accounts for care cycle complexity, such as patient diversity and treatment variation. However, few studies show how to apply the TDABC model in a real context, considering the existing hospitals' information systems (IS). OBJECTIVE Our primary goal was to design a patient-centered digital cost simulator for assessing the provider's cost of care delivery that complemented the outcomes analysis in Knee Surgery. The secondary goal was to synthesize the learning experience of implementing the method in two Portuguese private hospitals of the same provider. METHODS The proof-of-concept study was designed based on the TDABC model. As the two hospitals had different care delivery chains for the same procedure, each hospital's study was independent. The unit cost of supplying capacity was calculated using data collected from interviews, literature reviews, and general ledger accounts. Both care delivery chains were defined using information from interviews with hospital staff and mapped using Visual Paradigm©. Time estimations were based on direct observation and data exported from hospitals' IS. The patient-centered digital cost simulator was created using Google Sheets. Through a focus group, the multidisciplinary team evaluated the model feasibility and generalisability. RESULTS A patient-centered digital cost simulator and the data structure that allows collecting the most relevant cost analysis data are presented. The main lessons learned are described through this paper and are based on practical application: (1) the patient journey must drive data collection, organization, and analysis for the TDABC implementation; (2) the implementation of TDABC in healthcare involves the commitment and dedication of the healthcare provider's teams; (3) breaking the activities into operations helps to obtain time estimations and allocate resources in the patient care pathway; (4) the listing of the used resources should follow the financial IS classification. CONCLUSIONS The simulator that was developed is still a proof-of-concept, but it enlightened the healthcare provider of future improvements in the existing IS infrastructure. The TDABC implementation requires that the hospitals' IS collect and interoperate different data sources (clinical, financial, and logistics) along the patient pathway. Therefore, future research should focus on developing effective and efficient interfaces to allow importing process, activity, resources, and time information from the existing IS and calculate the total costs of care per patient. Such data needs to be integrated with health outcomes measures in order to monitor healthcare interventions' value.

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

2020 ◽  
Vol 9 (1) ◽  
pp. 283-288
Author(s):  
Louise Gliga ◽  
Isaac Lynch ◽  
Richard Preble ◽  
Philip Greilich
Keyword(s):  
Participatory Design ◽  
Best Practice ◽  
Medical Center ◽  
Academic Medical Center ◽  
Care Transitions ◽  
Implementation Process ◽  
Scaling Up ◽  
Transitions Of Care ◽  
Modified Delphi ◽  
Best Practice Guidelines

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

scholarly journals Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people

BMJ Open ◽  
2018 ◽  
Vol 8 (9) ◽  
pp. e022468 ◽  
Author(s):  
Ruth Baxter ◽  
Jane O’Hara ◽  
Jenni Murray ◽  
Laura Sheard ◽  
Alison Cracknell ◽  
...  
Keyword(s):  
Older People ◽  
Hospital Admissions ◽  
Transitional Care ◽  
Transition Period ◽  
Care Transitions ◽  
Transitions Of Care ◽  
Care Needs ◽  
High Performing ◽  
Health And Social Care ◽  
Hospital To Home

IntroductionHospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing (‘positively deviant’) teams successfully support transitions from hospital to home for older people.Methods and analysisSix high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success.Ethics and disseminationEthical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.

scholarly journals Evidence based processes to prevent readmissions: more is better, a ten-site observational study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jacqueline Pugh ◽  
Lauren S. Penney ◽  
Polly H. Noël ◽  
Sean Neller ◽  
Michael Mader ◽  
...  
Keyword(s):  
Observational Study ◽  
Transitional Care ◽  
Hospital Readmissions ◽  
Care Transitions ◽  
Transition Process ◽  
Care Transition ◽  
Evidence Based ◽  
Structured Interviews ◽  
Transition Processes ◽  
Recommended Care

Abstract Background 30-day hospital readmissions are an indicator of quality of care; hospitals are financially penalized by Medicare for high rates. Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). Methods Design: Mixed method, multi-stepped observational study. Data collection occurred 2014–2018 with data analyses completed in 2021. Setting: Ten VA hospitals, chosen for 5-year trend of improving or worsening RSRR prior to study start plus documented efforts to reduce readmissions. Participants: During five-day site visits, three observers conducted semi-structured interviews (n = 314) with staff responsible for care transition processes and observations of care transitions work (n = 105) in inpatient medicine, geriatrics, and primary care. Exposure: Frequency of use of twenty recommended care transition processes, scored 0–3. Sites’ individual process scores and cumulative total scores were tested for correlation with RSRR. Outcome: best fit predicted RSRR for quarter of site visit based on the 21 months surrounding the site visits. Results Total scores: Mean 38.3 (range 24–47). No site performed all 20 processes. Two processes (pre-discharge patient education, medication reconciliation prior to discharge) were performed at all facilities. Five processes were performed at most facilities but inconsistently and the other 13 processes were more varied across facilities. Total care transition process score was correlated with RSRR (R2 = 0..61, p < 0.007). Conclusions Sites making use of more recommended care transition processes had lower RSRR. Given the variability in implementation and barriers noted by clinicians to consistently perform processes, further reduction of readmissions will likely require new strategies to facilitate implementation of these evidence-based processes, should include consideration of how to better incorporate activities into workflow, and may benefit from more consistent use of some of the more underutilized processes including patient inclusion in discharge planning and increased utilization of community supports. Although all facilities had inpatient social workers and/or dedicated case managers working on transitions, many had none or limited true bridging personnel (following the patient from inpatient to home and even providing home visits). More investment in these roles may also be needed.

scholarly journals Care transition strategies in Latin American countries: an integrative review

2018 ◽  
Vol 39 (0) ◽  
Author(s):  
Maria Alice Dias da Silva Lima ◽  
Ana Maria Müller de Magalhães ◽  
Nelly Donszelmann Oelke ◽  
Giselda Quintana Marques ◽  
Elisiane Lorenzini ◽  
...  
Keyword(s):  
Latin American ◽  
Discharge Planning ◽  
Care Transitions ◽  
Patient Discharge ◽  
Care Transition ◽  
Team Members ◽  
Leading Role ◽  
Transition Strategies ◽  
Time Of Admission ◽  
Latin American Countries

Abstract OBJECTIVE To identify and analyze available literature on care transition strategies in Latin American countries. METHODS Integrative literature review that included studies indexed in PubMed, LILACS, Web of Science Core Collection, CINAHL, SCOPUS databases, and the Scientific Electronic Library Online (SciELO), published in Portuguese, Spanish or English, between 2010 and 2017. RESULTS Eleven articles were selected and the strategies were grouped into components of care transition: discharge planning, advanced care planning, patient education and promotion of self-management, medication safety, complete communication of information, and outpatient follow-up. These strategies were carried out by multidisciplinary team members, in which nurses play a leading role in promoting safe care transitions. CONCLUSIONS Care transition activities are generally initiated very close to patient discharge, this differs from recommendations of care transition programs and models, which suggest implementing care transition strategies from the time of admission until discharge.

scholarly journals Ascertaining Design Requirements for Postoperative Care Transition Interventions

2021 ◽  
Vol 12 (01) ◽  
pp. 107-115 ◽  
Author(s):  
Joanna Abraham ◽  
Christopher R. King ◽  
Alicia Meng
Keyword(s):  
Information Transfer ◽  
Potential Role ◽  
Care Transitions ◽  
Care Transition ◽  
Card Sorting ◽  
Patient Centered ◽  
Factors Affecting ◽  
Academic Center ◽  
Core Elements

Abstract Background Handoffs or care transitions from the operating room (OR) to intensive care unit (ICU) are fragmented and vulnerable to communication errors. Although protocols and checklists for standardization help reduce errors, such interventions suffer from limited sustainability. An unexplored aspect is the potential role of developing personalized postoperative transition interventions using artificial intelligence (AI)-generated risks. Objectives This study was aimed to (1) identify factors affecting sustainability of handoff standardization, (2) utilize a human-centered approach to develop design ideas and prototyping requirements for a sustainable handoff intervention, and (3) explore the potential role for AI risk assessment during handoffs. Methods We conducted four design workshops with 24 participants representing OR and ICU teams at a large medical academic center. Data collection phases were (1) open-ended questions, (2) closed card sorting of handoff information elements, and (3) scenario-based design ideation and prototyping for a handoff intervention. Data were analyzed using thematic analysis. Card sorts were further tallied to characterize handoff information elements as core, flexible, or unnecessary. Results Limited protocol awareness among clinicians and lack of an interdisciplinary electronic health record (EHR)-integrated handoff intervention prevented long-term sustainability of handoff standardization. Clinicians argued for a handoff intervention comprised of core elements (included for all patients) and flexible elements (tailored by patient condition and risks). They also identified unnecessary elements that could be omitted during handoffs. Similarities and differences in handoff intervention requirements among physicians and nurses were noted; in particular, clinicians expressed divergent views on the role of AI-generated postoperative risks. Conclusion Current postoperative handoff interventions focus largely on standardization of information transfer and handoff processes. Our design approach allowed us to visualize accurate models of user expectations for effective interdisciplinary communication. Insights from this study point toward EHR-integrated, “flexibly standardized” care transition interventions that can automatically generate a patient-centered summary and risk-based report.

scholarly journals Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges

2017 ◽  
Vol 9 (2) ◽  
pp. 184-189 ◽  
Author(s):  
Eric Young ◽  
Chad Stickrath ◽  
Monica McNulty ◽  
Aaron J. Calderon ◽  
Elizabeth Chapman ◽  
...  
Keyword(s):  
Transitional Care ◽  
Educational Experiences ◽  
Care Transitions ◽  
Correlation Coefficients ◽  
Clinic Visit ◽  
Transitions Of Care ◽  
Direct Patient Care ◽  
Hospital Discharges ◽  
Cross Sectional ◽  
Prior Experiences

ABSTRACT Background  There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. Objective  We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. Methods  A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014–2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility. Results  Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1–10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P =  001], respectively). Conclusions  IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.

scholarly journals ECHO-CT: An Interdisciplinary Video-Conference Model for Identifying Post-Discharge Transition-of-Care Events

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 78-78
Author(s):  
Mariana Gonzalez ◽  
Lauren Junge-maughan ◽  
Lewis Lipsitz ◽  
Amber Moore
Keyword(s):  
Care Setting ◽  
Transitional Care ◽  
Care Transitions ◽  
Care Transition ◽  
Transition Of Care ◽  
Acute Care Setting ◽  
Post Discharge ◽  
Discharge Transition ◽  
Discharge Communication ◽  
Safe Care

Abstract Introduction: Discharge from the hospital to a post-acute care setting can be complex and potentially dangerous, with opportunities for errors and lapses in communication between providers. Data collected through the Extension for Community Health Outcomes-Care Transitions (ECHO-CT) model were used to identify and classify transitional care events (TCEs.) Methods: The ECHO-CT model employs multidisciplinary teleconferences between a hospital-based team and providers in post-acute settings; during this conference, concerns arising in the patient’s care transition were identified and recorded. Results: 675 patients were discussed during interdisciplinary videoconferences. A total of 139 TCEs were identified; 52 (37.4%) were classified as medication issues, and 58 (41.7%) involved discharge communication or coordination errors. Conclusions: These identified TCEs highlight areas in which providers can work to reduce issues arising in the course of discharge to post-acute facilities. Standardized processes to identify, record, and report transition of care events are necessary to provide high-quality, safe care for patients as they move across care settings.

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