scholarly journals Screening by Social Workers in Medical Patients with Risk of Post-Acute Care Needs: A Stepped Wedge Cluster Randomized Trial / Evaluation eines Screenings durch Sozialarbeiter bei medizinischen Patienten mit einem Risiko für post-akuten Nachsorgebedarf: eine stepped wedge clusterrandomisierte Studie

2018 ◽  
Vol 5 (1) ◽  
pp. 25-34
Author(s):  
Antoinette Conca ◽  
Doaa Ebrahim ◽  
Sandra Noack ◽  
Angela Gabele ◽  
Helen Weber ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Social Workers ◽  
Acute Care ◽  
Discharge Planning ◽  
Control Period ◽  
Stepped Wedge ◽  
Intervention Period ◽  
Care Needs ◽  
Cluster Randomized ◽  
Post Acute Care

AbstractBackgroundElderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process.AimTo investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care.MethodsCluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences.ResultsA total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .11, 95%-CI -0.64 to 0.86).ConclusionScreening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planning.

scholarly journals Early and comprehensive care bundle in elderly for acute heart failure in the emergency department: study protocol of The ELISABETH stepped wedge cluster randomized trial

2018 ◽  
Author(s):  
Yonathan Freund ◽  
Judith Gorlick ◽  
Marine Cachanado ◽  
Sarah Salhi ◽  
Vanessa Lemaitre ◽  
...  
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Elderly Patients ◽  
Acute Heart Failure ◽  
Control Period ◽  
Care Bundle ◽  
Stepped Wedge ◽  
Precipitating Factors ◽  
Intervention Period ◽  
Cluster Randomized

Abstract Background: Acute heart failure (AHF) is one of the most common diagnoses for elderly patients in the emergency department (ED), with an admission rate higher than 80% and 1-month mortality around 10%. The European guidelines for the management of AHF are based on moderate levels of evidence, due to the lack of randomized controlled trials and the scarce evidence of any clinical added value of a specific treatment to improve outcomes. Recent reports suggest that the very early administration of full recommended therapy may decrease mortality. However, several studies highlighted that elderly patients often received suboptimal treatment. Our hypothesis is that an early care bundle that comprises early and comprehensive management of symptoms, along with prompt detection and treatment of precipitating factors should improve AHF outcome in elderly patients. Method/design: ELISABETH is a stepped-wedge, controlled cluster randomized, clinical trial in 15 emergency departments in France recruiting all patients aged 75 years and older with a diagnosis of AHF. The tested intervention is a care bundle with a checklist that mandates detection and early treatment of AHF precipitating factors, early and intensive treatment of congestion with intravenous nitrates boluses, and application of other recommended treatment (low dose diuretics, non-invasive ventilation when indicated, and preventive low molecular weight heparin). Each centre are randomized to the order in which they will switch from “control period” to “intervention period”. All centers begin the trials with the control period for two weeks, then after each two-weeks step a new centre will be in the intervention period. At the end of the trial, all clusters will receive the intervention regimen. The primary outcome is the number of days alive and out of the hospital at 30 days. Discussion: If our hypothesis is confirmed, this trial will strengthen the level of evidence of AHF guidelines and stress the importance of the associated early and comprehensive treatment of precipitating factors. This trial could be the first to report a reduction in short term morbidity and mortality in elderly AHF patients. Registration: NCT03683212, prospectively registered on September 25th 2018 Keywords: Elderly, acute heart failure, emergency department

scholarly journals Using Electronic Case Summaries to Elicit Multi-Disciplinary Expert Knowledge about Referrals to Post-Acute Care

2016 ◽  
Vol 07 (02) ◽  
pp. 368-379 ◽  
Author(s):  
Sarah Ratcliffe ◽  
Sheryl Potashnik ◽  
Maxim Topaz ◽  
John Holmes ◽  
Nai-Wei Shih ◽  
...  
Keyword(s):  
Social Workers ◽  
Case Studies ◽  
Acute Care ◽  
Expert Knowledge ◽  
Physical Therapists ◽  
Discharge Planning ◽  
Discharge Disposition ◽  
Multiple Challenges ◽  
Expert Decision Support System ◽  
Post Acute Care

SummaryEliciting knowledge from geographically dispersed experts given their time and scheduling constraints, while maintaining anonymity among them, presents multiple challenges.Describe an innovative, Internet based method to acquire knowledge from experts regarding patients who need post-acute referrals. Compare, 1) the percentage of patients referred by experts to percentage of patients actually referred by hospital clinicians, 2) experts’ referral decisions by disciplines and geographic regions, and 3) most common factors deemed important by discipline.De-identified case studies, developed from electronic health records (EHR), contained a comprehensive description of 1,496 acute care inpatients. In teams of three, physicians, nurses, social workers, and physical therapists reviewed case studies and assessed the need for post-acute care referrals; Delphi rounds followed when team members did not agree. Generalized estimating equations (GEEs) compared experts’ decisions by discipline, region of the country and to the decisions made by study hospital clinicians, adjusting for the repeated observations from each expert and case. Frequencies determined the most common case characteristics chosen as important by the experts.The experts recommended referral for 80% of the cases; the actual discharge disposition of the patients showed referrals for 67%. Experts from the Northeast and Midwest referred 5% more cases than experts from the West. Physicians and nurses referred patients at similar rates while both referred more often than social workers. Differences by discipline were seen in the factors identified as important to the decision.The method for eliciting expert knowledge enabled national dispersed expert clinicians to anonymously review case summaries and make decisions about post-acute care referrals. Having time and a comprehensive case summary may have assisted experts to identify more patients in need of post-acute care than the hospital clinicians. The methodology produced the data needed to develop an expert decision support system for discharge planning.Citation: Bowles KH, Ratcliffe S, Potashnik S, Topaz M, Holmes J, Shih N-W, Naylor MD. Using electronic case summaries to elicit multi-disciplinary expert knowledge about referrals to post-acute care.

scholarly journals Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
M. Toles ◽  
C. Colón-Emeric ◽  
L. C. Hanson ◽  
M. Naylor ◽  
M. Weinberger ◽  
...  
Keyword(s):  
Acute Care ◽  
Transitional Care ◽  
Discharge Planning ◽  
Cluster Randomized Trial ◽  
Stepped Wedge ◽  
Skilled Nursing ◽  
Transition Plan ◽  
Cluster Randomized ◽  
Seriously Ill

Abstract Background Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home. Methods The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress. Discussion Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. Trial registration ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

scholarly journals Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes

2020 ◽  
Vol 34 (5) ◽  
pp. 571-579 ◽  
Author(s):  
Liz Forbat ◽  
Wai-Man Liu ◽  
Jane Koerner ◽  
Lawrence Lam ◽  
Juliane Samara ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Care Home ◽  
Care Homes ◽  
Randomised Control Trial ◽  
Specialist Palliative Care ◽  
Stepped Wedge ◽  
Model Of Care ◽  
Care Needs ◽  
Palliative Care Needs

Background: Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home. Aim: To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital. Design: Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018. Setting/participants: 1700 residents in 12 Australian care homes for older people. Results: Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: −0.44, −0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m). Conclusion: The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.

Post acute care: Can hospitals do better with less?

1997 ◽  
Vol 20 (2) ◽  
pp. 43 ◽  
Author(s):  
Gideon A Caplan ◽  
Ann Brown
Keyword(s):  
Cost Effectiveness ◽  
Length Of Stay ◽  
Acute Care ◽  
Early Discharge ◽  
Government Funding ◽  
Discharge From Hospital ◽  
Post Acute Care

Judging by reports in medical magazines and journals, ?early discharge schemes?, bettertermed ?post acute care?, are not popular with doctors. However, government policyencourages earlier discharge from hospital, so that the choice facing clinicians is todischarge patients early with support, or early without support, or deal with theconsequences of length of stay overruns. Fortunately, government funding for post acutecare is increasing. There is a strong rationale for post acute care based on better patientoutcomes and cost-effectiveness, but these desirable results will only be achieved ifscrupulous attention is paid to detail, as embodied in the 10 principles of post acutecare. To function optimally, post acute care should be coordinated by the hospitalwhich provided the acute care.

scholarly journals An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial

2019 ◽  
Vol 30 (3) ◽  
pp. 505-515 ◽  
Author(s):  
Nicholas M. Selby ◽  
Anna Casula ◽  
Laura Lamming ◽  
John Stoves ◽  
Yohan Samarasinghe ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Randomized Trial ◽  
Cluster Randomized Trial ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Organizational Level ◽  
Care Process ◽  
Standards Of Care ◽  
Stepped Wedge ◽  
Cluster Randomized

BackgroundVariable standards of care may contribute to poor outcomes associated with AKI. We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program) would improve delivery of care and patient outcomes at an organizational level.MethodsA multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals, involving patients with AKI aged ≥18 years. The intervention was introduced sequentially across fixed three-month periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was 30-day mortality, with pre-specified secondary endpoints and a nested evaluation of care process delivery. The nature of the intervention precluded blinding, but data collection and analysis were independent of project delivery teams.ResultsWe studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference between control and intervention periods. Hospital length of stay was reduced with the intervention (decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment of process measures in 1048 patients showed improvements in several metrics including AKI recognition, medication optimization, and fluid assessment.ConclusionsA complex, hospital-wide intervention to reduce harm associated with AKI did not reduce 30-day AKI mortality but did result in reductions in hospital length of stay, accompanied by improvements in in quality of care. An increase in AKI incidence likely reflected improved recognition.

scholarly journals Post-Acute Care Service use in Lung Cancer Patients

2021 ◽  
Author(s):  
Mitra McLarney ◽  
Frances S. Shofer ◽  
Jasmine Zheng
Keyword(s):  
Lung Cancer ◽  
Length Of Stay ◽  
Cancer Patients ◽  
Acute Care ◽  
Service Use ◽  
Care Service ◽  
Rehabilitation Service ◽  
Lung Cancer Patients ◽  
Acute Care Service ◽  
Post Acute Care

Abstract Purpose: Lung cancer patients experience functional deconditioning secondary to their underlying cancer and treatment yet rehabilitation service use remains low. The goal of this study is to compare post-acute care service use in lung cancer patients admitted to a metropolitan academic medical center. Methods: Adult lung cancer patients admitted from January 1, 2017 to August 31, 2018 with a diagnosis of lung cancer based on International Classification of Diseases 10, C34.0-C34.9, were included in this study. Patient characteristics including age, gender, race, marital status, functional status on admission, length of stay, and number of comorbidities were compared based on discharge setting. Results: 1,139 lung cancer patients were included in our study. The majority of patients discharged home with home care (51%) followed by home without services (35%), skilled nursing facilities (SNF) (10%) and acute inpatient rehabilitation facilities (IRF) (4%). 44% (498) of patients were primarily admitted for their lung cancer diagnosis. In unadjusted analyses, patients who discharged to SNF compared to home were more likely to be older, black, unmarried, live alone and have died during the study period. Patients who discharged to IRF had longer acute care hospitalization length of stays. In adjusted analyses, age, number of concurrent comorbidities and length of stay significantly correlated with discharge location. Conclusion: Lung cancer patients are unlikely to be discharged to a post-acute care facility after an acute hospitalization. Rehabilitation service use differs by sociodemographic factors, concurrent medical history and functional status. Future study is needed to better understand why these differences in discharge setting persists.

scholarly journals Policy in Clinical Practice: Choosing Post-Acute Care in the New Decade

2021 ◽  
Vol 16 (3) ◽  
pp. 171-174 ◽  
Author(s):  
Anil N Makam ◽  
David C Grabowski
Keyword(s):  
Acute Care ◽  
Nursing Facilities ◽  
Care Needs ◽  
Skilled Nursing ◽  
Medically Ill ◽  
Home Health Agencies ◽  
Medicare Patients ◽  
New Policies ◽  
Rehabilitative Services ◽  
Post Acute Care

Nearly half of hospitalized Medicare patients in 2018 were discharged to post-acute care (PAC), accounting for approximately $60 billion in annual spending. There are four PAC settings, and these vary in the intensity and complexity of medical, skilled nursing, and rehabilitative services provided; each setting uses a separate payment system. Due to considerable variation in PAC use, with concerns that similar patients can be treated in different PAC settings, the Centers for Medicare & Medicaid Services (CMS) recently introduced several major policy changes. For home health agencies (HHAs) and skilled nursing facilities (SNFs), CMS implemented new payment models to better align payment with patients’ care needs rather than the provision of rehabilitation. For long-term acute care hospitals, CMS will now decrease payment for less medically ill patients. To choose PAC wisely, hospitalists and hospital leaders must understand how these new policies will change where patients can be discharged and the services these patients receive at these PAC settings.

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