August 7, 2019

Transitions in long-term care and potential implications for quality reporting in Ontario, Canada

PURPOSE To describe the proportion of long-term care (LTC) residents excluded from quality measurement because of standard length of stay inclusion criteria and the extent to which this varies across facilities. DESIGN AND METHODS A 2005 province-wide census of LTC residents’ charts was linked to additional databases from Ontario, Canada. […]
Read More
PURPOSE To describe the proportion of long-term care (LTC) residents excluded from quality measurement because of standard length of stay inclusion criteria and the extent to which this varies across facilities. DESIGN AND METHODS A 2005 province-wide census of LTC residents' charts was linked to additional databases from Ontario, Canada. The proportion of residents who were newly admitted (
Read Less
http://www.jamda.com/article/S1525-8610(10)00237-9/abstract

August 7, 2019

Care transitions and home health care

Transitions of care are becoming recognized as an important area for improvement in health care quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective hand-offs from one location of care to the next. Major lapses include absent or […]
Read More
Transitions of care are becoming recognized as an important area for improvement in health care quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective hand-offs from one location of care to the next. Major lapses include absent or limited clinical information and care plan content, plus errors related to medications. There are identifiable problems with half or more of the transitions that occur between care settings, and adverse consequences occur in 15 to 25 percent of patients. Undoubtedly these lapses contribute to the rates of re-hospitalization in post-acute care which affect 20 to 30 percent of patients within 60 days after hospital discharge. This article reviews models of transitional care intervention that have been tested and shown to be effective including less intensive coaching or guided care approaches, and more intensive case management strategies. Effective transitional care processes, linked with strong home care programs can reduce re-hospitalization by a third in some less intensive models and by half or more in some more intensive models.
Read Less
http://www.geriatric.theclinics.com/article/S0749-0690(08)00071-2/abstract

August 7, 2019

Patient Choice in the Discharge Planning Process

Purpose/objective: To describe steps in offering a patient a choice of post–acute care providers during the discharge planning process that reflects the case management principles and compliance to regulations related to patient’s rights to choice. Primary practice setting(s): Nurses and social workers, particularly those who work in case management or […]
Read More
Purpose/objective: To describe steps in offering a patient a choice of post–acute care providers during the discharge planning process that reflects the case management principles and compliance to regulations related to patient's rights to choice. Primary practice setting(s): Nurses and social workers, particularly those who work in case management or care coordination settings; staff nurses who do discharge planning in acute care settings; and liaison or intake coordinators from post—acute care providers such as skilled nursing facilities and home health agencies who are involved in offering choice to patients during the discharge process; payer-based case managers, particularly those in Medicare Advantage plans. Findings/conclusion: Patient choice is a right, including during the discharge planning process. Offering choice of available and appropriate options is a case management responsibility not only because of the federal regulations mandating choice but also because it is a reflection of advocacy for patients and families. The work leading up to preparing options from which a patient can choose closely follows the Case Management Standards of Practice (Case Management Society of America, 2002). Follow the process and providing choice becomes a safe and effective part of the transition of care. Note that this is not intended to be legal advice. Consult your own compliance officer for application of the information to your own setting. Every effort has been made to use the most current information. Implications for care management practice: 1. Patient's right to choice is based on the concept of choosing between appropriate and available options and is dependent on the professional skills and judgment of nurses and social workers, whose responsibilities include the process of discharge planning. 2. Offering patient choice is a function of advocating for patients by ensuring that they receive care needed in the appropriate setting at the appropriate time. 3. More study is needed on the influence of executive cognitive function assessment on patient choice. 4. Investing in software programs that assist in determining availability of appropriate post–acute care providers for individual patients is essential for efficient and safe discharge of patients.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2009/11000/Patient_Choice_in_the_Discharge_Planning_Process.7.aspx

August 7, 2019

Nursing Home Transition: Providing Assistance to Caregivers in Transition Program

Transition from a skilled nursing facility or rehabilitation center to the community can be fragmented and insufficiently case managed, resulting in inadequate care recommendations, patient-caregiver distress, a delay in discharge, and a higher risk of nursing home readmission. The Providing Assistance to Caregivers in Transition (PACT) program is an interdisciplinary […]
Read More
Transition from a skilled nursing facility or rehabilitation center to the community can be fragmented and insufficiently case managed, resulting in inadequate care recommendations, patient-caregiver distress, a delay in discharge, and a higher risk of nursing home readmission. The Providing Assistance to Caregivers in Transition (PACT) program is an interdisciplinary case management program designed to enhance nursing home discharge planning and case management support for the transitional period following a return to the community. During the PACT program's initial 24 months of operation, 38 of 42 opened cases were assisted in a discharge to the community. Of these, 30 remained at home for at least 6 months, 5 were readmitted within 6 months, and 3 others died. Caregivers reported satisfaction with instrumental (e.g., information about care options, facilitation of referrals to services) and emotional support. Nursing home cooperation was mixed. More work is needed to develop a broader referral base for the program.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2005/03000/Nursing_Home_Transition__Providing_Assistance_to.6.aspx

August 7, 2019

Medication discrepancies upon hospital to skilled nursing facility transitions

BACKGROUND Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the […]
Read More
BACKGROUND Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. DESIGN Cross-sectional study. PARTICIPANTS Patients admitted to SNF for subacute care. MEASUREMENTS Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders. RESULTS Of 2,319 medications reviewed on admission, 495 (21.3%) had a medication discrepancy. At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions. The discharge summary and the patient care referral form did not match in 104 of 199 (52.3%) SNF admissions. Disagreement between the discharge summary and the patient care referral form accounted for 62.0% (n = 307) of all medication discrepancies. Cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for over 50% of all discrepant medications. CONCLUSIONS Medication discrepancies occurred in almost three out of four SNF admissions and accounted for one in five medications prescribed on admission. The discharge summary and the patient care referral forms from the discharging institution are often in disagreement. Our study findings underscore the importance of current efforts to improve the quality of inter-institutional communication.
Read Less
http://connection.ebscohost.com/c/articles/37699519/medication-discrepancies-upon-hospital-skilled-nursing-facility-transitions

August 7, 2019

Smoothing transitions. Joint Commission targets patient handoffs

Handoffs—those critical moments when responsibility for a patient is passed from one caregiver to another—can set the stage for a host of bad consequences for patients. And although many hospitals have instituted some form of safeguard
Handoffs—those critical moments when responsibility for a patient is passed from one caregiver to another—can set the stage for a host of bad consequences for patients. And although many hospitals have instituted some form of safeguard
Read Less
http://www.modernhealthcare.com/article/20101025/MAGAZINE/101029981

August 7, 2019

Luck and Happenstance: How Older Adults Enroll in a Program of All-Inclusive Care for the Elderly

Purpose of the study: This qualitative study explores how older adults enroll in a Program of All-Inclusive Care for the Elderly (PACE). Primary practice setting: PACE is a community-based long-term care program for nursing home eligible older adults. Methodology and sample: The study includes interviews with older adults (n = […]
Read More
Purpose of the study: This qualitative study explores how older adults enroll in a Program of All-Inclusive Care for the Elderly (PACE). Primary practice setting: PACE is a community-based long-term care program for nursing home eligible older adults. Methodology and sample: The study includes interviews with older adults (n = 5), families (n = 4), and staff (n = 10). This study identified common circumstances that led to the recognition of a need for help. Results: These circumstances included the following: an acute event or crisis, older adult's or caregiver's drive to avoid entry into the nursing home, and the caregivers' recognition that they need relief from their care demands. Once this need was identified, families typically found out about PACE because of happenstance; they happened to talk to someone who knew about the program. Implications for case management practice: If PACE is going to be a sustainable alternative to nursing home care efforts, it needs to focus on moving the enrollment process beyond happenstance. Professional case managers are positioned to help older adults and families plan for long-term care by understanding the availability of local community services, developing contacts with local community and long-term care services, and considering what information older adults and their families need, especially during acute care discharges, primary care encounters, and queries for nursing home services.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2008/09000/Luck_and_Happenstance__How_Older_Adults_Enroll_in.7.aspx

August 7, 2019

Experience of continuity of care of patients with multiple long-term conditions in England

OBJECTIVES To examine patients’ experiences of continuity of care in the context of different long-term conditions and models of care, and to explore implications for the future organization care of long-term conditions. METHODS Qualitative semi-structured interviews were carried out with 33 patients recruited from seven general practices in South London. […]
Read More
OBJECTIVES To examine patients' experiences of continuity of care in the context of different long-term conditions and models of care, and to explore implications for the future organization care of long-term conditions. METHODS Qualitative semi-structured interviews were carried out with 33 patients recruited from seven general practices in South London. Patients were selected who had one or more of the following long-term conditions: arthritis, coronary heart disease, stroke, hypercholesterolaemia, hypertension, diabetes mellitus or chronic obstructive pulmonary disease. RESULTS Multiple morbidity was frequent and experiences of continuity were framed within patients' wider experiences of health care rather than the context of a particular diagnosis. Positive experiences of relational continuity were strongly associated with long-term GP-led or specialist-led care. Management continuity was experienced in the context of shared care in terms of transitions between professionals or organizations. Access and flexibility issues were identified as important barriers or facilitators of continuity. CONCLUSIONS Across a range of long-term conditions, patients' experiences of health care can be understood in terms of nuanced understandings of relational and management continuity. Continuity experiences, meanings and expectations, as well as barriers and facilitators, are influenced by the model of care rather than type of condition.
Read Less
http://jhsrp.rsmjournals.com/content/14/2/82.abstract

August 7, 2019

Scaling up: bringing the transitional care model into the mainstream

Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model […]
Read More
Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model (TCM), into mainstream practice. Together these projects demonstrate that successful translation of the TCM, which incorporates both in-person contact and a nurse-led, interdisciplinary team approach, can effectively interrupt patterns of frequent rehospitalizations, reduce costs, and improve patient health status. Findings from these projects inform challenges that must be overcome to facilitate the translation of effective care management innovations into mainstream practice.
Read Less
http://www.commonwealthfund.org/Publications/Issue-Briefs/2010/Nov/Scaling-Up-Transitional-Care.aspx

August 7, 2019

Emergency Department Case Management: The Dyad Team of Nurse Case Manager and Social Worker Improve Discharge Planning and Patient and Staff Satisfaction While Decreasing Inappropriate Admissions and Costs: A Literature Review

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction. 3 The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. […]
Read More
A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction. 3 The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2002/05000/Emergency_Department_Case_Management__The_Dyad.6.aspx

August 7, 2019

Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings

Adverse events commonly occur during hospital-to-home transitions and cause substantial morbidity. This study evaluated the effectiveness of Fast Forward Rounds (FFR), a novel educational intervention that aims to foster awareness of the essential elements of transitional care in 3rd-year medical students. FFR consists of two 90-minute sessions using lectures, an […]
Read More
Adverse events commonly occur during hospital-to-home transitions and cause substantial morbidity. This study evaluated the effectiveness of Fast Forward Rounds (FFR), a novel educational intervention that aims to foster awareness of the essential elements of transitional care in 3rd-year medical students. FFR consists of two 90-minute sessions using lectures, an interactive video, small-group discussion, and a team-based learning exercise. It emphasizes functional assessment to identify patients at risk for poor discharge outcomes, promotes interdisciplinary collaboration to link vulnerable patients with appropriate services, reviews Medicare and Medicaid reimbursement, and teaches development of comprehensive care plans. Using a pre/posttest design, participants' knowledge, attitudes and behaviors within the domains of transitional care, functional assessment, interdisciplinary team, community resources, and reimbursement were assessed. Of 103 students, 99.0% attended Session 1 and 97.1% attended Session 2 (pretest completion rate 99.0%, posttest 94.1%). Significant improvements were found in all domains, with the largest gains seen in transitional care. After the intervention, 56.0% identified medication errors as the most common source of adverse events after discharge (vs 14.9% before the intervention, P<.001). Significantly more participants reported feeling competent or expert in safely discharging chronically ill patients (66.3% vs 9.8%, P<.001) and in educating patients about discharge medications (75.8% vs 28.4%, P<.001). Participants also reported changes in transitional care behaviors (e.g., 71.6% now review the discharge medication list with patients and caregivers > or =50% of the time (vs 42.3%, P=.002)). A multimodal educational intervention for medical students increased their transitional care knowledge, reported frequency of transitional care behaviors, and perceived competence in managing the discharge process.
Read Less
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02203.x/abstract

August 7, 2019

Lessons learned from implementation of a computerized application for pending tests at hospital discharge

BACKGROUND Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help […]
Read More
BACKGROUND Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help inpatient physicians manage these test results. METHODS We modified an ambulatory electronic medical record (EMR)-based results management application to track pending tests at hospital discharge (Hospitalist Results Manager, HRM). We trained inpatient physicians at 2 academic medical centers to track these tests using this application. We surveyed inpatient physicians regarding usage of and satisfaction with the application, barriers to use, and the characteristics of an ideal system to track pending tests at discharge. RESULTS Of 29 survey respondents, 14 (48%) reported never using HRM, and 13 (45%) used it 1 to 2 times per week. A total of 23 (79%) reported barriers prohibiting use, including being inundated with clinically "irrelevant" results, not having sufficient time, and a lack of integration of post-discharge test result management into usual workflow. Twenty-one (72%) wanted to receive notification of abnormal and clinician-designated pending test results. Twenty-seven physicians (93%) agreed that an ideally designed computerized application would be valuable for managing pending tests at discharge. CONCLUSIONS Although inpatient physicians would highly value a computerized application to manage pending tests at discharge, the characteristics of an ideal system are unclear and there are important barriers prohibiting adoption and optimal usage of such systems. We outline suggestions for future electronic systems to manage pending tests at discharge. Journal of Hospital Medicine 2010;. (c) 2010 Society of Hospital Medicine
Read Less
http://onlinelibrary.wiley.com/doi/10.1002/jhm.794/abstract

August 7, 2019

“But I am not moving”: residents’ perspectives on transitions within a continuing care retirement community

PURPOSE This article investigates how continuing care retirement community (CCRC) residents define transitions between levels of care. Although older adults move to CCRCs to “age in place,” moving between levels of care is often stressful. More than half a million older adults live in CCRCs, with numbers continually increasing; yet, […]
Read More
PURPOSE This article investigates how continuing care retirement community (CCRC) residents define transitions between levels of care. Although older adults move to CCRCs to "age in place," moving between levels of care is often stressful. More than half a million older adults live in CCRCs, with numbers continually increasing; yet, no studies address transitions between levels of care in these communities. DESIGN AND METHODS I completed 23 months of live-in observation and conducted 35 face-to-face in-depth interviews with CCRC residents across 3 levels of care. I performed a thematic analysis of observation notes and interview transcripts. RESULTS Residents perceived transitions as both disempowering and final. They discussed decreases in social networks that occurred after such moves. Resident-maintained social boundaries exacerbated these challenges. IMPLICATIONS Although the transition to institutional living is one of the most important events in older persons' lives, transitions within CCRCs also are consequential especially because they are coupled with declining functional ability. These findings may inform policy for retirement facilities on topics such as increasing privacy, challenging social boundaries, and educating residents to prepare them for transitions.
Read Less
http://gerontologist.oxfordjournals.org/content/49/3/418.abstract

August 7, 2019

Case Management Accountability for Safe, Smooth, and Sustained Transitions: A Plea for Building “Wrap-around” Case Management Services Now

Purpose: The purpose is to encourage hospital administrations to address readmissions immediately and to restructure and significantly enhance case management services once and for all so that they can provide a “wraparound” service for the full clinical course from admission to transition for all patients and families. If 10 basic […]
Read More
Purpose: The purpose is to encourage hospital administrations to address readmissions immediately and to restructure and significantly enhance case management services once and for all so that they can provide a “wraparound” service for the full clinical course from admission to transition for all patients and families. If 10 basic interventions cannot be provided because of staffing limitations or processes, case management will continue to operate in a crisis mode and hospitals will suffer potentially large financial, quality, and satisfaction losses. If further customization cannot be provided to patients and their families, hospitals will be at risk to fail both their margin and their mission. Although other professionals and support staff will have distinct responsibilities, case management must be built, resourced, and restructured to be the authorized and accountable central control operation between level-of -care transitions. Primary Practice Setting: Acute care hospitals. Implications for Case Management: The national length of stay (LOS) has lowered from 7.8 days in 1970 to 5.2 days (males) and 4.5 days (females) in 2006 (DeFrances, C., Lucas, C., Buie, V., & Golosinskiy, A., 2008), whereas the national readmission rate for adult medical-surgical patients, depending on the diagnosis and the payer, has risen from a range of 5%–29% after 30 days (The Center for Case Management, 2009) to an average of 19% (Jencks, S., Williams, M., & Coleman, E., 2009). Of the key results for return on investment claimed by case management, the largest combined measure of quality, financial, and satisfaction outcomes lies in the delivery of safe, smooth, and sustained discharges/transitions. In other words, readmission rates should be the conscience of the hospital, especially of case management services. 2010 is the year for case management services and departments to adamantly request the authority and take the accountability that will be required to prevent readmissions while maintaining or continuing to decrease LOS, thus increasing flow and capacity. To achieve full accountability for 100% of patients' transitions from admission to transition, case management must build a wraparound service that covers 10 basic interventions and a handful of best practices to customize each transition. Two principles pertain: (1) If you have not met the patient or family until the discharge day, you don't know them and will make mistakes, and (2) there is no such thing
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2010/07000/Case_Management_Accountability_for_Safe,_Smooth,.5.aspx

August 7, 2019

Assessing the quality of patient handoffs at care transitions

Background: Effective handoff practices (ie, mechanisms for transferring information, responsibility and authority) are critical to ensure continuity of care and patient safety. Objective This study aimed to develop a rating tool (self-rating and external rating) for handoff quality that goes beyond mere information transfer. Methods The rating tool was piloted […]
Read More
Background: Effective handoff practices (ie, mechanisms for transferring information, responsibility and authority) are critical to ensure continuity of care and patient safety. Objective This study aimed to develop a rating tool (self-rating and external rating) for handoff quality that goes beyond mere information transfer. Methods The rating tool was piloted during 126 patient handoffs performed in three different clinical settings in a tertiary care hospital: (1) paramedic to emergency room staff, (2) anaesthesia care provider to postanaesthesia care unit (PACU) and (3) PACU nurse to ward nurse. Results We identified three factors (information transfer, shared understanding, working atmosphere) predicting handoff quality. Conclusions This study provides insights into the multidimensional concept of handoff quality. Our rating tool is feasible and comprehensive by including not only characteristics of the information process but also aspects of teamwork and, thus, provides an important tool for future research on patient handoff.
Read Less
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21127094

August 7, 2019

Connected Care: How a Health Science Centre Is Using Evidence to Improve Patient Transitions from Primary to Secondary Care

The department of emergency medicine at Queen Elizabeth II Health Sciences Centre in Nova Scotia’s Capital Health District is developing pathways to strengthen the ability of family physicians to manage their patients and improve the primary-secondary care transition. This diagnostic pathway initiative improves patient and caregiver satisfaction and also provides […]
Read More
The department of emergency medicine at Queen Elizabeth II Health Sciences Centre in Nova Scotia's Capital Health District is developing pathways to strengthen the ability of family physicians to manage their patients and improve the primary-secondary care transition. This diagnostic pathway initiative improves patient and caregiver satisfaction and also provides system benefits. This innovative initiative was recently featured in Promising Practices in Research Use, a series produced by the Canadian Health Services Research Foundation highlighting organizations that have invested their time, energy and resources to improve their ability to use research in the delivery of health services. Tell the Foundation your own stories and visit the Promising Practices in Research Use inventory at http://www.chsrf.ca/promising/index_e.php.
Read Less
http://www.chsrf.ca/publicationsandresources/pastseries/PromisingPracticesinResearchUse/article/08-04-01/5a22d864-cab6-4678-a375-009a1accf6e9.aspx

August 7, 2019

Enhancing Success in Transition Service Coordinators: Use of Transformational Leadership

Purpose: The lifespan of children with special healthcare needs has been extended because of improved technology and medical advances. Successful transition to the adult arena of healthcare, social services, and education by adolescents with special healthcare needs (ASHCN) is lacking. The transition service coordinator (TSC) is a multifaceted role of […]
Read More
Purpose: The lifespan of children with special healthcare needs has been extended because of improved technology and medical advances. Successful transition to the adult arena of healthcare, social services, and education by adolescents with special healthcare needs (ASHCN) is lacking. The transition service coordinator (TSC) is a multifaceted role of advanced practice nursing that provides highly specialized transition services to adolescents with special healthcare needs. The use of key concepts from the transformational leadership theory may improve healthcare outcomes. Primary Practice Settings: This article applies to pediatric and adult primary care and case management services that serve adolescents with special healthcare needs. Conclusion: Employing key concepts of transformational leadership theory will enhance the success of the TSC to improve both collaboration among stakeholders in the transitional team and young adults' transition to the world of adult services. Implications for Case Management Practice: * Enhanced communication resulting in improved sharing of information, understanding of the stakeholder roles, and provision of formal linkages between pediatric and adult medical providers is a significant outcome affecting the ASHCN. * Improved collaboration will produce a smooth transition for the ASHCN to the world of adult social services, education, and employment. * Incorporating the transformational leadership dimensions of idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration will enhance the ability of the TSC to improve collaboration among stakeholders in the transitional team and the quality of services for the ASHCN.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/09000/Enhancing_Success_in_Transition_Service.7.aspx

August 7, 2019

Case Managers Optimize Patient Safety by Facilitating Effective Care Transitions

In this new era of patient safety, the case manager, as an advocate and facilitator of care, has a pivotal role on the front line of healthcare delivery. Effective communication and collaboration between disciplines is key to the promotion of patient safety, and ultimately the avoidance of life-threatening medical errors. […]
Read More
In this new era of patient safety, the case manager, as an advocate and facilitator of care, has a pivotal role on the front line of healthcare delivery. Effective communication and collaboration between disciplines is key to the promotion of patient safety, and ultimately the avoidance of life-threatening medical errors. Across the healthcare continuum and within hospitals in particular, patients are routinely transferred from one service to another, from one level of care to another, or from one provider to another. As patients are stabilized and transitioned through the hospital system, there are multiple hand-offs of care or care transitions that can often expose the patient to fragmented service and increase the risk of communication breakdown. Ineffective hand-offs can result in a disruption of continuity between one level of care and the next. In a culture that places a strong emphasis on patient safety, case managers can facilitate opportunities that ease care transitions whereby a change in venue is no longer perceived as a disruption in the flow of care but rather is viewed as a coordinated changeover where cautious and comprehensive communication sets the tone for the continued delivery of safe and effective healthcare.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/03000/Case_Managers_Optimize_Patient_Safety_by.3.aspx

August 7, 2019

Implementation of the Care Transitions Intervention: Sustainability and Lessons Learned

Purpose: During care transitions, the movement of patients from one healthcare practitioner or setting to another, patients are vulnerable to serious lapses in the quality and safety of their medical care. The Care Transitions Intervention (CTI), a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from the acute […]
Read More
Purpose: During care transitions, the movement of patients from one healthcare practitioner or setting to another, patients are vulnerable to serious lapses in the quality and safety of their medical care. The Care Transitions Intervention (CTI), a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from the acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self-management needs are met, was implemented in 10 hospital–community-based partnership sites in California over a 12-month period. Five of the partnerships were hospital-led sites, and 5 were county-led sites. The primary goal of the project was to identify factors that promote sustainability of the intervention by (1) assessing features of each site's implementation and the site's likelihood of continuing the program; (2) soliciting feedback from the sites; and (3) analyzing site and patient characteristic data and data from the CTI measurement instruments (the 3-item Care Transition Measure [CTM-3] and the Patient Activation Assessment [PAA] tool). Primary practice setting(s): The CTI was implemented in 10 California hospital and community-based organizations that received training and technical support to implement the intervention. Findings: Presence of leadership support was determined to be the critical factor for sites reporting interest in and capacity for long-term support of the CTI. Sites identified engaging hospital- and community-based leaders, providing additional transition coach training, and the assigning of consistent and dedicated (funded) transition coaches as valuable lessons learned. Key findings from the measurement instruments indicate that future CTI implementations should focus on medication management, patients with cardiovascular conditions and diabetes, patients older than 85 years, and African American and Latino patients. Mean PAA scores were moderately higher for patients from hospital-led sites than for patients from county-led sites and moderately higher for patients from sites with full plans for continuation than for patients from sites with partial or minor plans to continue the CTI. Implications for case management practice: This implementation of the CTI, with its flexible design responsive to the diverse needs of patients, hospitals, and community organizations, provides a host of real-world lessons on how to improve and sustain effective patient tran
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2009/11000/Implementation_of_the_Care_Transitions.5.aspx

August 7, 2019

A Review of Case Management Functions Related to Transitions of Care at a Rural Nurse Managed Clinic

Purpose/objectives: Case management activities were reviewed in a rural, nurse-managed, primary healthcare setting over 3 months. The purpose was to determine the specific case management tasks and how these functions related to, or enhanced, lateral transitions in care. The transition from outpatient to inpatient care implies a vertical transition of […]
Read More
Purpose/objectives: Case management activities were reviewed in a rural, nurse-managed, primary healthcare setting over 3 months. The purpose was to determine the specific case management tasks and how these functions related to, or enhanced, lateral transitions in care. The transition from outpatient to inpatient care implies a vertical transition of care, as the care at the hospital level is more complex than in a physician's office. Many times, patients will move between different providers and clinics in the outpatient (or inpatient) setting; these are considered lateral transitions. In a nurse-managed clinic, there are many referrals, hence many handoffs. As these patients move to and from these appointments and referrals, new tests are conducted and new medication may be ordered. To maintain a high quality of care, new therapies and medications must be integrated into the plan of care. Primary practice setting(s): This study was conducted in a rural, nurse-managed, primary healthcare setting; however, the results are generalizable across many settings. Findings/conclusions: In this study, it was determined that the case managers were managing the transitions between the clinic and other outpatient services, as well as managing and ordering the patient's medications and therapies. Approximately 45%–50% of case management functions involved either obtaining medication assistance for patients without funding or assisting patients with the ordering and procurement of essential medicines. Another 45% of the case manager's time was spent coordinating referrals to a wide variety of specialty clinics for diagnostic testing, obtaining appointments with community-based family practice physicians, or coordinating examinations for specialty physicians. Implications for case management practice: Transitions in care have become a major focus in promoting patient safety. Case managers at the primary, secondary, and tertiary levels of care play a major role in making these transitions safe, whether these transitions are vertical or lateral. Safety issues come into play as patients move back and forth—or up and down—in the system, because providers do not always manage the safe handoff of the patient to other outpatient or inpatient services.
Read Less
http://journals.lww.com/professionalcasemanagementjournal/Abstract/2009/11000/A_Review_of_Case_Management_Functions_Related_to.10.aspx