Skilled Nursing facility

J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients’ care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

August 14, 2019

The geriatric floating interdisciplinary transition team

J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality […]
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J Am Geriatr Soc, 58;2:364–70 Authors: Arbaje, A. I., Maron, D. D., Yu, Q., Wendel, V. I., Tanner, E., Boult, C., Eubank, K. J., Durso, S. C. Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02682.x/abstract

August 13, 2019

One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management

Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are […]
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Tahan H. One Patient, Numerous Healthcare Providers, and Multiple Care Settings: Addressing the Concerns of Care Transitions Through Case Management. Professional Case Management. 2007;12(1): 37-46. http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx. Accessed July 24, 2014. Abstract: Care transitions are a natural occurrence in our healthcare delivery system. During a single episode of illness, patients are cared for in multiple care settings and by healthcare professionals of varied specialties and disciplines. Such dynamic events increase the risk of patients experiencing poor quality of care, especially as a result of medical errors and unsafe situations. Care coordination has been emphasized recently as a strategy for enhancing the effectiveness of care during such necessary transitions. This article describes the issue of care transitions and suggests how case management, through care coordination, can play an important role in ensuring safe and effective care transitions.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2007/01000/One_Patient,_Numerous_Healthcare_Providers,_and.8.aspx

August 8, 2019

Interventions to Reduce Acute Care Transfers (INTERACT)

Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal […]
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Florida Atlantic University. INTERACT. Interventions to Reduce Acute Care Transfers. Commonwealth Fund. http://interact2.net/. Updated February 7, 2011. Accessed July 25, 2014. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
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http://interact2.net/#

August 8, 2019

Integrating Care for Populations and Communities

Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers […]
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Integrating Care for Populations and Communities (ICPC). CFMC. Web Site. Http://www.cfmc.org/integratingcare/ . 2013. Accessed July 24, 2014. Integrating Care for Populations and Communities (ICPC) is a strategic Aim where Quality Improvement Organizations (QIOs) are bringing together hospitals, nursing homes, patient advocacy organizations, and other stakeholders in community coalitions. The Centers for Medicare & Medicaid Services (CMS) looks to QIOs to implement community-based projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.
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http://www.cfmc.org/integratingcare/

August 8, 2019

Transitions of Care Performance Measures: Paper by the NTOCC Measures Work Group, 2008

The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality […]
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The NTOCC Measures Work Group. Transitions of Care Measures. http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. 2008. Accessed July 24, 2014. The Case Management Society of America (CMSA) convenes the National Transitions of Care Coalition (NTOCC) to develop recommendations on actions that all participants in the health care delivery system can take to improve the quality of care transitions. The multi-disciplinary members of NTOCC work collaboratively to develop policies, tools, and resources as well as recommend actions and protocols to guide and support providers and patients in achieving safe and effective transitions of care.
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http://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf

August 8, 2019

Improving Transitions of Care: The Vision of the National Transitions of Care Coalition

The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient […]
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The National Transitions of Care Coalition. Improving Transitions of Care: The Vision of the National Transitions of Care Coalition. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. May 2008. Accessed July 24, 2014. This paper outlines the vision of the National Transitions of Care Coalition (NTOCC) to improve transitions of care, increasing quality of care and patient safety while controlling costs.
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http://www.ntocc.org/Portals/0/PolicyPaper.pdf

August 8, 2019

NTOCC Suggested Common/Essential Data Elements for Medication Reconciliation

NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
NTOCC. Suggested Common/Essential Data Elements for Medication Reconciliation. http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf . Published 4/17/08. Accessed 7/9/14. Contains data elements for medication reconciliation assessment on access to care setting and on transfer of care.
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http://www.ntocc.org/Portals/0/PDF/Resources/Medication_Reconciliation.pdf

August 8, 2019

Institute for Healthcare Improvement

The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for […]
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The Institute for Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. Updated 2014. Accessed 7/8/14. The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
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http://www.ihi.org

August 7, 2019

An internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department

OBJECTIVES To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. DESIGN: Interventional; before and after. SETTING ED of an urban teaching hospital with approximately 55,000 visits per […]
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OBJECTIVES To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. DESIGN: Interventional; before and after. SETTING ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF). PARTICIPANTS All patients transferred from the SNF to the ED over 16 months. INTERVENTION An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions. MEASUREMENTS Nine elements of patient information assessed before and after intervention through chart review. Secondary outcomes: changes in efficiency of information transfer and staff satisfaction. RESULTS Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention. CONCLUSION The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.02864.x/abstract

August 7, 2019

Care transitions by older adults from nursing homes to hospitals: implications for long-term care practice, geriatrics education, and research

Older adults residing in nursing homes are among the most vulnerable members of our society. A large percentage of nursing home residents are at risk of experiencing a care transition to a hospital. This review examines care transitions from nursing homes to hospitals, focusing on resident safely, effectiveness and timeliness […]
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Older adults residing in nursing homes are among the most vulnerable members of our society. A large percentage of nursing home residents are at risk of experiencing a care transition to a hospital. This review examines care transitions from nursing homes to hospitals, focusing on resident safely, effectiveness and timeliness of these transitions, and ways to enhance resident-centered care. Recommendations to improve care include promoting clear communication, managing medications, encouraging appropriate use of formal advance directives, providing timely access to care to reduce the risk of potentially avoidable hospitalization, and promoting an interdisciplinary resident-centered approach in geriatrics education. Studies examining nursing homes that have adopted models of care that emphasize resident autonomy as well as qualitative research focusing on in-depth ethnographic approaches can provide new perspectives of care transition experiences, and help to identify additional ways to improve care.
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http://www.jamda.com/article/S1525-8610(09)00306-5/abstract