August 7, 2019

Personal Health Record

Coleman E. The Care Transitions Program®. Personal Health Record. http://www.caretransitions.org/documents/phr.pdf [No date specified]. Accessed 7/10/14.
Coleman E. The Care Transitions Program®. Personal Health Record. http://www.caretransitions.org/documents/phr.pdf [No date specified]. Accessed 7/10/14.
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http://www.caretransitions.org/documents/phr.pdf

August 7, 2019

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

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 […]
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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 7, 2019

Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions

Boutwell A, Griffin F, Hwu S, Shannon D. Institute for Healthcare Improvement. Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions. http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf. 2009 . Accessed June 30, 2012. This document is intended to provide a sampling of the range of effective programs underway to reduce hospitalizations.
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Boutwell A, Griffin F, Hwu S, Shannon D. Institute for Healthcare Improvement. Effective Interventions to Reduce Hospitalizations: A Compendium of 15 Promising Interventions. http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf. 2009 . Accessed June 30, 2012. This document is intended to provide a sampling of the range of effective programs underway to reduce hospitalizations.
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http://ah.cms-plus.com/files/STAAR_A_Compendium_of_Promising_Interventions.pdf

August 7, 2019

AMDA Universal Transfer Form

AMDA. Universal Transfer Form. Tool. http://www.amda.com/tools/universal_transfer_form.pdf. Published 2007. Accessed July 24, 2014. AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from […]
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AMDA. Universal Transfer Form. Tool. http://www.amda.com/tools/universal_transfer_form.pdf. Published 2007. Accessed July 24, 2014. AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from the inaccurate or incomplete transfer of patient information. Use of the UTF can help to minimize the occurrence of such errors by ensuring that patient information is transmitted fully and in a timely fashion.
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http://www.amda.com/tools/universal_transfer_form.pdf

August 7, 2019

Defining and disseminating the hospital-at-home model CMAJ January 20, 2009 180:156-157

The hospital, which is the “gold standard” for the delivery of acute medical care, is not an ideal care environment for many patients. Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common. New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the […]
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The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal care environment for many patients. Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common. New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the time of hospital discharge also occur, contributing, ironically, to readmission to hospital. Furthermore, hospital care is very expensive. In this issue, Shepperd and colleagues present a meta-analysis of the effectiveness of "hospital-at-home programs."
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http://www.cmaj.ca/cgi/content/full/180/2/156

August 7, 2019

Challenges in transitional care between nursing homes and emergency departments

OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 […]
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OBJECTIVE To obtain opinions of knowledgeable professionals involved in the emergency care of nursing home (NH) residents. DESIGN Structured focus group interviews. PARTICIPANTS Five provider categories, including NH staff, NH physicians and nurse practitioners, emergency medical services (EMS) providers, emergency department (ED) nurses, and ED physicians. SETTING Two NHs, 2 EDs, and a county-wide EMS system. ANALYSIS Audiotaped discussions were transcribed and analyzed independently by 2 authors. RESULTS Themes included barriers to providing high-quality care, data needed when residents are transported in both directions between EDs and NHs, and possible solutions to improve care. Communication problems were the most frequently cited barrier to providing care. Residents are often transported in both directions without any written documentation; however, even when communication does occur, it is often not in a mode that is useable by the receiving provider. ED personnel need a small amount of organized, written information. When residents are released from the ED, NH personnel need a verbal report from ED nurses as well as written documentation. All groups were optimistic that communication can be improved. Ideas included use of (1) fax machines or audiotape cassette recorders to exchange information, (2) an emergency form in residents’ charts that contains predocumented information with an area to write in the reason for transfer, and (3) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs. CONCLUSION The transitional care of NH residents is laden with problems but has solutions that deserve additional development and investigation. KEYWORDS: Nursing homes, emergency service, hospital, emergency medical services, patient transfer
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http://www.jamda.com/article/S1525-8610(06)00174-5/abstract

August 7, 2019

Health Care Transition Initiative at the University of Florida

The mission of the Health Care Transition Initiative at the University of Florida is to increase awareness of, gain knowledge about, and promote cooperative efforts to improve the process transitioning from child-centered (pediatric) to adult oriented health care. Our vision is to improve the transition process for all adolescents and […]
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The mission of the Health Care Transition Initiative at the University of Florida is to increase awareness of, gain knowledge about, and promote cooperative efforts to improve the process transitioning from child-centered (pediatric) to adult oriented health care. Our vision is to improve the transition process for all adolescents and young adults, although our current efforts focus on those with disabilities and special health care needs.
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http://hctransitions.ichp.ufl.edu/

August 7, 2019

“Interventions to Improve Transitional Care Between Nursing Homes and Hospitals.” (Journal of the American Geriatrics Society, volume 58, number 4, pp 777-782)

Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for […]
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Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISIWeb, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.
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http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.02776.x/abstract

August 7, 2019

White Space or Black Hole: What Can We Do To Improve Care Transitions?

An emerging consortium of nine leading medical specialty societies – with the support of the ABIM Foundation, AHRQ, IHI, NCQA and others – has recently begun developing principles and initial standards to enhance care transitions. By defining ways to change medical culture, establishing agreed–upon practices, and eventually identifying related measures, […]
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An emerging consortium of nine leading medical specialty societies – with the support of the ABIM Foundation, AHRQ, IHI, NCQA and others – has recently begun developing principles and initial standards to enhance care transitions. By defining ways to change medical culture, establishing agreed–upon practices, and eventually identifying related measures, this consortium – the Stepping Up to the Plate (SUTTP) Alliance – is focused on designing a system of coordination between sites of care with the goal of reducing errors, gaps in care and waste.
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http://www.abimfoundation.org/~/media/Files/Publications/F06-05-2007_6.ashx

August 7, 2019

Medical errors related to discontinuity of care from an inpatient to an outpatient setting

OBJECTIVE To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS Eighty-six patients who had been hospitalized on the medicine service at a large […]
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OBJECTIVE To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
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http://onlinelibrary.wiley.com/doi/10.1046/j.1525-1497.2003.20722.x/abstract