August 7, 2019

Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient

The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and […]
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The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients' cognitive limitations. Evidence suggests deficits in communication by hospital physicians to primary care providers occur commonly but this is only one of many systems barriers to successful discharge. Review of the literature reveals interventions such as involvement of advance practice nurses or family members in the transition may overcome some of the difficulties inherent in discharge of the vulnerable geriatric patient. Weekend discharges present unique challenges and potential solutions are explored. This case offers the opportunity to review the elements necessary for success and insight into the systems limitations which underlie failed transitions.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.304/abstract

August 7, 2019

Hospitalists and care transitions: the divorce of inpatient and outpatient care

We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians’ participation on hospital medical staffs, which increases the burden of coordination […]
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We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians' participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. Arrangements where companies and multispecialty medical groups employ hospitalists are more likely than others to establish routines for ensuring coordinated transitions upon hospital admission and discharge. Policymakers could support the development of guiding principles for care coordination, greater reliance on nonphysicians, and reintegration of inpatient and outpatient providers.
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http://content.healthaffairs.org/content/27/5/1315.abstract

August 7, 2019

The role of the hospitalist in quality improvement: systems for improving the care of patients with acute coronary syndrome

Quality improvement (QI) initiatives for systems of care are vital to deliver quality care for patients with acute coronary syndrome (ACS) and hospitalists are instrumental to the QI process. Core hospitalist competencies include the development of protocols and outcomes measures that support quality of care measures established for ACS. The […]
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Quality improvement (QI) initiatives for systems of care are vital to deliver quality care for patients with acute coronary syndrome (ACS) and hospitalists are instrumental to the QI process. Core hospitalist competencies include the development of protocols and outcomes measures that support quality of care measures established for ACS. The hospitalist may lead, coordinate, or participate in a multidisciplinary team that designs, implements, and assesses an institutional system of care to address rapid identification of patients with ACS, medication safety, safe discharge, and meeting core measures that are quality benchmarks for ACS. The use of metrics and tools such as process flow mapping and run charts can identify quality gaps and show progress toward goals. These tools may be used to assess whether critical timeframes are met, such as the time to fibrinolysis or percutaneous coronary intervention (PCI), or whether patients receive guideline-recommended medications and counseling. At the institutional level, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is an initiative designed to improve outcomes in elderly patients who are at higher risk for adverse events during the transition from inpatient to outpatient care. BOOST offers resources related to project management and data collection, and tools for patients and physicians. Collection and analysis of objective data are essential for documenting quality gaps or achievement of quality benchmarks. Through QI initiatives, the hospitalist has an opportunity to contribute to an institution's success beyond direct patient care, particularly as required for public disclosure of institutional performance and financial incentives promoted by regulatory agencies.
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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20842745

August 7, 2019

Variables That Discriminate Length of Stay and Readmission Within 30 Days Among Heart Failure Patients

The purpose of this study was to determine which variables may discriminate between a short length of stay (LOS) and a long LOS and readmission within 30 days among heart failure (HF) patients discharged from a hospital. The charts of 188 patients who were discharged with diagnostic related group 127 […]
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The purpose of this study was to determine which variables may discriminate between a short length of stay (LOS) and a long LOS and readmission within 30 days among heart failure (HF) patients discharged from a hospital. The charts of 188 patients who were discharged with diagnostic related group 127 during September 30, 1997, until October 31, 1998, were retrospectively reviewed to examine the association between LOS and readmission among 12 variables. It was discovered that an increased number of physicians involved during the patient's hospitalization (p = 0.000) and case management involvement (p = 0.007) were discriminating variables for those patients with a longer LOS. The variables of serum sodium (p = 0.032) and higher NYHA classification (p = 0.018) approached significance in discriminating a longer LOS. HF patients who were readmitted within 30 days were significantly found to have an increased NYHA class (p = 0.002) and no specific follow-up plan arranged related to the patients' HF diagnosis (p = 0.005). The results of this study indicate several variables that significantly discriminate LOS and readmission within 30 days among HF patients that case managers can employ to improve care to this population.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2001/11000/Variables_That_Discriminate_Length_of_Stay_and.5.aspx

August 7, 2019

Hand-off communication: a requisite for perioperative patient safety

Transitions from one care provider to another put patients at increased risk of injuries and errors. A standardized approach to hand-off communication helps minimize these risks. One recognized approach to addressing this concern is the SBAR (ie, situation, background, assessment, recommendation) communication technique. Reference cards with the SBAR communication approach […]
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Transitions from one care provider to another put patients at increased risk of injuries and errors. A standardized approach to hand-off communication helps minimize these risks. One recognized approach to addressing this concern is the SBAR (ie, situation, background, assessment, recommendation) communication technique. Reference cards with the SBAR communication approach can be used by all staff members during hand offs in the preoperative, intraoperative, and postoperative phases of surgical patient care.
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http://www.aornjournal.org/article/S0001-2092(08)00519-X/abstract

August 7, 2019

Transitioning the patient with acute coronary syndrome from inpatient to primary care

Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of […]
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Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.829/pdf

August 7, 2019

Health status transitions in community-living elderly with complex care needs: a latent class approach

BACKGROUND For older persons with complex care needs, accounting for the variability and interdependency in how health dimensions manifest themselves is necessary to understand the dynamic of health status. Our objective is to test the hypothesis that a latent classification can capture this heterogeneity in a population of frail elderly […]
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BACKGROUND For older persons with complex care needs, accounting for the variability and interdependency in how health dimensions manifest themselves is necessary to understand the dynamic of health status. Our objective is to test the hypothesis that a latent classification can capture this heterogeneity in a population of frail elderly persons living in the community. Based on a person-centered approach, the classification corresponds to substantively meaningful groups of individuals who present with a comparable constellation of health problems. METHODS Using data collected for the SIPA project, a system of integrated care for frail older people (n = 1164), we performed latent class analyses to identify homogenous categories of health status (i.e. health profiles) based on 17 indicators of prevalent health problems (chronic conditions; depression; cognition; functional and sensory limitations; instrumental, mobility and personal care disability) Then, we conducted latent transition analyses to study change in profile membership over 2 consecutive periods of 12 and 10 months, respectively. We modeled competing risks for mortality and lost to follow-up as absorbing states to avoid attrition biases. RESULTS We identified four health profiles that distinguish the physical and cognitive dimensions of health and capture severity along the disability dimension. The profiles are stable over time and robust to mortality and lost to follow-up attrition. The differentiated and gender-specific patterns of transition probabilities demonstrate the profiles' sensitivity to change in health status and unmasked the differential relationship of physical and cognitive domains with progression in disability. CONCLUSION Our approach may prove useful at organization and policy levels where many issues call for classification of individuals into pragmatically meaningful groups. In dealing with attrition biases, our analytical strategy could provide critical information for the planning of longitudinal studies of aging. Combined, these findings address a central challenge in geriatrics by making the multidimensional and dynamic nature of health computationally tractable.
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http://rd.springer.com/article/10.1186/1471-2318-9-6

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 […]
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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.
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http://www.geriatric.theclinics.com/article/S0749-0690(08)00071-2/abstract

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 […]
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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.
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http://journals.lww.com/professionalcasemanagementjournal/Abstract/2005/03000/Nursing_Home_Transition__Providing_Assistance_to.6.aspx

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
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http://www.modernhealthcare.com/article/20101025/MAGAZINE/101029981