Engaging patients in designing a transmural allied health pathway: A qualitative exploration of hospital-to-home transitions.

INTRODUCTION: The transition from hospital to home is often suboptimal, resulting in patients not receiving the necessary allied healthcare after discharge. This may, in turn, lead to delayed recovery, a higher number of readmissions, more emergency department visits and an increase in mortality and healthcare costs. This study aimed to gain insight into patients' experiences, perceptions, and needs regarding hospital-to-home transition, focusing on allied healthcare as a first step towards the development of a transitional integrated allied healthcare pathway for patients with complex care needs after hospital discharge. METHODS: We conducted semistructured interviews with patients. Participants were recruited from universities and general hospitals in the Amsterdam region between May and July 2023. They were eligible if they (1) were discharged from the hospital minimally 3 and maximally 12 months after admission to an oncologic surgery department, internal medicine department, intensive care unit, or trauma centre, (2) received hospital-based care from at least one allied healthcare provider, who visited the patient at least twice during hospital admission, (3) spoke Dutch or English and (4) were 18 years or older. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis of the interview data. RESULTS: Nineteen patients were interviewed. Three themes emerged from the analysis. 'Allied healthcare support during transition' depicts patients' positive experiences when they felt supported by allied health professionals during the hospital-to-home transition. 'Patient and family involvement' illustrates how much patients value the involvement of their family members during discharge planning. 'Information recall and processing' portrays the challenges of understanding and remembering overwhelming amounts of information, sometimes unclear and provided at the wrong moment. Overall, patients' experiences of transitional care were positive when they were involved in the discharge process. Negative experiences occurred when their preferences for postdischarge communication were ignored. CONCLUSIONS: This study suggests that allied health professionals need to continuously collaborate and communicate with each other to provide patients and their families with the personalized support they need. To provide high-quality and person-centred care, it is essential to consider how, when, and what information to provide to patients and their families to allow them to contribute to their recovery actively. PATIENT OR PUBLIC CONTRIBUTION: The interview guide for this manuscript was developed with the assistance of patients, who reviewed it and provided us with feedback. Furthermore, patients provided us with their valuable lived experiences by participating in the interviews conducted for this study.

Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home (ACEPATH): Codesigning an intervention to improve patient and family caregiver experiences.

BACKGROUND: Returning home from the hospital for palliative-focused care is a common transition, but the process can be emotionally distressing and logistically challenging for patients and caregivers. While interventions exist to aid in the transition, none have been developed in partnership with patients and caregivers. OBJECTIVE: To undergo the initial stages of codesign to create an intervention (Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home [ACEPATH]) to improve the experience of hospital-to-home transitions for adult patients receiving palliative care and their caregiver(s). METHODS: The codesign process consisted of (1) the development of codesign workshop (CDW) materials to communicate key findings from prior research to CDW participants; (2) CDWs with patients, caregivers and healthcare providers (HCPs); and (3) low-fidelity prototype testing to review CDW outputs and develop low-fidelity prototypes of interventions. HCPs provided feedback on the viability of low-fidelity prototypes. RESULTS: Three patients, seven caregivers and five HCPs participated in eight CDWs from July 2022 to March 2023. CDWs resulted in four intervention prototypes: a checklist, quick reference sheets, a patient/caregiver workbook and a transition navigator role. Outputs from CDWs included descriptions of interventions and measures of success. In April 2023, the four prototypes were presented in four low-fidelity prototype sessions to 20 HCPs. Participants in the low-fidelity prototype sessions provided feedback on what the interventions could look like, what problems the interventions were trying to solve and concerns about the interventions. CONCLUSION: Insights gained from this codesign work will inform high-fidelity prototype testing and the eventual implementation and evaluation of an ACEPATH intervention that aims to improve hospital-to-home transitions for patients receiving a palliative approach to care. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers with lived experience attended CDWs aimed at designing an intervention to improve the transition from hospital to home. Their direct involvement aligns the intervention with patients' and caregivers' needs when transitioning from hospital to home. Furthermore, four patient/caregiver advisors were engaged throughout the project (from grant writing through to manuscript writing) to ensure all stages were patient- and caregiver-centred.

Creating 'good' hospital to home transfers in the rural north of Sweden: informal workarounds and opportunities for improvement.

Hospital to home transfers for older people require effective communication, coordination and collaboration across multiple service settings. Rural Nursing Theory and the Beyond Periphery model explain why this is particularly difficult in rural areas, but there are few examples of how rural services respond. This paper presents a case study of the district of Tärnaby in the inland north of Sweden. Data are drawn from interviews with health and care staff in Tärnaby, observations, and experiences of the researchers. Data were analyzed thematically, with four main themes emerging - role clarity, communication, geography, and understanding of the rural context. Responses to challenges included increasing opportunities for communication between service providers and improving documentation. The paper concludes that informal "workarounds" run the risk of further disconnecting rural service settings from "the city". Rather, the aim needs to be to improve contextual understanding through formally incorporating "the rural" in service design.

Mi Puente (My Bridge) Care Transitions Program for Hispanic/Latino Adults with Multimorbidity: Results of a Randomized Controlled Trial.

BACKGROUND: Multimorbidity frequently co-occurs with behavioral health concerns and leads to increased healthcare costs and reduced quality and quantity of life. Unplanned readmissions are a primary driver of high healthcare costs. OBJECTIVE: We tested the effectiveness of a culturally appropriate care transitions program for Latino adults with multiple cardiometabolic conditions and behavioral health concerns in reducing hospital utilization and improving patient-reported outcomes. DESIGN: Randomized, controlled, single-blind parallel-groups. PARTICIPANTS: Hispanic/Latino adults (N=536; 75% of those screened and eligible; M=62.3 years (SD=13.9); 48% women; 73% born in Mexico) with multiple chronic cardiometabolic conditions and at least one behavioral health concern (e.g., depression symptoms, alcohol misuse) hospitalized at a hospital that serves a large, mostly Hispanic/Latino, low-income population. INTERVENTIONS: Usual care (UC) involved best-practice discharge processes (e.g., discharge instructions, assistance with appointments). Mi Puente ("My Bridge"; MP) was a culturally appropriate program of UC plus inpatient and telephone encounters with a behavioral health nurse and community mentor team who addressed participants' social, medical, and behavioral health needs. MAIN MEASURES: The primary outcome was 30- and 180-day readmissions (inpatient, emergency, and observation visits). Patient-reported outcomes (quality of life, patient activation) and healthcare use were also examined. KEY RESULTS: In intention-to-treat models, the MP group evidenced a higher rate of recurrent hospitalization (15.9%) versus UC (9.4%) (OR=1.91 (95% CI 1.09, 3.33)), and a greater number of recurrent hospitalizations (M=0.20 (SD=0.49) MP versus 0.12 (SD=0.45) UC; P=0.02) at 30 days. Similar trends were observed at 180 days. Both groups showed improved patient-reported outcomes, with no advantage in the Mi Puente group. Results were similar in per protocol analyses. CONCLUSIONS: In this at-risk population, the MP group experienced increased hospital utilization and did not demonstrate an advantage in improved patient-reported outcomes, relative to UC. Possible reasons for these unexpected findings are discussed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02723019. Registered on 30 March 2016.

Long-term non-invasive ventilation in children: Transition from hospital to home.

Long-term non-invasive ventilation (NIV) is an accepted therapy for sleep-related respiratory disorders and respiratory insufficiency or failure. Increase in the use of long-term NIV may, in part, be driven by an increase in the number of children surviving critical illness with comorbidities. As a result, some children start on long-term NIV as part of transitioning from hospital to home. NIV may be used in acute illness to avoid intubation, facilitate extubation or support tracheostomy decannulation, and to avoid the need for a tracheostomy for long-term invasive ventilation. The decision about whether long-term NIV is appropriate for an individual child and their family needs to be made with care. Preparing for transition from the hospital to home involves understanding how NIV equipment is obtained and set-up, education and training for parents/caregivers, and arranging a plan for clinical follow-up. While planning for these transitions is challenging, the goals of a shorter time in hospital and a child living well at home with their family are important.

Hospital-to-home transitions for children with medical complexity: part 1, a systematic review of reported outcomes.

Outcome selection to evaluate interventions to support a successful transition from hospital to home of children with medical complexity (CMC) may be difficult due to the variety in available outcomes. To support researchers in outcome selection, this systematic review aimed to summarize and categorize outcomes currently reported in publications evaluating the effectiveness of hospital-to-home transitional care interventions for CMC. We searched the following databases: Medline, Embase, Cochrane library, CINAHL, PsychInfo, and Web of Science for studies published between 1 January 2010 and 15 March 2023. Two reviewers independently screened the articles and extracted the data with a focus on the outcomes. Our research group extensively discussed the outcome list to identify those with similar definitions, wording or meaning. Consensus meetings were organized to discuss disagreements, and to summarize and categorize the data. We identified 50 studies that reported in total 172 outcomes. Consensus was reached on 25 unique outcomes that were assigned to six outcome domains: mortality and survival, physical health, life impact (the impact on functioning, quality of life, delivery of care and personal circumstances), resource use, adverse events, and others. Most frequently studied outcomes reflected life impact and resource use. Apart from the heterogeneity in outcomes, we also found heterogeneity in designs, data sources, and measurement tools used to evaluate the outcomes.     Conclusion: This systematic review provides a categorized overview of outcomes that may be used to evaluate interventions to improve hospital-to-home transition for CMC. The results can be used in the development of a core outcome set transitional care for CMC.

Hospital-to-home transitions for children with medical complexity: part 2-a core outcome set.

Appropriate outcome measures as part of high-quality intervention trials are critical to advancing hospital-to-home transitions for Children with Medical Complexity (CMC). Our aim was to conduct a Delphi study and focus groups to identify a Core Outcome Set (COS) that healthcare professionals and parents consider essential outcomes for future intervention research. The development process consisted of two phases: (1) a three-round Delphi study in which different professionals rated outcomes, previously described in a systematic review, for inclusion in the COS and (2) focus groups with parents of CMC to validate the results of the Delphi study. Forty-five professionals participated in the Delphi study. The response rates were 55%, 57%, and 58% in the three rounds, respectively. In addition to the 24 outcomes from the literature, the participants suggested 12 additional outcomes. The Delphi rounds resulted in the following core outcomes: (1) disease management, (2) child's quality of life, and (3) impact on the life of families. Two focus groups with seven parents highlighted another core outcome: (4) self-efficacy of parents.   Conclusion: An evidence-informed COS has been developed based on consensus among healthcare professionals and parents. These core outcomes could facilitate standard reporting in future CMC hospital to home transition research. This study facilitated the next step of COS development: selecting the appropriate measurement instruments for every outcome. What is Known: • Hospital-to-home transition for Children with Medical Complexity is a challenging process. • The use of core outcome sets could improve the quality and consistency of research reporting, ultimately leading to better outcomes for children and families. What is New: • The Core Outcome Set for transitional care for Children with Medical Complexity includes four outcomes: disease management, children's quality of life, impact on the life of families, and self-efficacy of parents.

Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review.

BACKGROUND: Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models. METHODS: We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary. RESULTS: A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions. CONCLUSIONS: There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.

Being well? A meta-ethnography of older patients and their relatives' descriptions of suffering and well-being in the transition from hospital to home.

BACKGROUND: As the average length of hospital stay decreases, more and more older patients will need support during and after the hospital transition, which will mainly be provided by their relatives. Studies highlight the enormous effect such a transition has on the lives of older patients and their relatives. However, research is lacking regarding in-depth understanding of the complexities and the notions of suffering and well-being the older patients and their relatives describe in the transition from hospital to home. Therefore, this study aims to examine the description of suffering and well-being on a deeper, existential level by drawing on existing phenomenological research. METHODS: In order to synthesize and reinterpret primary findings, we used the seven-step method for meta-ethnography. Following specific inclusion criteria and focusing on empirical phenomenological studies about older patients and their relatives experiences of hospital to home transitions, a systematic literature search was conducted. Data from ten studies have been analyzed. RESULTS: Our analysis identified three intertwined themes: i) 'Being excluded vs. being included in the transition process', ii) 'Being a team: a call for support and a call to support' and iii) 'Riding an emotional rollercoaster'. The last theme was unfolded by the two subthemes 'Taking on the new role as a caregiver: oscillating between struggling and accepting' and 'Getting back to normal: oscillating between uncertainty and hope'. Within those themes, older patients and their relatives described rather similar than contradictory aspects. CONCLUSIONS: This study offers insights into the tension between existential suffering and well-being described by the older patients and their relatives during the transition from hospital to home. Especially, the description of well-being in all its nuances which, if achieved, enables older patients and their relatives to identify with the situation and to move forward, this process can then be supported by the health care professionals. However, there is still lack of knowledge with regards to a deeper understanding of existential well-being in this process. Given the increasing tendency towards early hospital discharges, the findings underpin the need to further investigate the experiences of well-being in this process.

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-A systematic review.

AIM: The aim of this systematic review is to describe and evaluate the effectiveness of transition interventions to safeguard patient safety and satisfaction during patients' transition from hospital to home health care. DESIGN: Systematic review. DATA SOURCES: MEDLINE, Ovid Nursing Database, PsycINFO, EMBASE, CINAHL, Clinical Trials and SveMed+ was systematic searched in January 2019 and September 2020 to identify peer-reviewed papers. No language, geographical or publication date restrictions. REVIEW METHODS: Cochrane Handbook for Systematic Reviews of Interventions was used. Data analysis focused on aggregated data and a descriptive synthesis. Risk of bias was rated using Cochrane risk-of-bias tool. RESULTS: In total, 10,524 references were identified in the literature search, twenty-six articles were included. The interventions were divided into three main groups: (i). systematic patient education pre-discharge; (ii). establishment of contact with the local healthcare services pre-discharge and (iii). follow-up initiated by nurses from the hospital at home post-discharge. The studies either used one intervention or combined two or three interventions. We considered the intervention to improve patient safety or satisfaction when they reported statistically significant results. Only four interventions increased both patient safety and satisfaction, seven interventions increased patient safety and thirteen increased patient satisfaction. Interventions that appear to be quite similar, with the same duration, measured different effects on patients' satisfaction and safety. Interventions that ensured patient safety did not necessarily facilitate patient satisfaction and vice versa. CONCLUSION: Interventions can improve patient safety and satisfaction during transfer. However, interventions that improve patient safety or satisfaction do not always match. IMPACT: This review suggests that transition interventions can improve patients' safety and satisfaction. However, to compare the impact of future interventions is it important to use standardized measurement tools of satisfaction. There is a need to try out tailored interventions, where interventions are customized to the needs of each patient.

Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review.

AIM: To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity. BACKGROUND: Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions. DESIGN: Scoping review. METHODS: Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies. RESULTS: Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.

Parental caregivers' perception of their transition from hospital to home in children with cerebral palsy who have undergone orthopedic surgery.

PURPOSE: Evaluate parental perception of the quality of discharge teaching, readiness for discharge, and the impact of these on post discharge coping difficulty and resource utilization in children with cerebral palsy (CP) following surgery. DESIGN AND METHODS: Prospective cohort study conducted from September 2017-March 2021 at a pediatric academic medical center. Demographics were collected pre-operatively. Parents completed the Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS) within four hours of discharge. Four weeks post-discharge, parents completed the Post-discharge Coping Difficulty Scale (PDCDS). Utilization of healthcare resources were extracted from the electronic health record for 90 days post-operatively. Associations among demographics, RHDS, QDTS, PDCDS and resource utilization were assessed using general linear models; PDCDS's open-ended questions were analyzed using directed content analysis. RESULTS: 114 parental caregivers participated. Post discharge coping was significantly associated with additional resource utilization: length of stay (p = 0.046), readmissions (p = 0.001), emergency department visits (p = 0.001), clinic calls (p = 0.001) and unplanned clinic visits (p = 0.006). PDCDS was negatively correlated with the QDTS Quality of Teaching Delivered subscale (r = -0.32; p = 0.004) and three of five RHDS subscales: 1) Child's Personal Status (r = -0.24; p = 0.02); 2) Knowledge (r = -0.30; p = 0.005); and 3) Coping Ability (r = -0.39; p < 0.001). Four themes explicated parental coping difficulties. CONCLUSION: Parents experiencing coping difficulties were more likely to have difficulty managing their child's care needs at home and required additional health care resources. PRACTICE IMPLICATIONS: Recognizing that parents' readiness for discharge may not reflect their coping abilities post-discharge requiring nurses to coordinate pre- and post-discharge education and support services.

Interventions, stakeholders, and organisation related to pressure ulcer prevention for individuals with spinal cord injuries in transition from hospital to home - A scoping review.

STUDY DESIGN: Scoping review. AIM OF THE STUDY: To obtain an overview of initiatives, organisational components, and stakeholders' perspectives on PU prevention in transitional care. METHODS: Scoping review searching the databases: MEDLINE, EMBASE), CINAHL, Cochrane Library, Web of Science, and SCOPUS in May 2022. Inclusion of English-written research on pressure ulcer prevention in adult people with spinal cord injury in transition from hospital or rehabilitation centre to the home care environment. RESULTS: Fifteen studies of different types are included in this study: six qualitative studies, four randomized controlled trials, three cohort studies, one cross-sectional study and an interventional study. The included studies are relatively low-level evidence but of acceptable quality. CONCLUSION: Continuous tailored education and information about PU prevention and follow-up services are essential components in preventing PUs and rehabilitating people with SCI. The complexity of SCI requires adaptations, equipment and access to specialist care and treatment after discharge. However, there is a discrepancy between the international recommendations, the perceived needs, and the delivered healthcare services. The consequences are a lower quality of life and a higher risk of PUs for people with SCI.

A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

INTRODUCTION: Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. AIM: To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6 months. METHODS: Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1 week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. RESULT: Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. CONCLUSION AND PRACTICE IMPLICATION: A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

[Transitional care from hospital to home: how to target the right population?] / Soins de transition entre l'hôpital et le domicile: pour quels patient-es ?

When patients are discharged from the hospital and return home, they are at risk of adverse events if the continuity of care is broken. So far, the evidence for transitional care models to reduce readmission rates has focused mainly on patients with a single condition. Based on this observation, we identified the population that may benefit the most from the development of a new transitional care model, as part of the INSTEAD project, by consensus between patients and professionals in hospitals and the community. To ensure continuity of care, it is necessary to consider the patients' perception, their understanding of the care plan and changes impacting the home care plan. Interprofessional collaboration is essential to achieve this.

Lorsqu'un-e patient-e retourne à domicile suite à une hospitalisation il-elle est souvent confronté-e à des événements indésirables si la continuité de ses soins n'est pas assurée. Jusqu'à ce jour, les modèles de soins de transition qui ont montré une diminution du taux de réadmission concernaient des patient-es ne souffrant que d'une seule pathologie. Partant de ce constat, nous avons identifié la population qui pourrait le plus bénéficier de soins de transition, dans le cadre du projet INSTEAD, par un consensus incluant d'une part des patient-es et, d'autre part, des professionnel-les hospitaliers et communautaires. Pour assurer la continuité des soins, il s'avère nécessaire de prendre en compte la perception de la personne, sa compréhension ainsi que les changements influençant son plan de soins à domicile. Pour ce faire, une collaboration interprofessionnelle est indispensable.

Implementation of the Mental Capacity Act: a national observational study comparing resultant trends in place of death for older heart failure decedents with or without comorbid dementia.

BACKGROUND: Heart failure (HF) is increasingly prevalent in the growing elderly population and commonly associated with cognitive impairment. We compared trends in place of death (PoD) of HF patients with/without comorbid dementia around the implementation period of the Mental Capacity Act (MCA) in October 2007, this legislation supporting patient-centred decision making for those with reduced agency. METHODS: Analyses of death certification data for England between January 2001 and December 2018, describing the PoD and sociodemographic characteristics of all people ≥ 65 years registered with HF as the underlying cause of death, with/without a mention of comorbid dementia. We used modified Poisson regression with robust error variance to determine the prevalence ratio (PR) of the outcome in dying at home, in care homes or hospices compared to dying in hospital. Covariates included year of death, age, gender, marital status, comorbidity burden, index of multiple deprivation and urban/rural settings. RESULTS: One hundred twenty thousand sixty-eight HF-related death records were included of which 8199 mentioned dementia as a contributory cause. The overall prevalence proportion of dementia was 6.8%, the trend significantly increasing from 5.6 to 8.0% pre- and post-MCA (Cochran-Armitage trend test p < 0.0001). Dementia was coded as unspecified (78.2%), Alzheimer's disease (13.5%) and vascular (8.3%). Demented decedents were commonly older, female, and with more comorbidities. Pre-MCA, PoD for non-demented HF patients was hospital 68.2%, care homes 20.2% and 10.7% dying at home. Corresponding figures for those with comorbid dementia were 47.6%, 48.0% and 4.2%, respectively. Following MCA enforcement, PoD for those without dementia shifted from hospital to home, 62.5% and 17.2%, respectively; PR: 1.026 [95%CI: 1.024-1.029]. While home deaths also rose to 10.0% for those with dementia, with hospital deaths increasing to 50.4%, this trend was insignificant, PR: 1.001 [0.988-1.015]. Care home deaths reduced for all, with/without dementia, PR: 0.959 [0.949-0.969] and PR: 0.996 [0.993-0.998], respectively. Hospice as PoD was rare for both groups with no appreciable change over the study period. CONCLUSIONS: Our analyses suggest the MCA did not materially affect the PoD of HF decedents with comorbid dementia, likely reflecting difficulties implementing this legislation in real-life clinical practice.

Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study.

INTRODUCTION: Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization. METHODS: We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days. RESULTS: We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: -1.6, 97.5% CI -3.3 to 0.1, p=0.03), informational support (adjusted difference: -0.01, 97.5% CI -2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05). CONCLUSIONS: In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02114515.

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home.

BACKGROUND: The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention. METHODS: This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims. RESULTS: Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness. CONCLUSION: The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing. PATIENT OR PUBLIC CONTRIBUTION: This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.

Experiences of family caregivers of patients with post-traumatic hydrocephalus from hospital to home: a qualitative study.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a complication of traumatic brain injury (TBI) that requires treatment and postoperative care. The shunt is one of the main treatments for PTH, which presents with dysfunction and infection. Considering brain injury, hydrocephalus shunt malfunction, and infection, family caregivers need to be responsible for caring for PTH patients, recognizing shunt malfunction and infection, and managing those patients accordingly from hospital to home. Understanding the experiences and needs of caregivers is beneficial for knowing their competency and quality of health care, ameliorating and ensuring future transition care. The study aimed to explore the feelings, experiences, and needs of family caregivers when caring for patients with TBI, PTH and shunts. METHODS: This was exploratory research of a purposive sample of 12 family caregivers of adult patients with TBI, PTH and shunts in five neurosurgery departments at a general hospital in Zhengzhou, Henan Province, China, using a semi-structured interview method. Data were collected from October 2021 to March 2022 before being analyzed by content analysis methods. RESULTS: Caregivers required professional and social knowledge and support in the areas of TBI, PTH and shunts, caregiving interventions, psychological care needs, and health insurance, just as caregivers do, but unlike other general caregivers, care for patients with TBI, PTH, and shunt is fraught with uncertainty and the need to manage shunt setting, and caregivers often experience 'complex emotional reaction' during the transitional period, where care needs and complex emotions may lead to a lack of caregiver confidence, which in turn may affect caregiving behaviors, and experiences that affect care may be mediated through caregiving confidence. The perceived availability of resources, particularly those that are still available to them when they return home, has a significant impact on participants' emotional response and sense of confidence. CONCLUSIONS: The emotional response and the impact of stressor caregivers after TBI, PTH, and shunt was important, and sometimes confidence in care appeared to be an intermediate and useful factor that needed to be considered as health professionals prepared to develop care resources on how to manage and empower patients with TBI, PTH, and shunt. Meanwhile, there may be gaps and inequities in supportive care for patients diagnosed with TBI, PTH, and shunt in China.

Implementing a Departure Lounge: A Strategy to Improve Patient Flow and the Discharge Process.

This column presents the development of a Departure Lounge at Cedars Sinai Medical Center as a mechanism to assist in addressing capacity constraints. Departure lounges have been presented as an option to improve hospital throughput by providing a safe space for discharged patients to wait once medical and nursing care has been completed.