Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program.

BACKGROUND: Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC. METHODS: Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). RESULTS: We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. CONCLUSIONS: HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative.

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Trends in telehealth and in-person transitional care management visits during the COVID-19 pandemic.

BACKGROUND/OBJECTIVES: Transitional care management (TCM) visits delivered following hospitalization have been associated with reductions in mortality, readmissions, and total costs; however, uptake remains low. We sought to describe trends in TCM visit delivery during the COVID-19 pandemic. DESIGN: Cross-sectional study of ambulatory electronic health records from December 30, 2019 and January 3, 2021. SETTING: United States. PARTICIPANTS: Forty four thousand six hundred and eighty-one patients receiving transitional care management services. MEASUREMENTS: Weekly rates of in-person and telehealth TCM visits before COVID-19 was declared a national emergency (December 30, 2019 to March 15, 2020), during the initial pandemic period (March 16, 2020 to April 12, 2020) and later period (April 12, 2020 to January 3, 2021). Characteristics of patients receiving in-person and telehealth TCM visits were compared. RESULTS: A total of 44,681 TCM visits occurred during the study period with the majority of patients receiving TCM visits age 65 years and older (68.0%) and female (55.0%) Prior to the COVID-19 pandemic, nearly all TCM visits were conducted in-person. In the initial pandemic, there was an immediate decline in overall TCM visits and a rise in telehealth TCM visits, accounting for 15.4% of TCM visits during this period. In the later pandemic, the average weekly number of TCM visits was 841 and 14.0% were telehealth. During the initial and later pandemic periods, 73.3% and 33.6% of COVID-19-related TCM visits were conducted by telehealth, respectively. Across periods, patterns of telehealth use for TCM visits were similar for younger and older adults. CONCLUSION: The study findings highlight a novel and sustained shift to providing TCM services via telehealth during the COVID-19 pandemic, which may reduce barriers to accessing a high-value service for older adults during a vulnerable transition period. Further investigations comparing outcomes of in-person and telehealth TCM visits are needed to inform innovation in ambulatory post-discharge care.

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness.

OBJECTIVE: To evaluate the impact of Maryland's behavioral health homes (BHHs) on receipt of follow-up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI). DATA SOURCES: Maryland Medicaid administrative claims for 12 232 individuals. STUDY DESIGN: Weighted marginal structural models were estimated to account for time-varying exposure to BHH enrollment and time-varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow-up care within 7 and 30 days following hospitalization. DATA COLLECTION/EXTRACTION METHODS: Eligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21-64 years; and use of psychiatric rehabilitation services. PRINCIPAL FINDINGS: Over three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow-up service within 7 days of discharge from a mental illness-related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow-up within 7 days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission. CONCLUSIONS: BHHs may improve follow-up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.

A telephone-based surgical transitional care program with improved patient satisfaction scores and fiscal neutrality.

BACKGROUND: Limited data exist regarding the downstream effects of surgical transitional care programs. We explored the impact of such programs on patient satisfaction and fiscal metrics. METHODS: A telephone-based surgical transitional care program enrolled patients undergoing complex abdominal surgery between 2015 to 2017. A matched cohort undergoing similar procedures between 2010 to 2015 were used as controls. Press Ganey scores were used to reflect patient satisfaction. Hospital costs, reimbursements, and margins were analyzed for index hospitalizations and readmissions within 90 days of surgery. RESULTS: There were 607 patients in the control group and 608 in the transitional care program; survey response rates were 37% and 35%, respectively. Transitional care patients rated their understanding of personal responsibilities in post-discharge care higher than controls (59% vs 69%, P = .02). Transitional care patients felt they received better educational materials about their condition or treatment (55% vs 68%, P < .01) and rated their global hospital experience higher (46% vs 57%, P = .02). The aggregate (index plus readmission) cost was greater for the transitional care ($22,814 vs $25,827, P < .01), but there was no difference in aggregate margin ($7,027 vs $4,698, P = .25). Multivariable adjustment yielded similar results for the aggregate cost (ref vs $2,232, P = .03) and margin (ref vs $1,299, P = .23). CONCLUSION: The use of this dedicated abdominal surgery transitional care program is associated with improved Press Ganey patient education and global rating scores. The cost to support this program did not adversely affect the hospital margin when considering all factors. These data support broader investment in patient centered initiatives that may significantly enhance patient experience.

DesHospitaliza: plano de gestão para alta responsável de pacientes idosos com doenças crônicas / Dishospitalizes: management plan for senior care of elderly patients with chronic diseases

Introdução: O Brasil está passando pelo envelhecimento demográfico mais rápido do mundo. No Brasil o segmento populacional que mais aumenta é o de idosos, com taxas de crescimento acima de 4% ao ano no período de 2012 a 2022. As consequências desse crescimento são o aumento das demandas assistenciais, previdenciárias, econômica, familiares e de saúde para atender esse segmento. Além disso, os sistemas de atenção à saúde são fragmentados, atuam de forma isolada, sem uma comunicação entre os pontos de cuidado, ou seja, a atenção primária à saúde não se comunica fluidamente com a atenção secundária à saúde e esses dois também não se comunicam com a atenção terciária, nem com os sistemas de apoio. Nesse contexto, e pensando na contribuição para a melhoria da assistência prestada ao paciente idoso portador de doença crônica, emerge a questão norteadora: na elaboração de um plano de gestão para alta responsável, que categorias deverão ser contempladas para atender o idoso de forma integral e integrada durante a internação e alta hospitalar, com vistas a continuidade do cuidado pela Atenção Primária à Saúde (APS)? Objetivos: O principal foi elaborar o plano de gestão para alta responsável de pacientes idosos com doenças crônicas como estratégia para a transição segura do cuidado e sua continuidade na APS. Os objetivos específicos foram: Identificar as categorias fundamentais que devem compor o plano de gestão para alta responsável e validar as categorias e orientações a serem apresentados no Deshospitaliza- Plano de Gestão para Alta Responsável. Método: Trata-se de um estudo descritivo exploratório com abordagem qualitativa e quantitativo, com uso da técnica de grupo focal (segunda etapa do estudo) e método Delphi (etapa de validação do plano de alta). Resultados: A partir dos resultados obtidos com o grupo focal foram identificadas as seguintes categorias: acolhimento e porta de entrada; planejamento para alta responsável; atenção centrada na pessoa e educação em saúde e, posteriormente, obteve a validação da mesmas (IVC=0,97 e coeficiente de kappa=0,87), bem como das orientações presentes no plano de gestão para alta responsável de pacientes idoso com doenças crônicas. Conclusão: A produção técnica desta pesquisa caracteriza-se como uma tecnologia leve dura que se propõem a operar no processo de trabalho em saúde, pensando num cuidado integral, considerando o conjunto de necessidades e riscos do usuário, com articulação pactuada entre profissionais de diferentes setores do hospital ou pontos de atenção à saúde. Tem alto impacto social por ser um documento norteador para os hospitais federais no Rio de Janeiro, podendo ser referência para demais unidades hospitalares estaduais e nacionais

Introduction: Brazil is experiencing the fastest demographic aging in the world. In Brazil, the population segment that most increases is the elderly, with growth rates above 4% per year in the period from 2012 to 2022. The consequences of this growth are the increase in assistance, social security, economic, family and health demands to serve this segment . In addition, health care systems are fragmented, acting in isolation, without communication between the points of care, that is, primary health care does not communicate fluently with secondary health care and these two do not communicate either. communicate with tertiary care or support systems. In this context, and considering the contribution to the improvement of the care provided to elderly patients with chronic illness, the guiding question emerges: in the elaboration of a management plan for senior managers, which categories should be considered to fully assist the elderly and integrated during hospitalization and hospital discharge, with a view to the continuity of care through Primary Health Care (PHC)? Objectives: main The was and laboring the management plan for the igh responsible of elderly patients with chronic diseases like and stratégia for safe transition of care and continuity in the APS. The objectives specific were: Identify the key categories that should be included in the management plan for the igh responsible e v Alidar categories and guidelines to be presented at Deshospitaliza- Management Plan for the igh responsible. Method: This is a descriptive exploratory study with a qualitative and quantitative approach, using the focus group technique (second stage of the study) and the Delphi method (stage of validation of the discharge plan). Results: Based on the results obtained with the focus group, the following categories were identified: reception and entrance door; planning for senior management; person-centered attention and health education and subsequently obtained their validation (CVI = 0.97 and kappa coefficient = 0.87), as well as the guidelines in the management plan for responsible discharge of elderly patients with diseases chronic. Conclusion: This is a tough lightweight technology that purport to operate r n health work process, thinking n integral care, considering the set of user needs and risks, with the agreed coordination between professionals from different sectors hospital or health care points. It has a high social impact as it is a guiding document for federal hospitals in Rio de Janeiro, and can be a reference for other state and national hospital units.

Visualizing healthcare system variability and resilience: a longitudinal study of patient movements following discharge from a Swedish psychiatric clinic.

BACKGROUND: As healthcare becomes increasingly complex, new methods are needed to identify weaknesses in the system that could lead to increased risk. Traditionally, the focus for patient safety is to study incident reports and adverse events, but that starting point has been contested with a new era of safety investigations: the analysis of everyday clinical work, and the resilient healthcare. This study introduces a new approach of system monitoring as a way to strengthen patient safety and has focused on discharge in psychiatry as a risk for adverse outcomes. The aim was to analyse a psychiatric clinic's everyday 'normal' performance variability of discharge from inpatient psychiatric care to outpatient care. METHOD: A retrospective longitudinal correlation study with a strategic selection. Data consist of 70,797 patient visits within one psychiatric clinic, and the visits were compared between 81 different wards in Stockholm County by using a model of time-lapse visualization. RESULTS: The time-lapse visualization shows a discrepancy in types of visits and the proportion of cancelled visits to the outward units. 42% of all patients that were scheduled as an outward patient, did not complete this transition, but instead, they revisit the clinics' emergency ward and did not receive the planned care treatment. The patients who visit the emergency ward instead of their planned outpatient visit did this within 20 days. CONCLUSIONS: The findings show a potential increased demand for emergency psychiatric care from 2010 to 2018 within the clinic. It also suggests that the healthcare system creates a space of temporal as well as functional variability, and that patients use this space to adapt to their changing conditions. This understanding can assist management in prioritising allocation of resources and thereby strengthen patient safety. Today's incident reporting systems in healthcare are ineffective in monitoring patterns of more cancelled visits in outward units and sooner visit to the emergency ward. By using time-lapse visualization of patient interactions, stakeholders might analyse current-, and estimate future, stressors within the system to identify and understand potential system migration towards risk in healthcare. This could help healthcare management understand where resources should be prioritized.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review.

AIMS AND OBJECTIVES: To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home. BACKGROUND: Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment. DESIGN: Systematic review following PRISMA guidelines. METHODS: A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0-20. RESULTS: A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13-18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home. CONCLUSIONS: Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often-challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

Telehealth Uptake into Prenatal Care and Provider Attitudes during the COVID-19 Pandemic in New York City: A Quantitative and Qualitative Analysis.

OBJECTIVE: This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition. STUDY DESIGN: Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth. RESULTS: During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth (n = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients. CONCLUSION: Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required. KEY POINTS: · Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs.

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Avoidable 30-day readmissions in patients undergoing vascular surgery.

Background: Vascular surgery has one of the highest unplanned 30-day readmission rates of all surgical specialties. The degree to which these may be avoidable and the optimal strategies to reduce their occurrence are unknown. The aim of this study was to identify and classify avoidable 30-day readmissions in patients undergoing vascular surgery in order to plan targeted interventions to reduce their occurrence, improve outcomes and reduce cost. Methods: A retrospective analysis of discharges over a 12-month period from a single tertiary vascular unit was performed. A multidisciplinary panel conducted a manual case-note review to identify and classify those 30-day unplanned emergency readmissions deemed avoidable. Results: An unplanned 30-day readmission occurred in 72 of 885 admissions (8·1 per cent). These unplanned readmissions were deemed avoidable in 36 (50 per cent) of these 72 patients, and were most frequently due to unresolved medical issues (19 of 36, 53 per cent) and inappropriate admission with the potential for outpatient management (7 of 36, 19 per cent). A smaller number were due to inadequate social care provision (4 of 36, 11 per cent) and the occurrence of other avoidable adverse events (4 of 36, 11 per cent). Conclusion: Half of all 30-day readmissions following vascular surgery are potentially avoidable. Multidisciplinary coordination of inpatient care and the transition from hospital to community care after discharge need to be improved.

Antecedentes: La cirugía vascular tiene una de las tasas más elevadas de reingresos no planificados a los 30 días de todas las especialidades quirúrgicas. Se desconoce hasta qué punto este problema puede ser evitable y las estrategias óptimas para su disminución. El objetivo de este estudio fue identificar y clasificar los reingresos evitables a los 30 días en pacientes sometidos a cirugía vascular para planificar intervenciones dirigidas a su disminución, mejorar los resultados y reducir el coste. Métodos: Se realizó un análisis retrospectivo de las altas hospitalarias durante un periodo de 12 meses en una unidad vascular terciaria. Un panel multidisciplinario realizó una revisión manual de los casos para identificar y clasificar aquellos reingresos urgentes no planificados a los 30 días que se considerasen evitables. Resultados: Se registró un reingreso no planificado a los 30 días en 72/885 (8,1%) ingresos. Estos reingresos no planificados fueron considerados evitables en el 50,0% (36/72) y fueron debidos con más frecuencia a cuestiones médicas sin resolver (19/36, 52,8%) y a un ingreso no apropiado con la posibilidad de tratamiento ambulatorio (7/36, 19,4%). En un número menor de casos se debió a una asistencia social inadecuada (4/36, 11,1%) y la aparición de otros eventos adversos evitables (4/36, 11,1%). Conclusión: La mitad de los reingresos a los 30 días en pacientes vasculares son potencialmente evitables. Tras el alta hospitalaria debe mejorarse la coordinación multidisciplinaria de la atención hospitalaria y la transición desde el hospital a la atención comunitaria.

Supporting carers of stroke survivors to reduce carer burden: development of the Preparing is Caring intervention using Intervention Mapping.

BACKGROUND: Burden is well documented among carers of stroke survivors, yet current evidence is insufficient to determine if any strategies reduce this negative outcome. Existing interventions for carers of stroke survivors typically involve supporting carers according to their individual needs through face-to-face interactions and provision of information including workbooks or educational guides. To date, no interventions have been developed using a method which systematically incorporates evidence, behaviour change theories, and stakeholder involvement to change the behaviours of carers and relevant individuals who support carers. This study aimed to develop a programme plan for a theory and evidence-based intervention to reduce burden in carers of stroke survivors. METHODS: Informed by evidence from two systematic reviews and 33 qualitative interviews, the first four stages of Intervention Mapping were used to guide the intervention development process: 1) needs assessment; 2) identifying outcomes and objectives; 3) selecting theoretical methods and practical applications; and 4) creating a programme plan. Structured and facilitated involvement from stakeholders, including carers, researchers, and professionals from health and community services was integral to the intervention development process. Stakeholders helped to prioritise the focus of the intervention, develop the goals, outcomes and objectives for the programme, and generate and refine intervention ideas. RESULTS: Stakeholders prioritised the need for carers to feel prepared before and during the transition from hospital to home as key to reducing burden. The proposed intervention 'Preparing is Caring' targets this need and involves providing and signposting carers to relevant information and support for practical and emotional needs. This is to be delivered before, during, and immediately after the stroke survivor's transition from hospital to home by a person taking on a single point of contact role. It is comprised of multiple theory-based components including: training packages for information and support providers working with carers and wider staff teams, plus elements to support carers to feel prepared. CONCLUSIONS: We have developed a comprehensive programme plan for a multiple-component, theory and evidence informed behaviour change intervention aimed at preparing carers before and during the transition from hospital to home. Future work is required to refine, implement and evaluate the Preparing is Caring intervention.

Financial impact of improving patient care setting selection after bariatric surgery.

BACKGROUND: Potentially avoidable emergency department (ED) visits are a significant source of excess healthcare spending. Despite improvement in postoperative readmissions, 20% of bariatric surgery patients use the ED postoperatively. Many of these visits may be appropriately managed in lower-acuity centers. OBJECTIVE: We sought to evaluate the economic impact of shifting potentially avoidable ED visits after bariatric surgery to lower-acuity centers. SETTING: Statewide quality improvement collaborative. METHODS: We performed an observational study of patients who underwent bariatric surgery between 2011 and 2017 using a linked data registry, including clinical data from a large-quality improvement collaborative and payment data from a statewide value collaborative. Postoperative ED visits and readmission rates were determined. Ninety-day ED and urgent care center (UCC) visit claims were matched to a clinical registry. Price-standardized payments for UCC and ED visits without admission were compared. RESULTS: Among the 36,071 patients who underwent bariatric surgery, 8.4% presented to the ED postoperatively. Approximately 50% of these visits resulted in readmission. Three hundred eighty-eight ED visits without readmission (i.e., potentially avoidable ED visits) and 110 UCC encounters with claims data were identified. Triaging a potentially avoidable ED visit to an UCC would generate a savings of $4238 per patient, reducing spending in this cohort by $1.6 million. CONCLUSION: Shifting potentially avoidable ED visits after bariatric surgery could result in significant cost savings. Efforts to improve patients' selection of healthcare setting and increase utilization of lower-acuity centers may serve as a template for appropriately meeting the needs of patients and containing spending after bariatric surgery.

Mothers' Voices Related to Caregiving: The Transition of a Technology-Dependent Infant from the NICU to Home.

PURPOSE: The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge. DESIGN: A qualitative, descriptive, longitudinal design was employed. SAMPLE: Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU. MAIN OUTCOME VARIABLE: Description of mothers' transition experience. RESULTS: Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.

Evaluation of a Family Medicine Transitional Care Service Line.

INTRODUCTION: As of 2013, the all-cause readmission rate among Medicare fee-for-service beneficiaries was 17.5%. In addition to poor outcomes, 30-day hospital readmissions account for over $17 billion in Medicare expenditures. The presence and involvement of a primary care provider can be essential during the transition period from hospital discharge to the outpatient setting. OBJECTIVE: In an effort to reduce 30-day hospital readmissions a transitional care management (TCM) service was implemented in a multi-site family medicine practice. METHODS: The transitional care service line was structured after the 2013 Centers for Medicare & Medicaid Services recommended process for transitioning patients from an inpatient to an outpatient setting. The service included a care team RN, electronic documentation in an electronic medical record and the primary care physician. RESULTS: The 30-day readmission rate was 12.0% in the 10 months before implementation of the new service line and 12.4% in the first 10 months after implementation of the new service line. There was no evidence of an impact of the new service line on a decline in 30-day readmission rates (P = .18). DISCUSSION: Hospital readmissions generate unnecessary costs and often present a major burden on patients and their families. Early engagement with patients after hospital discharge will help to address any acute needs, verify medication adherence and ensure that necessary equipment and services are available. CONCLUSION: Although there was no evidence of an impact of the new service line on a decline in 30-day readmission rates it was decided that this service was a benefit to the patients and the physicians involved.

[Socio-economic vulnerability, support and hospitalisation plan in people aged over 75]. / Vulnérabilité socio-économique, plan d'aide et hospitalisation chez les plus de 75 ans.

The return home after a period in hospital is a high-risk situation for an elderly person. Services exist to facilitate the hospital-home transition but are sometimes not used. Few studies suggest that socio-economic vulnerability is an important factor in a successful return home. One study shows that this relationship is vague and disputed. In fact, compliance with a support plan, recommended when a patient returns home, is multifactorial and does not seem to depend on the existence or otherwise of socio-economic vulnerability.

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

BACKGROUND: Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. OBJECTIVE: To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. DESIGN: Quasi-experimental study. PATIENTS: Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. INTERVENTIONS: The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. MAIN MEASURES: Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures. KEY RESULTS: Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%). CONCLUSIONS: Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

Practicality of Acute and Transitional Care and its consequences in the era of SwissDRG: a focus group study.

BACKGROUND: Switzerland recently introduced Acute and Transitional Care (ATC) as a new financing option and a preventive measure to mitigate potential side effects of Swiss Diagnosis Related Group (SwissDRG). The goal of ATC was to support patients who after acute treatment at a hospital require temporary increased professional care. However, evidence is lacking as to the practicality of ATC. METHODS: Using qualitative focus group methodology, we sought to understand the implementation and use of ATC. A purposive sample of forty-two professionals from five Swiss cantons participated in this study. We used a descriptive thematic approach to analyse the data. RESULTS: Our findings first reveal that ATC's implementation differs in the five cantons (i.e. federal states). In two cantons, only ambulatory variant of ATC is used; in one canton only stationary ATC has been created, and two cantons had both ambulatory and stationary ATC but preferred the latter. Second, there are intrinsic practical challenges associated with ATC, which include physicians' lack of familiarity with ATC and its regulatory limitations. Finally, participants felt that due to shorter hospital stays because of SwissDRG, premature discharge of patients with complex care needs to stationary ATC takes place. This development does not fit the nursing home concept of care tailored to long-term patients. CONCLUSION: This empirical study underscores that there is a strong need to improve ATC so that it is uniformly implemented throughout the country and its application is streamlined. In light of the newness of ATC as well as SwissDRG, their impact on the quality of care received by patients is yet to be fully understood. Empirical evidence is necessary to improve these two measures.

Transitional care practices, services, and delivery in childhood cancer survivor programs: A survey study of U.S. survivorship providers.

PURPOSE: There are limited reports describing transition of young adult childhood cancer survivors (CCS) from pediatric to adult-focused survivorship care. The purpose of this study was to characterize current transitional care practices in the United States. PROJECT DESCRIPTION: An online survey was sent to one preselected respondent at 163 Children's Oncology Group member institutions in the United States. Data were collected about (i) the availability and type of long-term follow-up services for adult CCS and (ii) policies and procedures for transitioning. Logistic regression was used to evaluate factors related to care for CCS. RESULTS: The response rate was 60% (97/163). Eighty-one respondents (84%) represented centers with specialized pediatric-focused CCS programs. Thirty-nine percent (38/97) of programs delivered specialized transitional care for adult CCS. Adult-centered care was delivered in both pediatric (39%, 15/38) and adult oncology clinics (39%, 15/38). The most common perceived transition barriers were lack of available partnering adult providers and adult providers' lack of knowledge regarding CCS. The larger the program in terms of new diagnoses, the more likely they were to offer formal transitional care (<50 vs >200: odds ratios [OR] 20.0; 95% CI 3.2, 100.0, P = 0.004). CONCLUSIONS: A variety of models are utilized for delivering care to adult CCS. Our results suggest that interventions to establish effective partnerships with adult providers on appropriate care of CCS may facilitate expanded availability of these services.