The "Hand-in" Project: Jump-starting Communication Between Inpatient and Outpatient Providers.

OBJECTIVES: Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. METHODS: This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. RESULTS: Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. CONCLUSIONS: A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

Qualitative study of perspectives concerning recent rehospitalisations among a high-risk cohort of veteran patients in Connecticut, USA.

OBJECTIVES: Veterans Affairs (VA) patients are at risk for rehospitalisation due to their lower socioeconomic status, older age, poor social support or multiple comorbidities. The study explored inpatients' perceptions about factors contributing to their rehospitalisation and their recommendations to reduce this risk. DESIGN: Thematic qualitative data analysis of interviews with 18 VA inpatients. SETTING: VA Connecticut Healthcare System, West Haven Hospital medical inpatient units. PARTICIPANTS: All were aged 18+ years, rehospitalised within 30 days of most recent discharge, medically stable and competent to provide consent. MEASUREMENTS: Interviews assessed inpatients' health status after last discharge, reason for rehospitalisation, access to and support from primary care providers (PCP), medication management, home support systems and history of substance use or mental health disorders. RESULTS: The mean age was 71.6 years (11.1 SD); all were Caucasian, living on limited budgets, and many had serious medical conditions or histories of mental health disorders. Participants considered structural barriers to accessing PCP and limited PCP involvement in medical decision-making as contributing to their rehospitalisation, although most believed that rehospitalisation had been inevitable. Peridischarge themes included beliefs about premature discharge, inadequate understanding of postdischarge plans and insufficiently coordinated postdischarge services. Most highly valued their VA healthcare but recommended increasing PCPs' involvement and reducing structural barriers to accessing primary and specialty care. CONCLUSIONS: Increased PCP involvement in medical decision-making about rehospitalisation, expanded clinic hours, reduced travel distances, improved communications to patients and their families about predischarge and postdischarge plans and proactive postdischarge outreach to high-risk patients may reduce rehospitalisation risk.

Huntingtin facilitates dynein/dynactin-mediated vesicle transport.

Cytoplasmic dynein is a multisubunit microtubule motor complex that, together with its activator, dynactin, drives vesicular cargo toward the minus ends of microtubules. Huntingtin (Htt) is a vesicle-associated protein found in both neuronal and nonneuronal cells that is thought to be involved in vesicular transport. In this study, we demonstrate through yeast two-hybrid and affinity chromatography assays that Htt and dynein intermediate chain interact directly; endogenous Htt and dynein co-immunoprecipitate from mouse brain cytosol. Htt RNAi in HeLa cells results in Golgi disruption, similar to the effects of compromising dynein/dynactin function. In vitro studies reveal that Htt and dynein are both present on vesicles purified from mouse brain. Antibodies to Htt inhibited vesicular transport along microtubules, suggesting that Htt facilitates dynein-mediated vesicle motility. In vivo inhibition of dynein function results in a significant redistribution of Htt to the cell periphery, suggesting that dynein transports Htt-associated vesicles toward the cell center. Together these findings indicate that Htt binds to dynein and acts in a complex along with dynactin and Htt-associated protein-1 to facilitate vesicular transport.