Disparities in transitions of acute stroke care: The transitions of care stroke disparities study methodological report.

OBJECTIVE: The Transitions of Stroke Care Disparities Study (TCSD-S) is an observational study designed to determine race-ethnic and sex disparities in post-hospital discharge transitions of stroke care and stroke outcomes and to develop hospital-level initiatives to reduce these disparities to improve stroke outcomes. MATERIALS AND METHODS: Here, we present the study rationale, describe the methodology, report preliminary outcomes, and discuss a critical need for the development, implementation, and dissemination of interventions for successful post-hospital transition of stroke care. The preliminary outcomes describe the demographic, stroke risk factor, socioeconomic, and acute care characteristics of eligible participants by race-ethnicity and sex. We also report on all-cause and vascular-related death, readmissions, and hospital/emergency room representations at 30- and 90-days after hospital discharge. RESULTS: The preliminary sample included data from 1048 ischemic stroke and intracerebral hemorrhage discharged from 10 comprehensive stroke centers across the state of Florida. The overall sample was 45% female, 22% Non-Hispanic Black and 21% Hispanic participants, with an average age of 64 ± 14 years. All cause death, readmissions, or hospital/emergency room representations are 10% and 19% at 30 and 90 days, respectively. One in 5 outcomes was vascular-related. CONCLUSIONS: This study highlights the transition from stroke hospitalization as an area in need for considerable improvement in systems of care for stroke patients discharged from hospital. Results from our preliminary analysis highlight the importance of investigating race-ethnic and sex differences in post-stroke outcomes.

Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial.

OBJECTIVES: To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization. DESIG: n: Multisite pragmatic randomized clinical trial. SETTING: Three hospitals in North Carolina from January 2019 to March 2020. PATIENTS: Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models. INTERVENTIONS: Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). CONCLUSIONS: In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study.

BACKGROUND: Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE: To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN: Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING: Two diverse Florida EDs. SUBJECTS: Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION: The Coleman Care Transition Intervention adapted for ED visitors. MEASURES: The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS: The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE: Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.

Short-term Focused Feedback: A Model to Enhance Patient Engagement in Research and Intervention Delivery.

BACKGROUND: Our grant from the Patient-Centered Outcomes Research Institute (PCORI) focused on the use of nurse home visits postdischarge for primarily pediatric hospital medicine patients. While our team recognized the importance of engaging parents and other stakeholders in our study, our project was one of the first funded to address transitions of care issues in patients without chronic illness; little evidence existed about how to engage acute stakeholders longitudinally. OBJECTIVE: This manuscript describes how we used both a short-term focused feedback model and longitudinal engagement methods to solicit input from parents, home care nurses, and other stakeholders throughout our 3-year study. RESULTS: Short-term focused feedback allowed the study team to collect feedback from hundreds of stakeholders. Initially, we conducted focus groups with parents with children recently discharged from the hospital. We used this feedback to modify our nurse home visit intervention, then used quality improvement methods with continued short-term focus feedback from families and nurses delivering the visits to adjust the visit processes and content. We also used their feedback to modify the outcome collection. Finally, during the randomized controlled trial, we added a parent to the study team to provide longitudinal input, as well as continued to solicit short-term focused feedback to increase recruitment and retention rates. CONCLUSION: Research studies can benefit from soliciting short-term focused feedback from many stakeholders; having this variety of perspectives allows for many voices to be heard, without placing an undue burden on a few stakeholders.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure.

Background: Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks. Objective: To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care. Design: Decision analytic microsimulation model. Data Sources: Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data. Target Population: Patients with HF who were aged 75 years at hospital discharge. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Disease management clinics, nurse home visits (NHVs), and nurse case management. Outcome Measures: Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained. Results of Sensitivity Analysis: Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained. Limitation: Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings. Conclusion: In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF. Primary Funding Source: Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use.

BACKGROUND: Population-based studies show there is a high prevalence of chronic kidney disease (CKD) patients suffering from chronic pain. While opiates are frequently prescribed in non-dialysis-dependent CKD (NDD-CKD) patients, there may be toxic accumulation of metabolites, particularly among those progressing to end-stage renal disease (ESRD). We examined the association of opiate versus other analgesic use during the pre-ESRD period with post-ESRD mortality among NDD-CKD patients transitioning to dialysis. METHODS: We examined a national cohort of US Veterans with NDD-CKD who transitioned to dialysis over 2007-14. Among patients who received ≥1 prescription(s) in the Veterans Affairs (VA) Healthcare System within 1 year of transitioning to dialysis, we examined associations of pre-ESRD analgesic status, defined as opiate, gabapentin/pregabalin, other non-opiate analgesic, versus no analgesic use, with post-ESRD mortality using multivariable Cox models. RESULTS: Among 57,764 patients who met eligibility criteria, pre-ESRD opiate and gabapentin/pregabalin use were each associated with higher post-ESRD mortality (ref: no analgesic use), whereas non-opiate analgesic use was not associated with higher mortality in expanded case-mix analyses: HRs (95% CIs) 1.07 (1.05-1.10), 1.07 (1.01-1.13), and 1.00 (0.94-1.06), respectively. In secondary analyses, increasing frequency of opiate prescriptions exceeding 1 opiate prescription in the 1-year pre-ESRD period was associated with incrementally higher post-ESRD mortality (ref: no analgesic use). CONCLUSIONS: In NDD-CKD patients transitioning to dialysis, pre-ESRD opiate and gabapentin/pregabalin use were associated with higher post-ESRD mortality, whereas non-opiate analgesic use was not associated with death. There was a graded association between increasing frequency of pre-ESRD opiate use and incrementally higher mortality.

Critical care transition programs on readmission or death: A systematic review and meta-analysis.

BACKGROUND: Deterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746). METHODS: We searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in-hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS-Itool, funnel plot and GRADE, respectively. RESULTS: Fifteen observational studies were included (11 in meta-analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64-0.96; TSA-adjusted 95% CI: 0.59-1.03) but not in-hospital mortality (RR 0.82; 95% CI: 0.64-1.06; TSA-adjusted 95% CI: 0.49-1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low. CONCLUSIONS: We found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence.

A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions.

Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial.

BACKGROUND: While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS: A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS: In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION: This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION: The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

A mapping review of clinical nurse leader and nurse educator transitional care skills and competencies.

BACKGROUND: Little is known about how nurses are prepared to participate or lead teams in conducting safe and effective care transitions, despite being a complex process in which the nurse has an integral role. PURPOSE: To conduct mapping review to identify and synthesize key recommendations regarding curriculum content needed to increase Clinical Nurse Leader and Nurse Educator student knowledge and skills regarding transitional care. METHOD: Guidelines for developing the transitional care nurse role published by national accrediting bodies and certification organizations were reviewed to identify the required competencies. FINDINGS: Components identified included: communication; teamwork and collaboration; education and engagement of patient and family; promoting and support for self-management; and assessing/ managing risks/symptoms. CONCLUSION: Research evidence is needed to support academic preparation of nurses as leaders in care transition. The core transitional components identified can be used to develop competencies to assist training efforts of nurses in practice and educational settings.

Non-home Discharge and Prolonged Length of Stay After Cytoreductive Surgery and HIPEC.

BACKGROUND: Predictive models for nonhome discharge (NHD) have been proposed in major surgical specialties. The rates and risk factors associated with NHD and prolonged length of stay (PLOS) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) have not been evaluated. The aim of this study is to identify risk factors for NHD and PLOS after CRS/HIPEC in a national cohort of patients. MATERIALS AND METHODS: CRS/HIPEC cases were identified from the National Surgical Quality Improvement Program 2011-2012 data set. Patients with an NHD or PLOS (>30 d) were compared with a group of patients discharged to home within 30 d. Univariate analysis was used to compare patient characteristics, operative variables, and postoperative complications among both groups. Multivariate regression analysis was used to identify independent predictors of NHD and PLOS. RESULTS: Five hundred fifty-six patients undergoing CRS/HIPEC were identified, of which 44 (7.9%) were not discharged to home within 30 d. The rate of NHD and PLOS in this cohort was 4.1% and 3.7%, respectively. Multivariate analysis identified age ≥65 y, pre-op albumin <3.0 g/dL, and having a multivisceral resection as independent predictors of NHD/PLOS. If all three predictors are met preoperatively, the probability of NHD/PLOS was calculated to be 30.2%. CONCLUSIONS: The main risk factors for NHD/PLOS after CRS/HIPEC were advanced age, hypoalbuminemia, and multivisceral resection. Adequate identification of these risk factors may facilitate preoperative discussion with patients, and improve discharge planning and resource utilization.

Experiences of adult cancer survivors in transitions.

PURPOSE: To understand the experiences of adult cancer survivors as they transition from the end of cancer treatment to follow-up care as a basis for developing actionable recommendations to integrate cancer care delivery and survivorship care. METHODS: A national survey was conducted in collaboration with ten Canadian provinces to identify unmet needs and experiences with follow-up for cancer survivors between 1 and 3 years post-treatment. Surveys were available in English and French and completed either on paper or on-line. Samples were drawn from provincial cancer registries and packages distributed by mail. RESULTS: A total of 40,790 survey packages were mailed out across the ten provinces and 12,929 surveys were completed by adults (age 30+ years), and 329 surveys were completed by adolescents and young adults (age 18 to 29 years) giving an overall response rate of 33.3%. For the purposes of this publication, the focus will be on the adult sample. In the adult cohort (age 30+ years), 51% of the sample were females, 60% were 65 years of age or older, and 77% had not experienced metastatic spread. Three-quarters reported their health as good/very good and 82% that their quality of life was good/very good. Overall, 87% experienced at least one physical concern, 78% experienced at least one emotional concern, and 44% experienced at least one practical concern. The average number of concerns reported for each domain ranged from 2.0 to 3.8. For those who sought help, a third experienced difficulty obtaining assistance or did not receive it. The most frequently cited reasons for not seeking help was that someone had told them what they were experiencing was normal. CONCLUSIONS: The results indicate that many adult survivors have concerns about physical, emotional, and practical issues but are not receiving help to reduce their suffering. It is imperative we take action to correct this current reality.

Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study.

BACKGROUND: transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable. OBJECTIVE: to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia. DESIGN: retrospective cohort study. SETTING: electronic records from a mental health provider in London, linked to national mortality and hospital data. SUBJECTS: people with dementia who died in 2007-2016. METHODS: end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression. RESULTS: of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001). CONCLUSIONS: in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.

Policy Flight Simulators: Accelerating Decisions to Adopt Evidence-Based Health Interventions.

EXECUTIVE SUMMARY: In this study, the authors used simulation to explore factors that might influence hospitals' decisions to adopt evidence-based interventions. Specifically, they developed a simulation model to examine the extent to which hospitals would benefit economically from the transitional care model (TCM). The TCM is designed to transition high-risk older adults from hospitals back to communities using interventions focused on preventing readmissions.The authors used qualitative methods to identify and validate simulation facets. Four simulation experiments explored the economic impact of the TCM on more than 3,000 U.S. hospitals: (1) magnitude of readmission penalty, (2) application to specific diagnosis-related groups, (3) level of cost sharing between payer and provider, and (4) capitated versus fee-for-service payments. The simulator projected hospital-specific economic effects. The authors used Monte Carlo methods for the simulations, which were parameterized with public data sets from the Centers for Medicare & Medicaid Services (CMS) and TCM data from randomized controlled trials and comparative effectiveness studies.Under current conditions, the simulation indicated that only 10 of more than 3,000 Medicare-certified hospitals would benefit financially from the TCM. If current readmission penalties were doubled, the number of hospitals projected to benefit would increase to 300. Targeting selected diagnosis cohorts would also increase the number of hospitals to 300. If payers reimbursed providers for 100% of the TCM costs, 2,000 hospitals would benefit financially. Under a capitated payment model, 1,500 hospitals would benefit from the TCM.Current CMS penalties-or reasonable increases-have little economic effect on the TCM. In the current environment, two strategies are likely to facilitate adoption: (1) persuading payers to reimburse TCM costs and (2) focusing on hospitals with higher bed occupancies and higher revenue patients.

A narrative review of mental health support for people during transition from incarceration to community: the grass can be greener on the other side of the fence.

BACKGROUND: Despite significant need for mental health services targeting the requirements of inmates transitioning into the community there is little research about successful recovery-oriented or person-centred transition programs. AIMS: This systematic narrative review brings together existing evidence to inform policymakers and practitioners about current practice in transition support, and barriers and facilitators of effective practice. METHOD: We carried out a systematic narrative review of recovery-oriented or person-centred mental health support programs supporting transition from incarceration to the community. Results were obtained from a systematic search of Medline, PubMed and Scopus databases. RESULTS: We found 23 papers which met the paper inclusion criteria along with four other papers which were identified incidentally. CONCLUSIONS: Identified barriers to the implementation of effective transition support programs are: administrative problems leading to ineffective in-reach into correctional facilities or untimely support, lack of support for immediate needs meaning that inmates deprioritise their mental health needs, a lack of ongoing program resources and poor communication between correctional facilities and mental health services. Enablers for transition reflect the inverse of these barriers, alongside other successful strategies including medical home models, regionalised programs, programs which target connections with primary care, nurse-led patient-centred health programs and peer support initiatives.

Facilitating Family Life Review during a Relocation to Assisted Living: Exploring Contextual Impact on Family Adjustment.

OBJECTIVES: The purpose of this study was to explore how contextual aspects of participants' lives before and throughout relocation to assisted living (ALF) informed family experience of family life review (FLR). METHOD: Fourteen families participated in a single FLR session within 6 months of the older adults' relocation. Semi-structured interviews, conducted one-month following the FLR session, were analyzed using the constant comparative method. Demographic and relational variables provided context for assessing how individual and family dynamics influenced the family relocation process. RESULTS: Techniques were used during the three phases of FLR (introduction, validation, consolidation) to encourage openness and mutual dialogue between family members. Health-related limitations challenged older adults' understanding and openness during the FLR. Mental health concerns linked to older adults' outlook on life, comfort in conversation during the FLR, and reflection of lifelong social ties. Family involvement and dynamics influenced how families communicated about their mutual narrative and the relocation transition. CONCLUSION: FLR is an adaptable intervention to assist older adults and their family during a transition to ALF. Although contextual challenges impacted how families experienced the FLR, they enjoyed FLR as a unifying event that promoted mutual understanding. CLINICAL IMPLICATIONS: The use of FLR facilitates enhanced understanding and communication during relocation. Older adults' health status as well as family dynamics need to be assessed prior to organizing a FLR to accommodate each families' unique needs.

Initiating transitional care for adolescents with cystic fibrosis at the age of 12 is both feasible and promising.

AIM: Adolescence is a vulnerable period in cystic fibrosis, associated with declining lung function. This study described, implemented and evaluated a transition programme for adolescents. METHODS: We conducted a single centre, nonrandomised and noncontrolled prospective programme at the cystic fibrosis centre at Copenhagen University Hospital Rigshospitalet from 2010 to 2011, assessing patients aged 12-18 at baseline and after 12 months. Changes implemented included staff training on communication, a more youth-friendly feel to the outpatient clinic, the introduction of youth consultations partly alone with the adolescent, and a parents' evening focusing on cystic fibrosis in adolescence. Lung function and body mass index (BMI) were measured monthly and adolescents were assessed for their readiness for transition and quality of life at baseline and 12 months. RESULTS: We found that 40 (98%) of the eligible patients participated and youth consultations were successfully implemented with no dropouts. The readiness checklist score increased significantly over the one-year study period, indicating increased readiness for transfer and self-care. Overall quality of life, lung function and BMI remained stable during the study period. CONCLUSION: A well-structured transition programme for cystic fibrosis patients as young as 12 years of age proved to be both feasible and sustainable.

Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints.

BACKGROUND: Cardiac-related complaints are leading drivers of Emergency Department (ED) utilization. Although a large proportion of cardiac patients can be discharged with appropriate outpatient follow-up, inadequate care coordination often leads to high revisit rates or unnecessary admissions. We evaluate the impact of implementing a structured transitional care pathway enrolling low-risk cardiac patients on ED discharges, 30-day revisits and admissions, and institutional revenues. METHODS: We prospectively enrolled eligible patients presenting to a single-center Emergency Department over a 12-month period. Standardized risk measures were used to identify patients suitable for early discharge with cardiology follow-up within 5 days. The primary endpoints were rates of discharge from the ED and 30-day ED revisit and admission rates, with a secondary endpoint including 30-day returns for myocardial infarction. A cost analysis of the program's impact on institutional revenues was performed. RESULTS: Among patients presenting with cardiac-related complaints, rates of discharge from the ED increased from 44.4 to 56.6% (p < 0.0001). Enrollment in the transitional care pathway was associated with a reduced risk of cardiac-related ED revisits (RR 0.22, p < 0.0001), all-cause ED revisits (RR 0.30, p < 0.0001), and admission at second ED visit (RR 0.56, p = 0.0047); among enrolled patients, the 30-day rate of return with a myocardial infarction was 0.35%. No significant reductions were seen in 30-day cardiac-related and all-cause revisits in the 12-months following transitional care pathway implementation; however, there was a significant reduction in admissions at second ED visit from 45.6 to 37.7% (p = 0.0338). An early gender disparity in care delivery was identified in the first 120 days following program implementation that was subsequently eliminated through targeted intervention. There was an estimated decline in institutional revenue of $300 per enrolled patient, driven predominantly by a reduction in admissions. CONCLUSIONS: A structured transitional care pathway identifying low-risk cardiac patients who may be safely discharged from the ED can be effective in shifting care delivery from hospital-based to lower cost ambulatory settings without adversely impacting 30-day ED revisit rates or patient outcomes.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device.

BACKGROUND: The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%. PROBLEM STATEMENT: Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices. METHODS: Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team. OUTCOMES: The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%. IMPLICATIONS FOR PRACTICE: Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

Transitions from Assertive Community Treatment Among Urban and Rural Teams: Identifying Barriers, Service Options, and Strategies.

An emerging focus of Assertive Community Treatment (ACT) teams is the transition of clients to less intensive services, which creates space for individuals in need of ACT and is consistent with a recovery orientation of treatment. However, there is limited research on team transition rates, post-ACT services, and strategies to overcome transition barriers. In addition, few studies have examined differences in these factors among urban and rural ACT teams. To address these knowledge gaps, we interviewed eight ACT teams in urban and rural areas of eastern Ontario regarding their transition rates, processes of transitioning ACT clients to less intensive services, transition barriers, and solutions to overcoming these barriers. On average, teams transitioned about 6% of their clients over our 3-year study period. Urban and rural teams described both similar and distinct clinical and systemic barriers, such as client reluctance to transition and finding psychiatric follow-up outside of ACT. Implications for ACT practice and policy are discussed.