Transitional Care Navigation.

OBJECTIVES: This manuscript aims to provide an extensive review of the literature, synthesize findings, and present substantial insights on the current state of transitional care navigation. Additionally, the existing models of care, pertaining to the concept and approach to transitional care navigation, will be highlighted. METHODS: An extensive search was conducted though using multiple search engines, topic-specific key terminology, eligibility of studies, as well as a limitation to only literature of existing relevance. Integrity of the evidence was established through a literature review matrix source document. A synthesis of nursing literature from organizations and professional publications was used to generate a comparison among various sources of evidence for this manuscript. Primary evidence sources consisted of peer-reviewed journals and publications from professional organizations such as the AHRQ, Academic Search Premier, CINAHL Plus with Full Text, and the Talbot research library. RESULTS: A total of five systematic reviews (four with meta-analysis) published between 2016 and 2022 and conducted in several countries (Brazil, Korea, Singapore, and the US) were included in this review. A combined total of 105 studies were included in the systematic reviews with 53 studies included in meta-analyses. The review of the systematic reviews identified three overarching themes: care coordination, care transition, and patient navigation. Care coordination was associated with an increase in care quality rating, increased the health-related quality of life in newly diagnosed patients, reduced hospitalization rates, reduced emergency department visits, timeliness in care, and increased appropriateness of healthcare utilization. Transitional care interventions resulted to reduced average number of admissions in the intervention (I) group vs control (C) (I = 0.75, C = 1.02) 180 days after a 60-day intervention, reduced readmissions at 6 months, and reduced average number of visits 180 days after 60-day intervention (I = 2.79, C = 3.60). Nurse navigators significantly improved the timeliness of care from cancer screening to first-course treatment visit (MD = 20.42, CI = 8.74 to 32.10, P = .001). CONCLUSION: The care of the cancer patient entails treatments, therapies, and follow-up care outside of the hospital setting. These transitions can be challenging as they require coordination and collaboration among various health care sites. The attributes of transitional care navigation overlap with care coordination, care transition, and patient navigation. There is an opportunity to formally develop a transitional care navigation model to effectively addresses the challenges in care transitions for patient including barriers to health professional exchange of information or communication across care settings and the complexity of coordination between care settings. The transitional care navigation and clinic model developed at a free-standing NCI-designated comprehensive cancer center is a multidisciplinary approach created to close the gaps in care from hospital to home. IMPLICATIONS FOR NURSING PRACTICE: A transitional care navigation model aims to transform the existing perspectives and viewpoints of hospital discharge and transition of care to home or post-acute care settings as two solitary processes to that of a collective approach to care. The model supports provides an integrated continuum of quality, comprehensive care that supports patient compliance with treatment regimens, reinforces patient and caregiver education, and improves health outcomes.

Transition to the Role of Family Caregiver of Older Adults After a Stroke: A Specific Theory / Transición del rol cuidador familiar de la persona adulta mayor post accidente cerebrovascular (ACV): teoría específica / Transição ao papel de cuidador familiar no idoso após acidente vascular cerebral (AVC): teoria específica

Introduction: Nursing professionals develop situation-specific theories to describe, explain, and provide comprehensive care during a family member's transition to the caregiver role. Objective: To develop a situation-specific theory about the transition to the role of family caregiver of older adults after a stroke. Methodology: The integrating approach by Meleis and Im was applied, which consists of five stages: 1) Description of the context and target population, 2) Verification of assumptions regarding the philosophical stance, 3) Exploration of multiple sources, 4) Theorization of concepts, and 5) Proposal of empirical indicators for validation and verification. Results: The prescriptive theory was developed in the light of Afaf Meleis' Theory of Transitions and was supported by an exhaustive literature review, with four underlying concepts: Situational transition to the family caregiver role, Care-related knowledge and skills, Self-confidence and coping in adopting the caregiver role, and Nursing therapeutic education. The following assumption emerges from these concepts: a healthy transition to the family caregiver role is directly dependent on the care-related knowledge and skills provided by Nursing therapeutic education to develop self-confidence and coping in adopting the caregiver role. Conclusions: The proposal provides a conceptual framework that identifies the transition challenges and needs faced by family caregivers to adopt the role of caregivers of older adults after a stroke.

Introducción: los profesionales de enfermería desarrollan teorías de situación específica para describir, explicar y proporcionar cuidados integrales durante la transición del familiar al rol cuidador. Objetivo: desarrollar una propuesta de teoría de situación específica sobre la transición al rol cuidador familiar de la persona adulta mayor post accidente cerebrovascular. Metodología: se aplicó el enfoque integrador de Meleis e Im, que consta de cinco etapas: 1) descripción del contexto y población blanco; 2) comprobación de suposiciones en relación con la postura filosófica; 3) exploración de múltiples fuentes; 4) teorización de conceptos; y 5) propuesta de indicadores empíricos para la validación y comprobación. Resultados: la teoría prescriptiva fue desarrollada a la luz de la teoría de las transiciones de Afaf Meleis y se apoyó en una revisión exhaustiva de literatura, con cuatro conceptos subyacentes: transición situacional del rol cuidador familiar, conocimiento y habilidad del cuidado, confianza y afrontamiento en la adopción del rol cuidador, y educación terapéutica de enfermería. A partir de estos, surge la siguiente proposición: la transición saludable al rol cuidador familiar depende directamente de los conocimientos y habilidades de cuidado que brinda la terapéutica de enfermería para el desarrollo de confianza y afrontamiento en la adopción del rol cuidador. Conclusiones: la propuesta proporciona un marco conceptual que identifica los desafíos y necesidades de transición de los cuidadores familiares para la adopción del rol cuidador de la persona adulta mayor post accidente cerebrovascular.

Introdução: os profissionais de enfermagem desenvolvem teorias específicas para descrever, explicar e prestar cuidados holísticos durante a transição do familiar para o papel de cuidador. Objetivo: desenvolver uma proposta de teoria específica sobre a transição para o papel de cuidador familiar do idoso pós-AVC. Metodologia: foi aplicada a abordagem integrativa de Meleis e Im, composta por cinco etapas: 1) descrição do contexto e da população-alvo; 2) teste de hipóteses em relação à postura filosófica; 3) exploração de múltiplas fontes; 4) teorização de conceitos; e 5) proposta de indicadores empíricos para validação e teste. Resultados: a teoria prescritiva foi desenvolvida à luz da teoria das transições de Afaf Meleis e com o suporte de uma revisão exaustiva da literatura, com quatro conceitos subjacentes: transição situacional do papel de cuidador familiar, conhecimentos e competências de cuidado, confiança e enfrentamento na adoção do papel de cuidador e educação terapêutica em enfermagem. Destes conceitos emerge a seguinte proposição: a transição saudável para o papel de cuidador familiar depende diretamente do conhecimento e das competências de cuidado proporcionadas pela enfermagem terapêutica para o desenvolvimento de confiança e capacidade de enfrentamento na adoção do papel de cuidador. Conclusões: A proposta fornece um quadro conceitual que identifica os desafios e as necessidades de transição dos cuidadores familiares na adoção do papel de cuidador do idoso após acidente vascular cerebral (AVC).

Transitional care of older ethnic minority patients: An integrative review.

AIMS: To critically synthesize the empirical literature on practice in transitional care and how to meet the care needs of older ethnic minority populations who discharged from hospital to community. DESIGN: An integrative literature review integrating empirical studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: PubMed, Web of Science, PsycINFO, EBSCO (including CINAHL and MEDLINE) and Scopus were searched for papers published between 2012 and September 2022. REVIEW METHODS: Full-text papers were screened against inclusion and exclusion criteria subsequent to screening titles and abstracts. All included papers were evaluated for methodological quality using the Critical Appraisal Skills Programme Checklists. After extracting findings, themes were created by critically examining and synthesizing of findings. RESULTS: The search yielded a total of 1180 studies, 1153 after removing duplicates and 27 papers meeting the inclusion criteria and exclusion criteria were included in the review. The main findings were categorized into four themes: (i) intervention-related outcomes; (ii) unmet needs of older minority people; (iii) transitional care-related characteristics of older minority people and (iv) challenges for healthcare providers. Findings indicated that the transitional care experience of ethnic minority older populations differed from natives to some extent which revealed unmet needs addressing how to provide culturally appropriate transitional care for this population. CONCLUSION: This review gave insight into facilitators in the transitional care of ethnic minority older adults. Future transitional care interventions should incorporate needs of ethnic minority population. IMPACT: This review highlighted the defined gaps between existing transitional care programmes and transitional care needs of older ethnic minority. Increasing follow-up completion, evidence defining deeply of ethnic phenomenon in the transitional care process, developing interventions that meet transitional care needs and increasing healthcare providers' cultural competency were featured headlines. No Patient or Public Contribution.

Augmenting a Transitional Care Model With Artificial Intelligence Decreased Readmissions.

OBJECTIVES: Evaluate if augmenting a transitions of care delivery model with insights from artificial intelligence (AI) that applied clinical and exogenous social determinants of health data would reduce rehospitalization in older adults. DESIGN: Retrospective case-control study. SETTING AND PARTICIPANTS: Adult patients discharged from integrated health system between November 1, 2019, and February 31, 2020, and enrolled in a rehospitalization reduction transitional care management program. INTERVENTION: An AI algorithm utilizing multiple data sources including clinical, socioeconomic, and behavioral data was developed to predict patients at highest risk for readmitting within 30 days and provide care navigators five care recommendations to prevent rehospitalization. METHODS: Adjusted incidence of rehospitalization was estimated with Poisson regression and compared between transitional care management enrollees that used AI insights and matched enrollees for whom AI insights were not used. RESULTS: Analyses included 6371 hospital encounters between November 2019 and February 2020 across 12 hospitals. Of the encounters 29.3% were identified by AI as being medium-high risk for re-hospitalizing within 30 days, for which AI provided transitional care recommendations to the transitional care management team. The navigation team completed 40.2% of AI recommendations for these high-risk older adults. These patients had overall 21.0% less adjusted incidence of 30-day rehospitalization compared with matched control encounters, or 69 fewer rehospitalizations per 1000 encounters (95% CI 0.65‒0.95). CONCLUSIONS AND IMPLICATIONS: Coordinating a patient's care continuum is critical for safe and effective transition of care. This study found that augmenting an existing transition of care navigation program with patient insights from AI reduced rehospitalization more than without AI insights. Augmenting transitional care with insights from AI could be a cost-effective intervention to improve transitional care outcomes and reduce unnecessary rehospitalization. Future studies should examine cost-effectiveness of augmenting transitional care models of care with AI when hospitals and post-acute providers partner with AI companies.

Using Nursing Interventions Classifications to Document Faith Community Nursing Transitional Care.

ABSTRACT: One out of five Medicare beneficiaries is readmitted within 30 days after hospital discharge, and as many as three in four readmissions are preventable. This study describes transitional care interventions (TCIs) delivered by one faith community nurse (FCN) to at-risk seniors living in a certain ZIP code. Two years of nursing documentation (2,280 interventions) were translated into Nursing Interventions Classification standardized nursing language. Results indicate the FCN provided priority TCIs including spiritual care. In fully describing TCIs using a nursing language, results support that the FCN transitional care model is a method worth exploring to provide wholistic transitional care.

Stakeholders' experiences and perception on transitional care initiatives within an integrated care project in Belgium: a qualitative interview study.

BACKGROUND: In 2015, a plan for integrated care was launched by the Belgium government that resulted in the implementation of 12 integrated care pilot project across Belgium. The pilot project Zorgzaam Leuven consists of a multidisciplinary local consortium aiming to bring lasting change towards integrated care for the region of Leuven. This study aims to explore experiences and perceptions of stakeholders involved in four transitional care actions that are part of Zorgzaam Leuven. METHODS: This qualitative case study is part of the European TRANS-SENIOR project. Four actions with a focus on improving transitional care were selected and stakeholders involved in those actions were identified using the snow-ball method. Fourteen semi-structured interviews were conducted and inductive thematic analysis was performed. RESULTS: Professionals appreciated to be involved in the decision making early onwards either by proposing own initiatives or by providing their input in shaping actions. Improved team spirit and community feeling with other health care professionals (HCPs) was reported to reduce communication barriers and was perceived to benefit both patients and professionals. The actions provided supportive tools and various learning opportunities that participants acknowledged. Technical shortcomings (e.g. lack of integrated patient records) and financial and political support were identified as key challenges impeding the sustainable implementation of the transitional care actions. CONCLUSION: The pilot project Zorgzaam Leuven created conditions that triggered work motivation for HCPs. It supported the development of multidisciplinary care partnerships at the local level that allowed early involvement and increased collaboration, which is crucial to successfully improve transitional care for vulnerable patients.

Implementing Four Transitional Care Interventions for Older Adults: A Retrospective Collective Case Study.

BACKGROUND AND OBJECTIVES: Four interventions to improve care transitions between hospital and home or community settings for older adults were implemented in Leuven, Belgium over the past 4 years. These complex interventions consist of multiple components that challenge their implementation in practice. This study examines the influencing factors, strategies used to address challenges in implementing these interventions, and implementation outcomes from the perspectives of health care professionals involved. RESEARCH DESIGN AND METHODS: This was a qualitative, collective case study that was part of the TRANS-SENIOR research network. Authors conducted semistructured interviews with health care professionals about their perceptions regarding the implementation. Thematic analysis was used, and the Consolidated Framework for Implementation Research guided the final data interpretation. RESULTS: Thirteen participants were interviewed. Participants reported major implementation bottlenecks at the organizational level (resources, structure, and information continuity), while facilitators were at the individual level (personal attributes and champions). They identified engagement as the primary strategy used, and suggested other important strategies for the future sustainability of the interventions (building strategic partnerships and lobbying for policies to support transitional care). They perceived the overall implementation favorably, with high uptake as a key outcome. DISCUSSION AND IMPLICATIONS: This study highlights the strong role of health care providers, being motivated and self-driven, to foster the implementation of interventions in transitional care in a bottom-up way. It is important to use implementation strategies targeting both the individual-level factors as well as the organizational barriers for transitional care interventions in the future.

The effectiveness of a mHealth-based integrated hospital-community-home program for people with type 2 diabetes in transitional care: a protocol for a multicenter pragmatic randomized controlled trial.

BACKGROUND: Diabetes is a progressive condition requiring long-term medical care and self-management. The ineffective transition from hospital to community or home health care may result in poor glycemic control and increase the risk of serious diabetes-related complications. In China, the most common transitional care model is home visits or telephone interventions led by a single healthcare setting, with a lack of cooperation between specialists and primary care, which leads to inadequate service and discontinuous care. Thus, an integrated hospital-community-home (i-HCH) transitional care program was developed to promote hospital and community cooperation and provide comprehensive and continuous medical care for type 2 diabetes mellitus (T2DM) via mobile health (mHealth) technology. METHODS: This protocol is for a multicenter randomized controlled trial in T2DM patients. Hospitalized patients diagnosed with T2DM who meet the eligibility criteria will be recruited. The patients will be randomly allocated to either the intervention or the control group and receive the i-HCH transitional care or usual transitional care intervention. The change in glycated hemoglobin is the primary outcome. Secondary outcome measures are blood pressure, lipids (total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein), body mass index, self-management skills, quality of life, diabetes knowledge, transitional care satisfaction and the rate of readmission. The follow-up period of this study is six months. DISCUSSION: The study will enhance the cooperation between local hospitals and communities for diabetes transitional care. Research on the effectiveness of diabetes outcomes will have potentially significant implications for chronic disease patients, family members, health caregivers and policymakers. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900023861: June 15, 2019.

Using comprehensive geriatric assessment for older adults undertaking a facility-based transition care program to evaluate functional outcomes: a feasibility study.

BACKGROUND: The study aimed to evaluate the feasibility of using a comprehensive geriatric assessment (CGA) in a residential transition care setting to measure older adults' functional outcomes. METHODS: A convenience sample of older adults (n = 10) and staff (n = 4) was recruited. The feasibility of using assessment tools that comprise a CGA to comprehensively measure function in physical, cognitive, social and emotional domains was evaluated pre- and post-rehabilitation. RESULTS: 10 older adults (mean ± SD age = 78.9 ± 9.1, n = 6 male) completed a CGA performed using assessments across physical, cognitive, social and emotional domains. The CGA took 55.9 ± 7.3 min to complete. Staff found CGA using the selected assessment tools to be acceptable and suitable for the transition care population. Older adults found the procedure to be timely and 60% found the assessments easy to comprehend. Participating in CGA also assisted older adults in understanding their present state of health. The older adults demonstrated improvements across all assessed domains including functional mobility (de Morton Mobility Index; baseline 41.5 ± 23.0, discharge 55.0 ± 24.0, p = 0.01) and quality of life (EQ-5D-5L; baseline 59.0 ± 21.7, discharge 78.0 ± 16.0, p < 0.01). CONCLUSIONS: Incorporating CGA to evaluate functional outcomes in transition care using a suite of assessment tools was feasible and enabled a holistic assessment.

Is it Feasible? A Quality Improvement Project to Integrate Complementary Therapy Into a Pain Management Program on a Transitional Care Unit.

BACKGROUND: The cost of pain to society is high, not only in dollars but in physical and emotional suffering. Undertreated pain in the geriatric population can lead to functional impairments and diminished quality of life. A transitional care unit (TCU) described having higher levels of moderate to severe pain than state and national levels in like facilities. OBJECTIVE: A team of university faculty and students, and staff members from the TCU developed a quality improvement project to examine the feasibility of integrating complementary therapies to treat pain into clinical practice. METHODS: The team integrated three evidence-based complementary therapies into staff workflow. RESULTS: The nursing and therapy staff reported minimal to no interruption to their workflow when patients used the complementary therapies. Staff expressed satisfaction with an expanded menu of pain management options. Patients reported statistically significant lower (p = 0.002) pain levels after using the complementary therapies and benefits beyond pain relief, including relaxation, stress reduction, and improved sleep. CONCLUSION: Adding complementary therapies to the pain management program was feasible and the patients had less pain along with other benefits when using the therapies with standard care. IMPLICATIONS FOR NURSING: Having additional methods for managing pain is beneficial and vital.

Reflection on young adult transitional care in the Boston Children's Hospital Perioperative Care Coordination Clinic.

THEORETICAL PRINCIPLES: The complexity of pediatric healthcare has increased due to advancement in research and identification of new treatment modalities. With these advancements, life expectancy has increased creating a greater need for young adult transition into adult medical settings and specialty care (Marani et al., 2020). The holistic approach of nursing care is essential in assisting young adults during this transitional period. PHENOMENON ADDRESSED: Many pediatric hospitals and subspecialties continue to care for young adults ≥18 years of age that have not transitioned to adult care. In the perioperative care coordination clinic at Boston Children's Hospital, pediatric nurses and advanced practice nurse practitioners provide care to patients from infancy to adulthood, throughout many specialties, to ensure safe perioperative care for a medically complex surgical population. The purpose of this paper is to describe the PCCC young adult care coordination process that provides engaging opportunities for the young adult to advocate for oneself and promote autonomy as they proceed through the stages of transition to adult care. RESEARCH LINKAGES: The perioperative care coordination process at Boston Children's Hospital aligns with the Society of Pediatric Nurses position statement that recommended pediatric nurses utilize a framework (Betz, 2017) and Meleis' middle-range theory of Transitions that identified the nursing role during the transitional process (Meleis et al., 2000). A suggestion for future nursing research includes development of a nursing framework that nurses can utilize when supporting young adults during their progression through the steps of transition from pediatric to adult perioperative programs.

Analysis of Readmissions in a Mobile Integrated Health Transitional Care Program Using Root Cause Analysis and Common Cause Analysis.

ABSTRACT: Mobile integrated health and community paramedicine (MIH-CP) programs are gaining popularity in the United States as a strategy to address the barriers to healthcare access and appropriate utilization. After one year of operation, leadership of Baltimore City's MIH-CP program was interested in understanding the circumstances surrounding readmission for enrolled patients and to incorporate quality improvement tools to direct program development. Retrospective chart review was performed to determine preventable versus unpreventable readmissions with a hypothesis that deficits in social determinants of health would play a more significant role in preventable readmissions. In the studied population, at least one root cause that can be considered a social determinant of health was present in 75.8% of preventable readmissions versus only 15.2% of unpreventable readmissions. Root Cause Analysis highlighted health literacy, functional status, and behavioral health issues among the root causes that most heavily influence preventable readmissions. Common Cause Analysis results suggest our MIH-CP program should focus its resources on mitigating poor health literacy and functional status. This project's findings successfully directed leadership of the city's MIH-CP program to modify program processes and advocate for the use of these quality improvement tools for other MIH-CP programs.

The effect of a mobile integrated health program on health care cost and utilization.

OBJECTIVE: To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. DATA SOURCES: Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. STUDY DESIGN: We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. DATA COLLECTION: Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. PRINCIPAL FINDINGS: The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio = 1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio = 1.78, 95% CI = [1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. CONCLUSIONS: We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio.

BACKGROUND: This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process. OBJECTIVES: This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI's programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI's Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work. CONCLUSIONS: The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Transitional Cancer Care Program from Hospital to Home in the Health Care System of Iran.

OBJECTIVES: Transitional care program refers to the health care continuity during transferring from one health care setting to another or to home. This is an essential program for cancer patients and reduces the risk of unnecessary hospital admissions as well as the complications of the disease. The aim of this study was to develop a transitional cancer care program from hospital to home in the health care system of Iran. METHODS: This study is a health policy and system research. It was conducted in four stages from October 2019 to January 2020. The first stage was a qualitative study. The qualitative data were collected through semi-structured interviews with 24 participants and a focus group with eight experts. In the second stage, a literature review of transitional care models was carried out. The initial version of the transitional cancer care program was developed based on the qualitative results and the literature review in the third stage. The validity and feasibility of the program were assessed using the Delphi study in the fourth stage. RESULTS: Six major categories were extracted from the qualitative results, consisting of "integrated services for the continuity of care", "holistic care", "care standardization", "the use of telemedicine", "the transparency of rules" and "the care process provision". Using these results and extracted the three common models of transitional care, the initial program was developed in three phases of pre-discharge, post-discharge, and transitional care with six protocols. The content validity of the program (98.7%) and its feasibility (95.8%) were approved by experts in the Delphi rounds. CONCLUSIONS: It is necessary to revise hospitals' discharge program, and home health care center's plan for admission and delivering health care services for cancer patients. Also, a pilot program is necessary to find the system advantages and disadvantages.
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Understanding transitional care programs for older adults who experience delayed discharge: a scoping review.

BACKGROUND: Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs? METHODS: The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian's structure-process-outcome model. RESULTS: TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges. CONCLUSION: TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Acute Care Management During a Pandemic.

PURPOSE/OBJECTIVES: During the global pandemic of Covid-19, the hospital setting transitional care management was challenged by the complexities of the rapidly changing health care environment, requiring the implementation of an innovative approach to hospital discharge planning. The purpose of this article is to review the experiences of an integrated urban health system, exploring the strategic tactics to ensure effective communication between team members, patient and family engagement in discharge planning, establishing and maintaining trust, connecting patients to appropriate next level of care services, and providing transitional care management support. PRIMARY PRACTICE SETTINGS: The Covid-19 pandemic response stimulated the rapid transformation of the acute care management model amidst the tremendous challenge of meeting the discharge planning needs of the hospitalized population in one large, urban, integrated health care system. FINDINGS/CONCLUSIONS: Patients transitioning to the community setting following discharge are vulnerable and at risk for adverse sequelae, and transitional care management that does not end when the patient leaves the hospital setting is integral to promoting positive patient outcomes (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). The care management approach during the pandemic in one health care system precipitously shifted to an entirely virtual, remote model, and the team continued to provide transitional care support for hospitalized patients to avoid the common pitfalls that are associated with unfavorable outcomes. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The insights gleaned from one health system's experiences during the pandemic are transferable to other facets of care management in routine circumstances, with emphasis on the avoidance of the common care management snares that lead to less than optimal patient outcomes. The development and implementation of multifaceted interventions, with the goals of supporting health-promoting behavior changes and self-care capacity for at risk populations, are relevant in the current health care environment.

Development of a Logic Model to Guide Implementation and Evaluation of a Mobile Integrated Health Transitional Care Program.

To provide medical and social services to underserved communities, many health care organizations across the United States have expanded the role of emergency medical services to include mobile integrated health and community paramedicine (MIH-CP). Although MIH-CP programs differ in structure and setting, many share the common goal of improving health through home-based, patient-centered care management models. Ideally, these innovative programs reduce use of health care services, including 911 (US emergency system) calls and emergency department visits. In 2018 a large, urban academic medical center partnered with the city's fire department to establish an MIH-CP program to support patients as they transition in their first 30 days at home after hospitalization. Prior to launch, a multidisciplinary team developed a logic model to guide development, implementation, and evaluation of this complex and innovative program. This paper describes the team's structured process for developing a logic model. It also describes key components of the initial logic model and the Transitional Health Support program structure, as well as subsequent revisions to both.

Evaluation of a Transitional Care Program After Hospitalization for Heart Failure in an Integrated Health Care System.

Importance: Prompted by null findings from several care transition trials and practice changes for heart failure in recent years, leaders from a large integrated health care system aimed to reassess the outcomes of its 10-year multicomponent transitional care program for heart failure (HF-TCP). Objective: To examine the association of the individual HF-TCP components and their bundle with the primary outcome of all-cause 30-day inpatient or observation stay readmissions. Design, Setting, and Participants: This retrospective cohort study included patients enrolled in the HF-TCP during an inpatient encounter for heart failure at 13 Kaiser Permanente Southern California hospitals from January 1, 2013, to October 31, 2018, who were followed up from discharge until 30 days, readmission, or death. Data were analyzed from May 7, 2019, to May 1, 2020, with additional review from September 2 to October 1, 2020. Exposures: Patients received 1 home health visit or telecare (telephone) visit from a registered nurse within 2 days of hospital discharge, a heart failure care manager call within 7 days, and a clinic visit with a physician or a nurse practitioner within 7 days. Main Outcomes and Measures: Multivariable proportional hazards regression models were used to estimate the probability of 30-day readmission for those who received the individual or bundled HF-TCP components compared with those who did not. Results: A total of 26 128 patients were included; 57.0% were male, and the mean (SD) age was 73 (13) years. The 30-day readmission rate was 18.1%. Both exposure to a home health visit within 2 days of discharge (hazard ratio [HR], 1.03; 95% CI, 0.96-1.10) and a 7-day heart failure case manager call (HR, 1.08; 95% CI, 0.99-1.18) compared with no visit or call were not associated with a lower rate of readmission. Completion of a 7-day clinic visit was associated with a lower readmission rate (HR, 0.88; 95% CI, 0.81-0.94) compared with no clinic visit. There were no synergistic effects of all 3 components compared with clinic visit alone (HR, 1.05; 95% CI, 0.87-1.28). Conclusions and Relevance: This study found that HF-TCP as a whole was not associated with a reduction in 30-day readmission rates, although a follow-up clinic visit within 7 days of discharge may be helpful. These findings highlight the importance of continuous quality improvement and refinement of existing clinical programs.