Improving Transitions in Care for Patients and Family Caregivers Living in Rural and Underserved Areas: The Caregiver Advise, Record, Enable (CARE) Act.

In this Perspective, we contend bold action is needed to improve transitions from hospitals to home for aging patients and their family caregivers living in rural and underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed in over 40 US states, is intended to provide family caregivers of hospitalized patients with the knowledge and skills needed for safe and efficient transitions. It has broken important ground for family caregivers who assist with transitions in patient care. It may fall short, however, in addressing the unique needs of family caregivers living in rural and underserved areas. We contend that to realize the intended safety, cost, and care quality benefits of the CARE Act, especially for those living in rural and underserved areas, states need to expand the Act's scope. We provide three recommendations: 1) modify hospital information systems to support the care provided by family caregivers; 2) require assessments of family caregivers that reflect the challenges of family caregiving in rural and underserved areas; and 3) identify local resources to improve discharge planning. We describe the rationale for each recommendation and the potential ways that an expanded CARE Act could reduce the risks associated with transitions in care for aging patients.

Key Points:1. Recent state laws aim to support family caregivers of hospitalized patients.2. These laws do not account for the unique needs of rural caregivers.3. Expanding laws to address rural caregiver needs may improve patient outcomes.

Identifying and addressing gaps in the implementation of a community care team for care of Patients with multiple chronic conditions.

BACKGROUND: Patients with multiple chronic conditions represent a growing segment for healthcare. The Chronic Care Model (CCM) supports leveraging community programs to support patients and their caregivers overwhelmed by their treatment plans, but this component has lagged behind the adoption of other model elements. Community Care Teams (CCTs) leverage partnerships between healthcare delivery systems and existing community programs to address this deficiency. There remains a gap in moving CCTs from pilot phase to sustainable full-scale programs. Therefore, the purpose of this study was to identify the cognitive and structural needs of clinicians, social workers, and nurse care coordinators to effectively refer appropriate patients to the CCT and the value these stakeholders derived from referring to and receiving feedback from the CCT. We then sought to translate this knowledge into an implementation toolkit to bridge implementation gaps. METHODS: Our research process was guided by the Assess, Innovate, Develop, Engage, and Devolve (AIDED) implementation science framework. During the Assess process we conducted chart reviews, interviews, and observations and in Innovate and Develop phases, we worked with stakeholders to develop an implementation toolkit. The Engage and Devolve phases disseminate the toolkit through social networks of clinical champions and are ongoing. RESULTS: We completed 14 chart reviews, 11 interviews, and 2 observations. From these, facilitators and barriers to CCT referrals and patient re-integration into primary care were identified. These insights informed the development of a toolkit with seven components to address implementation gaps identified by the researchers and stakeholders. CONCLUSION: We identified implementation gaps to sustaining the CCT program, a community-healthcare partnership, and used this information to build an implementation toolkit. We established liaisons with clinical champions to diffuse this information. The AIDED Model, not previously used in high-income countries' primary care settings, proved adaptable and useful.

Describing pediatric hospital discharge planning care processes using the Omaha System.

PURPOSE: Although discharge planning (DP) is recognized as a critical component of hospital care, national initiatives have focused on older adults, with limited focus on pediatric patients. We aimed to describe patient problems and targeted interventions as documented by social workers or DP nurses providing specialized DP services in a children's hospital. METHODS: Text from 67 clinical notes for 28 patients was mapped to a standardized terminology (Omaha System). Data were deductively analyzed. RESULTS: A total of 517 phrases were mapped. Eleven of the 42 Omaha System problems were identified. The most frequent problem was health care supervision (297/517; 57.4%). Three Omaha System intervention categories were used (teaching, guidance, and counseling; case management; and surveillance). Intervention targets are varied by role. CONCLUSION: The findings provide a rich description of the nature of DP for complex pediatric patients and increase our understanding of the work of DP staff and the influence of the DP practice model.

Tracking Discharge Delays: Critical First Step Toward Mitigating Process Breakdowns and Inefficiencies.

This article reports on the development and evaluation of a mechanism designed for real-time tracking of discharge delays by bedside clinicians and the reporting of delays in a manner amenable to action. During the implementation phase, delay time totaled 23.6 days for 114 patients affected by a delay. More than one-half of delays (61.4%) occurred for patients whose discharge disposition was home to self-care.

Decision support tool use in colorectal surgery: what is the role?

BACKGROUND: Decision support tools prioritizing transitional care can help decrease medical readmissions but little evidence exists within surgical specialties. MATERIALS AND METHODS: This study evaluated the use of early screen for discharge planning and discharge decision support system screening tools or selective multidisciplinary clinical evaluation for targeting post-acute care interventions among higher risk colorectal surgery patients based on 30-d readmission status. Patients with positive screening tool scores underwent standard discharge planning education and evaluation during index operation hospitalization and were referred for targeted post-acute interventions; patients with negative screening tool scores were further clinically evaluated for selective referral for post-acute interventions. RESULTS: We identified 300 colorectal surgery patients; 30.3% (n = 91) of patients had a positive screening score (early screen for discharge planning and/or discharge decision support system). Positive screening scores did not correlate with hospital readmission (35% of readmitted patients versus 29% of non-readmitted had a positive screen; P = 0.424). After negative screening scores, selective referral based on clinical assessment for postdischarge interventions helped to concentrate resources in patients who were later readmitted. Index hospitalization complications were significantly associated with positive screening tool scores whereas postdischarge complications were most predictive of readmission. CONCLUSIONS: Among colorectal surgery patients, selective clinical referrals appeared to be the best method for targeting post-acute interventions in patients at higher risk for readmission. Future research should focus on improving existing processes of care to reduce postoperative complications and constructing better tools to assess individual patients' needs for targeted interventions in the post-acute setting.

A Model for Hospital Discharge Preparation: From Case Management to Care Transition.

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Identifying hospitalized pediatric patients for early discharge planning: a feasibility study.

A screening tool utilized by nurses at a critical point in the discharge planning process has the potential to improve caregiver decisions and enhance communication. The Early Screen for Discharge Planning-Child version (ESDP-C) identifies pediatric patients early in their hospital stay who will benefit from early engagement of a discharge planner. This study used a quasi-experimental, non-equivalent comparison group design to evaluate the impact of the ESDP-C on important outcomes related to discharge planning. Findings from the study provide preliminary evidence that the integration of the ESDP-C into the pediatric discharge planning process may be clinically useful.

The feasibility of using technology to enhance the transition of palliative care for rural patients.

Palliative care services for patients with life-limiting conditions enhance their quality of life. Most palliative care services, however, are located in hospitals with limited transitional care for patients who live in distant locations. The long-term goal of this program of research is to use existing technology for virtual visits to provide transitional care for patients initially hospitalized in an urban setting by a nurse practitioner located closer to patients' homes in distant, rural settings. The purpose of this proof-of-concept study was to determine the resources needed to use the system (efficiency) and the quality of the audio and visual components (effectiveness) to conduct virtual visits between a clinician at an academic center and community-dwelling adults living in rural locations. Guided by the Technology Acceptance Model, a mixed-methods field design was used. Because of the burden of testing technology with patients with life-limiting conditions, the sample included eight healthy adults. Participant satisfaction and perceptions of the ease of using the technology were also measured. Virtual visits were conducted using a 3G-enabled Apple iPad, cellular phone data service, and a Web-based video conference service. Participants and clinicians perceived the technology as easy to use. Observations revealed the importance of the visual cues provided by the technology to enhance communication, engagement, and satisfaction. Findings from this study will inform a subsequent study of technology-enhanced transitional care with palliative care patients.

Discharge planning rounds to the bedside: a patient- and family-centered approach.

Discharge planning rounds done at the bedside is an effective patient-centered approach to discharge planning and does not take any longer than traditional rounds apart from the patient and caregiver. Bedside rounds may decrease patient utilization of health care resources after discharge.

Caregiver recruitment strategies for interventions designed to optimize transitions from hospital to home: lessons from a randomized trial.

Challenges to recruitment of family caregivers exist and are amplified when consent must occur in the context of chaotic healthcare circumstances, such as the transition from hospital to home. The onset of the COVID-19 pandemic during our randomized controlled trial provided an opportunity for a natural experiment exploring and examining different consent processes for caregiver recruitment. The purpose of this publication is to describe different recruitment processes (in-person versus virtual) and compare diversity in recruitment rates in the context of a care recipient's hospitalization. We found rates of family caregiver recruitment for in-person versus virtual were 28% and 23%, respectively (p = 0.01). Differences existed across groups with family caregivers recruited virtually being more likely to be younger, white, have greater than high school education, and not be a spouse or significant other to the care recipient, such as a child. Future work is still needed to identify the modality and timing of family caregiver recruitment to maximize rates and enhance the representativeness of the population for equitable impact.

Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers.

OBJECTIVES: Compared to urban family caregivers (FCG), rural FCG experience greater burdens accessing coordinated care for their loved ones during and after hospitalization. The impact of technology-enhanced transitional palliative care (TPC) on caregiver outcomes is currently being evaluated in a randomized control trial. This study evaluates resource use and health system costs of this FCG-focused TPC intervention and potential Medicare reimbursement mechanisms. METHODS: Rural caregivers of hospitalized patients were randomized into an 8-week intervention consisting of video visits conducted by a registered nurse certified in palliative care, supplemented with phone calls and texts (n = 215), or attentional control. Labor costs were estimated for a registered nurse and compared to scenario analyses using a nurse practitioner or social worker wages. Medicare reimbursement scenarios included Transitional Care Management (TCM) and Chronic Care Management (CCM) CPT codes. RESULTS: In the base case, TPC cost was $395 per FCG facilitated by a registered nurse, compared to $337 and $585 if facilitated by a social worker or nurse practitioner, respectively. Mean Medicare reimbursement in the TCM-only scenario was $322 and $260 for high or moderate complexity patients, respectively. Reimbursement in the CCM only scenario was $348 and $274 for complex and non-complex patients, respectively. Reimbursement in the TCM+CCM scenario was $496 and $397, for high/complex and moderate/non-complex patients, respectively. CONCLUSION: TPC is a feasible, low cost and sustainable strategy to enhance FCG support in rural areas. Potential reimbursement mechanisms are available to offset the costs to the health system for providing transitional palliative care to caregivers of patients recently hospitalized.

Healthcare use and out-of-pocket costs for rural family caregivers and care recipients in a randomized controlled trial.

BACKGROUND: Rural family caregivers (FCGs) in the United States often experience high economic costs. This randomized controlled trial compared a transitional palliative care intervention (TPC) to support FCGs of seriously ill care recipients (CRs) to an attention control condition. We evaluated the TPC's effect on healthcare use and out-of-pocket spending for both FCGs and CRs. METHODS: TPC FCGs received teaching, guidance, and counseling via video calls for 8 weeks following CR discharge from the hospital. After discharge, a research assistant called all FCGs once a month for up to 6 months or CR death to collect self-reported healthcare utilization (e.g., outpatient, emergency department, and hospital), out-of-pocket healthcare spending (e.g., deductibles and coinsurance), and health-related travel costs (e.g., transportation, lodging, food) for FCGs and CRs. Incidence rate ratios (IRRs) were estimated using negative binomial regressions. RESULTS: The study included 282 FCG-CR dyads across three U.S. states. Follow-up over the 6-month period was shortened by high CR mortality rates across both arms (29%), but was similar across arms. TPC reduced nights in the hospital for CR (IRR = 0.75; 95% confidence interval [CI] = 0.56-0. 99). Total out-of-pocket spending was not significantly different for TPC versus control. Across both groups, mean out-of-pocket spending for dyads was $1401.85, with healthcare payments contributing $1048.58 and transportation expenses contributing $136.79. TPC dyads reported lower lodging costs (IRR = 0.71; 95% CI = 0.56-0.89). CONCLUSIONS: This study contributes to evidence that palliative care interventions reduce the number of nights in the hospital for seriously ill patients. Yet, overall rural FCGs and seriously ill CRs experience substantial out-of-pocket economic costs in the 6 months following hospitalization. Transitional care intervention design should consider impacts on patient and caregiver spending. CLINICALTRIALS: gov # is NCT03339271.

Targeting hospitalised patients for early discharge planning intervention.

AIMS AND OBJECTIVES: The purpose of the study was to describe the ability of an evidence-based discharge planning (DP) decision support tool to identify and prioritise patients appropriate for early DP intervention. Specifically, we aimed to determine whether patients with a high Early Screen for Discharge Planning (ESDP) score report more problems and continuing care needs in the first few weeks after discharge than patients with low ESDP scores. BACKGROUND: Improved methods are needed to efficiently and accurately identify hospitalised patients at risk of complex discharge plans. DESIGN: A descriptive cross-sectional study was designed using a quality health outcomes framework. METHODS: The ESDP was administered to 260 adults hospitalised in an academic health centre who returned home after discharge. Problems and continuing care needs were self-reported on the Problems After Discharge Questionnaire - English Version, mailed 6-10 days after discharge. RESULTS: Patients with high ESDP scores reported significantly more problems [mean, 16·3 (standard deviation ±8·7)] than those with low scores [12·2 (±8·4)]. Within the Problems After Discharge Questionnaire subscales, patients with high ESDP scores reported significantly more problems with personal care, household activities, mobility and physical difficulties than patients with low screen scores. Significantly more of the patients with a high ESDP score received consults to a Discharge Planner and referrals for postacute services than patients with low screen scores. CONCLUSION: The ESDP is effective as a decision support tool in identifying patients to prioritise for early DP intervention. RELEVANCE TO CLINICAL PRACTICE: Use of an evidence-based DP decision support tool minimises biases inherent in decision-making, promotes efficient use of hospital DP resources, and improves the opportunity for patients to access community resources they need to promote successful recovery after hospitalisation.

Developing a community care team: lessons learned from the community connections program, a health care home-community care team partnership.

This article describes the development of the Community Connections Program (CCP), a community care team, within a health care home (HCH), as a short-term, intensive, team-based service planning and coordination program for older adults with multiple chronic health conditions. Three proven approaches were combined to support patient's self-management, nurse care coordination, the Wraparound process, and use of community services. Particzpants'responses to the CCP demonstrated the success of the community care team in connecting patients and nurse care coordinators (NCCs) with community service providers, thus supplying primary care providers with important information regarding the development of a community care team to support patient-centered care within a HCH.

Dementia Care in the Last Year of Life: Experiences in a Community Practice and in Skilled Nursing Facilities.

OBJECTIVE: People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). METHODS: A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. RESULTS: Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs (P < .001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P < .001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P < .001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group (P < .001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs (P < .001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs (P = .67). CONCLUSIONS: Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.

A Methodological Approach for Documenting Multi-Component Interventions Targeting Family Caregivers.

Managing the complex care needs of seriously ill patients transitioning from hospital to home can have detrimental effects on family caregivers (FCG). Multi-component interventions tailored to FCG needs are most effective at reducing caregiver burden, distress, and depression. However, gaps exist in determining best methods to assess, document, and analyze intervention components for FCGs. Common methods used to capture patient data during transitions in care may not be appropriate or allowed for FCG needs. As such, we present a methodological approach for electronically capturing, reporting, and analyzing multiple intervention components. This approach uses a standardized terminology and pathway for tailoring intervention components in real time while evaluating intervention effects across time. We use examples from a randomized controlled trial to illustrate the benefits of the current approach for analyzing the effectiveness of multi-component interventions in the context of caregiving research.

Standardized discharge planning assessments: impact on patient outcomes.

The purpose of the study was to determine whether a difference exists in patient-reported problems and unmet needs after discharge when a standardized discharge planning assessment is added to usual care by staff nurses. Two groups of 130 adult patients were enrolled while hospitalized. The intervention group patients reported fewer unmet needs (P = .01) and had fewer problems complying with their discharge instructions (P = .04). Standardizing discharge planning assessments by staff nurses may improve identification of continuing care needs.

Standardizing hospital discharge planning at the Mayo Clinic.

BACKGROUND: Improving the quality of patient coordination in the transition from hospital to home is a high-priority health care concern. The Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation in the Medicare Program require that hospitals have a discharge planning (DP) process in effect that applies to all patients. The impact of a practice change in DP practice on the quality of care coordination at discharge was evaluated from patients' perspectives. METHODS: A multifactor, evidence-based DP practice change, which included merging of DP specialist roles and use of an early screen for DP decision support tool, was initiated in a large, Midwestern academic medical center and evaluated in a nonequivalent comparison group design with separate pre- and postpractice change samples. The three-item Care Transitions Measure (CTM-3) was mailed to adults recently discharged from one medical and one surgical nursing unit before and after the practice change. RESULTS: Response rates were 52.4% before (218/416) and 39.5% (153/387) after the practice change. There were no significant differences between characteristics of the pre- and postpractice change participants. The mean CTM-3 score of patients who received assistance from the nurse/ social worker DP team improved by 14 points (67.2 to 81.2), although the data were skewed with a ceiling effect, rendering the results inconclusive. CONCLUSIONS: Although the CTM-3 results were inconclusive, the practice change resulted in a clinically meaningful decrease in length of stay for a group of older patients at greater risk for complex discharge plans. The proactive approach to DP proved to be a valuable shift. The successes of the standardization of DP processes and improved multidisciplinary teamwork were important considerations for implementation throughout the organization.

Mapping a Strength-Oriented Approach to a Standardized Terminology: A Case Study.

As a new era of healthcare advocates a more valuable and intelligent approach to care management and delivery based on values and outcomes, shifts toward risk management to boost performance should be considered that encompass the capitalization of health assets or health strengths. To make full use of individuals' or populations' health assets, data capture and representation are needed. This paper uses a strengths-oriented case study mapped to an inter-disciplinary standardized terminology, the Omaha System, to illustrate and compare the conventional problem-based approach to care management with the strengths-oriented approach to care that demonstrates whole-person data capture of an individual's health and health assets leveraged to promote health values and performance. The Omaha system provides a standardized framework to organize the concepts of all of health from a whole-person perspective for documentation to enable data analysis, interoperability, and health information exchange.

Illuminating hospital discharge planning: staff nurse decision making.

This qualitative study proposed to examine staff RN's decision making related to discharge planning and perceptions of their role. Themes resulting from interviews were "following the script" and "RN as coordinator." The decision to consult a discharge planner occurred when the patient's situation did not follow the RN's expectations. Discharge planning for nonroutine situations was considered disruptive to the RN's workflow. The RN's role was limited to oversight when a discharge planner was involved. Understanding RNs' decision making in this key process provides valuable insights into differentiating routine from nonroutine patient situations and deploying appropriate resources in a timely fashion.