Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials.

BACKGROUND: Heart failure (HF) imposes a substantial burden on patients and healthcare systems. Hospital-to-home transitional care, involving time-limited interventions delivered predominantly by nurses, was introduced to lighten this burden. This study aimed to examine the effectiveness and dose-response of nurse-led transitional care interventions (TCIs) on healthcare utilization among patients with HF. METHODS: Health-related databases were systematically searched for articles published from January 2000 to June 2020. We included randomized controlled trials (RCTs) that compared nurse-led TCIs with usual care for adults hospitalized with HF and reported the following healthcare utilization outcomes: all-cause readmissions, HF-specific readmissions, emergency department visits, or length of hospital stay. Random-effects meta-analysis, meta-regression analysis, and dose-response analysis were performed to estimate the treatment effects and explain the heterogeneity. RESULTS: Twenty-five RCTs including 8422 patients with HF were included. Nurse-led TCIs for patients with HF resulted in a mean 9% (RR = 0.91; 95% CI = 0.82 to 0.99; p = 0.04; I2 = 46%) and 29% (RR = 0.71; 95% CI = 0.60 to 0.84; p < 0.0001; I2 = 0%) reduction in all-cause and HF-specific readmission risks respectively compared to usual care. The interventions were also effective in shortening the length of hospital stay (MD = -2.37; 95% CI = -3.16 to -1.58; p < 0.0001; I2 = 14%). However, no significant reduction was found for emergency department visits (RR = 0.96; 95% CI = 0.84 to 1.10; p = 0.58; I2 = 0%). The effect of meta-regression coefficients on all-cause and HF-specific readmissions was not statistically significant for any prespecified trial-level characteristic. Dose-response analysis revealed that the HF-specific readmission risk decreased in a dose-dependent manner with the complexity and intensity of nurse-led TCIs. CONCLUSIONS: Nurse-led TCIs were effective in decreasing all-cause and HF-specific readmission risks, as well as in reducing the length of hospital stay; however, the interventions were not effective in reducing the frequency of emergency department visits.

The effect of care transition pathway implementation on patients undergoing joint replacement during the COVID-19 pandemic: a quasi-experimental study from a tertiary care hospital orthopedic department in Beijing, China.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has had a massive impact on individuals globally. The Chinese government has formulated effective response measures, and medical personnel have been actively responding to challenges associated with the epidemic prevention and control strategies. This study aimed to evaluate the effect of the implementation of a care transition pathway on patients that underwent joint replacement during the COVID-19 pandemic. METHODS: A quasi-experimental study was designed to evaluate the effect of implementing a care transition pathway for patients who underwent joint replacement during the COVID-19 pandemic in the orthopedic department of a tertiary care hospital in Beijing, China. Using a convenient sampling method, a total of 96 patients were selected. Of these, 51 patients who had undergone joint replacement in 2019 and received treatment via the routine nursing path were included in the control group. The remaining 45 patients who underwent joint replacement during the COVID-19 epidemic in 2020 and received therapy via the care transition pathway due to the implementation of epidemic prevention and control measures were included in the observation group. The quality of care transition was assessed by the Care Transition Measure (CTM), and patients were followed up 1 week after discharge. RESULTS: The observation group was determined to have better general self-care preparation, written planning materials, doctor-patient communication, health monitoring, and quality of care transition than the control group. CONCLUSIONS: A care transition pathway was developed to provide patients with care while transitioning through periods of treatment. It improved the patient perceptions of nursing quality. The COVID-19 pandemic is a huge challenge for health professionals, but we have the ability to improve features of workflows to provide the best possible patient care.

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

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

Cuidado à pessoa com insuficiência cardíaca após alta hospitalar: revisão integrativa / Care for people with heart failure after hospital discharge: integrative review / Cuidado de personas con insuficiencia cardiaca después del alta del paciente: revisión integrativa

Objetivo: Identificar as evidências acerca das orientações que devem ser oferecidas à pessoa com Insuficiência Cardíaca para a continuidade do tratamento. Método: Revisão integrativa, com busca nas bases de dados Lilacs, Pubmed, Cinahl, Web of Science e Scopus. Resultados: Dos 5422 títulos identificados, 31 artigos foram incluídos para análise. Apreendeu-se que os estudos abordaram, dentre outros aspectos, a importância da orientação da doença, dos sinais e sintomas e da detecção da agudização; no entanto, constatou-se a dificuldade na utilização de linguagem adequada para facilitar a compreensão pela pessoa e/ou pelos familiares. Conclusão: Sugere-se que mais estudos sejam realizados a respeito desse tema, a fim de possibilitar aos profissionais de saúde a formulação de um plano de cuidados coerente, com fundamentação nas melhores evidências científicas

Objective: to identify the evidence on the guidance that should be offered to people with heart failure to continue treatment. Method:integrative review, searching the databases Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), National Library of Medicine (PUBMED/MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science e Scopus. Results: of the 5422 titles identified, 32 articles were included for analysis. It was understood that the studies addressed, among other aspects, the importance of disease orientation, signs and symptoms, and acute detection; however, it was found that it was difficult to use adequate language to facilitate understanding by the person and/or family members. Conclusion: it is suggested that more studies be conducted on this topic, in order to enable health professionals to formulate a coherent care plan, based on the best scientific evidence

Objetivo: identificar la evidencia sobre las pautas que deberían ofrecerse a las personas con insuficiencia cardíaca para continuar el tratamiento. Método: revisión integrativa, búsqueda en las bases de datos Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), National Library of Medicine (PUBMED/MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science e Scopus.Resultados: de los 5422 títulos identificados, se incluyeron 32 artículos para su análisis. Se entendió que los estudios abordaron, entre otros aspectos, la importancia de la orientación de la enfermedad, los signos y síntomas, y la detección aguda; sin embargo, se descubrió que era difícil usar un lenguaje adecuada para facilitar la comprensión por parte de la persona y/o miembros de la familia. Conclusión: Se sugiere que se realicen más estudios sobre este tema, a fin de permitir a los profesionales de la salud formular un plan de atención coherente, basado en la mejor evidencia científica

Clinical Nurse Specialists' Perceptions of Transitioning Into a Rural Community-Based Transitional Care Role.

OBJECTIVE: The aim of this study was to understand the experiences of nurses making the role transition from clinical nurse specialists (CNSs) (hospital based) into transitional care nurse (TCN) roles (community based). BACKGROUND: The shift from fee-for-service to value-based care has led to the development of transitional care programs. However, little is known about the perceptions of nurses transitioning from a hospital- to a community-based position. Their perceptions can inform training and future recommendations for the TCN role. METHODS: Five of 6 eligible TCNs from a community rural hospital in Vermont who transitioned from a CNS role to a TCN role participated in individual, face-to-face interviews using a semistructured interview guide. Data were audio recorded, transcribed verbatim, and analyzed using the constant comparative method. RESULTS: Seven major themes were identified: enhanced patient-centered care, collaboration among the other TCNs, transitioning from expert to novice, recommendations for navigating and negotiating systems, discomfort with the role transition, a level of altruism and autonomy, and recommendations for improving the TCN role. Minor themes supported the major themes. CONCLUSIONS: Our findings provide implications to improve the transitions of CNSs into a TCN role. Transitional care nurse programs are essential in transitioning individuals from hospital to home. To achieve maximum benefit from TCN programs and ensure their sustainability, nursing leaders must address gaps in both community resources and TCN training.

Transitional Care Home Visits Among Underserved Patients With Heart Failure.

Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination.

Perceptions of adult and child neurologists of transition programs in epilepsy in Latin America: A cross-sectional study.

PURPOSE: The objective of this study was to review the existence and opinion Latin American adult and child neurologists have about the development and function of transition programs in epilepsy. METHODS: This was a cross-sectional study. A questionnaire was constructed with sociodemographic variables, knowledge about transition programs, barriers for building up transition programs, and 21 topics regarding the degree of involvement of healthcare providers and carers should have during the transition process. The online questionnaire was sent to 136 Latin American chapter officers registered in the International League Against Epilepsy (ILAE) webpage and to 36 clinicians assisting to the 13th Latin American Summer School on Epilepsy. RESULTS: The answer rate was 68% (117/172), and all 19 Latin American countries were represented. Adult neurologists represented 60.7%. Only 16.2% knew of transition programs in epilepsy. The main limitations for transition programs were poor education about transition (76.9%), inflexible healthcare systems (75.2%), absence of financial support (61.5%), need of multidisciplinary teams (59%), and scarce communication between child and adult neurologists (53%). Providers and carers are expected to get involved at a high degree in all 21 presented topics for a transition process. The topics with highest percentage of commitment were violence and carrying weapons (93.2%), mental health (92.3%), alcohol and drugs (91.4%), suicide (90.6%), care of own's disease (90.5%), mortality risk (89.7%), and integral healthcare (92.2%). CONCLUSION: Only a few transition programs exist in Latin America. Knowing the benefits of and barriers for transition programs opens the opportunity to move further this strategy in the region considering local specificities. Education, communication skills, team working, and advocacy for adolescents with epilepsy could be initial starting points.

Evaluating the effects of a multidisciplinary transition care management program on hospital readmissions.

PURPOSE: To measure the effect of a pharmacist-initiated transitions of care (TOC) program on rates of 30-day all-cause readmissions and primary care follow-up. METHODS: A retrospective cohort study was conducted to evaluate a pharmacist-initiated TOC program for patients discharged from hospitals of a large health system from September 2015 through July 2016. Discharged patients of 13 primary care physicians (the intervention cohort) received TOC program services, and discharged patients seen by 12 other primary care physicians (the control cohort) received usual care. Patients in both cohorts were followed for 90 days. The primary outcome was 30-day all-cause readmissions, and secondary outcomes were 14-day primary care visits, TOC pharmacist identification and resolution of medication therapy problems (MTPs), and transition care management (TCM) billing. Multivariable modeling was performed to test the associations of patient receipt of TOC services with 30-day readmissions and 14-day primary care visits, with controlling for patient demographics and baseline healthcare utilization. RESULTS: A total of 492 patients received the TOC intervention, and 379 were followed in the usual care cohort. Among intervention patients, 960 MTPs were identified, and 85.7% of identified MTPs were resolved. Moreover, 9% of intervention cohort patients were readmitted within 30 days, compared to 15% of control cohort patients, and this effect was significant in the multivariable model (odds ratio, 1.82; 95% confidence interval, 1.15-2.89; P = 0.0108). Rates of primary care visits did not differ significantly between the groups; 65% of intervention group visits were billed using TCM codes. CONCLUSION: A pharmacist-initiated TOC program was effective in reducing 30-day all-cause readmissions.

Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities.

BACKGROUND: The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES: Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN: Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS: Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS: While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.

O processo de transiçãoda integração do recém-nascido na família alargada: confrontando diferentes perspetivas / The process of transition of the extended family in the newborn's integration: comparing different perspectives

Understanding the process of transition of the extended family in the newborn's inte-gration was the aim of this study.It is a qualitative study using the Grounded Theory. It is based on 14 families of one of the autonomous regions of Portugal and the semi-structured interview was used for data collection. The Causal Condition - Comparing Different Perspectives emerged from the analysis. It is characterized as the beginning of the newborn's integration in the family process trajectory, where the extended family hasn't integrated the changes yet and shows some difficulties in its operationalization. In the newborn's integration in the extended family process: Comparing Different Perspectives represents the confrontations/conflicts inside the cohabiting family, due to the existence of different perspectives in raising the new member. Thus, the study enabled us to understand not only the transitional process dynamics, as it is a reflection point and a raising of awareness to the change/innovation of the practice and formation contexts, but also how the extended family deals with the beginning of the experience as far as the newborn's integration in the family transition is concerned

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A Systematic Review of Transition Readiness in Youth with Chronic Disease.

The transition of chronically ill adolescents and young adults to adult health care is poorly managed, leading to poor outcomes due to insufficient disease knowledge and a lack of requisite skills to self-manage their chronic disease. This review analyzed 33 articles published between 2009 and 2019 to identify factors associated with transition readiness in adolescents and young adults with chronic diseases, which can be used to design effective interventions. Studies were predominantly cross-sectional survey designs that were guided by interdisciplinary research teams, assessed adolescents and young adults ages 12-26 years, and conducted in the outpatient setting. Modifiable factors, including psychosocial and self-management/transition education factors, and non-modifiable factors, including demographic/ecological and disease factors, associated with transition readiness were identified. Further research is necessary to address gaps identified in this review prior to intervention development, and there is a need for additional longitudinal studies designed to provide perspective on how transition readiness changes over time.

Habits and Routines during Transitions among Emerging Adults with Type 1 Diabetes.

To provide insight into poorly understood diabetes self-management among emerging adults with type 1 diabetes (TID) experiencing transitions, this study described their diabetes self-management-related habits, routines, and disruptions as well as explored relationships among habits and routines. A qualitative study, guided by critical incidence technique, was conducted. Participants were asked to describe situations when they did and did not check blood glucose, administer insulin, eat meals, and exercise as planned. They were also asked to describe activities in a typical day and in association with diabetes self-management. Content analysis with a priori definitions of habits and routines was performed. Participants described diabetes self-management-related transitional disruption as forgetting and disorder. They described habits associated with checking a blood glucose, giving an insulin dose, eating a meal, and initiating exercise. They described routines in association with meals, exercise, and overall diabetes management. These findings provide information on variables to target in intervention research.

Hospital transition care for the elderly: an integrative review.

OBJECTIVE: to identify evidence of scientific production on hospital transition care provided to the elderly. METHOD: an integrative review, with publications search in the MEDLINE, PubMed, LILACS, BDENF, Index Psychology and SciELO databases, with keywords and Mesh terms: elderly, hospitalization, patient discharge, health of the elderly, and transitional care, between 2013 and 2017 in English, Portuguese and Spanish. The 14 selected articles analysis was carried out through exploratory and critical reading of titles, abstracts and results of the researches. RESULTS: transitional care can prevent re-hospitalizations as they enable rehabilitation, promotion and cure of illnesses in the elderly. FINAL CONSIDERATIONS: transitional care implies the improvement of the quality of life of the elderly person, requiring skilled health professionals who involve the family through accessible communication.

Drug-Related Problems in the transitional care of the elderly from hospital to home.

OBJECTIVE: To identify the knowledge produced on Medication-Related Problems in the transitional care of the elderly from hospital to home. METHOD: Integrative review of the literature data, organized in six stages: guiding question; establishment of inclusion and exclusion criteria; extraction of data; analyze; interpretation of results; and presentation of the review. Articles were considered among 2002 and 2017, in Portuguese, English, and Spanish, in the databases LILACS, MEDLINE, CINAHL and EMBASE. RESULTS: 10 studies were selected and analyzed. They were categorized by subject and identified in three themes: Medication Discrepancy and Reconciliation (40%); Adhesion to Medication (30%); and Adverse Drug Events (30%). FINAL CONSIDERATIONS: Drug-Related Problems in the transitional care of the elderly from hospital to home, were presented as a relevant theme for nursing, involving complex issues related to care. Drug reconciliation was evidenced as a coherent and effective strategy in home care transitions for the elderly.

Status of transition care in inflammatory bowel disease in Spain. Different medical perspectives

Introduction: transition is important for a successful follow-up of adolescents with inflammatory bowel disease (IBD). The objectives of the study were to establish the situation of transition in Spain and to identify needs, requirements and barriers to transition from pediatric and adult gastroenterologist perspectives. Methods: a structured survey for self-completion using the REDCap platform was distributed via the Spanish Society for Pediatric Gastroenterology, Hepatology and Nutrition (SEGHNP) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU). The questionnaire contained closed and ranked questions concerning transition, perceived needs, organizational, clinician and patient related barriers to transition. Results: one hundred and forty surveys were answered, 53% in pediatrics (PG) and 47% from adult gastroenterologists (AG) among 90 hospitals; 66% of them were reference centers. There was a higher response from pediatricians (18.2%) versus adult gastroenterologists (8.3%) (p = 0.03). A structured transition program is adequate in 42.2% centers. A well-structured transition was perceived as very important by 79.5% of PG and 63% of AG (p = 0.03). A higher proportion of both groups identified inadequacies in the preparation of adolescents for transfer (43% and 38%, p = ns). The main deficit areas were the lack of knowledge about disease and treatment as well as the lack of self-advocacy and care coordination. Lack of resources, time and critical mass of patients were the highest ranked barriers by both groups. AG and PG (54% and 55%) highlighted suboptimal training in adolescent medicine. Conclusions: in Spain, nearly half of the centers have developed a structured transition program. Lack of training, time and insufficient resources are the main barriers for a successful transition

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Healthcare needs and programmatic gaps in transition from pediatric to adult care of vertically transmitted HIV infected adolescents in India.

Treatment transition for 'adolescents living with perinatally acquired HIV' (ALPH) from paediatric to adult care is not addressed adequately. This study explores the ALPH's health care needs and programmatic gaps in health systems for the care of ALPH in India. Forty-nine in-depth interviews were conducted with purposively selected primary and key stakeholders in India. Thematic analysis utilizing grounded theory was performed in QSR NUD*IST 6. Stakeholders explicitly recognized adolescent HIV to be a critical public health issue which requires a separate mandate in India. It was found that none of the health policies in India focus on adolescent age group; ALPH is therefore even more neglected population. No/partial HIV disclosure to ALPH is the first crisis for retention in care continuum and adherence to the treatment becomes sub-optimal. Unmet needs of transitioning from paediatric to adult care in existing settings was the major gap. Age-specific counselling guidelines and counselling skills among HCPs were found lacking where tailored counseling and capacity building of HCPs was an expectation. Need of holistic approach for adolescents led to consensus on establishing 'adolescent transition clinic' with a strict 'no' for 'standalone Adolescent HIV' clinics. School setting having peer-based counselling provision was recommended. Age disaggregated health data is required to inform the policymakers about adolescents' specific needs for developing interventions. Situational analysis to identify and shape health priorities of adolescents is recommended.

Perceptions and Experiences of Hospital Nurses During Transition to an Electronic Handover Informatics System.

An effective patient transfer, or handover, among healthcare professionals can help prevent communication-related medical errors, and a reliable electronic handover informatics system can standardize the handoff process. Adapting to a new handover system may cause stress for nurses. This descriptive qualitative study aimed to explore the perceptions and transition experiences of hospital nurses in adopting and adapting to a new handover informatics system. Thirty-eight nurses at a medical center in Taiwan participated in the study from December 2016 to January 2017. The researcher conducted five focus group interviews and analyzed all responses using content analysis. Results showed three major themes: "Perceptions of challenges and barriers related to the transition to a new handover informatics system," "Perceptions of benefits and strategies to the transition to a new handover informatics system," and "Suggestions for successful implementation of a new handover informatics system." Five subthemes emerged from the first theme, and six subthemes emerged from the second theme. The results of this study could enhance our understanding of nurses' perceptions and experiences with transition to a new handover informatics system and could provide a reference for hospitals to develop individualized strategies to facilitate the implementation of a handover informatics system.