Emergency department returns and early follow-up visits after heart failure hospitalization: Cohort study examining the role of race.

Health disparities in heart failure (HF) show that Black patients face greater ED utilization and worse clinical outcomes. Transitional care post-HF hospitalization, such as 7-day early follow-up visits, may prevent ED returns. We examine whether early follow-up is associated with lower ED returns visits within 30 days and whether Black race is associated with receiving early follow-up after HF hospitalization. This was a retrospective cohort analysis of all Black and White adult patients at 13 hospitals in Michigan hospitalized for HF from October 1, 2017, to September 30, 2020. Adjusted risk ratios (aRR) were estimated from multivariable logistic regressions. The analytic sample comprised 6,493 patients (mean age = 71 years (SD 15), 50% female, 37% Black, 9% Medicaid). Ten percent had an ED return within 30 days and almost half (43%) of patients had 7-day early follow-up. Patients with early follow-up had lower risk of ED returns (aRR 0.85 [95%CI, 0.71-0.98]). Regarding rates of early follow-up, there was no overall adjusted association with Black race, but the following variables were related to lower follow-up: Medicaid insurance (aRR 0.90 [95%CI, 0.80-1.00]), dialysis (aRR 0.86 [95%CI, 0.77-0.96]), depression (aRR 0.92 [95%CI, 0.86-0.98]), and discharged with opioids (aRR 0.94 [95%CI, 0.88-1.00]). When considering a hospital-level interaction, three of the 13 sites with the lowest percentage of Black patients had lower rates of early follow-up in Black patients (ranging from 15% to 55% reduced likelihood). Early follow-up visits were associated with a lower likelihood of ED returns for HF patients. Despite this potentially protective association, certain patient factors were associated with being less likely to receive scheduled follow-up visits. Hospitals with lower percentages of Black patients had lower rates of early follow-up for Black patients. Together, these may represent missed opportunities to intervene in high-risk groups to prevent ED returns in patients with HF.

Patient Perspectives on Care Transitions From Hospital to Home.

Importance: Understanding the patient's perspective of their care transition process from hospital or skilled nursing facility (SNF) to home may highlight gaps in care and inform system improvements. Objective: To gather data about patients' care transition experiences and factors associated with follow-up appointment completion. Design, Setting, and Participants: A survey tool was developed with input from patient advisors and organizations participating in a collaborative quality initiative. Seventeen hospitals, 12 practitioner organizations, and 6 SNFs in Michigan collaborated to identify shared patients who were aged 18 years and older, had a working telephone number, recently returned home or to an assisted living facility with a diagnosis of congestive heart failure or chronic obstructive pulmonary disease, or after an SNF stay. Using consecutive sampling, interviewers collected 5 telephone surveys per month. From October 2018 to December 2019, patients or caregivers were surveyed via telephone 8 to 12 days after discharge from a hospital or SNF. Data were analyzed from March 2020 to January 2022. Exposure: Care transition experiences. Main Outcomes and Measures: The primary outcome was to identify patient-perceived gaps during care transition experiences, including postdischarge follow-up. Results: On the basis of pilot data, the response rate was estimated at 34%, yielding 1257 surveys. Of 1257 survey respondents (mean [SD] age, 70 [12.94] years for 968 patients for whom age data was available), 654 (52%) were female; 829 (74%) were White, 250 (22%) were Black or African American, and 40 (4%) were another race. Eleven percent of patients reported not receiving a telephone number to call for postdischarge questions. Nearly 80% of patients (977 patients) received a follow-up telephone call, and most found it valuable. Twenty percent of patients (255 patients) reported at least 1 social determinant of health issue. Lack of transportation was associated with reduced likelihood of completing a follow-up visit, decreasing the odds of completing a follow-up by nearly 70% (odds ratio [OR], 0.31; 95% CI, 0.18-0.53; P < .001). Compared with other patient groups, Black patients were less likely to report completing a postdischarge follow-up visit (OR, 0.49; 95% CI, 0.36-0.67; P < .001) or to receive prescribed medical equipment (OR, 4.23; 95% CI, 1.30-13.83; P = .02). Conclusions and Relevance: An examination of patient discharge experiences from a hospital or SNF identified inconsistencies in care transition processes, social determinants of health issues needing to be addressed after discharge, and racial disparities between patients who attend follow-up appointments. Physicians should be aware of these findings and their consequences for patient experiences.

Development of the Socioeconomic Screening, Active Engagement, Follow-up, Education, Discharge Readiness, and Consistency (SAFEDC) Model for Improving Transitions of Care: Participatory Design.

BACKGROUND: Transition to home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require health care professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions. OBJECTIVE: This study aims to understand the usefulness of participatory design approaches in identifying the design implications of transition of care interventions in health care settings. Through a series of participatory design workshops, we have brought stakeholders of the health care system together. With a shared understanding of care transition and patient experience, we have provided participants with opportunities to generate possible design implications for care transitions. METHODS: We selected field observations in clinical settings and participatory design workshops to develop transitional care interventions that serve each hospital's unique situation and context. Patient journey maps were created and functioned as tools for creating a shared understanding of the discharge process across different stakeholders in the health care environment. The intervention sustainability was also assessed. By applying thematic analysis methods, we analyzed the problem statements and proposed interventions collected from participatory design workshops. The findings showed patterns of major discussion during the workshop. RESULTS: On the basis of the workshop results, we formalized the transition of care model-the socioeconomic, active engagement, follow-up, education, discharge readiness tool, and consistency (Integrated Michigan Patient-centered Alliance in Care Transitions transition of care model)-which other organizations can apply to improve patient experiences in care transition. This model highlights the most significant themes that should necessarily be considered to improve the transition of care. CONCLUSIONS: Our study presents the benefits of the participatory design approach in defining the challenges associated with transitions of care related to patient discharge and generating sustainable interventions to improve care transitions.

Environmental contamination with SARS-CoV-2 in nursing homes.

BACKGROUND: SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied. METHODS: A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs. Swabs from high-touch surfaces in COVID-19-infected patient rooms were obtained at enrollment and follow-up. Demographic and clinical data were collected from clinical records. Primary outcome of interest was the probability of SARS-CoV-2 RNA detection from specific environmental surfaces in COVID-19 patient rooms. We used multivariable logistic regression to assess patient risk factors for SARS-CoV-2 contamination. Pairwise Phi coefficients were calculated to measure correlation of site-specific environmental detection upon enrollment and during follow-up. RESULTS: One hundred and four patients with COVID-19 were enrolled (61.5% >80 years; 67.3% female; 89.4% non-Hispanic White; 51% short stay) and followed up for 241 visits. The study population had significant disabilities in activities of daily living (ADL; 81.7% dependent in four or more ADLs) and comorbidities, including dementia (55.8%), diabetes (40.4%), and heart failure (32.7%). Over the 3-month study period, 2087 swab specimens were collected (1896 COVID-19 patient rooms, 191 common areas). SARS-CoV-2 positivity was 28.4% (538/1896 swabs) on patient room surfaces and 3.7% (7/191 swabs) on common area surfaces. Nearly 90% (93/104) of patients had SARS-CoV-2 contamination in their room at least once. Environmental contamination upon enrollment correlated with contamination of the same site during follow-up. Functional independence increased the odds of proximate contamination. CONCLUSIONS: Environmental detection of viral RNA from surfaces in the rooms of COVID-19 patients is nearly universal and persistent; more investigation is needed to determine the implications of this for infectiousness. Patients with greater independence are more likely than fully dependent patients to contaminate their immediate environment.

A New Tool to Assess Clinician Experience With Patient Care Transitions.

BACKGROUND AND OBJECTIVES: Clinician experience of intrahospital patient care transfers can drive transfer success and safe patient care. Measuring clinician experience can provide insights into opportunities to improve transfer processes that impact patient care. As part of a quality improvement project, we developed a brief survey to gauge clinician experience with patient care transfers that occur within a hospital. METHODS: The survey framework was built upon a previously identified taxonomy of intrahospital transfers that includes categories of transfer activities: disposition, notification, preparation, communication, and coordination. The survey tool was administered twice to physicians, nurses, and other health professionals across a single hospital. Data were analyzed comparing providers sending patients, and those receiving patients. RESULTS: The survey response rate was 33% to 34% across both years. While helpful in demonstrating improving trends in provider experience and engagement with transfer processes, the survey also allowed for differences between the experiences of sending and receiving providers to be revealed. Nurses reported improved preparedness to receive patients and receivers overall reported improved teamwork. Senders' perceptions showed improved trends in all transfer categories. Preliminary data also suggest acceptable reliability across respondent type, item category, and time. Specifically, reliability across sending and receiving clinicians was demonstrated in the categories of timeliness (α = 0.85) and culture (α = 0.72). Responses of sending clinicians were internally consistent within culture (α = 0.82), while responses of receiving clinicians were internally consistent within culture (α = 0.86), timeliness (α = 0.76), notification (α = 0.77), communication (α = 0.73), and teamwork (α = 0.73). CONCLUSIONS: Overall, the survey was feasible to implement and built to optimize content, construct, and response process validity. Survey results drove practical improvement work, such as informing a verbal transfer protocol to improve nursing preparedness to receive patients on general medicine units. As a practical tool, the survey and its results can help hospital administrators to focus on categories of transfer activities that are most problematic for clinicians and to track trends for quality improvement.

Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes.

BACKGROUND/OBJECTIVES: Almost half of deaths related to COVID-19 in the United States are linked to nursing homes (NHs). We describe among short-term and long-term residents at three NHs in Michigan the outbreak identification process, universal testing, point prevalence of COVID-19, and subsequent containment efforts, outcomes, and challenges. DESIGN: Outbreak investigation. SETTING: Three NHs in southeast Michigan. PARTICIPANTS: All residents (N = 215) at three NHs (total beds = 356) affiliated with a large academic healthcare system. METHODS: Upon detection of confirmed cases within the facility, each NH in collaboration and consultation with local hospital, public health officials, and parent corporation implemented immediate facility-wide testing and the following intervention measures: cohorting of COVID-19 positive residents; communication regarding testing and results with residents, healthcare professionals, and families; personal protective equipment reeducation and use throughout facilities; and dedicated staffing for infected patients cohorted in a dedicated COVID-19 wing. We collected patient data regarding demographics, symptoms, comorbidities, hospitalization, and 14-day outcomes. RESULTS: A total of 29 cases of COVID-19 were identified at three participating NHs. Nineteen cases of COVID-19 were identified through symptom-triggered testing from March 23 to April 23, 2020; 10 (4.7%) additional cases were identified through universal testing of 215 residents conducted from April 7 to 15, 2020. The hospitalization rate was 37.9%. The case fatality rate was 20.7% (6/29); these patients had multiple comorbidities. No residents who tested positive through the point-prevalence survey required hospitalization, and five were discharged home within 14 days. CONCLUSION: Proactive and coordinated steps between NH medical directors and administrators, referral hospitals including their laboratories, and local public health officials are necessary to rapidly respond to an outbreak and limit the transmission of COVID-19. This coordinated public health approach may save lives, minimize the burden to the healthcare system, and reduce healthcare costs.

A taxonomy and cultural analysis of intra-hospital patient transfers.

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units. We conducted observations of staff (n = 16) working in four hospital departments and interviewed staff (n = 29) involved in transfers to general medicine floors from either the Emergency Department or the Medical Intensive Care Unit between February and September 2015. The collected data allowed us to understand transfers in the context of several hospital cultural microsystems. Decisions were made through the lens of the specific unit identity to which staff felt they belonged; staff actively strategized to manage workload; and empty beds were treated as a scarce commodity. Staff concepts informed the development of a taxonomy of intra-hospital transfers that includes five categories of activity: disposition, or determining the right floor and bed for the patient; notification to sending and receiving staff of patient assignment, departure and arrival; preparation to send and receive the patient; communication between sending and receiving units; and coordination to ensure that transfer components occur in a timely and seamless manner. This taxonomy widens the study of intra-hospital patient transfers from a communication activity to a complex cultural phenomenon with several categories of activity and views them as part of multidimensional hospital culture, as constructed and understood by staff.

Predictors for patients understanding reason for hospitalization.

OBJECTIVE: To examine predictors for understanding reason for hospitalization. METHODS: This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home. Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview. Predictors assessed were the following: jargon on discharge instructions, type of medical team, whether outpatient provider knew if the patient was admitted, and whether the patient reported more than one day notice before discharge. RESULTS: Among 377 patients, 59.8% of patients completely understood their diagnosis. Bivariate analyses demonstrated that outpatient provider being aware of admission and having more than a day notice prior to discharge were not associated with patient understanding diagnosis. Presence of jargon was not associated with increased likelihood of understanding in a multivariable analysis. Patients on housestaff and cardiology teams were more likely to understand diagnosis compared to non-teaching teams (OR 2.45, 95% CI 1.30-4.61, p<0.01 and OR 3.83, 95% CI 1.92-7.63, p<0.01, respectively). CONCLUSIONS: Non-teaching team patients were less likely to understand their diagnosis. Further investigation of how provider-patient interaction differs among teams may aid in development of tools to improve hospital to community transitions.

Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program.

IMPORTANCE: Feasibility, effectiveness, and sustainability of large-scale readmission reduction efforts are uncertain. The Greater New Haven Coalition for Safe Transitions and Readmission Reductions was funded by the Center for Medicare & Medicaid Services (CMS) to reduce readmissions among all discharged Medicare fee-for-service (FFS) patients. OBJECTIVE: To evaluate whether overall Medicare FFS readmissions were reduced through an intervention applied to high-risk discharge patients. DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental evaluation took place at an urban academic medical center. Target discharge patients were older than 64 years with Medicare FFS insurance, residing in nearby zip codes, and discharged alive to home or facility and not against medical advice or to hospice; control discharge patients were older than 54 years with the same zip codes and discharge disposition but without Medicare FFS insurance if older than 64 years. High-risk target discharge patients were selectively enrolled in the program. INTERVENTIONS: Personalized transitional care, including education, medication reconciliation, follow-up telephone calls, and linkage to community resources. MEASUREMENTS: We measured the 30-day unplanned same-hospital readmission rates in the baseline period (May 1, 2011, through April 30, 2012) and intervention period (October 1, 2012, through May 31, 2014). RESULTS: We enrolled 10 621 (58.3%) of 18 223 target discharge patients (73.9% of discharge patients screened as high risk) and included all target discharge patients in the analysis. The mean (SD) age of the target discharge patients was 79.7 (8.8) years. The adjusted readmission rate decreased from 21.5% to 19.5% in the target population and from 21.1% to 21.0% in the control population, a relative reduction of 9.3%. The number needed to treat to avoid 1 readmission was 50. In a difference-in-differences analysis using a logistic regression model, the odds of readmission in the target population decreased significantly more than that of the control population in the intervention period (odds ratio, 0.90; 95% CI, 0.83-0.99; P = .03). In a comparative interrupted time series analysis of the difference in monthly adjusted admission rates, the target population decreased an absolute -3.09 (95% CI, -6.47 to 0.29; P = .07) relative to the control population, a similar but nonsignificant effect. CONCLUSIONS AND RELEVANCE: This large-scale readmission reduction program reduced readmissions by 9.3% among the full population targeted by the CMS despite being delivered only to high-risk patients. However, it did not achieve the goal reduction set by the CMS.

Using the red/yellow/green discharge tool to improve the timeliness of hospital discharges.

BACKGROUND: As part of Yale-New Haven Hospital (Connecticut)'s Safe Patient Flow Initiative, the physician leadership developed the Red/Yellow/Green (RYG) Discharge Tool, an electronic medical record-based prompt to identify likelihood of patients' next-day discharge: green (very likely), yellow (possibly), and red (unlikely). The tool's purpose was to enhance communication with nursing/care coordination and trigger earlier discharge steps for patients identified as "green" or "yellow." METHODS: Data on discharge assignments, discharge dates/ times, and team designation were collected for all adult medicine patients discharged in October-December 2009 (Study Period 1) and October-December 2011 (Study Period 2), between which the tool's placement changed from the sign-out note to the daily progress note. RESULTS: In Study Period 1, 75.9% of the patients had discharge assignments, compared with 90.8% in Period 2 (p < .001). The overall 11 A.M. discharge rate improved from 10.4% to 21.2% from 2007 to 2011. "Green" patients were more likely to be discharged before 11 A.M. than "yellow" or "red" patients (p < .001). Patients with RYG assignments discharged by 11 A.M. had a lower length of stay than those without assignments and did not have an associated increased risk of readmission. Discharge prediction accuracy worsened after the change in placement, decreasing from 75.1% to 59.1% for "green" patients (p < .001), and from 34.5% to 29.2% (p < .001) for "yellow" patients. In both periods, hospitalists were more accurate than house staff in discharge predictions, suggesting that education and/or experience may contribute to discharge assignment. CONCLUSIONS: The RYG Discharge Tool helped facilitate earlier discharges, but accuracy depends on placement in daily work flow and experience.

Electronic handoff instruments: a truly multidisciplinary tool?

The objective was to assess use of a physician handoff tool embedded in the electronic medical record by nurses and other non-physicians. We administered a survey to nurses, physical therapists, discharge planners, social workers, and others to assess integration into daily practice, usefulness, and accuracy of the handoff tool. 231 individuals (61% response) participated. 60% used the tool often or usually/always during a shift. Nurses (46%) used the tool for shift transitions and found it helpful for medical history (79%) but not for acquiring medication, allergy, and responsible physician information. Nurses (96%) and others (75%) rated the tool as accurate. Medical nurses rated the tool more useful than surgical nurses, and pediatric nurses rarely used the tool. The tool was integrated into the daily workflow of non-physicians despite being designed for physician use. Non-physicians should be included in the design and implementation of electronic patient handoff systems.

Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE).

BACKGROUND: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. DESCRIPTION: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. EVALUATION: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees ($1,027.45 vs. $4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. CONCLUSIONS: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

The revolving hospital door: hospital readmissions among patients who are homeless.

BACKGROUND: National attention is increasingly focused on hospital readmissions. Little prior research has examined readmissions among patients who are homeless. OBJECTIVE: The aim of the study was to determine 30-day hospital readmission rates among patients who are homeless and examine factors associated with hospital readmissions in this population. METHODS: We conducted a retrospective chart review of patients who were homeless and hospitalized at a single urban hospital from May-August 2012. Homelessness was identified by an electronic medical record flag and confirmed by manual chart review. The primary outcome was all-cause hospital readmission to the study hospital within 30 days of hospital discharge. Patient-level and hospitalization-level factors associated with risk for readmission were examined using generalized estimating equations. RESULTS: There were 113 unique patients who were homeless and admitted to the hospital a total of 266 times during the study period. The mean age was 49 years, 27.4% of patients were women, and 75.2% had Medicaid. Half (50.8%) of all hospitalizations resulted in a 30-day hospital inpatient readmission and 70.3% resulted in either an inpatient readmission, observation status stay, or emergency department visit within 30 days of hospital discharge. Most readmissions occurred early after hospital discharge (53.9% within 1 week, 74.8% within 2 weeks). Discharge to the streets or shelter versus other living situations was associated with increased risk for readmission in multivariable analyses. CONCLUSIONS: Patients who were homeless had strikingly high 30-day hospital readmission rates. These findings suggest the urgent need for further research and interventions to improve postdischarge care for patients who are homeless.

Quality of discharge practices and patient understanding at an academic medical center.

IMPORTANCE: With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. OBJECTIVE: To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. DESIGN: Prospective observational cohort study, May 2009 through April 2010. SETTING: Urban, academic medical center. PARTICIPANTS: Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MAIN OUTCOMES AND MEASURES: Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. RESULTS: The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day's advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. CONCLUSIONS AND RELEVANCE: Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.