The Current Landscape of Transitions of Care Practice Models: A Scoping Review

Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions

BACKGROUND

To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions.

METHODS

Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission.

RESULTS

Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis.

CONCLUSIONS

Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.

Optimising the discharge process in internal medicine in Québec: A qualitative interpretive descriptive study to understand the challenges faced by healthcare professionals

Optimising the discharge process for internal medicine programs is a challenge given multiple social and practical constraints in transitions from hospital to home. The objective of this study is to explore healthcare professionals' perspectives on discharge processes in internal medicine within a context of organisational reform. This is an interpretive descriptive qualitative study using in-depth individual interviews with healthcare providers. Seventeen semi-structured interviews were conducted. The study comprised a sample of 18 healthcare professionals working on two internal medicine wards in an acute care teaching hospital in Quebec. A conceptual framework comprising core aspects of the discharge process (planning, coordination, teaching and outcomes) guided data collection and analysis. Thematic analysis was applied to analyse the data. Major themes were developed by contrasting empirical data and the conceptual framework. Five themes were developed (1) Iterative discharge planning; (2) Patient and family engagement in discharge planning and discharge readiness, (3) Lack of time for discharge teaching, (4) Discharge coordination and the placement of patients and (5) Inequitable social support and resources and risk of readmission. This study highlights the inter-relationship between discharge readiness and phases of the discharge process, in particular planning and coordination. Iterative planning along with strategies to coordinate discharge constitute efforts to ensure flexible processes that respond to patients' needs and preferences. Challenges persist for healthcare professionals regarding autonomy and resources, along with reduced opportunities for patient and family engagement in decision-making.

Development of a Primary Care Transitions Clinic in an Academic Medical Center

INTRODUCTION

Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status.

AIM

To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care.

SETTING

Brigham Health, an academic medical center in Boston, MA.

PROGRAM DESCRIPTION

The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established.

PROGRAM EVALUATION

In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4-6) work days post-discharge, with 2 (median; IQR 1-3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019). Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing.

DISCUSSION

A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.

Potential to Decrease Hospital Readmission Reduction Program Penalty Through Pharmacist Discharge Visits

SUMMARY

Student-Led discharge counseling program for High-Risk medications in a teaching hospital in Saudi Arabia: A pilot study

Discharge counseling by pharmacists reduces adverse medication events, emergency department visits, and readmissions. Studies indicate that pharmacy students in advanced pharmacy practice experiences (APPE) can deliver effective medication-related activities. An open label randomized controlled trial was conducted in adults discharged on warfarin, insulin, or both. Pharmacy students performed medication reconciliation, structured medication counseling, and follow-up calls 72-hours post-discharge. The usual care arm received traditional education. The primary outcome was the 30-day readmission rate post-discharge. Ninety-eight patients on high-risk medications were randomized to intervention (n = 51) or usual care (n = 47). The 30-day hospital readmission rate was lower in the intervention group (8/51, 15% vs. 11/47, 23%); (p = 0.48). There was no statistical difference in the time to first unplanned health care use (hazard ratio = 0.49 (95 %CI, 0.19–1.24), or the time-to-first clinic visit post-discharge (p = 0.94) between the two arms. Students identified 26 drug-related problems during reconciliation. Patients in the intervention arm reported high satisfaction with the service (mean 3.94; SD 0.11). Involving APPE students in the transition of care activities presents an excellent opportunity to minimize pharmacists' workload while maintaining patient care services.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives

BACKGROUND

Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions.

OBJECTIVE

We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions.

DESIGN

Semi-structured interviews with interdisciplinary hospital and SNF providers.

PARTICIPANTS

Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6).

APPROACH

Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs.

KEY RESULTS

Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge.

CONCLUSIONS

As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

Synthesising evidence regarding hospital to home transitions supported by volunteers of third sector organisations: a scoping review protocol

INTRODUCTION

Given the risks inherent in care transitions, it is imperative that patients discharged from hospital to home receive the integrated care services necessary to ensure a successful transition. Despite efforts by the healthcare sector to develop health system solutions to improve transitions, problems persist. Research on transitional support has predominantly focused on services delivered by healthcare professionals; the evidence for services provided by lay navigators or volunteers in this context has not been synthesised. This scoping review will map the available literature on the engagement of volunteers within third sector organisations supporting adults in the transition from hospital to home.

METHODS AND ANALYSIS

Using the well-established scoping review methodology outlined by the Joanna Briggs Institute, a five-stage review is outlined: (1) determining the research question, (2) search strategy, (3) inclusion criteria, (4) data extraction and (5) analysis and presentation of the results. The search strategy will be applied to 10 databases reflecting empirical and grey literature. A two-stage screening process will be used to determine eligibility of articles. To be included in the review, articles must describe a community-based programme delivered by a third sector organisation that engages volunteers in the provisions of services that support adults transitioning from hospital to home. All articles will be independently assessed for eligibility, and data from eligible articles will be extracted and charted using a standardised form. Extracted data will be analysed using narrative and descriptive analyses.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review. Members of an international special interest group focused on the voluntary sector will be consulted to provide insight and feedback on study findings, help with dissemination of the results and engage in the development of future research proposals. Dissemination activities will include peer-reviewed publications and academic presentations.

Transitional Care Experiences of Patients with Hip Fracture Across Different Health Care Settings

Background

Transitions of care often result in fragmented care, leading to unmet patient needs and poor satisfaction with care, especially in patients with multiple chronic conditions. This project aimed to understand how experiences of patients with hip fracture, caregivers, and healthcare providers differ across different points of transition.

Methods

A secondary analysis of 103 qualitative, semi-structured interviews was conducted using emergent coding techniques, to gain an understanding of how transitional care experiences may differ across varying settings of care. Following the secondary analysis, a focus group interview was conducted to review findings.

Results

Seven key themes, each relating to distinct transition points, emerged from the secondary analysis: (1) Multiple providers contributed to patient and caregiver confusion; (2) Family caregivers were not considered important in the patient's care; (3) System-related issues impacted experiences; (4) Patients and caregivers felt uninformed; (5) Transitions increased stress in patients and caregivers; (6) Care was not tailored to patient needs; (7) Providers faced barriers in getting adequate information. The focus group results built upon these themes, adding some additional context to understand the current transitional care landscape.

Discussion

In transitions to formal care settings, similarities were related to feeling confused, while in transitions to home, similarities existed in regards to feeling unprepared. These findings support the view that models of integrated care should consider the context to which they are applied.

Crossing knowledge boundaries: health care providers' perceptions and experiences of what is important to achieve more person-centered patient pathways for older people

BACKGROUND

Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Current research in the field highlights person-centered care as crucial; however, how to implement and enact this ideal in practice and thus achieve more person-centered patient pathways remains unclear. The aim of this study was to explore health care providers' (HCPs') perceptions and experiences of what is important to achieve more person-centered patient pathways for older people.

METHODS

This was a qualitative study. We performed individual semistructured interviews with 20 HCPs who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed.

RESULTS

A thematic analysis resulted in five themes which outline central elements of the HCPs' perceptions and experiences relevant to achieving more person-centered patient pathways: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathway; and 5) ambiguity toward checklists and practice implementation.

CONCLUSIONS

The findings can assist stakeholders in understanding factors important to practicing person-centered transitional care for older people. Through collaborative knowledge sharing the participants developed a more shared understanding of how to achieve person-centered patient pathways. The importance of assuming a shared responsibility and a more holistic understanding of the patient pathway by merging different ways of knowing was highlighted. Checklists incorporating the What matters to you? question and the mapping of the patient journey were important tools enabling the crossing of knowledge boundaries both between HCPs and between HCPs and the older patients. Home care providers were perceived to have important knowledge relevant to providing more person-centered patient pathways implying a central role for them as knowledge brokers during the patient's journey. The study draws attention to the benefits of focusing on the older patients' way of knowing the patient pathway as well as to placing what matters to the older patient at the heart of transitional care.

Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis

Purpose of Study:

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States ? and How effective are they in reducing low-value utilization and in improving continuity ?

Primary Practice Settings:

U.S. urban, suburban, and rural health care sites within primary care, veterans’ services, behavioral health, and palliative care.

Methodology and Sample:

Utilizing the Joanna Briggs Institute and PRISMA guidelines for scoping reviews, a stepwise method was applied to search multiple databases for peer-reviewed published research on transitional care models serving HNHC adult patients in the United States from 2008 to 2018. All eligible studies were included regardless of quality rating. Exclusions were foreign models, studies published prior to 2008, review articles, care reports, and studies with participants younger than 18 years. The search returned 1,088 studies, of which 19 were included.

Results:

Four studies were randomized controlled trials and other designs included case reports and observational, quasi-experimental, cohort, and descriptive studies. Studies focused on Medicaid, Medicare, dual-eligible patients, veterans, and the uninsured or underinsured. High-need, high-cost patients were identified on the basis of prior utilization patterns of inpatient and emergency department visits, high cost, multiple chronic medical diagnoses, or a combination of these factors. Tools used to identify these patients included the hierarchical condition category predictive model, the Elder Risk Assessment, and the 4-year prognostic index score. The majority of studies combined characteristics of multiple case management models with varying levels of impact.

Implications for Case Management Practice:

Healthcare professionals' experiences of inter-professional collaboration during patient's transfers between care settings in palliative care: A focus group study

BACKGROUND

Continuity of care is challenging when transferring patients across palliative care settings. These transfers are common due to the complexity of palliative care, which has increased significantly since the advent of palliative care services. It is unclear how palliative care services and professionals currently collaborate and communicate to ensure the continuity of care across settings, and how patient and family members are involved.

AIM

To explore healthcare professionals' experiences regarding the communicative aspects of inter-professional collaboration and the involvement of patient and family members.

DESIGN

Qualitative design, including focus group discussions.

SETTING/PARTICIPANTS

The study focused on one palliative care network in Belgium and involved all palliative care settings: hospital, hospital's palliative care unit, home care, nursing home. Nine group discussions were conducted, with diverse professionals (n = 53) from different care settings.

RESULTS

Timely and effective inter-professional information exchange was considered fundamental. A perceived barrier for interprofessional collaboration was the lack of a shared electronic health record. Efficiency regarding multidisciplinary team meetings and inter-professional communication were subject to improvement.A striking study finding was the perceived insufficient open communication of specialists towards patients and the lack of shared decision making. This not only hampered advance care planning discussions and early integration of palliative home care, but also the functioning of other professionals.

CONCLUSION

From the perspective of the integrated care framework, several areas of improvement on different levels of care and collaboration are identified. Support from policymakers and researchers is required to achieve integrated palliative care in regional networks.

Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

BACKGROUND

Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions.

AIM

The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings.

DESIGN

A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662.

DATA SOURCES

We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes.

RESULTS

Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home.

CONCLUSION

This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

Impact of pharmacist interventions during transition of care in older adults to reduce the use of healthcare services: A scoping review

BACKGROUND

Current literature has shown increasing risk of error in transition of care between different healthcare settings, especially in the older population. Moreover, drug-related hospital readmission has been reported due to lack of appropriate communication. However, the literature is not clear about the impact of pharmacist interventions during transition of care of older adults on the reduction in use of healthcare services.

OBJECTIVE

The goal of the scoping review was to describe the impact of pharmacist interventions during transitions of care for older adults on the use of healthcare services.

METHODS

MEDLINE was searched for randomized controlled trials and controlled studies that analyzed pharmacist interventions during transition of care of older adults with regard to use of healthcare services. Four reviewers, grouped in pairs, independently screened all references published from 1990 to 2019 and extracted and analyzed the data. A pharmaceutical model of 8 pharmacist-led interventions was adapted from literature to compare the included studies.

RESULTS

There were 1527 publications screened, 17 of which met inclusion criteria. Pharmacist-led interventions decreased the use of healthcare services in 11 of these studies. The majority of studies were of very good or good quality based on Mixed Methods Appraisal Tool. Pharmacist were implicated at all times during the transition of care process (i.e. admission/during stay, discharge and post-discharge) in 4 of the effective studies, whereas none did in the not effective studies. More interventions were accomplished by pharmacists in studies with positive outcomes.

CONCLUSION

By diversifying their interventions at different moments throughout transition of care, pharmacists can reduce the use of healthcare services for older adults during transition of care. This scoping review also shows the need to better understand key components of post-discharge interventions and to have a dynamic pharmaceutical model accepted by the scientific community.

Patient-centredness in acute stroke care - a qualitative study from the perspectives of patients, relatives and staff

BACKGROUND AND PURPOSE

Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff.

METHODS

A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned.

RESULTS

Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures.

CONCLUSIONS

In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol

Annually approximately 2-3 million Americans are so severely injured that they require inpatient hospitalization. The study team, which includes patients, clinical researchers, front-line provider and policy maker stakeholders, has been working together for over a decade to develop interventions that target improvements for US trauma care systems nationally. This pragmatic randomized trial compares a multidisciplinary team collaborative care intervention that integrates front-line trauma center staff with peer interventionists, versus trauma team notification of patient emotional distress with mental health consultation as enhanced usual care. The peer-integrated collaborative care intervention will be supported by a novel emergency department exchange health information technology platform. A total of 424 patients will be randomized to peer-integrated collaborative care (n = 212) and surgical team notification (n = 212) conditions. The study hypothesizes that patient's randomized to peer integrated collaborative care intervention will demonstrate significant reductions in emergency department health service utilization, severity of patient concerns, post traumatic stress disorder symptoms, and physical limitations when compared to surgical team notification. These four primary outcomes will be followed-up at 1- 3-, 6-, 9- and 12-months after injury for all patients. The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method will be used to assess implementation processes. Data from the primary outcome analysis and implementation process assessment will be used to inform an end-of-study policy summit with the American College of Surgeons Committee on Trauma. The policy summit will facilitate acute care practice changes related to patient-centered care transitions over the course of a single 5-year funding cycle. Trial registration: (Clinicaltrials.govNCT03569878).

Multidisciplinary Team Utilizing Pharmacists in Multimodal, Bundled Care Reduce Chronic Obstructive Pulmonary Disease Hospital Readmission Rates

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major contributor of morbidity and mortality in the United States resulting in high hospitalization and readmission rates. For health systems, identifying an effective strategy to reduce COPD readmissions has remained difficult. Multiple COPD care bundles have been developed with varying degrees of success. Bundles that were multidisciplinary and included pharmacists were successful in reducing readmissions.

OBJECTIVE

To describe and assess a multidisciplinary, 5-element, COPD care bundle that was implemented in an academic, urban safety-net hospital to reduce COPD readmissions and the role of pharmacists in bundle implementation.

METHODS

A multidisciplinary team collaborated to develop a 5-element COPD care bundle that met unmet patient needs. The bundle elements included the following, with pharmacy responsible for the first two: optimization of COPD inhalers, 30-day supply of insurance-compatible inhalers, individualized patient inhaler teaching, provision of standardized discharge instructions, and scheduling of a 15-day discharge follow-up appointment. Bundle was implemented with multiple Plan-Do-Study-Act (PDSA) cycles to develop intra- and interdepartment processes.

RESULTS

Prior to bundle implementation, the health system COPD readmission rates were 22.7%. Reliable implementation of the bundle reduced readmissions to 14.7% over a 6-month period. Pharmacy adherence to completion of the bundle was over 95% over 2 years of bundle use.

CONCLUSION

Pharmacists have a crucial role in hospital-based transitions of care to reduce COPD readmissions.

Palliative Care Transitions From Acute Care to Community-Based Care-A Systematic Review

CONTEXT

Although the literature on transitions from hospital to the community is extensive, little is known about this experience within the context of palliative care (PC).

OBJECTIVE

We conducted a systematic review to investigate the impact of receiving palliative care in hospital on the transition from hospital to the community.

METHODS

We systematically searched MEDLINE, Embase, ProQuest, and CINAHL from 1995 until April 10, 2018, and extracted relevant references. Eligible articles were published in English, included adult patients receiving PC as inpatients, and explored transitions from hospital to the community.

RESULTS

A total of 1514 studies were identified and eight met inclusion criteria. Studies were published recently (>2012; n = 7, 88%). Specialist PC interventions were delivered by multidisciplinary care teams as part of inpatient PC triggers, discharge planning programs, and transitional care programs. Common outcomes reported with significant findings consisted of length of stay (n = 5), discharge support (n = 5), and hospital readmissions (n = 6) for those who received inpatient PC. Most studies were at high risk of bias.

CONCLUSION

Heterogeneity of study designs, outcomes, findings, and poor methodological quality renders it challenging to draw conclusions regarding PC's impact on the transition from hospital to home. Further research should use standardized outcomes with randomized controlled trial and/or propensity matched cohort designs.

Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study

BACKGROUND

Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process.

METHODS

We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations.

RESULTS

The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider-provider and provider-patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed.

INTERPRETATION

Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery

To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companion Program (DCP), a pharmacist- and nurse-coordinated interprofessional, collaborative TOC program. Adult patients (18 years and older) from a single hospital, discharged with at least one qualifying diagnosis, were eligible for this service. The hospital transitional care coordinator nurse referred qualified patients to the DCP nurse coordinator, who scheduled telephonic medication therapy management (MTM) reviews with the DCP pharmacist at one- and three-weeks postdischarge. Hospital records and DCP documentation were reviewed to describe respective interventions and assess the impact on 30-day readmissions. A total of 456 patients were referred to the DCP between 31 August, 2015 and 7 September, 2016. Of the 340 patients who participated (DCP group), 44 (13%) compared to 17% (n = 20) of the usual care, were readmitted within 30-days postdischarge. The DCP pharmacists conducted 1242 clinical interventions with participants, demonstrating the benefits of an interprofessional TOC model involving multiple, pharmacist-delivered MTM intervention touchpoints within 30 days post-hospital discharge.

Using pharmacy technicians and telepharmacy to obtain medication histories in the emergency department

OBJECTIVES

To determine if telepharmacy can be used to collect medication histories on patients admitted in the emergency department (ED) in a large health system.

PRACTICE DESCRIPTION

As part of an effort to address safety concerns, resource limitations, and a decline in medication history completions, a program was developed to use telepharmacy to conduct medication histories on patients admitted in the ED.

SETTING

The medication history program covers 5 large facilities. It is staffed by 6 full-time pharmacy technicians 7 days a week and is overseen by a pharmacist.

INNOVATION

Medication histories are conducted with the use of mobile carts enhanced with videoconferencing equipment allowing technicians to operate from a remote central location. The program allows the technicians to observe multiple EDs at one time, interview patients through videoconferencing, and document completed medication histories in the electronic medical record (EMR). The technicians also transcribe preoperation (pre-op) medication lists for patients being admitted for surgeries.

EVALUATION

Medication history completion rates and barriers were assessed. In addition, potential medication errors, medication history accuracy rates for nursing and pharmacy technicians, and a cost analysis of preventable ADEs were explored.

RESULTS

The program, on average, conducts medication histories on 56% to 79% of patients admitted through the ED during hours of operation. In fiscal year 2018, the technicians entered 24,980 medication histories and pre-op lists. A cross-sectional analysis of data collected from December 2016 to March 2017, including 124 patients, revealed 320 potential medication errors among a total of 382 high-risk medications.

CONCLUSION

Based on the current performance and continued expansion of this novel strategy, use of telepharmacy to obtain medication histories in the ED has led to resource optimization for the remote delivery of a pharmacy service.

A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture

OBJECTIVE

Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the "Transitions of Care" (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions.

DESIGN

Here we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study.

SETTING AND PARTICIPANTS

All 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged ≥65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews.

RESULTS

Taken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC.

CONCLUSIONS AND IMPLICATIONS

With comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.

Using a sociomaterial approach to generate new insights into the nature of interprofessional collaboration: Findings from an inpatient medicine teaching unit

Today's hospitals are burdened with patients who have complex health needs. This is readily apparent in an inpatient internal medicine setting. While important elements of effective interprofessional collaboration have been identified and trialled across clinical settings, their promise continues to be elusive. One reason may be that caring for patients requires understanding the size and complexity of healthcare networks. For example, the non-human 'things' that healthcare providers work with and take for granted in their professional practice-patient beds, diagnostic imaging, accreditation standards, work schedules, hospital policies, team rounds-also play a role in how care is shaped. To date, how the human and non-human act together to exclude, invite, and regulate particular enactments of interprofessional collaboration has been subject to limited scrutiny. Our paper addresses this gap by attending specifically to the sociomaterial. Drawing on empirical data collected from an Academic Health Sciences Centre's inpatient medicine teaching unit setting in Ontario, Canada, we explore the influence of the sociomaterial on the achievement of progressive collaborative refinement, an ideal of how teams should work to support safe and effective patient care as patients move through the system. Foregrounding the sociomaterial, we were able to trace how assemblies of the human and the non-human are performed into existence to produce particular enactments of interprofessional collaboration that, in many instances, undermined the quality of care provided. Our research findings reveal the "messiness" of interprofessional collaboration, making visible how things presently assemble within the inpatient setting, albeit not always in the ways intended. These findings can be used to guide future innovation work in this and other similar settings.

Identifying essential elements to include in Intensive Care Unit to hospital ward transfer summaries: A consensus methodology

PURPOSE

Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important.

MATERIALS AND METHODS

A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition.

RESULTS

A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability.

CONCLUSION

We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward.

Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey

BACKGROUND

The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement.

OBJECTIVE

To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools.

DESIGN

Cross-sectional survey design.

PARTICIPANTS

We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents.

KEY RESULTS

In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be "primarily responsible" for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures.

CONCLUSION

ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist.

Allocation of faculty and curricular time to the teaching of transitions of care concepts by colleges of pharmacy

INTRODUCTION

To determine the allocation of faculty and curricular time to the teaching of transitions of care (ToC) concepts by colleges of pharmacy (COPs) to equip students with the necessary skills for the provision of these services.

METHODS

A novel 15-question anonymous electronic survey was sent to 136 pharmacy practice chairpersons.

RESULTS

Response rate was 26.5% (n = 36). Of these, 47% employed ToC faculty while 44% are not actively recruiting for that position in the foreseeable future. Median total curriculum hours dedicated to teaching ToC was four (interquartile range two to 10 hours). Medication reconciliation skills were taught didactically and via interactive lab sessions by 53% of respondents. Only 11% offered an interdisciplinary ToC program. A significant association between not having ToC faculty and lack of implementation of ToC concepts within a pharmacy curriculum (p = 0.02, Fisher's Exact) and practice site (p = 0.045, Pearson's) was observed. Barriers to adopting ToC within the curriculum (e.g., uncertainty of placement within curriculum, resistance by faculty and administrators) and at a practice site (e.g., inadequate infrastructure to accommodate ToC delivery, ToC faculty unavailability and resistance by other health care providers) were reported.

DISCUSSION AND CONCLUSIONS

This study demonstrated that COPs devote curricular time to ToC activities and involve dedicated faculty in the provision of these services. Several barriers to employing ToC faculty and planning additional time in the curriculum for teaching these skills were identified. Future research should determine the best methods for training students to ensure competence in performing ToC tasks.

Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease

INTRODUCTION

Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD.

METHODS

A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July-November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5-7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting.

RESULTS

Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient's and caregiver's comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme.

CONCLUSION

We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.

Clinical Update on Nursing Home Medicine: 2016

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward

PURPOSE

To provide a 360-degree description of ICU-to-ward transfers.

METHODS

Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer.

RESULTS

Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).

CONCLUSIONS

ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Preventing drug-related adverse events following hospital discharge: the role of the pharmacist

Transition of care (ToC) points, and in particular hospital admission and discharge, can be associated with an increased risk of adverse drug events (ADEs) and other drug-related problems (DRPs). The growing recognition of the pharmacist as an expert in medication management, patient education and communication makes them well placed to intervene. There is evidence to indicate that the inclusion of pharmacists in the health care team at ToC points reduces ADEs and DRPs and improves patient outcomes. The objectives of this paper are to outline the following using current literature: 1) the increased risk of medication-related problems at ToC points; 2) to highlight some strategies that have been successful in reducing these problems; and 3) to illustrate how the role of the pharmacist across all facets of care can contribute to the reduction of ADEs, particularly for patients at ToC points.

Protocol to describe the analysis of text-based communication in medical records for patients discharged from intensive care to hospital ward

INTRODUCTION

Effective communication during hospital transitions of patient care is fundamental to ensuring patient safety and continuity of quality care. This study will describe text-based communication included in patient medical records before, during and after patient transfer from the intensive care unit (ICU) to a hospital ward (n=10 days) by documenting (1) the structure and focus of physician progress notes within and between medical specialties, (2) the organisation of subjective and objective information, including the location and accessibility of patient data and whether/how this changes during the hospital stay and (3) missing, illegible and erroneous information.

METHODS

This study is part of a larger mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. Medical records will be collected and photocopied for each consenting patient for a period of up to 10 consecutive days, including the final 2 days in the ICU, the day of transfer and the first 7 days on the ward (n=10 days). Textual analysis of medical record data will be completed by 2 independent reviewers to describe communication between stakeholders involved in ICU transfer.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained at all study sites, including the coordinating study centre (which covers 4 Calgary-based sites; UofC REB 13-0021) and 6 additional study sites (UofA Pro00050646; UBC PHC Hi4-01667; Sunnybrook 336-2014; QCH 20140345-01H; Sherbrooke 14-172; Laval 2015-2171). Findings from this study will inform the development of an evidence-based tool that will be used to systematically analyse the series of notes in a patient's medical record.