Transitions of Care for the Geriatric Patient in the Emergency Department

Development and validation of the Patient-Reported Outcome Measure-Older adult care Transitions from the Emergency Department (PROM-OTED) tool

BACKGROUND

Care transitions from the emergency department (ED) to the community represent a critical period that can significantly impact clinical outcomes of older adults, yet there is a lack of standardized tools to measure patient-reported experiences and outcomes during this transition. Our objective was to develop and validate the Patient-Reported Outcome Measure-Older adult care Transitions in the ED (PROM-OTED) tool to measure care transition outcomes within 4-10 days after ED discharge.

METHODS

Older adults (65+ years) discharged from four EDs were enrolled between November 2021 and April 2024 in a multiphase process: qualitative interviews, item generation, member checking, cognitive debriefing, technical expert panel review, and psychometric evaluation and validation. We employed descriptive statistics, item analysis, interitem correlation, and factor analyses to assess the tool's validity and reliability.

RESULTS

Across all phases, we enrolled 290 older adults. The final 18-item PROM-OTED tool included items that addressed understanding of discharge instructions, medication management, follow-up care, and quality of life. The tool demonstrated feasibility with a mean (±SD) completion time of 4.97 (±3.04) min and was able to be administered electronically or via telephone. The tool additionally demonstrated excellent internal consistency (Cronbach's alpha 0.9376, McDonald's omega 0.9988) and good test-retest reliability (r = 0.8437). Exploratory factor analysis supported a robust factor structure and significant correlations between the PROM-OTED tool with the Care Transitions Measure-3, a general measure of hospital discharge quality of care, support its concurrent validity.

CONCLUSIONS

The PROM-OTED tool is a reliable and preliminarily valid instrument for use during the immediate post-ED period, with potential clinical applications in enhancing discharge practices and assessing care transition outcomes of older adults during observational or interventional studies.

Detection of Acute Deterioration in Care Home Residents: A Multicenter Qualitative Exploration of Barriers and Enablers

INTRODUCTION

Delay in detecting acute deterioration in older adults in care homes is associated with avoidable hospitalizations and adverse outcomes, including premature death.

OBJECTIVE

Underpinned by the Knowledge to Action Framework, this study aimed to understand the barriers and enablers to direct care staff detecting and responding to the early signs of acute deterioration in care home residents.

STUDY DESIGN

Online focus groups or interviews with regulated (registered and enrolled nurses) and unregulated (assistants in nursing and personal care workers) direct care staff from participating care homes were conducted. Homes were recruited using disproportionate stratified random sampling to include metropolitan, inner regional, and outer regional care homes. Interview and focus group recordings were transcribed verbatim and analyzed using inductive thematic analysis.

RESULTS

Eighty direct care staff (n = 48 regulated; n = 32 unregulated) from eight care homes participated. Fifteen focus groups (n = 7 unregulated staff, n = 8 regulated staff) and two interviews (n = 1 regulated staff, n = 1 unregulated staff) were conducted between July 2021 and October 2022. Four themes related to the barriers and enablers of detecting and responding to acute deterioration were generated: decision-making within the scope of practice; resource availability; streamlined communication; and teamwork.

CONCLUSION

Findings highlight the challenges direct care staff encounter in being able to detect early signs of acute deterioration and implement appropriate care pathways. Perceived barriers and enablers highlighted in this study need to be considered when developing and implementing programs to optimize the timely detection of, and response to, acute deterioration in care homes.

CLINICAL RELEVANCE

Workforce knowledge, experience, and confidence deficits are significant barriers to detecting acute deterioration, while the unique workforce mix in care homes poses additional challenges for the accurate detection of early signs of acute deterioration. Knowing the resident, working as a team, and valuing the contribution of aged care staff and families in managing acute deterioration are enablers to achieving better outcomes for residents experiencing acute deterioration.

An emergency department transitional care team prevents unnecessary hospitalization of older adults: a mixed methods study

INTRODUCTION

Older adults with acute functional decline may visit emergency departments (EDs) for medical support despite a lack of strict medical urgency. The introduction of transitional care teams (TCT) at the ED has shown promise in reducing avoidable admittances. However, the optimal composition and implementation of TCTs are still poorly defined. We evaluated the effect of TCTs consisting of an elderly care physician (ECP) and transfer nurse versus a transfer nurse only on reducing hospital admissions, as well as the experience of patients and caregivers regarding quality of care.

METHODS

We assessed older adults (≥ 65 years) at the ED with acute functional decline but no medical indication for admission. Data were collected on type and post-ED care, and re-visits were evaluated over a 30-day follow-up period. Semi-structured interviews with stakeholders were based on the Consolidated-Framework-for-Implementation-Research, while patient and caregiver experiences were collected through open-ended interviews.

RESULTS

Among older adults (N = 821) evaluated by the TCT, ECP and transfer nurse prevented unnecessary hospitalization at the same rate (81.2%) versus a transfer nurse alone (79.5%). ED re-visits were 15.6% (ECP and transfer nurse) versus 13.5%. The interviews highlighted the added value of an ECP, which consisted of better staff awareness, knowledge transfer and networking with external organizations. The TCT intervention in general was broadly supported, but adaptability was regarded as an important prerequisite.

CONCLUSION

Regardless of composition, a TCT can prevent unnecessary hospitalization of older adults without increasing ED re-visiting rates, while the addition of an ECP has a favourable impact on patient and professional experiences.

Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments

OBJECTIVE

Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions.

METHODS

The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR).

RESULTS

Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic.

CONCLUSION

Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

An Interdisciplinary Videoconference to Improve Transitions of Care and Reduce Readmission, Cost, and Post-Acute Length of Stay in a Teaching and Community Hospital

OBJECTIVES

Coordination of care across health care settings is needed to ensure safe patient transfers. We examined the effects of the ECHO-Care Transitions program (ECHO-CT) on readmissions, skilled nursing facility (SNF) length of stay (LOS), and costs.

DESIGN

This is a prospective cohort study evaluating the ECHO-CT program. The intervention consisted of weekly 90-minute teleconferences between hospital and SNF-based teams to discuss the care of recently discharged patients.

SETTING AND PARTICIPANTS

The intervention occurred at one small community hospital and 7 affiliated SNFs and 1 large teaching hospital and 11 associated SNFs between March 23, 2019, and February 25, 2021. A total of 882 patients received the intervention.

METHODS

We selected 13 hospitals and 172 SNFs as controls. Specific hospital-SNF pairings within the intervention and control groups are referred to as hospital-SNF dyads. Using Medicare claims data for more than 10,000 patients with transfers between these hospital-SNF dyads, we performed multivariable regression to evaluate differences in 30-day rehospitalization rates, SNF lengths of stay, and SNF costs between patients discharged to intervention and control hospital-SNF dyads. We split the post period into pre-COVID and COVID periods and ran models separately for the small community and large teaching hospitals.

RESULTS

There was no significant difference-in-differences among intervention compared to control facilities during either post-acute care period for any of the outcomes.

CONCLUSIONS AND IMPLICATIONS

Although video-communication of care plans between hospitalists and post-acute care clinicians makes good clinical sense, our analysis was unable to detect significant reductions in rehospitalizations, SNF lengths of stay, or SNF Medicare costs. Disruption of the usual processes of care by the COVID pandemic may have played a role in the null findings.

Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population

This article describes emergency department (ED)-to-community care transitions for older adults and associated challenges, measurement, proven efficacious and effective interventions, and policy considerations. Older adults experiencing social isolation and impairments in functional status or cognition represent unique populations that are particularly at risk during ED-to-community transitions of care and may benefit from targeted intervention implementation. Future efforts should target optimizing screening techniques to identify those at risk, developing and validating patient-centered outcome measures, and using policy and reimbursement levers to include transitional care management services for older adults within the ED setting.

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study

OBJECTIVE

We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults.

DESIGN

Repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019.

METHODS

We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios.

RESULTS

There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults.

CONCLUSIONS AND IMPLICATIONS

The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.

Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis

BACKGROUND

Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup.

OBJECTIVES

We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect.

RESEARCH DESIGN

Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership.

SUBJECTS

Participants were ED patients (age 60 y and above) discharged to a community residence.

MEASURES

Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors.

RESULTS

We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03).

CONCLUSIONS

Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Interorganizational health information exchange-related patient safety incidents: A descriptive register-based qualitative study

PURPOSE

The current literature related to patient safety of interorganizational health information is fragmented. This study aims to identify interorganizational health information exchange-related patient safety incidents occurring in the emergency department, emergency medical services, and home care. The research also aimed to describe the causes and consequences of these incidents.

METHODS

A total of sixty (n = 60) interorganizational health information exchange-related patient safety incident free text reports were analyzed. The reports were reported in the emergency department, emergency medical services, or home care between January 2016 and December 2019 in one hospital district in Finland.

RESULTS

The identified interorganizational health information exchange-related incidents were grouped under two main categories: "Inadequate documentation"; and "Inadequate use of information". The causes of these incidents were grouped under the two main categories "Factors related to the healthcare professional " and "Organizational factors", while the consequences of these incidents fell under the two main categories "Adverse events" and "Additional actions to prevent, avoid, and correct adverse events".

CONCLUSION

This study shows that the inadequate documentation and use of information is mainly caused by factors related to the healthcare professional and organization, including technical problems. These incidents cause adverse events and additional actions to prevent, avoid, and correct the events. The sociotechnical perspective, including factors related to health care professionals, organization, and technology, should be emphasized in patient safety development of inter-organizational health information exchange and it will be the focus of our future research. Continuous research and development work is needed because the processes and information systems used in health care are constantly evolving.

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

OBJECTIVES

We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

ED patients with cognitive impairment and/or their care partners.

METHODS

Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.

RESULTS

From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.

CONCLUSIONS AND IMPLICATIONS

This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.

Transitional care interventions to reduce emergency department visits in older adults: A systematic review

Background

Preventable illnesses cause many emergency department visits in older adults, which can be minimized by implementing appropriate transitional care interventions. However, the most effective transitional care strategies for older adults are unknown.

Objective

To discover and consolidate transitional care interventions that can help older people avoid going to the emergency department.

Methods

From January 2011 to August 2021, PubMed, The Cochrane Library, CINAHL, Web of Science, ProQuest, and The JAMA Network were used to search. Two authors independently screened and selected papers, assessed the risk of bias, and extracted data into a standardized form in accordance with Cochrane guidelines. For the risk of bias in studies, the RevMan 5.4.1 program was utilized.

Results

Six randomized controlled trials, four non-randomized controlled trials, and three retrospective investigations were among the 13 studies examined. All studies evaluated emergency department visits but in different periods (ranging from 1-12 months after discharge) and with varying groups of baselines (pre-post intervention and between groups). The multi-component strategies, either pre or postdischarge phase using high-intensity care delivered within six months of discharge, were implemented in transitional care that had been shown to reduce emergency department visits in older adults.

Conclusion

To prevent emergency department visits by older patients, nurses should arrange for a high-intensity transitional care intervention that involves both pre-and postdischarge interventions. The effectiveness of the intervention in reducing emergency department visits in older adults is difficult to determine due to inter-study heterogeneity and poor methodological quality. There is a need for more evidence-based research with consistent and trustworthy effect assessments.

PROSPERO registration number

CRD42021261326.

Registered Nurses' and Medical Doctors' Experiences of Patient Safety in Health Information Exchange During Interorganizational Care Transitions: A Qualitative Review

OBJECTIVE

This systematic review aimed to identify, critically appraise, and synthesize the best available literature on registered nurses' and medical doctors' experiences of patient safety in health information exchange (HIE) during interorganizational care transitions.

METHODS

The review was conducted according to the JBI methodology for systematic reviews of qualitative evidence. A total of 5 multidisciplinary databases were searched from January 2010 to September 2020 to identify qualitative or mixed methods studies. The qualitative findings were pooled using JBI SUMARI with the meta-aggregation approach.

RESULTS

The final review included 6 original studies. The 53 distinct findings were aggregated into 9 categories, which were further merged into 3 synthesized findings: (1) HIE efficiency and accuracy support patient safety during interorganizational care transitions; (2) inaccuracies in content and structure, along with poor HIE usability, jeopardize patient safety during interorganizational care transitions; and (3) health care professionals' (HCP) actions in HIE are associated with patient safety during interorganizational care transitions.

CONCLUSIONS

The results of this review identified several advantages of HIE, namely, improvements in patient safety based on reduced human error. Nevertheless, a lack of usability and functionality can amplify the effects of human error and increase the risk of adverse events. In addition, HCPs' individual actions in HIE were found to influence patient safety. Hence, the cognitive and sociotechnical perspectives of work related to HIE should be studied. In addition, HCPs' experiences of each stage of HIE deployment should be clarified to ensure a high standard of patient safety. Registration: PROSPERO CRD42020220631, registered on November 13, 2020.

Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians

BACKGROUND

Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic.

METHODS

From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared.

RESULTS

Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic.

CONCLUSION

Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.

A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Background

Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care.

Methods

The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit.

Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively.

Discussion

Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT.

Trial registration

The trial was registered in Clinical Trials Protocols and Results System as of 21^st July 2021, with registration number NCT049836020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00954-5.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial

BACKGROUND

Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge.

METHODS

We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses.

RESULTS

Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71).

CONCLUSIONS

The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Barriers and facilitators for implementation of a complex health services intervention in long-term care homes: a qualitative study using focus groups

Background

With rising numbers of elderly people living in nursing homes in Germany, the need for on-site primary care is increasing. A lack of primary care in nursing homes can lead to unnecessary hospitalization, higher mortality, and morbidity in the elderly. The project CoCare (“coordinated medical care”) has therefore implemented a complex health intervention in nursing homes, using inter alia, regular medical rounds, a shared patient medical record and medication checks, with the aim of improving the coordination of medical care. This study reports upon the results of a qualitative study assessing the perceived barriers and facilitators of the implementation of CoCare by stakeholders.

Methods

Focus group interviews were held between October 2018 and November 2019 with nurses, general practitioners and GP’s assistants working or consulting in a participating nursing home. A semi-structured modular guideline was used to ask participants for their opinion on different aspects of CoCare and which barriers and facilitators they perceived. Focus groups were analyzed using qualitative content analysis.

Results

In total, N = 11 focus group interviews with N = 74 participants were conducted. We found six themes describing barriers and facilitators in respect of the implementation of CoCare: understaffing, bureaucracy, complexity, structural barriers, financial compensation, communication and collaboration. Furthermore, participants described the incorporation of the intervention into standard care.

Conclusion

Barriers perceived by stakeholders are well known in the literature (e.g. understaffing and complexity). However, CoCare provides a good structure to overcome barriers and some barriers will dissolve after implementation into routine care (e.g. bureaucracy). In contrast, especially communication and collaboration were perceived as facilitators in CoCare, with the project being received as a team building intervention itself.

Trial registration

WHO UTN: U1111–1196-6611; DRKS-ID: DRKS00012703 (Date of Registration in DRKS: 2017 Aug 23).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02579-y.

Improving Care Transitions: An Initiative between the Emergency Department and Senior Care Facilities

INTRODUCTION

The transfer of individuals (i.e., residents) between senior care facilities (SCF) and the emergency department (ED) remains an ongoing healthcare quality gap as communication of key resident information is often lost. For this study, a sample of SCF representatives were invited to join a collaborative group termed Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve SCF resident transitions of care.

STUDY PURPOSE

The purpose of this pilot study was to invite a convenience sample of SCF facilities to join a collaborative intervention named Safe Transition of All Residents For yoU and Me (STARForUM, STAR-F) to improve information exchange during SCF residents' transitions of care. The potential influence of a hospital-SCF collaboration program to improve transfer of essential SCF resident information sent to the hospital ED was used as an evaluation measure.

METHODS

This study project enrolled a total of 120 residents (i.e., patients) with 40 (33%) transferred from participating STAR-F facilities.

RESULTS

Following the authors' development of a transfer checklist, STAR-F facilities sent a significantly greater number of essential elements comprised of the resident's medical history information to the ED compared to non-STAR-F facilities. Controlling for the standard classification of skill level of the individual facility, STAR-F residents had significantly higher essential information transmission composite scores (10.5 + 2.9 for STAR-F patients vs. 7.75 + 3.1 for non-STAR-Fs p = < 0.01) that may have served to reduce number of associated transition errors.

CONCLUSIONS

The findings of this study suggest that a collaborative hospital-SCF initiative can significantly improve transfer of information for elderly residents during ED visits, help guide clinical decision-making and optimize care coordination.

Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents

Background

An existing hospital avoidance program, the Aged Care Rapid Response Team (ARRT), rapidly delivers geriatric outreach services to acutely unwell or older people with declining health at risk of hospitalisation. The aim of the current study was to explore health professionals’ perspectives on the factors impacting ARRT utilisation in the care of acutely unwell residential aged care facility residents.

Methods

Semi-structured interviews were conducted with two Geriatricians, two ARRT Clinical Nurse Consultants, an ED-based Clinical Nurse Specialist, and an Extended Care Paramedic. Interview questions elicited views on key factors regarding care decisions and care transitions for acutely unwell residential aged care facility residents. Thematic analysis was undertaken to identify themes and sub-themes from interviews.

Results

Analysis of interviews identified five overarching themes affecting ARRT utilisation in the care of acutely unwell residents: (1) resident care needs; (2) family factors; (3) enabling factors; (4) barriers; and (5) adaptability and responsiveness to the COVID-19 pandemic.

Conclusion

Various factors impact on hospital avoidance program utilisation in the care of acutely unwell older aged care facility residents. This information provides additional context to existing quantitative evaluations of hospital avoidance programs, as well as informing the design of future hospital avoidance programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06575-1.

ECHO-CT: An Interdisciplinary Videoconference Model for Identifying Potential Postdischarge Transition-of-Care Events

BACKGROUND

Discharge from the hospital to a post-acute care setting can be complex and potentially dangerous, with opportunities for errors and lapses in communication between providers. Data collected through the Extension for Community Health Outcomes- Care Transitions (ECHO-CT) model were used to identify and classify transition-of-care events (TCEs).

METHODS

The ECHO-CT model employs multidisciplinary videoconferences between a hospital-based team and providers in post-acute care settings; during these conferences, concerns regarding the patient's care transition were identified and recorded. The videoconferences took place from January 2016 to October 2018 and included patients discharged from inpatient medical and surgical services to a total of eight participating post-acute care facilities (skilled nursing facilities or long-term acute care hospitals).

RESULTS

During the interdisciplinary videoconferences in this period, 675 patients were discussed. A total of 139 TCEs were identified; 58 (41.7%) involved discharge communication or coordination errors and 52 (37.4%) were classified as medication issues.

CONCLUSION

The TCEs identified in this study highlight areas in which providers can work to reduce issues arising during the course of discharge to post-acute care facilities. Standardized processes to identify, record, and report TCEs are necessary to provide high-quality, safe care for patients as they move across care settings.

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments

BACKGROUND

Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States.

METHOD

We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital.

RESULTS

Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals.

CONCLUSION

Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.

Prompt Outpatient Care For Older Adults Discharged From The Emergency Department Reduces Recidivism

INTRODUCTION

Older adults present unique challenges to both emergency clinicians and health systems. These challenges are especially evident with respect to discharge after an emergency department (ED) visit as older adults are at risk for short-term, negative outcomes including repeat ED visits. The aim of this study was to evaluate characteristics and risk factors associated with repeat ED utilization by older adults.

METHODS

ED visits among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003-2016 were examined using linked Medicare claims data to identify such visits and resulting disposition. Multilevel proportional hazards models examined associations of age, comorbidity status, race, gender, Medicaid dual eligibility status, social support characteristics (living alone or caregiver support), and use of ambulatory primary and subspecialty care with repeat ED utilization.

RESULTS

Older adults discharged from the ED seen by a primary care provider (hazard ratio [HR] = 0.93, confidence interval [CI], 0.87-0.98, p = 0.01) or subspecialist (HR = 0.91, CI 0.86-0.97, P <0.01) after the ED visit were less likely to return to the ED within 30 days compared to those who did not have such post-ED ambulatory visits. Additionally, comorbidity (HR =1.14, 95% CI, 1.13-1.16, P <0.01) and dual eligibility for Medicare and Medicaid (HR = 1.34, 95% CI, 1.20-1.50, p<0.01) were associated with return to the ED within 30 days. Those who were older (HR = 1.10, 95% CI, 1.05-1.15), had more comorbidities (HR = 1.17, 95% CI 1.15-1.18), Black (HR = 1.23, 95% CI, 1.14-1.33,P <0.01), and dually eligible (HR =1.23, 95% CI, 1.14-1.33, P <0.01) were more likely to return within 31-90 days after their initial presentation. The association of outpatient visits with repeat ED visits was no longer seen beyond 30 days. Patients without a caregiver or who lived alone were no more likely to return to the ED in the time periods evaluated in our study.

CONCLUSION

Both primary care and subspecialty care visits among older adults who are seen in the ED and discharged are associated with less frequent repeat ED visits within 30 days.

Key strategies for improving transitions of care collaboration: lessons from the ECHO-care transitions program

Transitioning the care of a patient from a hospital to a skilled nursing facility (SNF) is critical and often risky. Poor care transitions can result in delays, medication mistakes, incomplete follow-up care, and adverse health outcomes. Ensuring a smooth and effective care transition is the goal for providers at both the hospital and SNF. At its foundation, successful care transitions rely on teamwork, relationship building, and communication among diverse groups of providers. Beth Israel Deaconess Medical Center (BIDMC) developed the ECHO-CT (Extension for Community Healthcare Outcomes-Care Transitions) program to improve transitions of care through structured, bi-directional communication between hospital-based and SNF-based providers. This paper describes key strategies for success in this model including: facilitating teamwork, eliminating hierarchy, and encouraging a bi-directional learning environment. We propose these as strategies that could be implemented in other organizations seeking to improve value during transitions of care.

Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department

INTRODUCTION

In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments.

METHODS

Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators.

RESULTS

Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls.

DISCUSSION

QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.

Where would acute care nurses prefer to receive end-of-life care? a cross-sectional survey

BACKGROUND

Hospital-based nurses can offer a unique perspective about factors that can contribute to a good end-of-life experience, including the location in which end-of-life care is delivered.

OBJECTIVES

To examine in a sample of hospital-based nurses, the location in which they personally would most and least prefer to be cared for at the end of life, and the reasons for these preferences.

DESIGN

Questionnaire-based, cross-sectional study.

SETTING AND PARTICIPANTS

170 registered and enrolled nurses employed in acute care wards of three metropolitan hospitals in Australia between April 2016 and February 2017.

RESULTS

Nurses would most prefer to be cared for at home (53%) or in a hospice/palliative care unit (41%) at the end-of-life. Being in a familiar environment and feeling like dying is a more normal process were the main reasons reported for choosing these settings. The main reasons given by nurses for choosing a hospice/palliative care unit were that being cared for at home may place a burden on family/friends and hinder appropriate symptom management. Nurses would least prefer being cared for in an emergency department (49%) due to a perceived lack of privacy and adverse impact on the family; and residential aged care facilities (25%) due to perceived suboptimal symptom management and reduced likelihood of wishes being respected.

CONCLUSION

Nurses in this study value familiarity of environment and normalising the dying process. The majority do not wish to burden their family and friends at the end of their lives. Important next steps in providing services that meet the needs of people facing the end of their lives include understanding how nurses' personal views may influence decision-making conversations with patients and families about location of care at the end-of-life, as well as determining the capacity of available services to meet patient and family needs.

A Systematic Review of Interventions to Improve Nursing Home to Emergency Department Care Transitions

This study aimed to identify interventions that are effective in improving the transitions of care for patients from nursing homes (NHs) to emergency departments (EDs). A total of 607 studies were identified, from which 19 studies were included for full-text review. Nine pre-post intervention studies and two retrospective cohort studies met all criteria for inclusion. In the quality assessment, two (18.2%) were assessed as good quality; seven (63.6%) were fair; and two (18.2%) were poor. Nine studies (81.2%) had a severe risk of bias, primarily due to confounding and deviation from the intended intervention. Pre-post intervention studies utilized transfer checklists/forms, web-based communication networks, and multimodal approaches to improve transitions of care. Eight studies reported significant improvement in critical NH-ED transfer information completeness after intervention implementation. Three studies assessed health care utilization after intervention implementation with two studies reporting no reduction in utilization and one study reporting decreased 30-day hospital readmission and ED revisit rates. Studies evaluating patient-centered outcomes, such as whether interventions reduced harm to patients by decreasing medical errors, hospital length of stay, or the overall number of facility transfers, are needed.

Understanding transitional care provided to older adults with and without dementia: A mixed methods study

Introduction

There are numerous effective transitional care interventions yet they are not routinely implemented. Furthermore, few interventions exist for older adults with dementia. A first step in developing effective interventions for dementia patients and increasing intervention uptake for all patients is to understand the current delivery process of transitional care.

Methods

A mixed methods study using an explanatory multiphase design was conducted. Guided by provider interviews, medical charts were reviewed to collect information on the day-to-day transitional care being delivered to older adults. Then providers were interviewed again to assess the accuracy of those results and provide context.

Results

The medical charts of 210 older adults (126 with dementia and 84 without) were reviewed and nine providers representing various professional roles including social work, nursing, and case management were interviewed. Social workers and case managers were primarily involved in discharge planning, communicating with providers outside the hospital, advanced care planning, providing social and community supports, and making follow-up appointments. Registered nurses were the primary providers of patient education and medication safety while physicians were primarily involved in ensuring that necessary information was available in the discharge summary and that it was available in the chart.

Discussion

This study found distinct patterns in the delivery of transitional care, including the unique roles nursing, social work, and case management have in the process. Furthermore, these patterns were found to differ between patients with and without dementia. These findings are both consistent and inconsistent with the existing literature on transitional care interventions.

How Often, Where, and by Which Specialty Do Long-Term Care Home Residents Receive Specialist Physician Care? A Retrospective Cohort Study

This retrospective cohort study describes the rates, location, and determinants of specialist physician visits among 257,216 long-term care (LTC) residents across 648 LTC homes in Ontario, Canada, between 2007 and 2016. Visit rates in the last year of life were calculated for a sub-cohort of residents who died in LTC between 2013 and 2016. Visits were measured per resident-year using physician billings. Over 10 years, the rate of visits to specialists outside the LTC home was consistently higher than within LTC (2.99 vs. 1.55 visits/resident-year). Residents were less likely to receive specialist care if they were older, had dementia, or lived in urban LTC homes. From 12 months before death to the last week of life, rates of specialist visits increased by 246% and 56% inside and outside of LTC, respectively. Improving access to physician specialist care in LTC homes may reduce burdensome transitions and improve resident quality of life.

Interventions to Improve Emergency Department-Related Transitions in Care for Adult Patients With Atrial Fibrillation and Flutter

BACKGROUND

Patients presenting to emergency departments (EDs) with acute atrial fibrillation or flutter undergo numerous transitions in care (TiC), including changes in their provider, level of care, and location. During transitions, gaps in communications and care may lead to poor outcomes.

OBJECTIVE

We sought to examine the effectiveness of ED-based interventions to improve length of stay, return to normal sinus rhythm, and hospitalization, among other critical patient TiC outcomes.

METHODS

Comprehensive searches of electronic databases and the gray literature were conducted. Two independent reviewers completed study selection, quality, and data extraction. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model, where appropriate.

RESULTS

From 823 citations, 11 studies were included. Interventions consisted of within-ED clinical pathways (n = 6) and specialized observation units (n = 2) and post-ED structured patient education and referrals (n = 3). Three of five studies assessing hospital length of stay reported a significant decrease associated with TiC interventions. Patients undergoing within-ED interventions were also more likely to receive electrical cardioversion. Two of 3 clinical pathways reporting hospitalization proportions showed significant decreases associated with TiC interventions (RR = 0.63 [95% CI 0.42-0.92] and RR = 0.20 [95% CI 0.12-0.32]), as did 1 observation unit (RR = 0.54 [95% CI 0.36-0.80]). No significant differences in mortality, complications, or relapse were found between groupings among the studies.

CONCLUSIONS

There is low to moderate quality evidence suggesting that within-ED TiC interventions may reduce hospital length of stay and decrease hospitalizations. Additional high-quality comparative effectiveness studies, however, are warranted.

Differences in Transitional Care Provided to Patients With and Without Dementia

Older adults with dementia experience more care transitions than those without dementia yet are routinely excluded from transitional care studies. The purpose of the current study was to understand the transitional care delivered to older adults with dementia compared to those without dementia. The medical charts of 210 patients (126 with dementia, 84 without dementia) 70 years and older hospitalized at a single hospital were reviewed for evidence of transitional care, including discharge planning, patient education, and follow-up appointments. Patients with dementia were significantly less likely to receive education related to their follow-up needs, whom to contact after discharge, medication regimens after discharge, and symptoms after discharge than patients without dementia. Caregivers to patients with dementia have previously reported a desire for more education and information from hospital providers so they can advocate for patients in aftercare; therefore, nurses and social workers should consider providing education regardless of a patient's dementia diagnosis. [Journal of Gerontological Nursing, 45(8), 15-22.].

Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review

Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Background

Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.

Methods

Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.

Results

Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.

Conclusions

The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

The Use of Health Information Exchange to Augment Patient Handoff in Long-Term Care: A Systematic Review

BACKGROUND

Legislation aimed at increasing the use of a health information exchange (HIE) in healthcare has excluded long-term care facilities, resulting in a vulnerable patient population that can benefit from the improvement of communication and reduction of waste.

OBJECTIVE

The purpose of this review is to provide a framework for future research by identifying themes in the long-term care information technology sector that could function to enable the adoption and use of HIE mechanisms for patient handoff between long-term care facilities and other levels of care to increase communication between providers, shorten length of stay, reduce 60-day readmissions, and increase patient safety.

METHODS

The authors conducted a systematic search of literature through CINAHL, PubMed, and Discovery Services for Texas A&M University Libraries. Search terms used were ("health information exchange" OR "healthcare information exchange" OR "HIE") AND ("long term care" OR "long-term care" OR "nursing home" OR "nursing facility" OR "skilled nursing facility" OR "SNF" OR "residential care" OR "assisted living"). Articles were eligible for selection if they were published between 2010 and 2017, published in English, and published in academic journals. All articles were reviewed by all reviewers and literature not relevant to the research objective was excluded.

RESULTS

Researchers selected and reviewed 22 articles for common themes. Results concluded that the largest facilitator and barrier to the adoption of HIE mechanisms is workflow integration/augmentation and the organizational structure/culture, respectively. Other identified facilitator themes were enhanced communication, increased effectiveness of care, and patient safety. The additional barriers were missing/incomplete data, inefficiency, and market conditions.

CONCLUSION

The long-term care industry has been left out of incentives from which the industry could have benefited tremendously. Organizations that are not utilizing health information technology mechanisms, such as electronic health records and HIEs, are at a disadvantage as insurers switch to capitated forms of payment that rely on reduced waste to generate a profit.

How well does the minimum data set measure healthcare use? a validation study

Background

To improve care, planners require accurate information about nursing home (NH) residents and their healthcare use. We evaluated how accurately measures of resident user status and healthcare use were captured in the Minimum Data Set (MDS) versus administrative data.

Methods

This retrospective observational cohort study was conducted on all NH residents (N = 8832) from Winnipeg, Manitoba, Canada, between April 1, 2011 and March 31, 2013. Six study measures exist. NH user status (newly admitted NH residents, those who transferred from one NH to another, and those who died) was measured using both MDS and administrative data. Rates of in-patient hospitalizations, emergency department (ED) visits without subsequent hospitalization, and physician examinations were also measured in each data source. We calculated the sensitivity, specificity, positive and negative predictive values (PPV, NPV), and overall agreement (kappa, κ) of each measure as captured by MDS using administrative data as the reference source. Also for each measure, logistic regression tested if the level of disagreement between data systems was associated with resident age and sex plus NH owner-operator status.

Results

MDS accurately identified newly admitted residents (κ = 0.97), those who transferred between NHs (κ = 0.90), and those who died (κ = 0.95). Measures of healthcare use were captured less accurately by MDS, with high levels of both under-reporting and false positives (e.g., for in-patient hospitalizations sensitivity = 0.58, PPV = 0.45), and moderate overall agreement levels (e.g., κ = 0.39 for ED visits). Disagreement was sometimes greater for younger males, and for residents living in for-profit NHs.

Conclusions

MDS can be used as a stand-alone tool to accurately capture basic measures of NH use (admission, transfer, and death), and by proxy NH length of stay. As compared to administrative data, MDS does not accurately capture NH resident healthcare use. Research investigating these and other healthcare transitions by NH residents requires a combination of the MDS and administrative data systems.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3089-7) contains supplementary material, which is available to authorized users.

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Background

Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.

Objectives

To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.

Design

A systematic mapping review.

Setting

Evidence from developed countries on interventions delivered in the ED.

Participants

Frail and high-risk older people and general populations of older people (aged > 65 years).

Interventions

Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.

Main outcome measures

Patient outcomes (direct and indirect) and health service outcomes.

Data sources

Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.

Review methods

A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.

Results

Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.

Limitations

This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.

Conclusions

A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.

Future work

Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.

Study registration

This study is registered as PROSPERO CRD42016043260.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Nursing home care educational intervention for family caregivers of older adults post stroke (SHARE): study protocol for a randomised trial

BACKGROUND

Family caregivers of aged stroke survivors face challenging difficulties such as the lack of support and the knowledge and skills to practice home care. These aspects negatively influence the caregivers' burden and quality of life, the use of health services, and hospital readmissions of the stroke survivor. The aim of this research is to describe an educational intervention focused on family caregivers of stroke survivors for the development of home care in the south of Brazil.

METHODS

A randomized clinical trial with 48 family caregivers of stroke survivors will be recruited and divided into two groups: 24 in the intervention group and 24 in the control group. The intervention will consist of the systematic follow-up by nurses who will perform three home visits over a period of 1 month. The control group will not receive the visits and will have the usual care guidelines of the health services. Primary outcomes: burden and quality of life of the caregiver.

SECONDARY OUTCOMES

functional capacity and readmissions of the stroke survivors; the use of health services of the stroke survivors and their family caregivers. Outcomes will be measured 2 months after discharge. The project was approved in April 2016.

DISCUSSION

This research offers information for conducting educational intervention with family caregivers of stroke survivors, presenting knowledge so that nurses can structure and plan the actions aimed at the education of the family caregiver. It is expected that the educational intervention will contribute to reducing caregiver burden and improving their quality of life, as well as avoiding readmissions and inadequate use of health services by stroke survivors.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02807012 . Registered on 3 June 2016. Name: Nursing Home Care Intervention Post Stroke (SHARE).

Barriers to ethical nursing practice for older adults in long-term care facilities

AIMS AND OBJECTIVES

To explore barriers to ethical nursing practice for older adults in long-term care facilities from the perspectives of nurses in South Korea.

BACKGROUND

The number of older adults admitted to long-term care facilities is increasing rapidly in South Korea. To provide this population with quality care, a solid moral foundation should be emphasised to ensure the provision of ethical nursing practices. Barriers to implementing an ethical nursing practice for older adults in long-term care facilities have not been fully explored in previous literature.

DESIGN

A qualitative, descriptive design was used to explore barriers to ethical nursing practice as perceived by registered nurses in long-term care facilities in South Korea.

METHODS

Individual interviews were conducted with 17 registered nurses recruited using purposive (snowball) sampling who care for older adults in long-term care facilities in South Korea. Data were analysed using qualitative content analysis.

RESULTS

Five main themes emerged from the data analysis concerning barriers to the ethical nursing practice of long-term care facilities: emotional distress, treatments restricting freedom of physical activities, difficulty coping with emergencies, difficulty communicating with the older adult patients and friction between nurses and nursing assistants.

CONCLUSIONS

This study has identified methods that could be used to improve ethical nursing practices for older adults in long-term care facilities. Because it is difficult to improve the quality of care through education and staffing alone, other factors may also require attention.

RELEVANCE FOR CLINICAL PRACTICE

Support programmes and educational opportunities are needed for nurses who experience emotional distress and lack of competency to strengthen their resilience towards some of the negative aspects of care and being a nurse that were identified in this study.

Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions

PURPOSE

Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.

METHODS

We undertook a prospective cohort study comparing cost and health care utilization outcomes between ECHO-CT facilities and matched comparisons from January 2014-December 2014.

RESULTS

Thirty-day readmission rates were significantly lower in the intervention group (odds ratio 0.57; 95% CI, 0.34-0.96; P-value .04), as were the 30-day total health care cost ($2602.19 lower; 95% CI, -$4133.90 to -$1070.48; P-value <.001) and the average length of stay at the skilled nursing facility (-5.52 days; 95% CI, -9.61 to -1.43; P = .001). The 30-day mortality rate was not significantly lower in the intervention group (odds ratio 0.38; 95% CI, 0.11-1.24; P = .11).

CONCLUSION

Patients discharged to skilled nursing facilities participating in the ECHO-CT program had shorter lengths of stay, lower 30-day rehospitalization rates, and lower 30-day health care costs compared with those in matched skilled nursing facilities delivering usual care. ECHO-CT may improve patient transitions to postacute care at lower overall cost.

Development, validation and testing of a nursing home to emergency room transfer checklist

AIMS AND OBJECTIVES

To develop and test the feasibility of an instrument to support patients' nursing home to emergency room transfer.

BACKGROUND

Transfers from a nursing home care facility to an acute care facility such as a hospital emergency room are common. However, the prevalence of an information gap for transferring residents' health data to acute care facility is high. An evidence-based transfer instrument, which could fill this gap, is lacking.

DESIGN

Development of a nursing home to emergency room transfer checklist, validation of items using the Delphi method and testing the feasibility and benefits of using the nursing home to emergency room transfer checklist.

METHODS

Items were developed based on qualitative data from previous research. Delphi validation, retrospective chart review (baseline data) and a 6-month prospective study design were applied to test the feasibility of using the checklist. Variables for testing the feasibility of the checklist included residents' 30-day readmission rate and length of hospital stay.

RESULTS

Development of the nursing home to emergency room transfer checklist resulted in four main parts: (i) demographic data of the nursing home resident; (ii) critical data for nursing home to emergency room transfer; (iii) contact information and (iv) critical data for emergency room to nursing home transfer. Two rounds of Delphi validation resulted in a mean score (standard deviation) ranging from 4.39 (1.13)-4.98 (.15). Time required to complete the checklist was 3-5 min. Use of the nursing home to emergency room transfer checklist resulted in a 30-day readmission rate of 13.4%, which was lower than the baseline rate of 15.9%.

CONCLUSIONS

The nursing home to emergency room transfer checklist was developed for transferring nursing home residents to an emergency room. The instrument was found to be an effective tool for this process.

RELEVANCE TO CLINICAL PRACTICE

Use of the nursing home to emergency room transfer checklist for nursing home transfers could fill the information gap that exists when transferring older adults between facilities such as nursing homes and hospitals.

Transitions From Acute Care to Long-Term Care: Evaluation of the Continued Access Model

Improving communication during transitions from acute care hospitals into long-term post-acute care (LTPAC) settings is imperative for clinical staff to have the information they need to admit and care for the patient with accurate medical information provided in an efficient way. The research goals of this study are to examine the user experience of a new data sharing method, "Continued Access," a supplement to the standard summary of care, and to evaluate staff attitudes of the model on LTPAC residents' care. Clinical staff ( n = 20) from a U.S. Midwestern LTPAC setting were interviewed to give their evaluation of the new model of data access, their concerns, and ways to improve the effectiveness of the model. Respondents reported better opportunities for quality care based on improved insight and clarity around patients' medical history, medications, and tests. Strategies for integrating Continued Access into the workflow and improving quality outcomes are discussed.

Discrepancy between information provided and information required by emergency physicians for long-term care patients

Objectives

The primary objective of this study was to identify information included in long-term care (LTC) transfer documentation and to compare it to the information required by local emergency department (ED) physicians to provide optimal care and make decisions for LTC patients.

Methods

A retrospective chart review was conducted for a sample of LTC residents transferred by ambulance to the ED of an academic, tertiary care hospital over a 1-year period. All emergency physicians working at the institution were invited to complete an online questionnaire about information included in LTC transfer documentation and information required by emergency physicians to provide care for LTC patients.

Results

Of the 200 charts reviewed, the most common information transferred to the ED with the LTC patient was the patient’s past medical history (n=184, 92.0%), name of family physician (n=182, 91.0%), a list of known allergies (n=179, 89.5%), the reason for transfer to the ED (n=155, 77.5%), the patient’s emergency contact information (n=152, 76.0%), and medication administration record (n=150, 75.0%). From a physician’s perspective, the most frequently requested pieces of information included reason for transfer, past medical history, cognitive status, advanced directives for level of care and resuscitation, and the patient’s emergency contact information. This information was provided 77.5% (n=155), 92.0% (n=184), 24.0% (n=48), 62.0% (n=124), and 76.0% (n=152) of the time, respectively.

Conclusions

Our study demonstrates a clear discrepancy between information provided and information required by emergency physicians for LTC patients. Quality improvement initiatives at the local level may help reduce this discrepancy.

Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease

One of the goals of the National Plan to Address Alzheimer's Disease is to ensure safe care transitions. To facilitate safe and effective transitions from home to hospital, the ADMIT (Alzheimer's, Dementia, Memory Impaired Transitions) Me tool was developed and three focus groups were conducted with caregivers (n = 6), emergency department nurses (n = 6), and first responders (n = 14) to determine its usefulness and applicability to practice. Feedback was used to enhance the tool to reflect their needs. Each group expressed that the tool would help promote safety in care transitions. Using ADMIT Me, nurses can practice with clear communication and collaboration in care transitions, and provide patient-centered care based on the behaviors and unique needs of the individual with dementia. [Journal of Gerontological Nursing, 43(5), 32-38.].

Extension for Community Healthcare Outcomes-Care Transitions: Enhancing Geriatric Care Transitions Through a Multidisciplinary Videoconference

OBJECTIVES

To examine whether a novel videoconference that connects an interdisciplinary hospital-based team with clinicians at postacute care sites improves interprofessional communication and reduces medication errors.

DESIGN

Prospective cohort.

SETTING

One tertiary care medical center and eight postacute care sites.

PARTICIPANTS

Hospital-based providers (hospitalists, geriatricians, pharmacists, social workers, medical trainees, and subspecialists) and postacute care clinicians.

INTERVENTION

All patients discharged to eight postacute care sites were discussed in a weekly videoconference.

MEASUREMENT

Preliminary data including demographic characteristics of the patients discussed, postacute care provider satisfaction survey results, and data on medication errors are reported.

RESULTS

Over 2 years, 907 patients were discussed; 84.6% were discussed with staff at subacute skilled nursing facilities and the remainder with clinicians at one long-term acute care facility. They had an average hospital length of stay of 6.8 days. Postacute care providers felt that the videoconference enhanced communication and provided much-needed access to information and hospital staff. Of the 106 pharmacy discrepancies identified, 16% involved an omission of a medication.

CONCLUSION

As increasing numbers of older adults are discharged to postacute care facilities, they face high-risk care transitions. Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) facilitates interdisciplinary communication between hospital and postacute care providers, who normally have minimal interaction. Preliminary data suggests that ECHO-CT may improve the transitions of care processes between these sites.

Comparison of functional outcomes in elderly who have sustained a minor trauma with or without head injury: a prospective multicenter cohort study

OBJECTIVES

The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a head injury on the functional outcomes six months post-injury in older adults who sustained a minor trauma.

METHODS

This multicenter prospective cohort study in eight sites included patients who were aged 65 years or older, previously independent, presenting to the emergency department (ED) for a minor trauma, and discharged within 48 hours. To assess the functional decline, we used a validated test: the Older Americans' Resources and Services Scale. The cognitive function of study patients was also evaluated. Finally, we explored the influence of a concomitant injury on the functional decline in the MT-HI group.

RESULTS

All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 minor trauma without head injury. After six months, the functional decline was similar in both groups: 10.8% and 11.9%, respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of patients with mild cognitive disabilities was also similar: 21.7% and 22.8%, respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR=1.35 [95% CI: 0.71-2.59]).

CONCLUSION

This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population, six months after injury.