Training nursing staff to recognize depression in home healthcare

Home-based nursing care competencies: A scoping review

AIMS AND OBJECTIVES

To identify and consolidate the available evidence about nursing-related competencies for home-based care.

BACKGROUND

Over recent years, the demand for home-based nursing care has increased because of the need to meet the increasing need for chronic disease care to be delivered in patients' homes. However, knowledge is lacking about the expected competencies for home-based care nurses.

DESIGN

A scoping review was conducted in accordance with Arksey and O'Malley's six-step scoping review framework and the PRISMA-ScR guidelines. The review identified literature using five electronic databases (CINAHL, PubMed, Embase, Cochrane and Scopus) and a hand search for grey literature in relevant home-based care journals and online searches. Key search terms and inclusion and exclusion criteria were used as strategies to identify relevant articles.

RESULTS

Sixty-four articles were eligible for inclusion. Mapping and narrative synthesis of 116 elements related to home-based nursing care competencies identified the following 10 competencies: (1) care assessments; (2) performance of nursing procedures; (3) management of health conditions; (4) critical thinking and problem-solving skills; (5) interpersonal relationships and communication; (6) interdisciplinary collaboration; (7) leadership and resource management; (8) professional development; (9) technological literacy; (10) quality and safety.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

This review provides insight into current knowledge about home-based nursing care competencies. These competencies could be used to evaluate nurses' competence level for home-based care or for development of appropriate professional education. The review also outlines the scope of nursing practice in home-based care, which provides support for some form of standardisation of home-based nursing care expectations across various stakeholders.

Screening for depression in older adults with cognitive impairment in the homecare setting: a systematic review

OBJECTIVE

Previous systematic reviews have examined depression screening in older adults with cognitive impairment (CI) in outpatient and inpatient clinics, nursing homes, and residential care. Despite an increasing number of older adults with CI receiving care in their homes, less is known about best depression screening practices in homecare. The objective of this review is to identify evidence-based practices for depression screening for individuals with CI receiving homecare by assessing tool performance and establishing the current evidence for screening practices in this setting.

METHODS

This review is registered under PROSPERO (ID: CRD42018110243). A systematic search was conducted using MEDLINE, EMBASE, Health and Psychosocial Abstracts, PsycINFO and CINAHL. The following criteria were used: assessment of depression at home in older adults (>55 years) with CI, where performance outcomes of the depression screening tool were reported.

RESULTS

Of 5,453 studies, only three met eligibility criteria. These studies evaluated the Patient Health Questionnaire (n = 236), the Geriatric Depression Scale (n = 79) and the Mental Health Index (n = 1,444) in older adults at home with and without CI. Psychometric evaluation demonstrated moderate performance in the subsamples of people with CI.

CONCLUSION

At present, there is insufficient evidence to support best practices in screening for depression in people with CI in homecare.

Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study

BACKGROUND

Depressive symptoms and/or depression are commonly experienced by older people. Both are underdiagnosed, undertreated and regularly overlooked by healthcare professionals. Healthcare facilities for people aged ≥75 years have been in place in Sweden since 2015. The aim of these care centres, which are managed by registered nurses (RNs), is to offer care adjusted to cater to the complex needs and health problems of older people. Although the mental health of older people is prioritised in these centres, research into the experience of RNs of depressive symptoms and/or depression in older people in this setting is limited. Therefore, this study aimed to illuminate RNs, working at care centres for older people, experience of identifying and intervening in cases of depressive symptoms.

METHODS

The data for this qualitative descriptive study were collected through interviews (n = 10) with RNs working at 10 care centres for older people in southern Sweden. The transcribed texts were analysed using inductive content analysis.

RESULTS

The participants' experiences could be understood from four predominant themes: (1) challenging to identify, (2) described interventions, (3) prerequisites for identification, and (4) contextual influences. Key findings were that it was difficult to identify depression as it often manifested as physical symptoms; evidence-based nursing interventions were generally not the first-line treatment used; trust, continuity and the ability of RNs to think laterally; and the context influenced the ability of RNs to manage older people's depressive symptoms and/or depression.

CONCLUSIONS

The process of identifying depressive symptoms and performing an appropriate intervention was found to be complex, especially as older people were reluctant to present at the centres and provided obscure reasons for doing so. A nurse-patient relationship that was built on trust and was characterised by continuity of care was identified as a necessary prerequisite. Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression. Further research is also needed into efficacious nursing interventions targeting depressive symptoms and/or depression.

Home Health Nurses' Perspectives and Care Processes Related to Older Persons with Frailty and Depression: A Mixed Method Pilot Study

The objectives of this study were (1) to describe home health care (HHC) nurses' perception of and care processes related to geriatric depression and frailty, and (2) to identify barriers to care delivery for older persons with these two conditions. Ten semi-structured interviews were conducted with HHC nurses, and 16 HHC nursing visits to 16 older patients (≥65 years) were observed. Mixed method analysis showed that HHC nurses did not routinely assess for frailty and depression. Major barriers to care delivery included insufficient training, documentation burden, limited reimbursement, and high caseload. Addressing these barriers would facilitate HHC nursing care for frail, depressed elders.

A Guide for Planning and Implementing Successful Mental Health Educational Programs

INTRODUCTION

Considering the global burden of mental disorders, there is a worldwide need to improve the quality of mental health care. In order to address this issue, a change in how health care professionals are trained may be essential. However, the majority of the few reports published on this field's training programs do not discuss the characteristics associated with the success or failure of these strategies. The purpose of this review was to systematically examine the literature about mental health training programs designed for health care professionals in order to identify the relevant factors associated with their effective implementation.

METHODS

The MEDLINE/PubMed, SciELO, and Virtual Health Library databases were used to search for articles published before February 2017 and reviewed by two double-blind reviewers.

RESULTS

We found 77 original papers about mental health educational programs. Many of these studies were conducted in the USA (39%), addressed depression as the main subject (34%), and applied a quasi-experimental design (52%). Effective interventions were associated with the following characteristics: the use of learner-centered and interactive methodological approaches; a curriculum based on challenges in the trainees' daily routines; the involvement of experts in the program's development; the enrollment of experienced participants; interdisciplinary group work; flexible timing; the use of e-learning resources; and optimizing the implementation of knowledge into the participants' routine work practices.

IMPLICATIONS FOR PRACTICE

These results will be helpful for planning and improving the quality of future educational programs in mental health.

A training program to enhance recognition of depression in nursing homes, assisted living, and other long-term care settings: Description and evaluation

Low levels of symptom recognition by staff have been "gateway" barriers to the management of depression in long-term care. The study aims were to refine a depression training program for front-line staff in long-term care and provide evaluative knowledge outcome data. Three primary training modules provide an overview of depression symptoms; a review of causes and situational and environmental contributing factors; and communication strategies, medications, and clinical treatment strategies. McNemar's chi-square tests and paired t-tests were used to examine change in knowledge. Data were analyzed for up to 143 staff members, the majority from nursing. Significant changes (p < .001) in knowledge were observed for all modules, with an average change of between 2 and 3 points. Evidence was provided that participants acquired desired information in the recognition, detection, and differential diagnosis and treatment strategies for those persons at significant risk for a depressive disorder.

Testing of a Statewide Initiative to Enhance Depression Care in Older Home Care Patients

Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.

Chile: Acceptability of a Training Program for Depression Management in Primary Care

Background: In Chile, there are inconsistencies in the management of depression in primary care settings, and the National Depression Program, currently in effect, was implemented without a standardized training program. The objective of this study is to evaluate the acceptability of a training program on the management of depression for primary care health teams.

Methods: The study was a randomized controlled trial, and two primary centers from the Metropolitan Region of Santiago were randomly selected to carry out the intervention training program. Pre-post surveys were applied, to evaluate expectations and satisfaction with the intervention, respectively. Descriptive and content analysis was carried out.

Result: The sample consisted of 41 health professionals, 56.1% of who reported that their expectations for the intervention were met. All of the training activities were evaluated with scores higher than 6.4 (on a 1–7 scale). The trainers, the methodology, and the learning environment were considered strengths and facilitators of the program, while the limited duration of the training, the logistical problems faced during part of the program, and the lack of educational material were viewed as weaknesses.

Conclusion: The intervention was well accepted by primary health care teams. However, the clinical impact in patients still has to be evaluated.

Addressing gaps in mental health needs of diverse, at-risk, underserved, and disenfranchised populations: a call for nursing action

Psychiatric nurses have an essential role in meeting the mental health needs of diverse, at-risk, underserved, and disenfranchised populations across the lifespan. This paper summarizes the needs of individuals especially at-risk for mental health disorders, acknowledging that such vulnerability is contextual, age-specific, and influenced by biological, behavioral, socio-demographic and cultural factors. With its longstanding commitment to cultural sensitivity and social justice, its pivotal role in healthcare, and its broad educational base, psychiatric nursing is well-positioned for leadership in addressing the gaps in mental health prevention and treatment services for vulnerable and underserved populations. This paper describes these issues, presents psychiatric nursing exemplars that address the problems, and makes strong recommendations to psychiatric nurse leaders, policy makers and mental health advocates to help achieve change.

Racial and ethnic variation in home healthcare nurse depression assessment of older minority patients

OBJECTIVE

The objective of this study is to determine the racial/ethnic effect of depression symptom recognition by home healthcare nurses.

METHODS

This is a secondary analysis of administrative data from a large urban home healthcare agency. Patients' age were 65 years and older with a valid depression screen, identified as Caucasian, African American, or Hispanic and admitted to homecare in 2010 (N = 3711). All demographic and clinical information were obtained from the electronic medical record.

RESULTS

Subjects were 29.34% Caucasian, 37.81% African American, and 32.85% Hispanic. About 6.52% had a formal chart diagnosis of depression, and 13.39% received antidepressant therapy. The rates of positive depression screens by nurses were higher in Caucasians than that of in African Americans or Hispanics (13.41% vs. 9.27% vs. 10.99%; χ(2)  = 10.70, df [degrees of freedom] = 2; p < 0.01). Depression screening rates were then stratified by the number of clinical indicators from the chart (depression diagnosis or antidepressant on medication list). The proportion of positive screen increased for minorities with an increase in the number of indicators. African Americans had significantly greater positive screens with two indicators compared with that of the Caucasians and Hispanics (50.00% vs. 23.81% vs. 35.59%; χ(2)  = 6.65, df = 2; p = 0.04).

CONCLUSIONS

These findings show a wide range of variation in screening for depression among ethnic groups. The rates increase for minorities with the presence of increased clinical indicators, suggesting that nurses may screen higher in minorities when there is higher clinical suspicion. Future research in home healthcare should be aimed at training nurses to conduct culturally tailored depression screening to improve management of depression in older minorities.

Depression in older adults: screening and referral

Depression is related to disability and affects rehabilitation participation, outcomes, and compliance with treatment. Improving older adult depression detection and referral requires knowledge, skills, supportive organizational policies, and access to mental health experts. This review provides a selected overview of evidence-based approaches for screening of suspected cases of depression in older adults by physical therapists and other non-mental health professionals and discusses procedures to refer suspected cases to primary care providers and/or mental health specialists for evaluation, including resources and a tool to assist in communicating depression-related information to the primary care provider or mental health specialist. We hope that this review will promote the incorporation of evidence-based screening and referral of suspected cases of depression in older adults into routine practice.

Pilot Testing of the Home Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities Intervention

The primary aim of this pilot study was to develop, implement, and test the feasibility and efficacy of the Home Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities (HEART) trial, a nurse-directed multicomponent home care intervention. A total of 50 patients with a primary diagnosis of heart failure (HF) were assigned to the intervention ( n = 26) or control group ( n = 24) according to geographical location in a large multibranch Medicare-certified home health agency. Forty-six patients completed the study. Patients participating in the HEART intervention demonstrated significantly improved HF knowledge ( F = 1.31, p < .001) in comparison with control group patients’ at the study endpoint. There was a non-significant trend toward improved quality of life (QOL) and lower hospital readmission rates (6 patients vs. 9 patients) in the intervention group.

Including nurses in care models for older people with mild to moderate depression: an integrative review

AIMS AND OBJECTIVES

The aim of this integrative literature review was twofold: (1) to investigate different collaborative programmes for older people with depression living at home with diverse access to care and (2) to describe conceptualisation of the nurses' role and interventions within these care models.

BACKGROUND

One in four older people who visits a General Practitioner suffers from depression. Depression is a concern for 15% of all older home-care service clients. Detecting and managing depression in older people is highlighted as a key role of nurses. A literature review has been conducted to investigate collaborative models of care, aimed at ensuring low-threshold access to care and exploring the scope of nurse practice within these models.

METHODS

Literature review comprising 14 studies and reviews.

RESULTS

Three different collaborative care programmes (Collaborative Care Model, Community Mental Health Team and Psychogeriatric Assessment and Treatment in City Housing programme) were identified. In all programmes, the essential aspects were complex and multifaceted interventions, provided by a variety of healthcare professionals, but the access to care differed. All studies described the role of nurses differently and with wide variations.

CONCLUSIONS

Despite a broad scope of practice, nurses play a pivotal role within the different models of care. Nurses have to have the educational background and expertise in mental health issues to recognise depression and eventually be able to provide more comprehensive interventions to alleviate depression in older people.

RELEVANCE TO PRACTICE

Collaboration is needed to meet the needs of older people with depression. New forms of work divisions are pivotal to achieve this objective.

The development and first use of the QUEST measures to evaluate school nurses' knowledge and skills for depression recognition and management

BACKGROUND

Depression affects around 5% of adolescents and its identification and management is an important part of front-line professionals' roles. There are few validated measures of knowledge and skills in this area. We describe a multiple-choice question set to test nurses' depression knowledge and vignettes to examine case recognition skills.

METHODS

A 24-item knowledge test and 12 vignettes were developed based on relevant literature and expert panel review. Three rounds of panel review assessed face and content validity and expert agreement of vignette depression status. The measures were piloted with 26 school nurses. Following amendments, administered to 146 school nurses. A depression attitude scale was used concurrently so that associations among knowledge, attitudes, and condition recognition could be explored.

RESULTS

Readability for the knowledge test and vignettes was satisfactory. Item difficulty and discrimination indices for most knowledge questions were acceptable; overall, participants scored 50% correctly, with less than 5% unanswered. The panel reached 89% agreement about vignette depression status, and nurse participants' judgments of the vignettes achieved 65% sensitivity and 47% specificity.

CONCLUSION

The study produced psychometrically tested instruments for measuring depression recognition and knowledge. There was evidence for content validity, and limited evidence of convergent validity from associations among measures. Some of the items may be modified, and a smaller set of vignettes having the best expert agreement may be useful in future research.

Pilot Study of a Statewide Initiative to Enhance Depression Care Among Older Home Care Patients

Late-life depression is prevalent in home care. This pilot study, part of a statewide initiative to enhance depression care, evaluated the influence of a 2-hour depression screening and intervention workshop on home care professionals’ knowledge, self-efficacy, and attitudes related to depression in older home care patients. A pretest, posttest design was used to evaluate the effects of the workshop with 280 home care professionals from 7 home care agencies. Following the depression workshop, participants’ knowledge levels in evidence-based screening and care for depressed older adults was significantly increased, t(280) = 16.49, p<.001. A significant increase in confidence and attitude ratings were found (p<.001). Findings from this pilot study support broader dissemination throughout Connecticut home care agencies.

Impairments in life quality among clients in geriatric home care: associations with depressive and anxiety symptoms

OBJECTIVE

The aim of this study was to determine the independent contributions of depressive and anxiety symptoms to quality of life among older adults who were receiving services through a home care program.

METHODS

The study sample consisted of 66 community-dwelling older adults (ages 65 years and older), who were experiencing chronic medical illness and concomitant functional disability necessitating home care. Participants completed self-report measures of depression, anxiety, and health-related quality of life. Additional data on cognitive, health, and functional status were collected to be used as covariates.

RESULTS

The associations of depressive symptoms with quality of life impairments in home care were substantial and pervasive. Depressive symptoms were significantly associated with quality of life impairments in nearly all domains. After controlling for depressive symptoms, anxiety symptoms accounted for additional and statistically significant variance in impaired life quality in the domains of mental health, role emotional functioning, and bodily pain.

CONCLUSIONS

These results indicate that depressive and anxiety symptoms demonstrate negative associations with life quality among older adults in home care and highlight the importance of developing community-based programs to assess and treat depressive and anxiety symptoms among home care clients.

Late-Life Depression in Home Healthcare

Major depression is disproportionately common among elderly adults receiving home healthcare and is characterized by greater medical illness, functional impairment, and pain. Depression is persistent in this population and is associated with numerous poor outcomes such as increased risk of hospitalization, injury-producing falls, and higher health care costs. Despite the need for mental health care in these patients, significant barriers unique to the home healthcare setting contribute to under-detection and under-treatment of depression. Intervention models target the home healthcare nurse as liaison between patients and physicians, and instruct in the identification and management of depression for their patients. Successful implementation requires interventions that 'fit' how home healthcare is organized and practiced, and long distance implementation strategies are required to increase the reach of these interventions.

Identification and recognition of depression in community care assessments: impact of a national policy in England

BACKGROUND

Depression continues to be under-recognized in older people. Most policies addressing this issue focus on the primary health care team. However, recognition may be improved by use of assessment tools and collaboration between secondary health and social care, particularly at the assessment stage. This study aimed to evaluate whether the Single Assessment Process (SAP), introduced in England from April 2004, promoting such processes, improved the identification and correct recognition of depression by enhancing the content of statutory community care assessments by social services care managers.

METHODS

An observational study compared depression identification and its accuracy ("correct recognition") in samples of older people before and after SAP introduction. Participants were interviewed using standardized measures including the Geriatric Depression Scale (GDS). Depression elicited from the GDS was compared with that recorded in community care assessments with calculation of inter-rater reliabilities (kappa statistic) pre- and post-SAP. Logistic regression examined the associations between the policy's introduction, potential confounding factors (depression, cognitive impairment, function, behavior and characteristics) and the identification and correct recognition of depression.

RESULTS

Whilst the identification of depression was more likely after SAP, its correct recognition did not improve after the policy, with only slight agreement between GDS and community care assessments. The existence of depression and cognitive impairment made identification, but not correct recognition, more likely.

CONCLUSIONS

Correct recognition of depression was not improved in these statutory care assessments following the policy. Recognizing and thus responding to depression in a coordinated and appropriate way in the community requires further action.

Preferences for depression treatment among elderly home health care patients

OBJECTIVE

The authors hypothesized that the depression treatment preferences of elderly home care patients would vary by their experience of depression and that preferences for active treatment would be associated with current depression and with antidepressant treatment.

METHODS

The authors conducted cross-sectional secondary analyses of data from the TRIAD study (Training in the Assessment of Depression) of 256 randomly selected elderly patients newly admitted to home care. The study assessed preference for active treatments (medication or psychotherapy) and nonactive or complementary approaches (such as religious activities or doing nothing). Nondepressed patients were asked to choose as if they had serious depression. Two separate indicators of depression experience were used: a current diagnosis of major or minor depression and current or previous antidepressant treatment.

RESULTS

Of the 256 patients, 16% (N=41) met criteria for major or minor depression. Forty-seven percent of the sample (N=121) preferred an active treatment as their first choice, and others preferred nonactive or complementary approaches. Logistic regression indicated that current antidepressant use, previous psychotherapy experience, white or Hispanic race-ethnicity (versus black), greater impairment in instrumental activities of daily living, and less personal stigma about depression were independently associated with preference for an active treatment.

CONCLUSIONS

Elderly home care patients had a variety of treatment preferences, ranging from active treatments, to religious or spiritual activities, to no treatment. Several factors were associated with a preference for active treatment, including treatment experience, physical impairment, race-ethnicity, and attitudes and beliefs. An understanding of patient preferences may help engage older depressed home care patients in treatment.

Preferences for depression treatment among elderly home health care patients

OBJECTIVE

The authors hypothesized that the depression treatment preferences of elderly home care patients would vary by their experience of depression and that preferences for active treatment would be associated with current depression and with antidepressant treatment.

METHODS

The authors conducted cross-sectional secondary analyses of data from the TRIAD study (Training in the Assessment of Depression) of 256 randomly selected elderly patients newly admitted to home care. The study assessed preference for active treatments (medication or psychotherapy) and nonactive or complementary approaches (such as religious activities or doing nothing). Nondepressed patients were asked to choose as if they had serious depression. Two separate indicators of depression experience were used: a current diagnosis of major or minor depression and current or previous antidepressant treatment.

RESULTS

Of the 256 patients, 16% (N=41) met criteria for major or minor depression. Forty-seven percent of the sample (N=121) preferred an active treatment as their first choice, and others preferred nonactive or complementary approaches. Logistic regression indicated that current antidepressant use, previous psychotherapy experience, white or Hispanic race-ethnicity (versus black), greater impairment in instrumental activities of daily living, and less personal stigma about depression were independently associated with preference for an active treatment.

CONCLUSIONS

Elderly home care patients had a variety of treatment preferences, ranging from active treatments, to religious or spiritual activities, to no treatment. Several factors were associated with a preference for active treatment, including treatment experience, physical impairment, race-ethnicity, and attitudes and beliefs. An understanding of patient preferences may help engage older depressed home care patients in treatment.

Overview of depression: epidemiology and implications for community nursing practice

Depressive disorders are among the most common psychological conditions currently affecting individuals living in the Westernized world. Yet, available data indicate that fewer than one third of adults with depression obtain appropriate professional treatment. This is attributed, among other reasons, to the under-recognition of the problem by health professionals, including district nurses. In order to improve recognition of the problem, it is imperative for nurses and especially those working in community settings, to appreciate the importance of prompt diagnosis which presumes both an understanding and knowledge of basic aspects of the problem and, an understanding of their role in dealing with depression. This overview presents epidemiological data and identifies the potential consequences of depression on daily functioning and other aspects of life among adults in Westernized countries, aiming to raise awareness and sensitize district nurses about the issue The article discusses how the role of district nurses can be enhanced to improve recognition rates.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

Care management's challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults

Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.