Understanding patient-centred readmission factors: a multi-site, mixed-methods study

Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce

PURPOSE

Optimising dysphagia service delivery is crucial to minimise personal and service impacts associated with dysphagia. However, limited data exist on how to achieve this in Singapore. This study aimed to develop prioritised enhancements that the speech-language pathology workforce perceived as needed to improve dysphagia services in Singapore.

METHOD

Using a concept mapping approach, 19 speech-language pathologists (SLPs) and 10 managers listed suggestions for dysphagia service optimisation. Within their groups, the collated suggestions were sorted based on similarity, and individually rated on a 5-point scale based on importance and changeability. Using cluster and bivariate analysis, clusters of similar suggestions and prioritised suggestions for service optimisation were identified.

RESULT

The SLPs and managers proposed 73 and 51 unique suggestions respectively. Six clusters were identified for each group, with similar themes suggesting agreement of service improvements. All clusters were rated as more important than changeable. The managers perceived services as easier to change. The SLPs and managers rated 37% (27/73) and 43% (22/51) of suggestions, respectively, as high priority, with similarities relating to workforce capacity and capability, support and services access, care transitions, and telehealth services.

CONCLUSION

Prioritised enhancements identified by SLPs and managers provide direction for dysphagia service optimisation in Singapore.

Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes

OBJECTIVE

To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes.

METHODS

This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions.

RESULTS

The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396).

CONCLUSION

Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups.

LEVEL OF EVIDENCE: 3

Laryngoscope, 134:954-962, 2024.

Multimodal home-based rehabilitation intervention after discharge from inpatient geriatric rehabilitation (GeRas): study protocol for a multicenter randomized controlled trial

BACKGROUND

Geriatric rehabilitation aims to maintain the functional reserves of older adults in order to optimize social participation and prevent disability. After discharge from inpatient geriatric rehabilitation, patients are at high risk for decreased physical capacity, increased vulnerability, and limitations in mobility. As a result, ageing in place becomes uncertain for a plethora of patients after discharge from geriatric rehabilitation and effective strategies to prevent physical decline are required. Collaboration between different health-care providers is essential to improve continuity of care after discharge from inpatient geriatric rehabilitation. The aim of this study is to evaluate the effectiveness of a multi-professional home-based intervention program (GeRas) to improve functional capacity and social participation in older persons after discharge from inpatient geriatric rehabilitation.

METHODS

The study is a multicenter, three-arm, randomized controlled trial with a three-month intervention period. Two hundred and seventy community-dwelling older people receiving inpatient geriatric rehabilitation will be randomized with a 1:1:1 ratio to one of the parallel intervention groups (conventional IG or tablet IG) or the control group (CG). The participants of both IGs will receive a home-based physical exercise program supervised by physical therapists, a nutritional recommendation by a physician, and social counseling by social workers of the health insurance company. The collaboration between the health-care providers and management of participants will be realized within a cloud environment based on a telemedicine platform and supported by multi-professional case conferences. The CG will receive usual care, two short handouts on general health-related topics, and facultative lifestyle counseling with general recommendations for a healthy diet and active ageing. The primary outcomes will be the physical capacity measured by the Short Physical Performance Battery and social participation assessed by the modified Reintegration to Normal Living Index, three months after discharge.

DISCUSSION

The GeRas program is designed to improve the collaboration between health-care providers in the transition from inpatient geriatric rehabilitation to outpatient settings. Compared to usual care, it is expected to improve physical capacity and participation in geriatric patients after discharge from inpatient geriatric rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00029559). Registered on October 05, 2022.

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project

PURPOSE OF STUDY

Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission.

PRIMARY PRACTICE SETTING

The setting was a vertically integrated health care system located in Northern California.

METHODOLOGY AND SAMPLE

This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings.

RESULTS

Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).

"And if my goal is never to leave Casey House?": The significance of place attachment for patients at a specialty HIV hospital in Toronto, Canada

The current healthcare context prioritizes shorter hospital stays and fewer readmissions. However, these measures may not fully capture care experiences for people living with HIV, especially those experiencing medical, psychosocial, and economic complexity. As part of a larger study, we conducted seven focus groups with people living with HIV (n = 52), who were current/former patients at a Toronto-based specialty hospital, examining their desires/needs for hospital programs. Using a novel place attachment lens, we conducted a thematic analysis focusing on the emotional bond between person (patient) and place (hospital). Our findings show that participants wanted an ongoing connection to hospital to fulfill their need(s) for control, security, restoration and belonging. Indeed, continual attachment to hospital may be beneficial for patients with complex care needs. Our research has implications for care engagement and retention frameworks.

Prevalence of factors contributing to unplanned hospital readmission of older medical patients when assessed by patients, their significant others and healthcare professionals: a cross-sectional survey

OBJECTIVE

To describe the prevalence of factors contributing to readmission of older medical patients perceived by patients, significant others and healthcare professionals and to examine the agreement of factors contributing to readmission.

METHODS

This cross-sectional survey was conducted at Horsens Regional Hospital from September 2020 to June 2021. Patients aged ≥ 65 years and who were readmitted within 30 days were included. The questionnaire covered eight themes: disease; diagnosing, treatment and care; network; organisation; communication; skills and knowledge; resources; and practical arrangements. Response groups were patients, significant others, GPs, district nurses and hospital physicians. Outcomes were the prevalence of factors contributing to 30-day readmission and inter-rater agreement between respondents.

RESULTS

In total, 165 patients, 147 significant others, 115 GPs, 75 district nurses and 165 hospital physicians were included. The patients' median age was 79 years (IQR 74-85), and 44% were women. The following were the most prevalent contributing factors: (1) relapse of the condition that caused the index admission, (2) the patient could not manage the symptoms or illness, (3) worsening of other illnesses or conditions, (4) the patient was not fully treated at the time of discharge and (5) the patient's situation was too complex for the medical practice to handle. Kappas ranged from 0.0142 to 0.2421 for patient-significant other dyads and 0.0032 to 0.2459 for GP-hospital physician dyads.

CONCLUSION

From the perspectives of the included respondents, factors associated with the disease and its management were the most prevalent contributors to readmission for older medical patients. Agreement on the contributing factors was generally low.

TRIAL REGISTRATION

Clinical trial number NCT05116644. Registration date October 27, 2021.

Mixed-methods study examining family carers' perceptions of the relationship between intrahospital transitions and patient readiness for discharge

INTRODUCTION

Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals. However, carers frequently experience exclusion from care planning during IHTs, potentially decreasing their awareness of patients' clinical status, postdischarge needs and carer preparation. The purpose of this study was to explore family carers' perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.

METHODS

Sequential, explanatory mixed-methods study involving retrospective analysis of hospital inpatients from a parent study (1R01HS026248; PI Wallace) for whom patient and family carer Readiness for Hospital Discharge Scale (RHDS) score frequency of IHTs and patient and caregiver characteristics were available. Maximum variation sampling was used to recruit a subsample of carers with diverse backgrounds and experiences for the participation in semistructured interviews to understand their views of how IHTs influenced preparation for discharge.

RESULTS

Of discharged patients from July 2020 to April 2021, a total of 268 had completed the RHDS and 23 completed the semistructured interviews. Most patients experienced 0-2 IHTs and reported high levels of discharge readiness. During quantitative analysis, no association was found between IHTs and patients' RHDS scores. However, carers' perceptions of patient discharge readiness were negatively associated with increased IHTs. Moreover, non-spouse carers reported lower RHDS scores than spousal carers. During interviews, carers shared barriers experienced during IHTs and discussed the importance of inclusion during discharge care planning.

CONCLUSIONS

IHTs often represent disruptive events that may influence carers' understanding of patient readiness for discharge to home and, thus, their own preparation for discharge. Further consideration is needed regarding how to support carers during IHT to facilitate high-quality discharge planning.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury

OBJECTIVE

To investigate the association between higher injury severity and increased informal caregiving received by injured older adults.

SUMMARY OF BACKGROUND DATA

Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family.

METHODS

We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge.

RESULTS

We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week.

CONCLUSIONS

Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

Association of Diagnosed Dementia with Post-discharge Mortality and Readmission Among Hospitalized Medicare Beneficiaries

BACKGROUND

Patients with dementia are frequently hospitalized and may face barriers in post-discharge care.

OBJECTIVE

To determine whether patients with dementia have an increased risk of adverse outcomes following discharge.

DESIGN

Retrospective cohort study.

SUBJECTS

Medicare beneficiaries hospitalized in 2016.

MAIN MEASURES

Co-primary outcomes were mortality and readmission within 30 days of discharge. Multivariable logistic regression models were estimated to assess the risk of each outcome for patients with and without dementia accounting for demographics, comorbidities, frailty, hospitalization factors, and disposition.

KEY RESULTS

The cohort included 1,089,109 hospitalizations of which 211,698 (19.3%) were of patients with diagnosed dementia (median (IQR) age 83 (76-89); 61.5% female) and 886,411 were of patients without dementia (median (IQR) age 76 (79-83); 55.0% female). At 30 days following discharge, 5.7% of patients with dementia had died compared to 3.1% of patients without dementia (adjusted odds ratio (aOR) 1.21; 95% CI 1.17 to 1.24). At 30 days following discharge, 17.7% of patients with dementia had been readmitted compared to 13.1% of patients without dementia (aOR 1.02; CI 1.002 to 1.04). Dementia was associated with an increased odds of readmission among patients discharged to the community (aOR 1.07, CI 1.05 to 1.09) but a decreased odds of readmission among patients discharge to nursing facilities (aOR 0.93, CI 0.90 to 0.95). Patients with dementia who were discharged to the community were more likely to be readmitted than those discharged to nursing facilities (18.9% vs 16.0%), and, when readmitted, were more likely to die during the readmission (20.7% vs 4.4%).

CONCLUSIONS

Diagnosed dementia was associated with a substantially increased risk of mortality and a modestly increased risk of readmission within 30 days of discharge. Patients with dementia discharged to the community had particularly elevated risk of adverse outcomes indicating possible gaps in post-discharge services and caregiver support.

Development, implementation, and evaluation of Teach Back curriculum for community health workers

Teach Back is a commonly used communication method to improve patient understanding and retention of health information. The method has been shown to be effective in improving patient and healthcare system outcomes, including patient health literacy and hospital readmissions. Community health workers (CHWs) are frontline healthcare workers who can help address patient health and social needs associated with hospital readmissions. However, a gap exists in Teach Back curricula and training methods reflecting the scope of work for CHWs. The objective of this training was to provide CHWs with didactic information and skill building practice curriculum focused on the integration of Teach Back into clinical patient interactions, care coordination, and follow-up support. A multidisciplinary team of academic and clinical partners at a large academic health university developed, implemented, and evaluated a 3-week pilot Teach Back training with CHWs through a quality improvement approach. The CHWs reported overall satisfaction with the training and instructors. The academic clinical partnership allowed the training to be tailored to the daily clinical workflow as reflected in the CHWs agreement that the training was relevant and practical. With the repeated exposure to Teach Back each week, the CHWs also reported an increase in confidence and conviction in using Teach Back. Additional implementation and evaluation of the training curriculum for CHWs is needed to gain further insights into Teach Back and training best practices and translation into practice.

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home

BACKGROUND

The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention.

METHODS

This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims.

RESULTS

Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness.

CONCLUSION

The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing.

PATIENT OR PUBLIC CONTRIBUTION

This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.

Dismissal disagreement and discharge delays: Associations of patient-clinician plan of care agreement with discharge outcomes

BACKGROUND

Many hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.

OBJECTIVE

To measure the correlation between patient-clinician care agreement and discharge outcomes.

DESIGN

A prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).

SETTING AND PARTICIPANTS

Internal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019-March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.

MAIN OUTCOME AND MEASURES

Patient-clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30-day readmission was measured. Then, associations between patient-clinician agreement, delayed discharge, and 30-day readmissions were analyzed using multivariable logistic regression.

RESULTS

Of the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient-clinician agreement scores were not significantly correlated with discharge outcomes. Patient-clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home-goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).

CONCLUSIONS

Patients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.

Health literacy in medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

When discharged from hospital patients are often assumed to have sufficient health literacy (HL) to participate in their medical treatment and manage medical self-care after discharge. However, limited HL is a widespread concern and patient participation during discharge is lacking. In this study, we explore how HL influences medication communication during hospital discharge.

DESIGN

A qualitative case study, comprising unstructured observations of patient-healthcare personnel (HCP) encounters followed by semistructured interviews. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANT

Fifteen patients aged 40-89 years were included close to the day of discharge.

RESULTS

The following themes describing dimensions of HL emerged: (1) access, (2) understand, (3) appraise and (4) apply. Most patients sought access to medication information from HCP, while some felt dependent on HCP to provide it. However, their abilities to understand, evaluate and make informed decisions were challenged, partly because HCPs' ability to adapt their communication to the patient's knowledgebase varied.

CONCLUSION

The results give a broader understanding of how HL influences medication communication during hospital discharge. To consider central dimensions of HL is important to achieve optimal medication communication, as the communication only can be exercised within the frames of the patient's HL. The findings in this study support that HL should be described as a shared responsibility between the patients and HCP. Attention should be focused to the HCP's responsibility to adapt the communication to the patient's knowledgebase.

Development and validation of a social vulnerabilities survey for medical inpatients

OBJECTIVES

Our objective was to validate a Social Vulnerabilities Survey that was developed to identify patient barriers in the following domains: (1) salience or priority of health; (2) social support; (3) transportation; and (4) finances.

DESIGN

Cross-sectional psychometric study.Questions for one domain (health salience) were developed de novo while questions for the other domains were derived from national surveys and/or previously validated questionnaires. We tested construct (ie, convergent and discriminative) validity for these new questions through hypothesis testing of correlations between question responses and patient characteristics. Exploratory factor analysis was conducted to determine structural validity of the survey as a whole.

SETTING

Patients admitted to the inpatient internal medicine service at a tertiary care hospital in Calgary, Canada.

PARTICIPANTS

A total of 406 patients were included in the study.

RESULTS

The mean age of respondents was 55.5 (SD 18.6) years, with the majority being men (55.4%). In feasibility testing of the first 107 patients, the Social Vulnerabilities Survey was felt to be acceptable, comprehensive and met face validity. Hypothesis testing of the health salience questions revealed that the majority of observed correlations were exactly as predicted. Exploratory factor analysis of the global survey revealed the presence of five factors (eigenvalue >1): social support, health salience, drug insurance, transportation barriers and drug costs. All but four questions loaded to these five factors.

CONCLUSIONS

The Social Vulnerabilities Survey has face, construct and structural validity. It can be used to measure modifiable social vulnerabilities, such that their effects on health outcomes can be explored and understood.

‘Is my journey destination home?’ Exploring the experiences of older adults who undertake a transition care programme: a qualitative study

Transition care programmes (TCP) provide older adults with goal-oriented rehabilitation after hospitalisation. However, limited research has focused on understanding older adults' experiences when undertaking TCP. Using a phenomenological approach, we explored the lived experience of older adults undertaking a TCP at a transition care facility in Australia. A purposive sample (N = 33 participants: 16 older adults, four family members and 13 staff) was recruited. Semi-structured interviews were undertaken at three time-points during admission and inductive thematic analysis was utilised. Older adults reflected on their TCP experiences through an emotional lens through which they deliberated, ‘is my destination home?’ Fear of losing independence and uncertainty about their discharge destination strongly influenced older adults' perspectives regarding their TCP experience. Emotional responses, both positive and negative, were influenced by expectations prior to admission, level of family support and staff behaviour. Staff and family concurred that many older adults were confused about their admission to the facility and initially were unprepared to engage in the rehabilitation provided. Older adults experienced TCP as a time of great uncertainty and feared the unknown when discharged from hospital to transition care. They expressed grief at the loss of existing life roles and anxiety about the possibility of being unable to return home. Health professionals need to inform and tailor rehabilitation for older adults to better support this transient time of life.

The Perioperative Patient Experience During COVID-19

Background

Access to elective surgical procedures has been impacted by the COVID-19 pandemic.

Methods

We sought to understand the patient experience by developing and distributing an anonymous online survey to those who underwent non-emergency surgery at a large academic tertiary medical center between March and October 2020.

Results

The survey was completed by 184 patients; the majority were white (84%), female (74.6%), and ranged from 18 to 88 years old. Patients were likely unaware of case delay as only 23.6% reported a delay, 82% of which agreed with that decision. Conversely, 44% felt that the delay negatively impacted their quality of life. Overall, 82.7% of patients indicated high satisfaction with their care. African American patients more often indicated a “neutral” vs “satisfactory” hospital experience (P < .05) and considered postponing their surgery (P < .01). Interestingly, younger patients (<60) were more likely than older (≥60) patients to note anxiety associated with having surgery during the pandemic (P < .01), feeling unprepared for discharge (P < .02), not being allowed visitors (P < .02), and learning about the spread of COVID-19 from health care providers (P < .02).

Discussion

These results suggest that patients are resilient and accepting of changes to health care delivery during the current pandemic; however, certain patient populations may have higher levels of anxiety which could be addressed by their care provider. These findings can help inform and guide ongoing and future health care delivery adaptations in response to care disruptions.

Bridging the impactibility gap in population health management: a systematic review

OBJECTIVES

Assess whether impactibility modelling is being used to refine risk stratification for preventive health interventions.

DESIGN

Systematic review.

SETTING

Primary and secondary healthcare populations.

PAPERS

Articles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms 'intervenability', 'amenability', and 'propensity to succeed' (PTS) and associated with the themes 'care sensitivity', 'characteristic responders', 'needs gap', 'case finding', 'patient selection' and 'risk stratification'.

INTERVENTIONS

Qualitative synthesis to identify themes for approaches to impactibility modelling.

RESULTS

Of 1244 records identified, 20 were eligible for inclusion. Identified themes were 'health conditions amenable to care' (n=6), 'PTS modelling' (n=8) and 'comparison or combination with clinical judgement' (n=6). For the theme 'health conditions amenable to care', changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For 'PTS modelling', high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The 'comparison or combination with clinical judgement' theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum.

CONCLUSIONS

The efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

Readiness for hospital discharge in primary caregivers for children with acute lymphoblastic leukaemia

AIM

To investigate existing status and factors affecting the readiness for hospital discharge in primary caregivers for children with acute lymphoblastic leukaemia in China.

BACKGROUND

Acute lymphoblastic leukaemia is the most common childhood cancer, but there is not enough research on the readiness for hospital discharge.

DESIGN

A cross-sectional study was performed by convenience sampling and questionnaire survey.

METHODS

A self-developed questionnaire of general and clinical characteristics of patients, self-developed questionnaire of general status of family and primary caregivers, questionnaire of readiness of hospital discharge scale and social support rating scale for primary caregivers were delivered to 264 primary caregivers of childhood acute lymphoblastic leukaemia patients. Data collection was carried out 24 h before discharge at bedside. In this study, the STROBE checklist was followed.

RESULTS

In total, 253 patients aged 0-16 years, including their primary caregivers in the hospital, were included from November 2016 to August 2017. Based on the readiness scale, the total mean score of readiness was 157.36. Based on the social support scale, the total mean score was 42.17. According to multivariate analysis, periods of chemotherapy (p < .001), complications (p = .019), family economic situation (p = .023), understanding of leukaemia (p < .001), objective support (p = .004), subjective support (p < .001) and availability of support (p = .045) were the main influencers of readiness.

CONCLUSIONS

The readiness for hospital discharge in primary caregivers for childhood lymphoblastic leukaemia patients is not satisfactory in China.

RELEVANCE TO CLINICAL PRACTICE

This study has implications for public health administration, asking for better community services and disease education. In addition, more effort should be made to provide high-quality family and primary caregiver assessments and discharge education by nurses.

The Experience of Chronic Illness Transitional Care: A Qualitative Systematic Review

This is a qualitative systematic review of recent qualitative studies of the experiences and perceptions of both individuals with chronic illness(es) and their caregivers regarding hospital-to-home transitions. Thematic synthesis was used to identify common themes from seven qualitative studies published from 2012 to 2021 and extracted from four electronic databases. This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Quality appraisal was assessed and adequate methodological rigor was determined. A total of three barriers to transitional care (communication with multiple healthcare providers, self-management, and psychological stress) and two facilitators of transitional care (family caregiver support and nurse-provided patient-centered care) were identified. These findings can be used by nursing research and healthcare managers to reform transitional care practices for chronic illnesses and caregivers.

Socio-demographic and -economic factors associated with 30-day readmission for conditions targeted by the hospital readmissions reduction program: a population-based study

Background

Early hospital readmissions remain common in patients with conditions targeted by the CMS Hospital Readmission Reduction Program (HRRP). There is still no consensus on whether readmission measures should be adjusted based on social factors, and there are few population studies within the U.S. examining how social characteristics influence readmissions for HRRP-targeted conditions. The objective of this study was to determine if specific socio-demographic and -economic factors are associated with 30-day readmissions in HRRP-targeted conditions: acute exacerbation of chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, and heart failure.

Methods

The Nationwide Readmissions Database was used to identify patients admitted with HRRP-targeted conditions between January 1, 2010 and September 30, 2015. Stroke was included as a control condition because it is not included in the HRRP. Multivariate models were used to assess the relationship between three social and economic characteristics (gender, urban/rural hospital designation, and estimated median household income within the patient’s zip code) and 30-day readmission rates using a hierarchical two-level logistic model. Age-adjusted models were used to assess relationship differences between Medicare vs. non-Medicare populations.

Results

There were 19,253,997 weighted index hospital admissions for all diagnoses and 3,613,488 30-day readmissions between 2010 and 2015. Patients in the lowest income quartile (≤$37,999) had an increased odds of 30-day readmission across all conditions (P < 0.0001). Female gender and rural hospital designation were associated with a decreased odds of 30-day readmission for most targeted conditions (P < 0.05). Similar findings were also seen in patients ≥65 years old.

Conclusions

Socio-demographic and -economic factors are associated with 30-day readmission rates and should be incorporated into tools or interventions to improve discharge planning and mitigate against readmission.

An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population

BACKGROUND/OBJECTIVE

Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans.

METHODS

In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate.

RESULTS

The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up.

CONCLUSIONS

A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

Tailored Education Increased Capability and Motivation for Fall Prevention in Older People After Hospitalization

Recently hospitalized older people are at risk of falls and face barriers to undertaking fall prevention strategies after they return home from hospital. The authors examined the effects of tailored education delivered by physiotherapists on the knowledge (capability) and the motivation of older people to engage in fall prevention after hospital discharge. Utilizing data gathered from a recent trial, data was analyzed from 390 people who were 60 years and over without impaired cognition (>7/10 abbreviated mental test score) and discharged from three Australian hospitals. Motivation and capability were measured at baseline in the hospital and at 6-months after hospital discharge by blinded assistants using structured surveys. Bivariate analysis using generalized linear modeling explored the impact of education on the capability and motivation. Engagement in fall prevention strategies was entered as an independent variable during analysis to determine associations with capability and motivation. The education significantly improved capability [-0.4, 95% CI (-0.7, -0.2), p < 0.01] and motivation [-0.8, 95% CI (-1.1, -0.5), p < 0.01] compared with social-control at the time of hospital discharge. In contrast, social-control participants gained capability and motivation over the 6-months, and no significant differences were found between groups in capability [0.001, 95% CI (-0.2, 0.2), p = 0.9] and motivation [-0.01, 95% CI (-0.3, 0.3), p = 0.9] at follow-up. Tailored fall prevention education is recommended around hospital discharge. Participants still needed to overcome barriers to falls prevention engagement post hospitalization. Thus, tailored education along with direct clinical services such as physiotherapy and social supports is warranted for older people to avoid falls and regain function following hospitalization.

Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis

BACKGROUND

Although Transition Care Programmes (TCP) are designed to assist older adults to regain functional ability after hospitalisation, it is unclear whether TCP improve older adults' health-related outcomes.

OBJECTIVES

The objective of the review was to synthesise the best available evidence for the effectiveness of TCP on health-related outcomes for older adults admitted to a transition care facility after hospitalisation.

METHODS

Searches were conducted using the databases PubMed, AMED (Ovid), Embase (Ovid), PscyINFO (Ovid) and CINAHL (Full text) and grey literature from January 2000 to May 2020 in English only. Studies that reported health-related outcomes of older adults (aged 65 and above) who received TCP in a facility setting were deemed eligible for inclusion following critical appraisal by two reviewers. Data were pooled in meta-analysis where possible, or reported narratively.

RESULTS

A total of 21 studies from seven countries [(n = 5 RCT, n = 16 observational cohort studies) participants' mean age 80.2 (±8.3)] were included. Pooled analysis (2069 participants, 7 studies) demonstrated that 80% of older adults undertaking TCP were discharged home [95% CI (0.78-0.82, p < 0.001), I² = 21.99%, very low GRADE evidence]. Proportions of older adults discharged home varied widely between countries (33.3%-86.4%). There was a significant improvement in ability to perform activities of daily living (2001 participants, 7 studies) as measured by the Modified Barthel Index [17.65 points (95% CI 5.68-29.62, p = 0.004), I²  = 0.00%, very low GRADE evidence].

CONCLUSIONS

The proportion of older adults discharged home from TCP compared to other discharge destinations differs between countries. This could be due to the intensity of the rehabilitation delivered and the maximum length of stay allowed prior to discharge.

IMPLICATIONS FOR PRACTICE

Future studies that comprehensively evaluate the efficacy of TCP on health-related outcomes including quality of life are required. Further investigation is required to identify which aspects of TCP affect successful discharge home.

Effectiveness of a nurse-led hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms.

DESIGN AND SETTING

Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control).

PARTICIPANTS

127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms.

INTERVENTION

This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months.

OUTCOME MEASURES

The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling.

RESULTS

Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group.

CONCLUSIONS

Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03157999.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

Readiness for Discharge from Hospital after Myocardial Infarction: A Cross-Sectional Study

Myocardial infarction (MI) is a common cause of cardiovascular deaths. Education of patients with myocardial infarctions essential to prevent further cardiovascular events and reduce the risk of mortality. The study aimed to evaluate the associations between patients’ readiness for hospital discharge after myocardial infarction, acceptance of illness, social, demographic, and clinical factors. The study used a cross-sectional design and included 102 patients, who were hospitalized for myocardial infarction after percutaneous coronary intervention (PCI). Two questionnaires were used: The Readiness for Hospital Discharge After Myocardial Infarction Scale (RHD-MIS) and Acceptance of Illness Scale (AIS). Low readiness characterized nearly half of patients (47.06%), 27.45% of patients showed an intermediate level of readiness, while 25.49% of patients had high readiness. Readiness for hospital discharge was higher among younger patients, respondents living in relationships, living with a family, with tertiary or secondary education, and professionally active. Acceptance of illness was higher among male patients, respondents living in relationships, and family, with secondary education and professionally active. The AIS score positively correlated with readiness for hospital discharge.

Evaluating the provision of Further Enabling Care at Home (FECH+) for informal caregivers of older adults discharged home from hospital: protocol for a multicentre randomised controlled trial

INTRODUCTION

There are personal and societal benefits from caregiving; however, caregiving can jeopardise caregivers' health. The Further Enabling Care at Home (FECH+) programme provides structured nurse support, through telephone outreach, to informal caregivers of older adults following discharge from acute hospital care to home. The trial aims to evaluate the efficacy of the FECH+ programme on caregivers' health-related quality of life (HRQOL) after care recipients' hospital discharge.

METHODS AND ANALYSIS

A multisite, parallel-group, randomised controlled trial with blinded baseline and outcome assessment and intention-to-treat analysis, adhering to Consolidated Standards of Reporting Trials guidelines will be conducted. Participants (N=925 dyads) comprising informal home caregiver (18 years or older) and care recipient (70 years or older) will be recruited when the care recipient is discharged from hospital. Caregivers of patients discharged from wards in three hospitals in Australia (one in Western Australia and two in Queensland) are eligible for inclusion. Participants will be randomly assigned to one of the two groups. The intervention group receive the FECH+ programme, which provides structured support and problem-solving for the caregiver after the care recipient's discharge, in addition to usual care. The control group receives usual care. The programme is delivered by a registered nurse and comprises six 30-45 min telephone support sessions over 6 months. The primary outcome is caregivers' HRQOL measured using the Assessment of Quality of Life-eight dimensions. Secondary outcomes include caregiver preparedness, strain and distress and use of healthcare services. Changes in HRQOL between groups will be compared using a mixed regression model that accounts for the correlation between repeated measurements.

ETHICS AND DISSEMINATION

Participants will provide written informed consent. Ethics approvals have been obtained from Sir Charles Gairdner and Osborne Park Health Care Group, Curtin University, Griffith University, Gold Coast Health Service and government health data linkage services. Findings will be disseminated through presentations, peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620000060943.

The factors of patient-reported readiness for hospital discharge in patients with depression: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: The attributes of readiness for hospital discharge (RHD) have been identified to be physical stability, adequate support, psychological ability, and adequate information and knowledge. Patient-reported RHD has been regarded as an outcome indicator, and poor RHD leads to unplanned readmission, emergency department visits and even death. Knowledge regarding patient-reported RHD and its factors among patients with depression is limited. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: RHD among patients with depression is at a moderate level. More than a quarter of people with depression had low RHD. The knowledge dimension of the RHDS among patients with depression should be further strengthened. The length of stay, content received and delivery dimensions of the QDTS were significantly associated with RHD. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study encourages nurses to assess patient-reported RHD at discharge in mental health settings. Nurses should pay more attention to patients with hospital stays longer than 20 days. Nurses could improve RHD by enhancing the quality of discharge teaching, particularly the content received and the skills nurses used to deliver such content. Nurses' managers could develop programmes to improve teaching skills via Internet technology, such as simulated patients and online interprofessional discharge planning. ABSTRACT: Introduction Low readiness for hospital discharge (RHD) can be followed by negative healthcare outcomes. However, no studies have investigated RHD among patients with depression. Aim This study aimed to examine patient-reported RHD and its factors among patients with depression. Method In total, 367 inpatients with depression were recruited and completed the Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS). A binary logistic regression analysis was performed to explore the factors of RHD among patients with depression. Results The total RHDS score was 7.70 ± 1.52. Approximately 28.9% of the participants had low RHD (RHDS score < 7). The results revealed that RHD was significantly associated with the length of stay, content received and delivery. Discussion RHD among patients with depression is at a moderate level. More than a quarter of people with depression had low RHD. To improve RHD, enhancing the quality of discharge teaching is imperative for patients with depression. Implications for Practice Nurses should pay more attention to patients with a hospital stay longer than 20 days. Nurses could improve RHD by enhancing the quality of discharge teaching, particularly the content received and the skills nurses used to deliver such content.

Discharge Practices for COVID-19 Patients: Rapid Review of Published Guidance and Synthesis of Documents and Practices at 22 US Academic Medical Centers

BACKGROUND

There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital.

OBJECTIVE

To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices.

DESIGN

Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN).

RESULTS

We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up.

LIMITATIONS

We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers.

CONCLUSION

AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied.

Capturing rich person-centred discharge information: exploring the challenges in developing a new model

Purpose

Capture, consumption and use of person-centred information presents challenges for hospitals when operating within the scope of limited resources and the push for organisational routines and efficiencies. This paper explores these challenges for patients with Acute Coronary Syndrome (ACS) and the examination of information that supports successful hospital discharge. It aims to determine how the likelihood of readmission may be prevented through the capturing of rich, person-specific information during in-patient care to improve the process for discharge to home.

Design/methodology/approach

The authors combine four research data collection and analysis techniques: one, an analysis of the patient record; two, semi-structured longitudinal interviews; three, an analysis of the patient's journey using process mining to provide analytics about the discharge process, and four, a focus group with nurses to validate and confirm our findings.

Findings

The authors’ contribution is to show that information systems which support discharge need to consider models focused on individual patient stressors. The authors find that current discharge information capture does not provide the required person-centred information to support a successful discharge. Data indicate that rich, detailed information about the person acquired through additional nursing assessments are required to complement data provided about the patient's journey in order to support the patients’ post-discharge recovery at home.

Originality/value

Prior research has focused on information collection constrained by pre-determined limitations and barriers of system design. This work has not considered the information provided by multiple sources during the whole patient journey as a mechanism to reshape the discharge process to become more person-centred. Using a novel combination of research techniques and theory, the authors have shown that patient information collected through multiple channels across the patient care journey may significantly extend the quality of patient care beyond hospital discharge. Although not assessed in this study, rich, person-centred discharge information may also decrease the likelihood of patient readmission.

Treatment provision for adults with ADHD during the COVID-19 pandemic: an exploratory study on patient and therapist experience with on-site sessions using face masks vs. telepsychiatric sessions

BACKGROUND

Maintaining the therapeutic care of psychiatric patients during the first wave of the COVID-19 pandemic in Switzerland required changes to the way in which sessions were conducted, such as telepsychiatric interventions or using face masks during on-site sessions. While little is known about how face masks affect the therapeutic experience of patients and therapists, the effectiveness of telepsychiatry is well documented for several psychiatric disorders. However, research on the benefits of telepsychiatry in adult patients with attention-deficit/hyperactivity disorder (ADHD) remains scarce. This seems problematic since the symptoms typically associated with ADHD, such as attention problems and distractibility, may lessen the utility of telepsychiatry for this particular group. The present study's aim was to explore how adult patients with ADHD and their therapists experienced therapy sessions during the COVID-19 pandemic in three different settings: face-to-face with the therapist wearing a face mask, via telephone, or via videoconferencing.

METHODS

In this exploratory, quantitatively driven mixed-method study (quantitative questionnaire data and qualitative data from open-ended responses), we assessed patients' evaluation of the session, their treatment satisfaction, and patients' and therapists' ratings of therapeutic alliance. We also collected qualitative comments on both sides' experience of the session. Overall, 97 therapist and 66 patient questionnaires were completed. Results are reported for the N = 60 cases for which data from both parties were available. Sequential multiple regressions adjusted for therapist and number of sessions were used for the main quantitative analyses.

RESULTS

No statistically significant differences regarding session flow, post-session positivity, satisfaction and therapeutic alliance were observed. The only exception was that telepsychiatric sessions were rated as significantly less deep than face-to-face sessions, an effect that may decline over time, especially in the videoconferencing group. Patients and therapists identified similar facilitating and complicating aspects, but differed in their emphasis of specific elements.

CONCLUSIONS

Both settings, on-site with the therapist wearing a face mask and telepsychiatric, seem to be valid options to continue treatment of adults with ADHD during a situation such as the COVID-19 pandemic. Aspects such as patient preference, session content, and therapeutic methods may be useful to identify the most suitable modality.

Relationships Between Time-at-Bedside During Hospital Ward Rounds, Clinician-Patient Agreement, and Patient Experience

Hospital medicine ward rounds are often conducted away from patients’ bedsides, but it is unknown if more time-at-bedside is associated with improved patient outcomes. Our objective is to measure the association between “time-at-bedside,” patient experience, and patient–clinician care agreement during ward rounds. Research assistants directly observed medicine services to quantify the amount of time spent discussing each patient’s care inside versus outside the patient’s room. “Time-at-bedside” was defined as the proportion of time spent discussing a patient’s care in his or her room. Patient experience and patient–clinician care agreement both were measured immediately after ward rounds. Results demonstrated that the majority of patient and physicians completely agreement on planned tests (66.3%), planned procedures (79.7%), medication changes (50.6%), and discharge location (66.9%), but had no agreement on the patient’s main concern (74.4%) and discharge date (50.6%). Time-at-bedside was not correlated with care agreement or patient experience (P > .05 for all comparisons). This study demonstrates that spending more time at the bedside during ward rounds, alone, is insufficient to improve patient experience.

Framework for patient, family-centred care within an Australian Community Hospital: development and description

OBJECTIVE

To describe the development of a patient and family-centred care (PFCC) conceptual framework within a small community Australian Hospital.

METHODS

A scoping review of scientific and grey literature and community hospital stakeholder discussions were used to identify and design a conceptual framework for PFCC across five core pillars of leadership, engagement, service delivery, learning and environment.

RESULTS

107 publications were identified and 76 were included for data extraction. A draft framework was constructed and modified following consultation with hospital stakeholders across a small Australian Community Hospital. The 'Caring Together' framework outlines three core layers: (1) the focus of our care is the experiences of our consumers and staff; (2) concepts of leadership, environment, service delivery, engagement and learning; and (3) the overarching fundamental values of being heard, respected, valued and supported by staff and consumers at all levels in an organisation.

CONCLUSIONS

The conceptual Caring Together framework structures key PFCC concepts across organisational priority areas within an Australian healthcare setting and can be used to guide implementation of PFCC at other small hospital facilities. Changes to national and state healthcare funding may help facilitate improved hospital facility implementation of PFCC, and ultimately improve consumer healthcare satisfaction and clinical outcomes.

Does Feedback to Physicians of a Patient-Reported Readiness for Discharge Checklist Improve Discharge?

Limited data exist describing how hospital discharge readiness checklists might be incorporated into care. To evaluate how assessing patient readiness for discharge effects discharge outcomes. We assessed hospitalized adults' readiness for discharge daily using a checklist. In the first feedback period, readiness data were given to patients, compared to the second feedback period, where data were given to patients and physicians. In the first feedback period, 163 patients completed 296 checklists, and in the second feedback period, 179 patients completed 371 checklists. In the first feedback period, 889 discharge barriers were identified, and 1154 in the second feedback period (P = .27). We found no association between the mean number of discharge barriers by hospital day and whether data were provided to physicians (P = .39). Eighty-nine physicians completed our survey, with 76 (85%) recalling receiving checklist data. Twenty-three (30%) of these thought the data helpful, and 45 (59%) stated it "never" or "rarely" highlighted anything new. Patients continued to report discharge barriers even when physicians received patient-reported data about key discharge transition domains.

A Nurse-Led Bridging Program to Reduce 30-Day Readmissions of Older Patients Discharged From Acute Care Units

OBJECTIVES

Older hospitalized patients are at high risk of early readmissions, requiring the implementation of enhanced coordinated transition programs on discharge. The objective of this study was to evaluate the impact of a nurse-led transition bridging program on the rate of unscheduled readmissions of older patients within 30 days from discharge from geriatric acute care units.

DESIGN

A stepped-wedge cluster randomized trial.

SETTING AND PARTICIPANTS

Seven hundred five patients aged ≥75 years hospitalized in one of 10 acute geriatric units, with at least 2 readmission risk-screening criteria (derived from the Triage Risk Screening Tool), were included from July 2015 to August 2016.

METHODS

The intervention condition consisted in a nurse-led hospital-to-home bridging program with 4 weeks postdischarge follow-up (2 home visits and 2 telephone calls). Unscheduled hospital readmission or emergency department (ED) visits were compared in intervention and control condition within 30 days from discharge.

RESULTS

The rate of 30-day readmission or ED visit was 15.5% in the intervention condition vs 17.6% in the control condition [hazard ratio stratified on clusters: 0.61 (upper limit unilateral 95% confidence interval = 1.11), P = .09]. Rate of presence of professional caregivers was increased in the intervention condition (P < .001).

CONCLUSIONS AND IMPLICATIONS

Although the intervention resulted in an increase in the rate of implementation of a package of care at the 4-week of follow-up, we could not demonstrate a reduction in the rate of 30-day readmissions or ED visits of older patients at risk of readmission. These findings support the evaluation of this type of program on the longer term.

Perspectives of older adults regarding barriers and enablers to engaging in fall prevention activities after hospital discharge

Older adults recently discharged from hospital are at high risk of functional decline and falls. A tailored fall prevention education provided at hospital discharge aimed to improve the capacity of older adults to engage in falls prevention activities. What remains unknown are the factors affecting behaviour change after hospital discharge. This study identified the perceived barriers and enablers of older adults to engagement in fall prevention activities during the 6-month period post-discharge. An exploratory approach using interpretative phenomenological analysis focused on the lived experience of a purposive sample (n = 30) of participants. All were recruited as a part of an RCT (n = 390) that delivered a tailored fall prevention education program at three hospital rehabilitation wards in Perth, Australia. Data were collected at 6-month post-discharge using semi-structured telephone surveys. Personal stories confirmed that some older adults have difficulty recovering functional ability after hospital discharge. Reduced physical capability, such as experiences of fatigue, chronic pain and feeling unsteady when walking were barriers for participants to safely return to their normal daily activities. Participants who received the tailored fall education program reported positive effects on knowledge and motivation to engage in fall prevention. Participants who had opportunities to access therapy or social supports described more positive experiences of recovery compared to individuals who persevered without assistance. A lack of physical and social support was associated with apprehension and fear toward adverse events such as falls, injuries, and hospital readmission. The lived experience of participants following hospital discharge strongly suggested that they required more supports from both healthcare professionals and caregivers to ensure that their needs were met. Further research that evaluates how to assist this population to engage in programs that will mitigate the high risk of falls and hospital readmissions is required.

Validation of the Partners at Care Transitions Measure (PACT-M): assessing the quality and safety of care transitions for older people in the UK

BACKGROUND

The Partners at Care Transitions Measure (PACT-M) is a patient-reported questionnaire for evaluation of the quality and safety of care transitions from hospital to home, as experienced by older adults. PACT-M has two components; PACT-M 1 to capture the immediate post discharge period and PACT-M 2 to assess the experience of managing care at home. In this study, we aim to examine the psychometric properties, factor structure, validity and reliability of the PACT-M.

METHODS

We administered the PACT-M over the phone and by mail, within one week post discharge with 138 participants and one month after discharge with 110 participants. We performed principal components analysis and factors were assessed for internal consistency, reliability and construct validity.

RESULTS

Reliability was assessed by calculating Cronbach's alpha for the 9-item PACT-M 1 and 8-item PACT-M 2 and exploratory factor analysis was performed to evaluate dimensionality of the scales. Principal components analysis was chosen using pair-wise deletion. Both PACT-M 1 and PACT-M 2 showed high internal consistency and good internal reliability values and conveyed unidimensional scale characteristics with high reliability scores; above 0.8.

CONCLUSIONS

The PACT-M has shown evidence to suggest that it is a reliable measure to capture patients' perception of the quality of discharge arrangements and also on patients' ability to manage their care at home one month post discharge. PACT-M 1 is a marker of patient experience of transition and PACT-M 2 of coping at home.

Association of Patient-reported Experiences and Surgical Outcomes Among Group Practices: Retrospective Cohort Study

OBJECTIVE

The aim of the study was to determine the association of patient-reported experiences (PREs) and risk-adjusted surgical outcomes among group practices.

BACKGROUND

The Centers for Medicare and Medicaid Services required large group practices to submit PREs data for successful participation in the Physician Quality Reporting System (PQRS) using the Consumer Assessment of Healthcare Providers and Systems for PQRS survey. Whether these PREs data correlate with perioperative outcomes remains ill defined.

METHODS

Operations between January 1, 2014 and December 31, 2016 in the American College of Surgeons' National Surgical Quality Improvement Program registry were merged with 2015 Consumer Assessment of Healthcare Providers and Systems for PQRS survey data. Hierarchical logistic models were constructed to estimate associations between 7 subscales and 1 composite score of PREs and 30-day morbidity, unplanned readmission, and unplanned reoperation, separately, while adjusting for patient- and procedure mix.

RESULTS

Among 328 group practices identified, patients reported their experiences with clinician communication the highest (mean ± standard deviation, 82.66 ± 3.10), and with attention to medication cost the lowest (25.96 ± 5.14). The mean composite score was 61.08 (±6.66). On multivariable analyses, better PREs scores regarding medication cost, between-visit communication, and the composite score of experience were each associated with 4% decreased odds of morbidity [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.92-0.99], readmission (OR 0.96, 95% CI 0.93-0.99), and reoperation (OR 0.96, 95% CI 0.93-0.99), respectively. In sensitivity analyses, better between-visit communication remained significantly associated with fewer readmissions.

CONCLUSIONS

In these data, patients' report of better between-visit communication was associated with fewer readmissions. More sensitive, surgery-specific PRE assessments may reveal additional unique insights for improving the quality of surgical care.

A pragmatic randomized controlled trial of a cardiac hospital-to-home transitional care program in a Singapore academic medical center

Background

Rehospitalizations are common in healthcare. They are costly for hospitals and patients and a substantial percentage are preventable, partly because hospital-to-community transitions are often unmanaged or poorly managed. In this study, we conducted a pragmatic randomized, controlled trial to evaluate the effectiveness of a new nurse–practitioner-led transitional care program called CareHub, piloted in Singapore’s National University Hospital.

Methods

Study population included all eligible cardiac patients admitted between July 2016 and November 2016. Patients were followed for six months post-discharge. Primary outcomes other than emergency department visits were all cardiac-related: number of readmissions, specialist visits, emergency department visits, and total days readmitted. Secondary outcomes: variables related to quality of life and transitional care. Regression analyses were used to estimate the intent-to-treat effect of CareHub and explore treatment heterogeneity.

Results

CareHub reduced the mean number of unplanned readmissions by 0.23 (a 39% reduction relative to control mean of 0.60 unplanned readmissions, p < 0.05), mean number of all readmissions by 0.20 (31% reduction relative to control mean of 0.63 readmissions, p = 0.10), mean number of total unplanned days in hospital by 2.2 (56% reduction relative to control mean of 4.0 days, p < 0.05), mean number of total days in hospital by 2.0 (42% reduction relative to control mean of 4.3 days, p < 0.10). Treatment effects varied by pre-admission health and socio-economic status.

Conclusion

A carefully designed protocolized cardiac hospital-to-home transition program can reduce resource utilization while improving quality of life.

Colorectal patients' readiness for hospital discharge following management of enhanced recovery after surgery pathway: A cross-sectional study from China

The aim of this study was to ascertain the status quo of perceived readiness for hospital discharge in colorectal cancer patients who underwent enhanced recovery pathway and identify the variables that affect patients' perceptions about their readiness for discharge.A cross-sectional survey was conducted in West China Hospital, Sichuan University. The Readiness for Hospital Discharge Scale and the Quality of Discharge Teaching Scale were delivered to 130 colorectal cancer (CRC) patients who underwent enhanced recovery pathway. Data collection was carried out 4 hours before discharge.The total score of readiness for hospital discharge was 149.86 ± 33.65. The multiple linear regression analysis revealed that the quality of discharge teaching, discharge to a rehabilitative institution were associated with the readiness for hospital discharge.The level of CRC patients' readiness for hospital discharge needs to be improved. Medical staff should improve the quality of discharge guidance and pay more attention to patients transferred to rehabilitation institutions when they leave hospital.

Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping

BACKGROUND

Patients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement.

METHODS

We conducted group concept mapping over 11 months with patients-and their caregivers-who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual.

RESULTS

736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): 'Not enough publicly funded home care services to meet the need', 'Home care support is not in place when arriving home from hospital' and 'Having to advocate to get enough home care'. The top priority was consistent across multiple subgroups.

CONCLUSIONS

In a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.

Importance of Communication and Relationships: Addressing Disparities in Hospitalizations for African-American Patients in Academic Primary Care

BACKGROUND

There are many interventions to facilitate seamless continuity of care for patients in transition from hospital back to primary care; however, disparities remain in readmission rates for vulnerable populations, especially African-Americans.

OBJECTIVES

We set out to investigate the association of race and ethnicity with 30-day readmission in our urban academic setting and to identify factors that could be leveraged in primary care to address disparities in hospitalizations.

METHODS/APPROACH

Using data originally collected for quality improvement purposes, we evaluated 30-day readmission rates for our primary care patients (January 1, 2013-September 30, 2014) by race and ethnicity, adjusting for demographic and clinical characteristics. Then, using inductive and deductive methods, we coded semi-structured interviews with 24 African-American primary care patients who were discharged from the Medicine or Cardiology service at our tertiary care hospital during the study period.

KEY RESULTS

African-Americans had the highest readmission rate (21.7%) and a higher adjusted odds of readmission (1.37; 95% CI 1.04-1.81) compared to Whites. Five major themes emerged as having potential to be leveraged in primary care to help prevent multiple hospitalizations: (1) dependable patient-physician relationships, (2) healthcare coordination across settings, (3) continuity with one primary care provider (PCP), (4) disease self-management, and (5) trust in resident physicians. Participants also made several recommendations to keep patients like themselves from returning to the hospital: increased time to tell their story during their primary care visit, more direct patient-physician communication during the visit, and improved access between visits.

CONCLUSIONS

While African-American patients in our practice experience higher rates of hospital readmissions than their White counterparts, they emphasize the significance of their PCP relationship and communication to enhance disease management and prevent hospitalizations. Ongoing efforts are needed to establish and implement best practice communication trainings for patients at increased risk of hospitalization, particularly for resident physicians.

Effects of Accessible Health Technology and Caregiver Support Posthospitalization on 30-Day Readmission Risk: A Randomized Trial

INTRODUCTION

Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-to-use, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems.

METHODS

A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronary artery disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records.

RESULTS

Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31-1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts (p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11-0.87; p = 0.026).

CONCLUSION

The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses.

A randomized controlled trial to improve engagement of hospitalized patients with their patient portals

Objectives

To test a patient-centered, tablet-based bedside educational intervention in the hospital and to evaluate the efficacy of this intervention to increase patient engagement with their patient portals during hospitalization and after discharge.

Materials and Methods

We conducted a randomized controlled trial of adult patients admitted to the hospitalist service in one large, academic medical center. All participants were supplied with a tablet computer for 1 day during their inpatient stay and assistance with portal registration and initial login as needed. Additionally, intervention group patients received a focused bedside education to demonstrate key functions of the portal and explain the importance of these functions to their upcoming transition to post-discharge care. Our primary outcomes were proportion of patients who logged into the portal and completed specific tasks after discharge. Secondary outcomes were observed ability to navigate the portal before discharge and self-reported patient satisfaction with bedside tablet use to access the portal.

Results

We enrolled 97 participants (50 intervention; 47 control); overall 57% logged into their portals ≥1 time within 7 days of discharge (58% intervention vs. 55% control). Mean number of logins was higher for the intervention group (3.48 vs. 2.94 control), and mean number of specific portal tasks performed was higher in the intervention group; however, no individual comparison reached statistical significance. Observed ability to login and navigate the portal in the hospital was higher for the intervention group (64% vs. 60% control), but only 1 specific portal task was significant (view provider messaging tab: 92% vs. 77% control, P = .04). Time needed to deliver the intervention was brief (<15 min for 80%), and satisfaction with the bedside tablet to access the portal was high in the intervention group (88% satisfied/very satisfied).

Conclusion

Our intervention was highly feasible and acceptable to patients, and we found a highly consistent, but statistically non-significant, trend towards higher inpatient engagement and post-discharge use of key portal functions among patients in the intervention group.

Falls After Hospital Discharge: A Randomized Clinical Trial of Individualized Multimodal Falls Prevention Education

BACKGROUND

Older people are at high risk of falls after hospital discharge. The study aimed to evaluate the effect of providing individualized falls prevention education in addition to usual care on falls rates in older people after hospital discharge compared to providing a social intervention in addition to usual care.

METHODS

A randomized clinical trial at three hospitals in Western Australia: participants followed for 6 months after discharge. Baseline and outcomes measured by assessors masked to group allocation. Participants: aged 60 years and over, admitted for rehabilitation. Eligibility included: cognitively able to undertake education (Abbreviated mental test score >7/10). Intervention: tailored education comprising patient video and workbook, structured discussion and goal setting led by trained therapist. Main outcomes: falls in the 6 months after discharge; proportion of participants sustaining one or more falls.

RESULTS

There were 382 (194 intervention; 188 control) participants (mean age 77.7 [SD 8.7] years). There were 378 falls (fall rate per 1,000 patient-days, 5.9 intervention; 5.9 control) reported by 164 (42.9%) participants in the 6 months following hospital discharge; 188 (49.7%) of these falls were injurious. There were no significant differences in falls rates between intervention and control groups: (adjusted IRR, 1.09; 95% CI [0.78 to 1.52]) or the proportion of participants who fell once or more (adjusted OR, 1.37; 95% CI [0.90 to 2.07]).

CONCLUSIONS

Providing individualized falls prevention education prior to discharge did not reduce falls at home after discharge. Further research is warranted to investigate how to reduce falls during this high-risk transition period.

Developing a measure to assess the quality of care transitions for older people

BACKGROUND

The transition of older patients (over 65 years of age) from hospital to their own home is a time when patients are at high risk. No measure currently exists to assess the experience, quality and safety of care transitions relevant to UK population. We aim to describe the development and initial testing of the Partners at Care Transitions Measure (PACT-M) as a patient-reported questionnaire for evaluation of the quality and safety of care transitions from hospital to home in older patients.

METHODS

We used an established measure development procedure which includes conceptualising the components of care transitions, item development, conducting a modified Delphi process and pilot-testing of the PACT-M with patients over 65 years old using telephone administration.

RESULTS

Pilot testing of the PACT-M suggests that the components identified cover the issues of most importance to patients. Face validity testing showed that the measure in its current form is acceptable to older patients.

CONCLUSIONS

The measure developed in this study shows promise for use by those involved in planning, implementing and evaluating discharge care, and could be used to inform interventions to improve the transition from hospital to home for older patients.

How older people enact care involvement during transition from hospital to home: A systematic review and model

Background

Current models of patient‐enacted involvement do not capture the nuanced dynamic and interactional nature of involvement in care. This is important for the development of flexible interventions that can support patients to ‘reach‐in’ to complex health‐care systems.

Objective

To develop a dynamic and interactional model of patient‐enacted involvement in care.

Search strategy

Electronic search strategy run in five databases and adapted to run in an Internet search engine supplemented with searching of reference lists and forward citations.

Inclusion criteria

Qualitative empirical published reports of older people's experiences of care transitions from hospital to home.

Data extraction and synthesis

Reported findings meeting our definition of involvement in care initially coded into an existing framework. Progression from deductive to inductive coding leads to the development of a new framework and thereafter a model representing changing states of involvement.

Main results

Patients and caregivers occupy and move through multiple states of involvement in response to perceived interactions with health‐care professionals as they attempt to resolve health‐ and well‐being‐related goals. ‘Non‐involvement’, ‘information‐acting’, ‘challenging and chasing’ and ‘autonomous‐acting’ were the main states of involvement. Feeling uninvolved as a consequence of perceived exclusion leads patients to act autonomously, creating the potential to cause harm.

Discussion and conclusion

The model suggests that involvement is highly challenging for older people during care transitions. Going forward, interventions which seek to support patient involvement should attempt to address the dynamic states of involvement and their mediating factors.

Evaluation of Tailored Falls Education on Older Adults' Behavior Following Hospitalization

BACKGROUND

Older adults recently discharged from the hospital are known to be at risk of functional decline and falls. This study evaluated the effect of a tailored education program provided in the hospital on older adult engagement in fall prevention strategies within 6 months after hospital discharge.

METHODS

A process evaluation of a randomized controlled trial that aimed to improve older adult fall prevention behaviors after hospital discharge. Participants (n = 390) were aged 60 years and older with good cognitive function (greater than 7 of 10 Abbreviated Mental Test Score), discharged home from three hospital rehabilitation wards in Perth, Australia. The primary outcomes were engagement in fall prevention strategies, including assistance with daily activities, home modifications, and exercise. Data were analyzed using generalized linear modeling.

RESULTS

There were 76.4% (n = 292) of participants who completed the final interview (n = 149 intervention, n = 143 control). There were no significant differences between groups in engagement in fall prevention strategies, including receiving instrumental activity of daily living (IADL) assistance (adjusted odds ratio [AOR] = 1.3 [95% confidence interval {CI} = 0.7-2.1]; P = .3), completion of home modifications (AOR = 1.2 [95% CI = 0.7-1.9]; P = .4), and exercise (AOR = 1.3 [95% CI = 0.7-2.2]; P = .3). There was a high proportion of unmet ADL needs within both groups, and levels of participant dependency remained higher at 6 months compared to baseline levels at admission. The proportion of all participants who engaged in exercise following hospital discharge increased by 30%; however, the mean duration of exercise reduced from 3 hours per week at baseline to 1 hour per week at 6-month follow-up (SD = 1.12 hours per week).

CONCLUSION

Tailored education did not increase older adult engagement in fall prevention strategies after hospital discharge compared to usual care. Further research is required to evaluate older adults' capacity to change their behaviors once they return home from hospital, which may enable a safer recovery of their independence. J Am Geriatr Soc 67:2274-2281, 2019.