Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: a realist synthesis

Hospital-to-home transitional care as support for older adult's caregivers: a scoping review

OBJECTIVE

To explore, in the literature, how transitional care from hospital to home supports the caregivers of older adults with functional dependence.

METHOD

Scoping review according to Joanna Briggs, with articles indexed in six databases and gray literature, from March to October 2022. Covidence Systematic Review was used to select the studies. The data obtained is described according to the modified PRISMA-ScR. The analysis and discussion were based on the Afaf Meleis Theory.

RESULTS

1.220 studies were identified and, after selection, nine publications were used for analysis. The studies found indicated that transitional care supported the caregiver of older people with functional dependence through health education, involvement in decision-making, emotional support, telemonitoring and home visits after discharge. These interventions improved care for older people, reduced anxiety and promoted a sense of security.

CONCLUSION

Transitional care helps the caregiver adapt to providing care at home and should be adjusted according to the caregiver's context and available support network.

External Validation of the Walter Index for Posthospitalization Mortality Prediction in Older Adults

Importance

The Walter Index is a widely used prognostic tool for assessing 12-month mortality risk among hospitalized older adults. Developed in the US in 2001, its accuracy in contemporary non-US contexts is unclear.

Objective

To evaluate the external validity of the Walter Index in predicting posthospitalization mortality risk in Brazilian older adult inpatients.

Design, Setting, and Participants

This prognostic study used data from a cohort of adults aged 70 years or older admitted to the geriatric unit of a university hospital in Brazil from January 1, 2009, to February 28, 2020. Participants underwent comprehensive geriatric assessments at admission, were reevaluated at discharge, and were subsequently followed up for 48 months. Data were analyzed from March to July 2024.

Main Outcomes and Measures

The Walter Index, a score based on 6 risk factors (male sex, dependent activities of daily living at discharge, heart failure, cancer, high creatinine level, and low albumin level), was calculated to assess its predictive accuracy for 12-month mortality as well as 6-, 24-, and 48-month mortality. The study investigated whether incorporating delirium, frailty, or C-reactive protein level enhanced accuracy. Performance was assessed using discrimination, calibration, and clinical utility measures.

Results

In total, 2780 participants (mean [SD] age, 81 [7] years; 1795 [65%] female) were included, with 89 (3%) lost to follow-up. The 12-month posthospitalization mortality rate was 23% (646 participants). Mortality was 7% (47 of 634) in the lowest-risk group (0-1 point), 17% (111 of 668) for 2 to 3 points, 25% (198 of 803) for 4 to 6 points, and 43% (290 of 675) in the highest-risk group (≥7 points). The index demonstrated an area under the receiver operating characteristic curve (AUC) of 0.714 (95% CI, 0.691-0.736) for predicting 12-month posthospitalization mortality (AUCs were 0.75 and 0.80 in the original derivation and validation cohorts, respectively). Comparable results were observed for mortality at 6 months (AUC, 0.726; 95% CI, 0.700-0.752), 24 months (AUC, 0.711; 95% CI, 0.691-0.730), and 48 months (AUC, 0.719; 95% CI, 0.700-0.738). Adding delirium modestly increased the index's discrimination (AUC, 0.723; 95% CI, 0.702-0.749); additionally including frailty and C-reactive protein level did not improve discrimination further (AUC, 0.723; 95% CI, 0.701-0.744).

Conclusions and Relevance

In this prognostic study of hospitalized older adults in Brazil, the Walter Index showed similar discrimination in predicting postdischarge mortality as it did 2 decades ago in the US. These findings highlight the need for continuous validation and potential modification of established prognostic tools to improve their applicability across settings.

Utility of 3D modelling of the patient's living environment as perceived by occupational therapists

INTRODUCTION

Visiting a patient's living environment is important for occupational therapists, albeit costly and time consuming. MapIt is a mobile app producing a 3D representation of a home with the possibility of taking measurements. The purpose of this study was to explore the utility of a 3D representation of a patient's home for the clinical practice of occupational therapists.

METHODS

Case study in which the unit of analysis was the utility of MapIt as defined by ISO 9241-11:2018 and as perceived by occupational therapists in four different occupational therapy clinical settings (Canada). Onsite observations with 10 occupational therapists (and their patients) were triangulated with data from interviews, diaries, and logbooks. Inductive thematic condensation led to emerging conclusions for each clinical setting, fuelling the next case data collection and analysis. Inter-case analysis was corroborated by additional occupational therapists, through crowdsourcing and expert review.

RESULTS

Occupational therapists' clinical reasoning was supported by the MapIt app, enhancing and streamlining their work and inducing adjustments to treatment plans. Occupational therapists saw and measured the patient's environment remotely, to better match person-environment-occupation and promote occupational engagement. MapIt's 3D representations were judged useful to communicate between occupational therapists and stakeholders, to educate, allow continuity, optimise resources, minimise the patient's time on a waitlist for homecare, and save time for everyone.

DISCUSSION

MapIt allowed occupational therapists who performed home visits to bring a little of the patients' home to their office, whereas occupational therapists without access to the home could see it and take measurements. MapIt's utility was confirmed for practice in clinical settings and for better continuity of care between settings.

CONCLUSION

MapIt makes it possible for occupational therapists to 'walk around' the patient's home remotely, but the possibility of measuring environmental elements is a 3D model's true added value over currently used photos or short videos.

Effect of an educational intervention based on the Health Belief Model on prevention and fear of falling among older people

Fall-related injuries are the leading cause of injury, death and disability among older adults, and their health care costs are high. Therefore, the present study aimed to determine the effect of an educational intervention, based on the health belief model, on the prevention and fear of falling among older people. We conducted this experimental study on 140 older people in Fasa city, Fars Province, Iran, in 2023. We selected the subjects using a simple sampling method. The educational intervention for the experimental group included three 30-min sessions. We analyzed the data using SPSS 22 software, employing chi-square, independent t-tests and paired t-tests. The results showed that before the educational intervention, there was no significant difference between the experimental and control groups in terms of knowledge, perceived sensitivity, perceived intensity, perceived benefits, perceived barriers, self-efficacy, cues to action, and performance; however, three months after the educational intervention, the experimental group showed a significant increase in each of the mentioned variables except the perceived barriers. Additionally, after the educational intervention, the mean score of fear of falling in the experimental group showed a statistically significant decrease. This study demonstrated the effectiveness of an educational intervention based on the health belief model in preventing falls and reducing the fear of falls in older people. Therefore, we suggest using training based on this model to prevent and reduce falls among older people.

Evaluate the Differential Effectiveness of the Case Management and Primary Nursing Models in the Implementation of Discharge Planning

AIMS AND OBJECTIVES

This study aims to compare the effectiveness of the case management model and the primary nursing care model by focusing on hospital stay length, readmission, follow-up resource utilisation and survival.

BACKGROUND

To improve patient continuity of care, a discharge planning team has been established at the hospital to implement the service concept of long-term medical care. The team works with a multidisciplinary medical team to provide case management, which ensures high-quality patient care.

DESIGN

Retrospective case-control study.

METHODS

This study collected data from the medical record information system database and the Ministry of Health and Welfare's care service management information system to explore medical and follow-up care utilisation of patients discharged between 2017 and 2018. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, with the checklist used to ensure transparent and complete reporting of the methodology and results.

PATIENT OR PUBLIC CONTRIBUTION

To ensure comparability between the case management model group and the primary nursing model group, propensity score matching was used. After matching, 660 individuals from the case management model group and 2876 individuals from the primary nursing model group were selected for further analysis. In this study, patients were primarily involved in the research as participants, providing data through their medical records for analysis. However, no direct involvement from the public or patients was used in the planning or design stages of the research.

RESULTS

The study found that factors such as activities of daily living (ADL) score ≤ 60 points, catheterisation, poor chronic disease control and inadequate primary caregiver capacity can lead to longer hospitalisations. Males and patients with catheters have a higher risk of readmission within 30 days, and men, those aged ≥ 75 years, those with ADL score ≤ 60, catheterisation, pressure sores or unclean wounds, financial problems, insufficient primary caregiver capacity and those readmitted within 14 days after discharge had significantly increased mortality after discharge. Although the case management model group had higher hospitalisation days, they had lower readmission rates and higher survival rates than the primary nursing model group.

CONCLUSIONS

Early consultation with the case manager for discharge planning can help patients to continue to receive care and utilise relevant resources after returning home.

RELEVANCE TO CLINICAL PRACTICE

Identifying and addressing patient-specific factors can significantly improve patient outcomes by reducing hospitalizations and readmissions, and lowering mortality rates. The case management model is more effective than the primary nursing care model in reducing readmission rates and increasing survival rates. Early consultation with case managers for discharge planning is crucial to ensuring patient care continuity and resource utilization.

Hospital Discharge Process: Context-Sensitive Care

The transition from hospital to home after surgery is a vulnerable time for all cardiac surgical patients, particularly older adults. This postoperative phase presents multiple physical, physiological, emotional, and socioeconomic challenges, not only for patients but also for their families and informal caregivers, who often describe this period as stressful and overwhelming. Health-care professionals, particularly nurses, play an integral role in a patient's discharge process; the challenges can be ameliorated through timely discharge planning and effective discharge education. The context-sensitive solutions shared in this paper propose enhancing nurses' discharge practices to provide individualized care and to facilitate the hospital-to-home transition.

Effect of structured nurse-patient conversation on preventing falls among patients in an acute care hospital: A mixed study

Objectives

Inpatient falls are a major patient safety issue in acute care hospitals. Multifactorial in-hospital fall prevention programs have shown reductions in falls and related risks. One common element of successful programs is active patient involvement. This study objective was to explore patients' and nurses' experiences with a structured intervention to foster patient involvement.

Methods

This study was conducted between September 2020 and April 2021 in a university hospital neurological ward. The studied intervention consisted of a falls information leaflet, and a structured nurse-patient conversation about fall risk-reduction activities. Nurses were trained to deliver the intervention and supported throughout the study. Nurses' and patients' experiences regarding personal involvement, satisfaction, and confidence were surveyed and analyzed quantitatively and qualitatively.

Results

Fifty-six patients recruited by ward nurses received the intervention. After receiving the intervention, patients reported high levels of satisfaction with the in-hospital fall prevention conversation. Twenty-one nurses indicated that they would use the leaflet and communication aid. Twenty-one nurses commented on intervention facilitators and barriers. More specific facilitators included their shared perception that "handing out the leaflet to patients was not problematic" and that the leaflet was seen as "applicable in many patient situations." Their comments indicated two particularly prominent barriers to conducting the intervention in clinical practice: 1) "finding the time for the implementation in the daily clinical routine and workload" and 2) "environmental factors like a noisy and busy atmosphere on the ward."

Conclusions

This study provides insights into a patient involvement intervention featuring a structured nurse-patient discussion about fall risks. The accompanying information leaflet and communication guide require adaptations to facilitate sustainable implementation into the hospital's fall prevention program, but proved useful.

The impact of discharge letter content on unplanned hospital readmissions within 30 and 90 days in older adults with chronic illness - a mixed methods study

BACKGROUND

Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness.

METHODS

The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission.

RESULTS

All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

CONCLUSIONS

While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge.

TRIAL REGISTRATION

Clinical Trials. giv, NCT02823795, 01/09/2016.

Quality Improvement Intervention Using Social Prescribing at Discharge in a University Hospital in France: Quasi-Experimental Study

BACKGROUND

Social prescription is seen as a public health intervention tool with the potential to mitigate social determinants of health. On one side, social prescription is not yet well developed in France, where social workers usually attend to social needs, and historically, there is a deep divide between the health and social sectors. On the other side, discharge coordination is gaining attention in France as a critical tool to improve the quality of care, assessed indirectly using unplanned rehospitalization rates.

OBJECTIVE

This study aims to combine social prescription and discharge coordination to assess the need for social prescription and its effect on unplanned rehospitalization rates.

METHODS

We conducted a quasi-experimental study in two departments of medicine in a French university hospital in a disadvantaged suburb of Paris over 2 years (October 2019-October 2021). A discharge coordinator screened patients for social prescribing needs and provided services on the spot or referred the patient to the appropriate service when needed. The primary outcome was the description of the services delivered by the discharge coordinator and of its process, as well as the characteristics of the patients in terms of social needs. The secondary outcome was the comparison of unplanned rehospitalization rates after data chaining.

RESULTS

A total of 223 patients were included in the intervention arm, with recruitment being disrupted by the COVID-19 pandemic. More than two-thirds of patients (n=154, 69.1%) needed help understanding discharge information. Slightly less than half of the patients (n=98, 43.9%) seen by the discharge coordinator needed social prescribing, encompassing language, housing, health literacy, and financial issues. The social prescribing covered a large range of services, categorized into finding a general practitioner or private sector nurse, including language-matching; referral to a social worker; referral to nongovernmental organization or group activities; support for transportation issues; support for health-related administrative procedures; and support for additional appointments with nonmedical clinicians. All supports were delivered in a highly personalized way. Ethnic data collection was not legally permitted, but for 81% (n=182) of the patients, French was not the mother tongue. After data chaining, rehospitalization rates were compared between 203 patients who received the intervention (n=5, 3.1%) versus 2095 patients who did not (n=51, 2.6%), and there was no statistical difference.

CONCLUSIONS

First, our study revealed the breadth of patient's unmet social needs in our university hospital, which caters to an area where the immigrant population is high. The study also revealed the complexity of the discharge coordinator's work, who provided highly personalized support and managed to gain trust. Hospital discharge could be used in France as an opportunity in disadvantaged settings. Eventually, indicators other than the rehospitalization rate should be devised to evaluate the effect of social prescribing and discharge coordination.

Healthcare professionals' perception of barriers and facilitators for care coordination of older adults with complex care needs being discharged from hospital: A qualitative comparative study of two Nordic capitals

BACKGROUND

The handover of older adults with complex health and social care from hospital admissions to homebased healthcare requires coordination between multiple care providers. Providing insight to the care coordination from healthcare professionals' views is crucial to show what efforts are needed to manage patient handovers from hospitals to home care, and to identify strengths and weaknesses of the care systems in which they operate.

OBJECTIVE

This is a comparative study aiming to examine healthcare professionals' perceptions on barriers and facilitators for care coordination for older patients with complex health and social care needs being discharged from hospital in two capital cities Copenhagen (DK) and Stockholm (SE).

METHOD

Semi-structured interviews were conducted with 25 nurses and 2 assistant nurses involved in the coordination of the discharge process at hospitals or in the home healthcare services (Copenhagen n = 11, Stockholm n = 16). The interview guide included questions on the participants' contributions, responsibilities, and influence on decisions during the discharge process. They were also asked about collaboration and interaction with other professionals involved in the process. The data was analysed using thematic analysis.

RESULTS

Main themes were communication ways, organisational structures, and supplementary work by staff. We found that there were differences in the organisational structure of the two care systems in relation to integration between different actors and differences in accessibility to patient information, which influenced the coordination. Municipal discharge coordinators visiting patients at the hospital before discharge and the follow-home nurse were seen as facilitators in Copenhagen. In Stockholm the shared information system with access to patient records were lifted as a facilitator for coordination. Difficulties accessing collaborators were experienced in both settings. We also found that participants in both settings to a high degree engage in work tasks outside of their responsibilities to ensure patient safety.

CONCLUSIONS

There are lessons to be learned from both care systems. The written e-communication between hospitals and home health care runs more smoothly in Stockholm, whereas it is perceived as a one-way communication in Copenhagen. In Copenhagen there are more sector-overlapping work which might secure a safer transition from hospital to home. Participants in both settings initiated own actions to weigh out imperfections of the system.

Health Emergencies, Falls, and Use of Communication Technologies by Older People with Functional and Social Frailty: Ageing in Place in Deprived Areas of Italy

Frail older people ageing alone in place need help to perform daily living activities, especially when functional limitations are increasing and formal/informal supports are lacking. This context represents a risk of experiencing health emergencies, in particular falls. It is thus important to understand how seniors manage these potential difficulties and who helps them. The present study aimed to explore these dimensions in Italy, where 120 qualitative interviews were carried out in 2019 within the "Inclusive ageing in place" (IN-AGE) research project, involving frail older people living alone at home. A content analysis was conducted. Results showed that seniors need to manage health emergencies regarding heart and breathing problems but mainly episodes of falls are reported, with consequent fractures and fear of falling again. In several cases, the use of a mobile phone was crucial in order to seek for help, and the first to intervene were children, in addition to some neighbors. Some seniors also referred their ability to call independently the General Practitioner (GP) or the emergency room, in order to not disturb family members. These findings highlight new useful insights for policy makers, regarding health emergencies prevention and management measures to put in place, especially concerning falls, and the support provided by communication technologies.