Preparing adolescents with chronic disease for transition to adult care: a technology program.

PubMed

Huang, Jeannie S; Terrones, Laura; Tompane, Trevor; Dillon, Lindsay; Pian, Mark; Gottschalk, Michael; Norman, Gregory J; Bartholomew, L Kay

2014-06-01

Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving. Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time. MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls. Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD. Copyright © 2014 by the American Academy of Pediatrics.

A cluster randomized trial of a transition intervention for adolescents with congenital heart disease: rationale and design of the CHAPTER 2 study.

PubMed

Mackie, Andrew S; Rempel, Gwen R; Kovacs, Adrienne H; Kaufman, Miriam; Rankin, Kathryn N; Jelen, Ahlexxi; Manlhiot, Cedric; Anthony, Samantha J; Magill-Evans, Joyce; Nicholas, David; Sananes, Renee; Oechslin, Erwin; Dragieva, Dimi; Mustafa, Sonila; Williams, Elina; Schuh, Michelle; McCrindle, Brian W

2016-06-06

The population of adolescents and young adults with congenital heart disease (CHD) is growing exponentially. These survivors are at risk of late cardiac complications and require lifelong cardiology care. However, there is a paucity of data on how to prepare adolescents to assume responsibility for their health and function within the adult health care system. Evidence-based transition strategies are required. The Congenital Heart Adolescents Participating in Transition Evaluation Research (CHAPTER 2) Study is a two-site cluster randomized clinical trial designed to evaluate the efficacy of a nurse-led transition intervention for 16-17 year olds with moderate or complex CHD. The primary endpoint is excess time to adult CHD care, defined as the time interval between the final pediatric cardiology appointment and the first adult CHD appointment, minus the recommended time interval between these appointments. Secondary endpoints include the MyHeart score (CHD knowledge), Transition Readiness Assessment Questionnaire score, and need for catheter or surgical re-intervention. Participants are enrolled in clusters based on week of attendance in the pediatric cardiology clinic. The intervention consists of two one-hour individualized sessions between a cardiology nurse and study participant. Session One focuses on knowledge of the participant's CHD, review of their cardiac anatomy and prior interventions, and potential late cardiac complications. Session Two focuses on self-management and communication skills through review and discussion of videos and role-play. The study will recruit 120 participants. Many adolescents and young adults experience a gap in care predisposing them to late cardiac complications. The CHAPTER 2 Study will investigate the impact of a nurse-led transition intervention among adolescents with CHD. Fidelity of the intervention is a major focus and priority. This study will build on our experience by (i) enrolling at two tertiary care programs, (ii) including a self-management intervention component, and (iii) evaluating the impact of the intervention on time to ACHD care, a clinically relevant outcome. The results of this study will inform pediatric cardiology programs, patients and policy makers in judging whether a structured intervention program provides clinically meaningful outcomes for adolescents and young adults living with CHD. ClinicalTrials.gov ID NCT01723332.

Are two youth-focused interventions sufficient to empower youth with chronic health conditions in their transition to adult healthcare: a mixed-methods longitudinal prospective cohort study.

PubMed

Gorter, Jan Willem; Stewart, Deb; Cohen, Eyal; Hlyva, Oksana; Morrison, Andrea; Galuppi, Barb; Nguyen, Tram; Amaria, Khush; Punthakee, Zubin

2015-05-06

To assess use, utility and impact of transition interventions designed to support and empower self-management in youth with chronic health conditions during transition into adult healthcare. A 4-year mixed-method prospective cohort study. 2 academic paediatric hospitals (13 clinics) in Canada. 50 adolescents (42% male; mean age 17.9±0.9 years; 20 underlying diagnoses) with transfer to adult care planned within 1 year. The Youth KIT (an organisational tool that includes goal setting activities); an online transition mentor. Frequency of use, utility and impact of the transition interventions; goal achievement; post-transfer qualitative interviews with youth. 50 participants were enrolled during their last year of paediatric care; 36 (72%) were followed into adult care. All participants had access to the transition interventions from enrolment until the end of the study (exposure time: 12-47 months). Most youth (85%) reported using the medical/health section of the Youth KIT at least once; 20 (40%) participants engaged in chats with the mentor. The overall perceived utility of both interventions was modest; the Youth KIT received the highest ratings for 'help with goal setting': (mean (SD): 4.2 (2.3)) on a 7-point Likert scale. 45 (90%) participants set 294 transition goals. Goal achievement performance and satisfaction increased over time (p≤0.001). The qualitative evidence revealed reasons behind the variability in use and utility of the interventions, the interconnectedness of life-course and healthcare transitions, and the need for stronger partnerships between paediatric and adult healthcare systems. Participants' perceptions about the utility of the Youth KIT and the online mentor were modest. Transition supports need to be carefully tailored, timed and integrated into healthcare systems. Individualised goal setting may be an important 'active ingredient' in optimising transition supports and outcomes. Interventions that focus on youth only are insufficient for empowering self-management. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Methodology used in comparative studies assessing programmes of transition from paediatrics to adult care programmes: a systematic review.

PubMed

Le Roux, E; Mellerio, H; Guilmin-Crépon, S; Gottot, S; Jacquin, P; Boulkedid, R; Alberti, C

2017-01-27

To explore the methodologies employed in studies assessing transition of care interventions, with the aim of defining goals for the improvement of future studies. Systematic review of comparative studies assessing transition to adult care interventions for young people with chronic conditions. MEDLINE, EMBASE, ClinicalTrial.gov. 2 reviewers screened comparative studies with experimental and quasi-experimental designs, published or registered before July 2015. Eligible studies evaluate transition interventions at least in part after transfer to adult care of young people with chronic conditions with at least one outcome assessed quantitatively. 39 studies were reviewed, 26/39 (67%) published their final results and 13/39 (33%) were in progress. In 9 studies (9/39, 23%) comparisons were made between preintervention and postintervention in a single group. Randomised control groups were used in 9/39 (23%) studies. 2 (2/39, 5%) reported blinding strategies. Use of validated questionnaires was reported in 28% (11/39) of studies. In terms of reporting in published studies 15/26 (58%) did not report age at transfer, and 6/26 (23%) did not report the time of collection of each outcome. Few evaluative studies exist and their level of methodological quality is variable. The complexity of interventions, multiplicity of outcomes, difficulty of blinding and the small groups of patients have consequences on concluding on the effectiveness of interventions. The evaluation of the transition interventions requires an appropriate and common methodology which will provide access to a better level of evidence. We identified areas for improvement in terms of randomisation, recruitment and external validity, blinding, measurement validity, standardised assessment and reporting. Improvements will increase our capacity to determine effective interventions for transition care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Quality and safety in the transitional care of the elderly (phase 2): the study protocol of a quasi-experimental intervention study for a cross-level educational programme

PubMed Central

Storm, Marianne; Groene, Oliver; Testad, Ingelin; Dyrstad, Dagrunn N; Heskestad, Randi N; Aase, Karina

2014-01-01

Introduction Transitional care and patient handover are important areas to ensure quality and safety in elderly healthcare services. Previous studies showed that healthcare professionals have little knowledge of the setting they are transferring patients to and a limited understanding of roles and functions; these constitute barriers to effective communication and shared care responsibilities across levels of care. Aim The main objective is to implement a cross-level education-based intervention programme with healthcare professionals aimed at (1) increasing professionals’ awareness and competencies about quality and safety in the transitional care of the elderly; (2) creating a discussion platform for knowledge exchange and learning across levels and units of care and (3) improving patient safety culture, in particular, in transitional care. Methods and analysis A quasi-experimental control group study design with an intervention group and a control group; this includes a pretest, post-test and 1-year follow-up test assessment of patient safety culture. Qualitative data will be collected during the intervention programme and between the measurements. The study design will be beneficial for addressing the effects of the cross-level educational intervention programme on reports of patient safety culture and for addressing the feasibility of the intervention measures. Ethics and dissemination The study has been approved by the Regional Committees for Medical and Health Research Ethics in Norway, Ref. No. 2011/1978. The study is based on informed written consent; informants can withdraw from the study at any point in time. The results will be disseminated at research conferences, in peer review journals and through public presentations outside the scientific community. PMID:25082425

Social Work Intervention Focused on Transitions

ClinicalTrials.gov

2016-12-19

Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention; Heart Disease; Diabetes; Hypertension; Cancer; Depression; Asthma; Chronic Heart Failure; Chronic Obstructive Pulmonary Disease; Stroke

Initial Efficacy of a Cardiac Rehabilitation Transition Program: Cardiac TRUST

PubMed Central

Zullo, Melissa; Boxer, Rebecca; Moore, Shirley M.

2012-01-01

Patients recovering from cardiac events are increasingly using postacute care, such as home health care and skilled nursing facility services. The purpose of this pilot study was to test the initial efficacy, feasibility, and safety of a specially designed postacute care transitional rehabilitation intervention for cardiac patients. Cardiac Transitional Rehabilitation Using Self- Management Techniques (Cardiac TRUST) is a family-focused intervention that includes progressive low-intensity walking and education in self-management skills to facilitate recovery following a cardiac event. Using a randomized two-group design, exercise self-efficacy, steps walked, and participation in an outpatient cardiac rehabilitation program were compared in a sample of 38 older adults; 17 who received the Cardiac TRUST program and 21 who received usual care only. At discharge from postacute care, the intervention group had a trend for higher levels of self-efficacy for exercise outcomes (X=39.1, SD=7.4) than the usual care group (X=34.5; SD=7.0) (t-test 1.9, p=.06). During the 6 weeks following discharge, compared with the usual care group, the intervention group had more attendance in out-patient cardiac rehabilitation (33% compared to 11.8%, F=7.1, p=.03) and a trend toward more steps walked during the first week (X=1,307, SD=652 compared to X=782, SD=544, t-test 1.8, p=.07). The feasibility of the intervention was better for the home health participants than for those in the skilled nursing facility and there were no safety concerns. The provision of cardiac-focused rehabilitation during postacute care has the potential to bridge the gap in transitional services from hospitalization to outpatient cardiac rehabilitation for these patients at high risk for future cardiac events. Further evidence of the efficacy of Cardiac TRUST is warranted. PMID:22084960

Reducing Emergency Room Visits and In-Hospitalizations by Implementing Best Practice for Transitional Care Using Innovative Technology and Big Data.

PubMed

Hewner, Sharon; Sullivan, Suzanne S; Yu, Guan

2018-06-01

Efforts to improve care transitions require coordination across the healthcare continuum and interventions that enhance communication between acute and community settings. To improve post-discharge utilization value using technology to identify high-risk individuals who might benefit from rapid nurse outreach to assess social and behavioral determinants of health with the goal of reducing inpatient and emergency department visits. The project employed a before and after comparison of the intervention site with similar primary care practice sites using population-level Medicaid claims data. The intervention targeted discharged persons with preexisting chronic disease and delivered a care transition alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social determinants of health and incorporated problems into the EHR to share across settings. The project evaluated health outcomes and the value of nursing care on existing electronic claims data to compare utilization in the years before and during the intervention using negative binomial regression to account for rare events such as inpatient visits. Avoiding readmissions and emergency visits, and increasing timely outpatient visits improved the individual's experience of care and the work life of healthcare providers, while reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits, and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular Medicaid trend was $664 per adult with chronic disease, generating $71,289 in revenue from additional outpatient visits. Using health information exchange to deliver appropriate and timely evidence-based clinical decision support in the form of care transition alerts and assessment of social determinants of health, in conjunction with data science methods, demonstrates the value of nursing care and resulted in achieving the Quadruple Aim. © 2018 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.

Patient safety in transitional care of the elderly: effects of a quasi-experimental interorganisational educational intervention

PubMed Central

Storm, Marianne; Schulz, Jörn; Aase, Karina

2018-01-01

Objective The study objective was to assess the effects of an interorganisational educational intervention called the ‘Meeting Point’ on patient safety culture among staff in hospital and nursing home wards. Design The study employs a quasi-experimental, non-randomised design with a hospital and nursing home intervention group and a hospital and nursing home control group. The study uses one preintervention and two postintervention survey measurements. The intervention group participated in an educational programme ‘The Meeting Point’ including interorganisational staff meetings combining educational sessions with a discussion platform focusing on quality and safety in transitional care of the elderly. Results The results show a stable development over time for the patient safety culture factor ‘Handoff and transitions’, and small improvements for ‘Overall perceptions of patient safety culture’ and ‘Organisational learning - continuous improvement’ for the hospital intervention group. No similar development was reported in the nursing home intervention group, which is most likely explained by ongoing organisational changes. Qualitative data show the existence of ongoing initiatives in the hospital to improve transitional care, but not all were connected to the ‘Meeting Point’. Conclusion The ‘Meeting Point’ has the potential to be a useful measure for healthcare professionals when aiming to improve patient safety culture in transitional care. Further refinement of the key components and testing with a more robust study design will be beneficial. PMID:29391363

Ensuring Patient Safety in Care Transitions: An Empirical Evaluation of a Handoff Intervention Tool

PubMed Central

Abraham, Joanna; Kannampallil, Thomas; Patel, Bela; Almoosa, Khalid; Patel, Vimla L.

2012-01-01

Successful handoffs ensure smooth, efficient and safe patient care transitions. Tools and systems designed for standardization of clinician handoffs often focuses on ensuring the communication activity during transitions, with limited support for preparatory activities such as information seeking and organization. We designed and evaluated a Handoff Intervention Tool (HAND-IT) based on a checklist-inspired, body system format allowing structured information organization, and a problem-case narrative format allowing temporal description of patient care events. Based on a pre-post prospective study using a multi-method analysis we evaluated the effectiveness of HAND-IT as a documentation tool. We found that the use of HAND-IT led to fewer transition breakdowns, greater tool resilience, and likely led to better learning outcomes for less-experienced clinicians when compared to the current tool. We discuss the implications of our results for improving patient safety with a continuity of care-based approach. PMID:23304268

Common needs but divergent interventions for U.S. homeless and foster care children: results from a systematic review.

PubMed

Zlotnick, Cheryl; Tam, Tammy; Zerger, Suzanne

2012-09-01

Many children living in homeless situations in the U.S. have temporary stays in foster care, and both populations suffer disproportionately higher rates of physical, psychological and social difficulties compared with other children. However, very little is known about which specific interventions achieve the best outcomes for children in these overlapping transitional living situations. To address this gap, we review existing literature to identify the most promising practices for children living in transition. A standardised vocabulary specific to each of three electronic databases (i.e. Medline, PsychINFO and CINAHL) was employed to identify studies that described an intervention specifically targeting foster care or homeless children and families. Separate systematic searches were conducted for homeless and foster children, and only studies published in English between January 1993 and February 2009 were selected. The final sample (n = 43) of articles described interventions that fell into two categories: mental health (n = 17) and case management (n = 26). No article included a sample containing both homeless and foster care children, and most studies on homeless children used case management interventions while most studies on foster care children focused on mental health interventions. Few articles employed rigorous study designs. Although repeatedly studies have demonstrated the overlap between populations of homeless and foster care children, studies focused on one population or the other. Virtually all studies on both homeless and foster children devised interventions to reduce trauma and family instability; yet, no evidence-based practice addresses the overlapping needs and potentially relevant evidence-based practice for these two populations. An important and vital next step is to establish an effective evidence-based intervention that reduces the impact of trauma on both U.S. populations of children living in transition. © 2012 Blackwell Publishing Ltd.

A multicenter prospective quasi-experimental study on the impact of a transition-oriented generic patient education program on health service participation and quality of life in adolescents and young adults.

PubMed

Schmidt, Silke; Herrmann-Garitz, Carsten; Bomba, Franziska; Thyen, Ute

2016-03-01

The aim of the study was to test the effects of a generic transition-oriented patient education program on adolescents' health service participation and quality of life (QoL). We conducted a controlled trial comparing participants of 29 transition workshops with treatment as usual in 274 adolescents (16.8 mean age, SD=1.76) diagnosed with type I diabetes (DM), cystic fibrosis (CF) or inflammatory bowel disease (IBD). A two-day transition workshop was carried out at 12 sites in Germany, focusing in standardized modules on adjustment to adult care settings, organization of future disease management, career choices and partnership. Study outcomes were health-related transition competence, self-efficacy, satisfaction with care, patient activation and QoL. Measures were assessed at baseline and six-month follow-up. Repeated-measurement covariance analysis using age as a covariate showed that the transition workshop significantly affected transition competence, self-efficacy and satisfaction with school care six months post intervention. The intervention did not significantly affect patient activation and QoL. However, post-hoc analysis suggested different effects across conditions. The program has a positive effect on the competence of adolescents in the transition phase. The study demonstrates that an intervention can be effective in preparing adolescents with chronic conditions for transitions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Development and Preliminary Evaluation of the Resident Coordinated-Transitional Care (RC-TraC) Program: A Sustainable Option for Transitional Care Education

PubMed Central

Chapman, E.; Eastman, A.; Gilmore-Bykovskyi, A.; Vogelman, B.; Kind, A. J.

2016-01-01

Older adults often face poor outcomes when transitioning from hospital to home. Although physicians play a key role in overseeing transitions, there is a lack of practice-based educational programs that prepare resident physicians to manage care transitions of older adults. An educational intervention to provide residents with real-life transitional care practice was therefore developed – Resident-coordinated Transitional Care (RC-TraC). RC-TraC adapted the evidence-based Coordinated-Transitional Care (C-TraC) nurse role for residents, providing opportunities to follow patients during the peri-hospital period without additional costs to the residency program. Between July 2010 and June 2013, thirty-one Internal Medicine residents participated in RC-TraC, caring for 721 patients. RC-TraC has been a sustainable, low-cost, practice-based education experience that is recognized as transitional care education by residents and continues in operation to this day. RC-TraC is a promising option for geriatric-based transitional care education of resident physicians and could also be adapted for non-physician learners. PMID:27749162

Ethnographic process evaluation of a quality improvement project to improve transitions of care for older people

PubMed Central

Sutton, Elizabeth; Dixon-Woods, Mary; Tarrant, Carolyn

2016-01-01

Objectives Quality improvement projects to address transitions of care across care boundaries are increasingly common but meet with mixed success for reasons that are poorly understood. We aimed to characterise challenges in a project to improve transitions for older people between hospital and care homes. Design Independent process evaluation, using ethnographic observations and interviews, of a quality improvement project. Setting and participants An English hospital and two residential care homes for older people. Data 32 hours of non-participant observations and 12 semistructured interviews with project members, hospital and care home staff. Results A hospital-based improvement team sought to reduce unplanned readmissions from residential care homes using interventions including a community-based geriatric team that could be accessed directly by care homes and a communication tool intended to facilitate transfer of information between homes and hospital. Only very modest (if any) impacts of these interventions on readmission rates could be detected. The process evaluation identified multiple challenges in implementing interventions and securing improvement. Many of these arose because of lack of consensus on the nature of the problem and the proper solutions: while the hospital team was keen to reduce readmissions and saw the problems as lying in poor communication and lack of community-based support for care homes, the care home staff had different priorities. Care home staff were unconvinced that the improvement interventions were aligned with their needs or addressed their concerns, resulting in compromised implementation. Conclusions Process evaluations have a valuable role in quality improvement. Our study suggests that a key task for quality improvement projects aimed at transitions of care is that of developing a shared view of the problem to be addressed. A more participatory approach could help to surface assumptions, interpretations and interests and could facilitate the coproduction of solutions. This finding is likely to have broader applicability. PMID:27491666

[A Survey of the Factors of Influence and Interventional Strategies for Breast Cancer Survivors' Transition Care Across Multiple Theoretical Perspectives].

PubMed

Chao, Yu-Huan; Lee, Tzu-I; Sheu, Shuh-Jen

2018-02-01

Breast cancer significantly threatens the life of women, while the adverse effects of cancer treatment degrade quality of life and psychological well-being. The quality of transitional care following the completion of treatment significantly affects the ability of breast cancer patients to transition successfully into survivorship. This paper introduces multiple theoretical perspectives and provides an overview of the tenets of each in order to identify the positions of breast cancer survivors and to highlight the factors and strategies that influence their transitional care. The theoretical perspectives that are introduced include the social-ecological model, transition theory, and the strengths perspective. In order to improve the holistic care of women with breast cancer, factors relevant to transition are categorized into the individual, interpersonal, organizational, community, and policy levels. Furthermore, empirical interventions, which are based on the respective advantages of the various levels of the social-ecological model, are proposed in order to conform to the sociocultural context and clinical practices. Healthcare providers should leverage the strengths and resources at each level to develop feasible strategies and to provide quality of care in order to assist breast cancer patients to transition successfully from treatment to survivorship and to holistically improve their subsequent quality of life and function.

Engaging Adolescent Youth in Foster Care through Photography

ERIC Educational Resources Information Center

Rice, Karen; Girvin, Heather; Primak, Sarah

2014-01-01

Older youth in foster care are particularly vulnerable because they are poorly prepared for the transition from foster care to independent adulthood. Interventions designed to assist in this transition rarely engage youth directly; plans are made for youth rather than with them. Photographs can serve as an externalised medium for the expression of…

Reducing bottlenecks: professionals’ and adolescents’ experiences with transitional care delivery

PubMed Central

2014-01-01

Background The purpose of this study was to describe the interventions implemented in a quality improvement programme to improve transitional care and evaluate its effectiveness in reducing bottlenecks as perceived by professionals and improving chronically ill adolescents’ experiences with care delivery. Methods This longitudinal study was undertaken with adolescents and professionals who participated in the Dutch ‘On Your Own Feet Ahead!’ quality improvement programme. This programme followed the Breakthrough Series improvement and implementation strategy. A total of 102/128 (79.7%) professionals from 21 hospital teams filled out a questionnaire at the start of the programme (T0), and 79/123 (64.2%; five respondents had changed jobs) professionals completed the same questionnaire 1 year later (T1). Seventy-two (58.5%) professionals from 21 teams returned questionnaires at both time points. Of 389 and 430 participating adolescents, 36% and 41% returned questionnaires at T0 and T1, respectively. We used descriptive statistics and two-tailed, paired t-tests to investigate improvements in bottlenecks in transitional care (perceived by professionals) and care delivery (perceived by adolescents). Results Professionals observed improvement in all bottlenecks at T1 (vs. T0; p < 0.05), especially in the organisation of care, such as the presence of a joint mission between paediatric and adult care, coordination of care, and availability of more resources for joint care services. Within a 1-year period, the transition programme improved some aspects of patients’ experiences with care delivery, such as the provision of opportunities for adolescents to visit the clinic alone (p < 0.001) and to decide who should be present during consultations (p < 0.05). Conclusions This study demonstrated that transitional care interventions may improve the organisation and coordination of transitional care and better prepare adolescents for the transition to adult care within a 1-year period. By setting specific goals based on experiences with bottlenecks, the breakthrough approach helped to improve transitional care delivery for adolescents with chronic conditions. PMID:24485282

Navigating the Health Care System: An Adolescent Health Literacy Unit for High Schools

ERIC Educational Resources Information Center

Hughes, Denise; Maiden, Kristin

2018-01-01

Background: Currently, no intervention concerning transition of health care responsibilities from parents to teens exists for adolescents in the general population. The purpose of this intervention was to evaluate teacher satisfaction and student knowledge gain of a health unit developed for adolescents on becoming their own health care advocates.…

Rationale, design and baseline data of a mixed methods study examining the clinical impact of a brief transition programme for young people with juvenile idiopathic arthritis: the DON'T RETARD project.

PubMed

Hilderson, Deborah; Westhovens, Rene; Wouters, Carine; Van der Elst, Kristien; Goossens, Eva; Moons, Philip

2013-12-02

To describe (1) the content of a transition programme for young people with juvenile idiopathic arthritis (JIA) designed as a brief intervention, (2) the rationale and design of a mixed-methods study evaluating the clinical impact of this transition programme and (3) to provide baseline data of the intervention group. An 'embedded experimental' design is used for the evaluation of the transition programme. A 'one-group pretest-posttest, with a non-equivalent posttest-only comparison group design' is used to quantitatively evaluate the impact of the transition programme, applying both longitudinal and comparative analyses. Subsequently, experiences of adolescents and their parents who participated in the experimental group will be analysed qualitatively using content analysis. Participants in the intervention are recruited at a tertiary care centre in Belgium. The comparison group participants are recruited from one tertiary and three secondary care centres in Belgium. The intervention group consists of 33 young people (25 females; 8 males) with a median age of 16 years. Main diagnoses are persistent or extended oligoarticular JIA (33%), polyarticular JIA (30%), enthesitis-related JIA (21%) or systemic arthritis (15%). The transition programme comprises eight key components: (1) transition coordinator; (2) providing information and education; (3) availability by telephone; (4) information about and contact with an adult care programme; (5) guidance of parents; (6) meeting with peers; (7) transfer plan; and (8) actual transfer to adult care. The primary outcome is health status, as perceived by the adolescents. Secondary outcomes are health status, as perceived by the parents; medication adherence; illness-related knowledge; quality of life; fatigue; promotion of independence; support of autonomy; behavioural control and psychological control. At baseline, the median score was 69.2 (Q1=60.0;Q3=92.9) on psychosocial health and 68.8 (Q1=56.3; Q3=89.1) on physical health. Rheumatic-specific health scores ranged from 62.5 to 100. We present the rationale and design of a study intended to evaluate a transition programme for adolescents with JIA as a brief intervention.

Adolescent and Adult HIV Providers' Definitions of HIV-Infected Youths' Successful Transition to Adult Care in the United States.

PubMed

Philbin, Morgan M; Tanner, Amanda E; Ma, Alice; Chambers, Brittany D; Ware, Samuella; Kinnard, Elizabeth N; Hussen, Sophia A; Lee, Sonia; Fortenberry, J Dennis

2017-10-01

It is important for both individual- and population-level health that HIV-infected individuals progress through the Care Continuum. However, HIV-infected youth frequently disengage from care during transition from pediatric/adolescent to adult care; only 50% remain in adult care after 1 year. Understanding how providers define and approach a successful healthcare transition can improve the delivery of HIV-related services during critical years of HIV treatment. We conducted 58 staff interviews across 14 Adolescent Trials Network clinics (n = 30) and 20 adult clinics (n = 28). We used the constant comparative method to examine how providers defined and approached youths' successful transition. Providers identified four components critical to successful transition: (1) clinical outcomes (e.g., medication adherence and viral suppression); (2) youth knowing how to complete treatment-related activities (e.g., refilling prescriptions and making appointments); (3) youth taking responsibility for treatment-related activities and their overall health (e.g., "when they stop reaching out to the adolescent [clinic] to solve all their problems."); and (4) youth feeling a connection and trust toward the adult clinic (e.g., "they feel safe here"), with some providers even prioritizing connectedness over clinical outcomes (e.g., "Even if they're not taking meds but are connected [to care], …that's a success."). The identification of key components of successful transition can guide focused interventions and resources to improve youth maintenance in the HIV Care Continuum as they transition to adult care. Identifying what facilitates successful transitions, and the gaps that interventions can target, will help to ensure HIV-infected youth remain healthy across their lifespan.

Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial).

PubMed

Spaic, Tamara; Mahon, Jeff L; Hramiak, Irene; Byers, Nicole; Evans, Keira; Robinson, Tracy; Lawson, Margaret L; Malcolm, Janine; Goldbloom, Ellen B; Clarson, Cheril L

2013-10-09

Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care. This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital admissions, frequency of complication screening, and subject perception and satisfaction with care. This trial will determine if the support of a Transition Coordinator improves health outcomes for this at-risk population of young adults. NCT01351857.

Transitions of Care Between Acute and Chronic Heart Failure: Critical Steps in the Design of a Multidisciplinary Care Model for the Prevention of Rehospitalization.

PubMed

Comín-Colet, Josep; Enjuanes, Cristina; Lupón, Josep; Cainzos-Achirica, Miguel; Badosa, Neus; Verdú, José María

2016-10-01

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

A role for social workers in improving care setting transitions: a case study.

PubMed

Barber, Ruth D; Coulourides Kogan, Alexis; Riffenburgh, Anne; Enguidanos, Susan

2015-01-01

High 30-day readmission rates are a major burden to the American medical system. Much attention is on transitional care to decrease financial costs and improve patient outcomes. Social workers may be uniquely qualified to improve care transitions and have not previously been used in this role. We present a case study of an older, dually eligible Latina woman who received a social work-driven transition intervention that included in-home and telephone contacts. The patient was not readmitted during the six-month study period, mitigated her high pain levels, and engaged in social outings once again. These findings suggest the value of a social worker in a transitional care role.

Rationale, design and baseline data of a mixed methods study examining the clinical impact of a brief transition programme for young people with juvenile idiopathic arthritis: the DON'T RETARD project

PubMed Central

Hilderson, Deborah; Westhovens, Rene; Wouters, Carine; Van der Elst, Kristien; Goossens, Eva; Moons, Philip

2013-01-01

Objectives To describe (1) the content of a transition programme for young people with juvenile idiopathic arthritis (JIA) designed as a brief intervention, (2) the rationale and design of a mixed-methods study evaluating the clinical impact of this transition programme and (3) to provide baseline data of the intervention group. Design An ‘embedded experimental’ design is used for the evaluation of the transition programme. A ‘one-group pretest-posttest, with a non-equivalent posttest-only comparison group design’ is used to quantitatively evaluate the impact of the transition programme, applying both longitudinal and comparative analyses. Subsequently, experiences of adolescents and their parents who participated in the experimental group will be analysed qualitatively using content analysis. Setting Participants in the intervention are recruited at a tertiary care centre in Belgium. The comparison group participants are recruited from one tertiary and three secondary care centres in Belgium. Participants The intervention group consists of 33 young people (25 females; 8 males) with a median age of 16 years. Main diagnoses are persistent or extended oligoarticular JIA (33%), polyarticular JIA (30%), enthesitis-related JIA (21%) or systemic arthritis (15%). Intervention The transition programme comprises eight key components: (1) transition coordinator; (2) providing information and education; (3) availability by telephone; (4) information about and contact with an adult care programme; (5) guidance of parents; (6) meeting with peers; (7) transfer plan; and (8) actual transfer to adult care. Primary and secondary outcomes The primary outcome is health status, as perceived by the adolescents. Secondary outcomes are health status, as perceived by the parents; medication adherence; illness-related knowledge; quality of life; fatigue; promotion of independence; support of autonomy; behavioural control and psychological control. Results At baseline, the median score was 69.2 (Q1=60.0;Q3=92.9) on psychosocial health and 68.8 (Q1=56.3; Q3=89.1) on physical health. Rheumatic-specific health scores ranged from 62.5 to 100. Conclusions We present the rationale and design of a study intended to evaluate a transition programme for adolescents with JIA as a brief intervention. PMID:24302502

The Social Work Role in Reducing 30-Day Readmissions: The Effectiveness of the Bridge Model of Transitional Care.

PubMed

Alvarez, Renae; Ginsburg, Jacob; Grabowski, Jessica; Post, Sharon; Rosenberg, Walter

2016-04-01

The hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. Novel approaches to addressing the complexities of transitional care are emerging as possible solutions. The Bridge Model is a person-centered, social work-led, interdisciplinary transitional care intervention that helps older adults safely transition from the hospital back to their homes and communities. The Bridge Model combines 3 key components-care coordination, case management, and patient engagement-which provide a seamless transition during this stressful time and improve the overall quality of transitional care for older adults, including reducing hospital readmissions. The post Affordable Care Act (ACA) and managed care environment's emphasis on value and quality support further development and expansion of transitional care strategies, such as the Bridge Model, which offer promising avenues to fulfil the triple aim by improving the quality of individual patient care while also impacting population health and controlling per capita costs.

Ethnographic process evaluation of a quality improvement project to improve transitions of care for older people.

PubMed

Sutton, Elizabeth; Dixon-Woods, Mary; Tarrant, Carolyn

2016-08-04

Quality improvement projects to address transitions of care across care boundaries are increasingly common but meet with mixed success for reasons that are poorly understood. We aimed to characterise challenges in a project to improve transitions for older people between hospital and care homes. Independent process evaluation, using ethnographic observations and interviews, of a quality improvement project. An English hospital and two residential care homes for older people. 32 hours of non-participant observations and 12 semistructured interviews with project members, hospital and care home staff. A hospital-based improvement team sought to reduce unplanned readmissions from residential care homes using interventions including a community-based geriatric team that could be accessed directly by care homes and a communication tool intended to facilitate transfer of information between homes and hospital. Only very modest (if any) impacts of these interventions on readmission rates could be detected. The process evaluation identified multiple challenges in implementing interventions and securing improvement. Many of these arose because of lack of consensus on the nature of the problem and the proper solutions: while the hospital team was keen to reduce readmissions and saw the problems as lying in poor communication and lack of community-based support for care homes, the care home staff had different priorities. Care home staff were unconvinced that the improvement interventions were aligned with their needs or addressed their concerns, resulting in compromised implementation. Process evaluations have a valuable role in quality improvement. Our study suggests that a key task for quality improvement projects aimed at transitions of care is that of developing a shared view of the problem to be addressed. A more participatory approach could help to surface assumptions, interpretations and interests and could facilitate the coproduction of solutions. This finding is likely to have broader applicability. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A Pilot Study for Antimicrobial Stewardship Post-Discharge: Avoiding Pitfalls at the Transitions of Care.

PubMed

Jones, Justin M; Leedahl, Nathan D; Losing, Ashley; Carson, Paul J; Leedahl, David D

2018-04-01

Lack of patient follow-up is a major concern during care transitions, and the role of an antimicrobial stewardship program (ASP) in assessing antimicrobial regimens after hospital discharge is not well described. We implemented an expanded ASP to include patients recently discharged from the hospital and measured its impact on inappropriate antimicrobial therapy 72 hours after inpatient culture data were finalized. A prospective cohort study was conducted at a 583-bed tertiary care center in the Upper Midwest of America. All patients discharged from our facility on antimicrobial therapy with pending culture results between February 3, 2016, and March 2, 2016, were included for review. If a pathogen nonsusceptible to all prescribed antimicrobials was identified post-discharge, a recommendation for therapy modification was communicated to the prescriber. Thirty-eight patients discharged from our hospital on antimicrobial therapy with pending culture results were evaluated for intervention. When final culture susceptibilities were considered, 5 of 38 patients had been prescribed an inappropriate antimicrobial agent. An ASP pharmacist intervened on 4 of 5 patients, resulting in 3 of 5 patients transitioning to appropriate antimicrobial therapy. When compared to a historical cohort, our transitions-of-care ASP yielded a 3.6-fold increase in antimicrobial-related interventions among discharged patients while reducing inappropriate outpatient antimicrobial therapy by 39%. We believe this is the first pharmacist-driven ASP represented in the medical literature which evaluated all available inpatient culture data to serve patients discharged from the hospital. Antimicrobial stewardship for patients in care transitions may provide an opportunity to increase ASP interventions and reduce inappropriate antimicrobial therapy.

Evaluating the Impact of Dental Care on Housing Intervention Program Outcomes Among Homeless Veterans

PubMed Central

Nunez, Elizabeth; Gibson, Gretchen; Jones, Judith A.; Schinka, John A.

2013-01-01

Objectives. In this retrospective longitudinal cohort study, we examined the impact of dental care on outcomes among homeless veterans discharged from a Department of Veterans Affairs (VA) transitional housing intervention program. Methods. Our sample consisted of 9870 veterans who were admitted into a VA homeless intervention program during 2008 and 2009, 4482 of whom received dental care during treatment and 5388 of whom did not. Primary outcomes of interest were program completion, employment or stable financial status on discharge, and transition to permanent housing. We calculated descriptive statistics and compared the 2 study groups with respect to demographic characteristics, medical and psychiatric history (including alcohol and substance use), work and financial support, and treatment outcomes. Results. Veterans who received dental care were 30% more likely than those who did not to complete the program, 14% more likely to be employed or financially stable, and 15% more likely to have obtained residential housing. Conclusions. Provision of dental care has a substantial positive impact on outcomes among homeless veterans participating in housing intervention programs. This suggests that homeless programs need to weigh the benefits and cost of dental care in program planning and implementation. PMID:23678921

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics.

PubMed

Schaeffer, Christine; Teter, Caroline; Finch, Emily A; Hurt, Courtney; Keeter, Mary Kate; Liss, David T; Rogers, Angela; Sheth, Avani; Ackermann, Ronald

2018-02-01

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population. Copyright © 2017 Elsevier Inc. All rights reserved.

Integrating Social Determinants of Health into Primary Care Clinical and Informational Workflow during Care Transitions

PubMed Central

Hewner, Sharon; Casucci, Sabrina; Sullivan, Suzanne; Mistretta, Francine; Xue, Yuqing; Johnson, Barbara; Pratt, Rebekah; Lin, Li; Fox, Chester

2017-01-01

Context: Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. Case Description: The coordinating transitions intervention uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach. The intervention incorporates claims-based risk stratification to prioritize patients for follow-up and an assessment of social determinants of health using the Patient-centered Assessment Method (PCAM). Results from transitional care are stored and transmitted to qualified healthcare providers across the continuum. Findings: Reliance on tools that incorporated interoperability standards facilitated exchange of health information between the hospital and primary care. The PCAM was incorporated into both the clinical and informational workflow through the collaboration of clinical, industry, and academic partners. Health outcomes improved at the study practice over their baseline and in comparison with control practices and the regional Medicaid population. Major Themes: Current research supports the potential impact of systems approaches to care coordination in improving utilization value after discharge. The project demonstrated that flexibility in developing the informational and clinical workflow was critical in developing a solution that improved continuity during transitions. There is additional work needed in developing managerial continuity across settings such as shared comprehensive care plans. Conclusions: New clinical and informational workflows which incorporate social determinant of health data into standard practice transformed clinical practice and improved outcomes for patients.

Stress and burnout among critical care fellows: preliminary evaluation of an educational intervention.

PubMed

Kashani, Kianoush; Carrera, Perliveh; De Moraes, Alice Gallo; Sood, Amit; Onigkeit, James A; Ramar, Kannan

2015-01-01

Despite a demanding work environment, information on stress and burnout of critical care fellows is limited. To assess 1) levels of burnout, perceived stress, and quality of life in critical care fellows, and 2) the impact of a brief stress management training on these outcomes. In a tertiary care academic medical center, 58 critical care fellows of varying subspecialties and training levels were surveyed to assess baseline levels of stress and burnout. Twenty-one of the 58 critical care fellows who were in the first year of training at the time of this initial survey participated in a pre-test and 1-year post-test to determine the effects of a brief, 90-min stress management intervention. Based on responses (n=58) to the abbreviated Maslach Burnout Inventory, reported burnout was significantly lower in Asian fellows (p=0.04) and substantially higher among graduating fellows (versus new and transitioning fellows) (p=0.02). Among the intervention cohort, burnout did not significantly improve--though two-thirds of fellows reported using the interventional techniques to deal with stressful situations. Fellows who participated in the intervention rated the effectiveness of the course as 4 (IQR=3.75-5) using the 5-point Likert scale. In comparison with the new and transitioning trainees, burnout was highest among graduating critical care fellows. Although no significant improvements were found in first-year fellows' burnout scores following the single, 90-min training intervention, participants felt the training did provide them with tools to apply during stressful situations.

NAPNAP Position Statement. Position Statement on Pediatric Health Care/Medical Home: Key Issues on Care Coordination, Transitions, and Leadership.

PubMed

2016-01-01

The National Association of Pediatric Nurse Practitioners (NAPNAP) affirms that the delivery of children's health care should be family-centered, accessible, comprehensive, coordinated, culturally appropriate, compassionate, and focused on the overall well-being of children and families. All qualified pediatric health care providers should collaborate in providing health care services for children in pediatric health care/medical homes. Interventions must address the concepts of family-centered partnerships, community-based systems, and transitional care from pediatric to adult services.

Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial

ERIC Educational Resources Information Center

Altfeld, Susan J.; Shier, Gayle E.; Rooney, Madeleine; Johnson, Tricia J.; Golden, Robyn L.; Karavolos, Kelly; Avery, Elizabeth; Nandi, Vijay; Perry, Anthony J.

2013-01-01

Purpose of the Study: To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality. Design and Methods: Older adult inpatients who met criteria for risk of post-discharge complications were…

A social-ecological model of readiness for transition to adult-oriented care for adolescents and young adults with chronic health conditions.

PubMed

Schwartz, L A; Tuchman, L K; Hobbie, W L; Ginsberg, J P

2011-11-01

Policy and research related to transition to adult care for adolescents and young adults (AYAs) has focused primarily on patient age, disease skills and knowledge. In an effort to broaden conceptualization of transition and move beyond isolated patient variables, a new social-ecological model of AYA readiness for transition (SMART) was developed. SMART development was informed by related theories, literature, expert opinion and pilot data collection using a questionnaire developed to assess provider report of SMART components with 100 consecutive patients in a childhood cancer survivorship clinic. The literature, expert opinion and pilot data collection support the relevance of SMART components and a social-ecological conceptualization of transition. Provider report revealed that many components, representing more than age, disease knowledge and skills, related to provider plans for transferring patients. SMART consists of inter-related constructs of patients, parents and providers with emphasis on variables amenable to intervention. Results support SMART's broadened conceptualization of transition readiness and need for assessment of multiple stakeholders' perspectives of patient transition readiness. A companion measure of SMART, which will be able to be completed by patients, parents and providers, will be developed to target areas of intervention to facilitate optimal transition readiness. Similar research programmes to establish evidence-based transition measures and interventions are needed. © 2011 Blackwell Publishing Ltd.

Barriers to Gender Transition-Related Healthcare: Identifying Underserved Transgender Adults in Massachusetts

PubMed Central

White Hughto, Jaclyn M.; Rose, Adam J.; Pachankis, John E.; Reisner, Sari L.

2017-01-01

Abstract Purpose: The present study sought to examine whether individual (e.g., age, gender), interpersonal (e.g., healthcare provider discrimination), and structural (e.g., lack of insurance coverage) factors are associated with access to transition-related care in a statewide sample of transgender adults. Method: In 2013, 364 transgender residents of Massachusetts completed an electronic web-based survey online (87.1%) or in person (12.9%). A multivariable logistic regression model tested whether individual, interpersonal, and structural factors were associated with access to transition-related care. Results: Overall, 23.6% reported being unable to access transition-related care in the past 12 months. In a multivariable model, younger age, low income, low educational attainment, private insurance coverage, and healthcare discrimination were significantly associated with being unable to access transition-related care (all p<0.05). Discussion: Despite state nondiscrimination policies and universal access to healthcare, many of the Massachusetts transgender residents sampled were unable to access transition-related care. Multilevel interventions are needed, including supportive policies and policy enforcement, to ensure that underserved transgender adults can access medically necessary transition-related care. PMID:29082331

Developing a rural transitional care community case management program using clinical nurse specialists.

PubMed

Baldwin, Kathleen M; Black, Denice; Hammond, Sheri

2014-01-01

This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority. As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed. Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions. After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients. The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care. Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems. The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.

Associates of Engagement in Adult-Oriented Follow-Up Care for Childhood Cancer Survivors.

PubMed

Szalda, Dava; Piece, Lisa; Brumley, Lauren; Li, Yimei; Schapira, Marilyn M; Wasik, Monika; Hobbie, Wendy L; Ginsberg, Jill P; Schwartz, Lisa A

2017-02-01

Understanding how to predict appropriate uptake of adult-oriented medical care is important for adult patients with pediatric-onset chronic health conditions with continued health vulnerability. We examined associates of engagement in adult survivors of childhood cancer following transfer to adult-oriented care. Adult survivors of childhood cancer (N = 80), within 1-5 years post transfer from pediatric to adult-oriented follow-up care, completed assessments of engagement with recommended adult-oriented follow-up care and psychosocial and transition readiness measures. Measures were validated with adolescent and young adults and/or intended to measure readiness to transition to adult care. Earlier age at diagnosis, parental involvement in health care decision-making, higher motivation, and increased comfort speaking to providers about health concerns were significantly associated with attendance at adult-oriented follow-up care visits. Associates of engagement in adult care are complex, representing social-ecological variables. Current measures of transition readiness or adolescent and young adult health-related measures may not adequately capture the associates of engagement in care or identify targets of intervention to promote successful transfer of care. Identifying patients at risk for loss to follow-up will be useful to design interventions for young adult survivors of childhood cancer and other young adults with pediatric-onset chronic conditions who require ongoing adult-oriented care. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Impact of a transition-of-care pharmacist during hospital discharge.

PubMed

Balling, Lauren; Erstad, Brian L; Weibel, Kurt

2015-01-01

To assess the impact of a transition-of-care pharmacist during hospital discharge. An academic medical center in southern Arizona. One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications. The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education. Readmission rates and medication interventions made by the pharmacist at discharge. The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%). A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community

PubMed Central

Burke, Robert E.; Malone, Daniel; Ridgeway, Kyle J.; McManus, Beth M.; Stevens-Lapsley, Jennifer E.

2016-01-01

Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions. PMID:26939601

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community.

PubMed

Falvey, Jason R; Burke, Robert E; Malone, Daniel; Ridgeway, Kyle J; McManus, Beth M; Stevens-Lapsley, Jennifer E

2016-08-01

Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions. © 2016 American Physical Therapy Association.

Diabetes Empowerment Council: Integrative Pilot Intervention for Transitioning Young Adults With Type 1 Diabetes.

PubMed

Weigensberg, Marc J; Vigen, Cheryl; Sequeira, Paola; Spruijt-Metz, Donna; Juarez, Magaly; Florindez, Daniella; Provisor, Joseph; Peters, Anne; Pyatak, Elizabeth A

2018-01-01

The transition of young adults with type 1 diabetes (T1D) from pediatric to adult care is challenging and frequently accompanied by worsening of diabetes-related health. To date, there are no reports which prospectively assess the effects of theory-based psycho-behavioral interventions during the transition period neither on glycemic control nor on psychosocial factors that contribute to poor glycemic control. Therefore, the overall aim of this study was to develop and pilot test an integrative group intervention based on the underlying principles of self-determination theory (SDT), in young adults with T1D. Fifty-one young adults with T1D participated in an education and case management-based transition program, of which 9 took part in the Diabetes Empowerment Council (DEC), a 12-week holistic, multimodality facilitated group intervention consisting of "council" process based on indigenous community practices, stress-reduction guided imagery, narrative medicine modalities, simple ritual, and other integrative modalities. Feasibility, acceptability, potential mechanism of effects, and bio-behavioral outcomes were determined using mixed qualitative and quantitative methods. The intervention was highly acceptable to participants, though presented significant feasibility challenges. Participants in DEC showed significant reductions in perceived stress and depression, and increases in general well-being relative to other control participants. Reduction in perceived stress, independent of intervention group, was associated with reductions in hemoglobin A1C. A theoretical model explaining the effects of the intervention included the promotion of relatedness and autonomy support, 2 important aspects of SDT. The DEC is a promising group intervention for young adults with T1D going through transition to adult care. Future investigations will be necessary to resolve feasibility issues, optimize the multimodality intervention, determine full intervention effects, and fully test the role of the underlying theoretical model of action.ClinicalTrials.gov Registration Number NCT02807155; Registration date: June 15, 2016 (retrospectively registered).

Diabetes Empowerment Council: Integrative Pilot Intervention for Transitioning Young Adults With Type 1 Diabetes

PubMed Central

Weigensberg, Marc J; Vigen, Cheryl; Sequeira, Paola; Spruijt-Metz, Donna; Juarez, Magaly; Florindez, Daniella; Peters, Anne; Pyatak, Elizabeth A

2018-01-01

Background The transition of young adults with type 1 diabetes (T1D) from pediatric to adult care is challenging and frequently accompanied by worsening of diabetes-related health. To date, there are no reports which prospectively assess the effects of theory-based psycho-behavioral interventions during the transition period neither on glycemic control nor on psychosocial factors that contribute to poor glycemic control. Therefore, the overall aim of this study was to develop and pilot test an integrative group intervention based on the underlying principles of self-determination theory (SDT), in young adults with T1D. Methods Fifty-one young adults with T1D participated in an education and case management-based transition program, of which 9 took part in the Diabetes Empowerment Council (DEC), a 12-week holistic, multimodality facilitated group intervention consisting of “council” process based on indigenous community practices, stress-reduction guided imagery, narrative medicine modalities, simple ritual, and other integrative modalities. Feasibility, acceptability, potential mechanism of effects, and bio-behavioral outcomes were determined using mixed qualitative and quantitative methods. Results The intervention was highly acceptable to participants, though presented significant feasibility challenges. Participants in DEC showed significant reductions in perceived stress and depression, and increases in general well-being relative to other control participants. Reduction in perceived stress, independent of intervention group, was associated with reductions in hemoglobin A1C. A theoretical model explaining the effects of the intervention included the promotion of relatedness and autonomy support, 2 important aspects of SDT. Conclusions The DEC is a promising group intervention for young adults with T1D going through transition to adult care. Future investigations will be necessary to resolve feasibility issues, optimize the multimodality intervention, determine full intervention effects, and fully test the role of the underlying theoretical model of action. ClinicalTrials.gov Registration Number NCT02807155; Registration date: June 15, 2016 (retrospectively registered) PMID:29552422

Getting Out of Silos: An Innovative Transitional Care Curriculum for Internal Medicine Residents Through Experiential Interdisciplinary Learning

PubMed Central

Schoenborn, Nancy L.; Christmas, Colleen

2013-01-01

Background Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines. Intervention We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions. Setting/Participants Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics. Program Description The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises. Program Evaluation The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum. Conclusions Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior. PMID:24455024

Validity and reliability of the Palliative Care Transition Measure for Caregivers (PCTM-C).

PubMed

D'Angelo, Daniela; Mastroianni, Chiara; Artico, Marco; Biagioli, Valentina; Latina, Roberto; Guarda, Michela; Piredda, Michela; De Marinis, Maria Grazia

2018-01-21

Patients suffering from advanced disease face different care transitions. The transition from acute to palliative care is challenging and may lead to the discontinuity of care. Family caregivers become important sources of information, as patients begin to experience difficulties in coping with emotional transition events. The Care Transition Measure was developed to evaluate care transitions as experienced by the elderly. It has never been used in palliative care. The aim of this study was to test the validity and reliability of a modified version of the Palliative Care Transition Measure, specifically the Palliative Care Transition Measure for Caregivers (PCTM-C). The study included two main phases. Phase I focused on the construction of a modified version of the Palliative Care Transition Measure through two focus groups and by computing the content validity index. Phase II focused on testing the psychometric properties of the PCTM-C on 272 family caregivers through confirmatory factor analysis. Result The content validity index for each of the items was higher than 0.80, whereas that for the scale was 0.95. The model tested with confirmatory factor analysis fitted the data well and confirmed that the transition measures referred to communication, integrated care and a trusting-relationship, and therefore the core dimensions of continuity according to existing conceptual models. The internal consistency was high (Cronbach's alpha = 0.94). Significance of results The PCTM-C proved to be a suitable measure of the quality of such transitions. It may be used in clinical practice as a continuity quality indicator and has the potential to guide interventions to enhance family caregivers' experience of care continuity.

User experience and care for older people transitioning from hospital to home: Patients' and carers' perspectives.

PubMed

Allen, Jacqueline; Hutchinson, Alison M; Brown, Rhonda; Livingston, Patricia M

2018-04-01

Transitioning from hospital to home is challenging for many older people living with chronic health conditions. Transitional care facilitates safe and timely transfer of patients between levels of care and across care settings and includes communication between practitioners, assessment and planning, preparation, medication reconciliation, follow-up care and self-management education. To date, there is limited understanding of how to actively involve care recipient service users in transitional care. This study was part of a larger research project. The objective of this article was to report the first study phase, in which we aimed to describe user experience pertaining to patients and carers. The study design was qualitative descriptive using interviews. Patients (n = 19) and carers (n = 7) participated in semi-structured interviews about their experience of transition from hospital to home in an urban Australian health-care setting. Interview data were analysed using thematic analysis. All participants reported that they needed to become independent in transition. Participants perceived a range of social processes supported their independence at home: supportive relationships with carers, caring relationships with health-care practitioners, seeking information, discussing and negotiating the transitional care plan and learning to self-care. Findings contribute to our understanding that quality transitional care should focus on patients' need to regain independence. Social processes supporting the capacities of patients and carers should be emphasized in future initiatives. Future transitional care interventions should emphasize strategies to enable negotiation for suitable supports and assist care recipients to overcome barriers identified in this study. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Pediatric Heart Transplantation: Transitioning to Adult Care (TRANSIT): Baseline Findings.

PubMed

Grady, Kathleen L; Hof, Kathleen Van't; Andrei, Adin-Cristian; Shankel, Tamara; Chinnock, Richard; Miyamoto, Shelley; Ambardekar, Amrut V; Anderson, Allen; Addonizio, Linda; Latif, Farhana; Lefkowitz, Debra; Goldberg, Lee; Hollander, Seth A; Pham, Michael; Weissberg-Benchell, Jill; Cool, Nichole; Yancy, Clyde; Pahl, Elfriede

2018-02-01

Young adult solid organ transplant recipients who transfer from pediatric to adult care experience poor outcomes related to decreased adherence to the medical regimen. Our pilot trial for young adults who had heart transplant (HT) who transfer to adult care tests an intervention focused on increasing HT knowledge, self-management and self-advocacy skills, and enhancing support, as compared to usual care. We report baseline findings between groups regarding (1) patient-level outcomes and (2) components of the intervention. From 3/14 to 9/16, 88 subjects enrolled and randomized to intervention (n = 43) or usual care (n = 45) at six pediatric HT centers. Patient self-report questionnaires and medical records data were collected at baseline, and 3 and 6 months after transfer. For this report, baseline findings (at enrollment and prior to transfer to adult care) were analyzed using Chi-square and t-tests. Level of significance was p < 0.05. Baseline demographics were similar in the intervention and usual care arms: age 21.3 ± 3.2 vs 21.5 ± 3.3 years and female 44% vs 49%, respectively. At baseline, there were no differences between intervention and usual care for use of tacrolimus (70 vs 62%); tacrolimus level (mean ± SD = 6.5 ± 2.3 ng/ml vs 5.6 ± 2.3 ng/ml); average of the within patient standard deviation of the baseline mean tacrolimus levels (1.6 vs 1.3); and adherence to the medical regimen [3.6 ± 0.4 vs 3.5 ± 0.5 (1 = hardly ever to 4 = all of the time)], respectively. At baseline, both groups had a modest amount of HT knowledge, were learning self-management and self-advocacy, and perceived they were adequately supported. Baseline findings indicate that transitioning HT recipients lack essential knowledge about HT and have incomplete self-management and self-advocacy skills.

Interventions to support people with dementia and their caregivers during the transition from home care to nursing home care: A systematic review.

PubMed

Müller, Christian; Lautenschläger, Sindy; Meyer, Gabriele; Stephan, Astrid

2017-06-01

During the transition of people with dementia from home to nursing home family caregivers often feel burdened. We aimed to 1) identify interventions which support people with dementia and their caregivers in the transition from home care to nursing home care, 2) synthesize the evidence for efficacy of these interventions, and 3) examine whether the identified interventions have been systematically developed, evaluated and implemented according to the Medical Research Council guidance on complex interventions. A systematic review of randomised controlled trials was conducted according to the recommendations specified in the Cochrane Handbook for Intervention Reviews. The review protocol was registered in PROSPERO (2015: CRD42015019839). Reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. MEDLINE, CENTRAL, PsycINFO, CINAHL, OTseeker, and PEDro, were searched. Other sources included Google Scholar, and ALOIS. Two reviewers independently assessed the eligibility of the articles. Data extraction was performed by one reviewer and verified independently by another. The Cochrane Risk of Bias tool was used for critical appraisal. Development and evaluation of the identified interventions were assessed, taking the Medical Research Council guidance into account. Review findings were synthesized narratively. The search yielded 1278 records. Five studies were included, all conducted in the United States (4 RCTs and 1 cRCT with a total of 695 participants). The psychosocial interventions were individual and family counseling via telephone or ad hoc all of which addressed only informal caregivers. The intervention components, content and mode of delivery differed widely with inconsistent results. Significant intervention effects were found for the reduction of caregivers' depressive symptoms, burden, feeling of guilt, emotional distress, overload, and interactions with staff. Other outcomes, i.e. stress, placement adaptation, role overload, and role captivity, were not statistically significantly affected. The assessment for bias risk across studies varied from moderate to low. Only two studies tested the feasibility of the intervention before full scale evaluation, none evaluated the implementation process according to the Medical Research Council framework. We identified only a few studies with heterogeneous outcomes; evidence regarding the effectiveness of psychosocial interventions is thus insufficient. Further research is needed focusing on the development and evaluation of complex psychosocial interventions and more well-designed RCTs with larger sample sizes based on a rigorous methodology. Reporting on feasibility and implementation processes of interventions should be guaranteed, since it is crucial to evaluate transferability across care settings. Copyright © 2017 Elsevier Ltd. All rights reserved.

[Towards culturally sensitive care for elderly immigrants! Design and development of a community based intervention programme in the Netherlands].

PubMed

Steunenberg, B; Verhagen, I; Ros, W J; de Wit, N J

2014-04-01

In Western countries, health and social welfare facilities are not easily accessible for elderly immigrants and their needs are sub optimally addressed. A transition is needed towards culturally sensitive services to make cure and care accessible for elderly immigrants. We developed an intervention programme in which ethnic community health workers (CHWs) act as liaisons between immigrant elderly and local health care and social welfare services. In a quasi experimental design, the effectiveness of introduction of CHWs, will be evaluated in three (semi) urban residential areas in the Netherlands within three different migrant groups and compared with a control group. The primary outcome is use of health care and social welfare facilities by the elderly. Secondary outcomes are quality of life and functional impairments. Implementation of the intervention programme will be examined with focus groups and data registration of CHW activities. In this paper design and methodological issues are discussed. This study can contribute to the improvement of care for elderly immigrants by developing culturally sensitive care whereby the elderly immigrants themselves actively participate. To enable a successful transition, proper identification and recruitment of CHWs is required. Once proven effective, the CHW function can be further integrated into the existing local health care and welfare system.

Chronic Grief Management for Dementia Caregivers in Transition: Intervention Development and Implementation

PubMed Central

Paun, Olimpia; Farran, Carol J.

2013-01-01

Research reveals that Alzheimer’s disease (AD) caregivers (CGs) do not relinquish their role after placing a family member in long-term care. Caregivers report increased emotional upset around the time of placement, with sustained losses over time leading to chronic grief. Chronic grief increases caregivers’ risk for depression and suicide. There are no documented interventions designed to decrease CGs chronic grief post placement. The Chronic Grief Management Intervention (CGMI) builds on existing evidence to target caregiver chronic grief in the transition of a family member into long-term care. The intervention is structured into three major components: 1) knowledge, 2) skill in communication and conflict resolution, and 3) chronic grief mangement skill. The 12-week intervention was pilot tested with thirty four caregivers for feasibility and preliminary effects on caregiver skill, knowledge, chronic grief, and depression. This article presents a general study description while focusing on the development and implementation of the CGMI. PMID:22084962

Developmental and Interprofessional Care of the Preterm Infant: Neonatal Intensive Care Unit Through High-Risk Infant Follow-up.

PubMed

Lipner, Hildy S; Huron, Randye F

2018-02-01

Practices in the neonatal intensive care unit (NICU) that reduce infant stress and respond to behavioral cues positively influence developmental outcomes. Proactive developmental surveillance and timely introduction of early intervention services improve outcomes for premature infants. A model that emphasizes infant development and a continuum of care beginning in the NICU with transition to outpatient monitoring and provision of early intervention services is hypothesized to support the most optimal outcomes for premature infants. Copyright © 2017 Elsevier Inc. All rights reserved.

The impact of Kaua'i Care Transition Intervention on hospital readmission rates.

PubMed

Li, Fengfang; Guo, Jing; Suga-Nakagawa, Audrey; Takahashi, Ludvina K; Renaud, June

2015-10-01

To evaluate the effects of Kaua'i Care Transition Intervention (KCTI), a patient-centered intervention program, on reducing hospital readmission rates among patients 60 years or older. A prospective quasi-experimental prepost design. Hospital admissions data for the year 2010 (January 1 to December 31) served as the baseline data and were used to identify patients at risk of hospital readmission. KCTI was implemented over a 12-month period from April 1, 2012, to March 31, 2013, and 30-day, 60-day, and 1-year readmission rates were assessed for both the intervention and baseline periods. The impact of the intervention was examined by a logistic regression model, controlling for possible patient population differences. During the intervention period, a total of 269 patients 60 years or older were admitted to the hospital, of which, 58 were referred to the KCTI program. Logistic regression controlling for patients' primary health insurance, discharge sites, and certain admitting diagnoses (eg, arrhythmias, cellulitis, chronic obstructive pulmonary disease) found that the intervention reduced the 30-day readmission rate by two-thirds (odds ratio [OR], 0.34; P = .003). Readmission rates within 60 days (OR, 0.42; P < .01) and within a year (OR, 0.48; P < .001) during the intervention period were less than half of the baseline rates. By selecting patients with identified risk factors, then empowering and educating them with the intervention program, this study was successful in reducing hospital readmission rates. This study also demonstrated the value of carefully selecting patients for intervention programs.

Transition to Adult Care for Youth with Type 1 Diabetes

PubMed Central

Garvey, Katharine C.; Markowitz, Jessica T.

2014-01-01

Emerging adults with type 1 diabetes are at risk for poor glycemic control, gaps in medical care, and adverse health outcomes. With the increasing incidence in type 1 diabetes in the pediatric population, there will be an increase in the numbers of teens and young adults transferring their care from pediatric providers to adult diabetes services in the future. In recent years, the topic of transitioning pediatric patients with type 1 diabetes to adult diabetes care has been discussed at length in the literature and there have been many observational studies. However, there are few interventional studies and, to date, no randomized clinical trials. This paper discusses the rationale for studying this important area. We review both observational and interventional literature over the past several years, with a focus on new research. In addition, important areas for future research are outlined. PMID:22922877

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

PubMed

Moore, Amber B; Krupp, J Elyse; Dufour, Alyssa B; Sircar, Mousumi; Travison, Thomas G; Abrams, Alan; Farris, Grace; Mattison, Melissa L P; Lipsitz, Lewis A

2017-10-01

Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs. We undertook a prospective cohort study comparing cost and health care utilization outcomes between ECHO-CT facilities and matched comparisons from January 2014-December 2014. Thirty-day readmission rates were significantly lower in the intervention group (odds ratio 0.57; 95% CI, 0.34-0.96; P-value .04), as were the 30-day total health care cost ($2602.19 lower; 95% CI, -$4133.90 to -$1070.48; P-value <.001) and the average length of stay at the skilled nursing facility (-5.52 days; 95% CI, -9.61 to -1.43; P = .001). The 30-day mortality rate was not significantly lower in the intervention group (odds ratio 0.38; 95% CI, 0.11-1.24; P = .11). Patients discharged to skilled nursing facilities participating in the ECHO-CT program had shorter lengths of stay, lower 30-day rehospitalization rates, and lower 30-day health care costs compared with those in matched skilled nursing facilities delivering usual care. ECHO-CT may improve patient transitions to postacute care at lower overall cost. Copyright © 2017 Elsevier Inc. All rights reserved.

Knowledge to action: Rationale and design of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) stepped wedge cluster randomized trial.

PubMed

Van Spall, Harriette G C; Lee, Shun Fu; Xie, Feng; Ko, Dennis T; Thabane, Lehana; Ibrahim, Quazi; Mitoff, Peter R; Heffernan, Michael; Maingi, Manish; Tjandrawidjaja, Michael C; Zia, Mohammad I; Panju, Mohamed; Perez, Richard; Simek, Kim D; Porepa, Liane; Graham, Ian D; Haynes, R Brian; Haughton, Dilys; Connolly, Stuart J

2018-05-01

Heart Failure (HF) is a common cause of hospitalization in older adults. The transition from hospital to home is high-risk, and gaps in transitional care can increase the risk of re-hospitalization and death. Combining health care services supported by meta-analyses, we designed the PACT-HF transitional care model. Adopting an integrated Knowledge Translation (iKT) approach in which decision-makers and clinicians are partners in research, we implement and test the effectiveness of PACT-HF among patients hospitalized for HF. We use a pragmatic stepped wedge cluster randomized trial design to introduce the complex health service intervention to 10 large hospitals in a randomized sequence until all hospitals initiate the intervention. The goal is for all patients hospitalized with HF to receive self-care education, multidisciplinary care, and early follow-up with their health care providers; and in addition, for high-risk patients to receive post-discharge nurse-led home visits and outpatient care in Heart Function clinics. This requires integration of care across hospitals, home care agencies, and outpatient clinics in our publicly funded health care system. While hospitals are the unit of recruitment and analysis, patients (estimated sample size of 3200) are the unit of analysis. Primary outcomes are hierarchically ordered as time to composite all-cause readmissions / emergency department (ED) visits / death at 3 months and time to composite all-cause readmissions / ED visits at 30 days. In a nested study of 8 hospitals, we measure the patient-centered outcomes of Discharge Preparedness, Care Transitions Quality, and Quality Adjusted Life Years (QALY); and the 6-month health care resource use and costs. We obtain all clinical and cost outcomes via linkages to provincial administrative databases. This protocol describes the implementation and testing of a transitional care model comprising health care services informed by high-level evidence. The study adopts an iKT and pragmatic approach, uses a robust study design, links clinical trial data with outcomes held in administrative databases, and includes patient-reported outcomes. Findings will have implications on clinical practice, health care policy, and Knowledge Translation (KT) research methodology. Copyright © 2017 Elsevier Inc. All rights reserved.

"Are these adult doctors gonna know me?" Experiences of transition for young people with a liver transplant.

PubMed

Wright, J; Elwell, L; McDonagh, J E; Kelly, D A; Wray, J

2016-11-01

Excellent survival rates in paediatric LTx have resulted in increasing numbers of young people transferring from paediatric to adult care. Understanding the mechanisms of successful transition is imperative for ensuring good long-term outcomes and developing services for young people. Semi-structured interviews were conducted with 17 young people (10 females; age range: 15.2-25.1 years). Eight were within 1 year of transferring to adult services; nine had transferred. Interviews were analysed using IPA. Analysis revealed two major themes in both pre- and post-transfer groups: "relationships with healthcare professionals" and "continuity of care." Young people experienced difficulty ending relationships with paediatric clinicians and forming new relationships with adult clinicians. They expressed frustrations over a perceived lack of continuity of care after transfer and a fear of the unknown nature of adult services. The importance of a holistic approach to care was emphasized. Interventions are needed to support young people in transition, particularly in ending relationships in paediatric care and forming new relationships in adult care. Young people need help to develop strategies to cope with the different approaches in adult services. Interventions to provide clinicians with skills to communicate and engage with young people are imperative. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

“Missing Pieces” – Functional, Social, and Environmental Barriers to Recovery for Vulnerable Older Adults Transitioning From Hospital to Home

PubMed Central

Greysen, S. Ryan; Hoi-Cheung, Doug; Garcia, Veronica; Kessell, Eric; Sarkar, Urmimala; Goldman, Lauren; Schneidermann, Michelle; Critchfield, Jeffrey; Pierluissi, Edgar; Kushel, Margot

2014-01-01

Background Recent interventions to improve transitions in care for older adults focus on hospital discharge processes. Limited data exists on patient concerns for care at home after discharge, particularly for vulnerable older adults. Design We used in-depth, in-person interviews to describe barriers to recovery at home after leaving the hospital for vulnerable, older adults. We purposefully sampled by age, gender, race, and English proficiency to ensure a wide breadth of experiences. Interviews were independently coded by two investigators using the constant comparative method. Thematic analysis was performed by the entire research team with diverse backgrounds in primary care, hospital medicine, geriatrics, and nursing. Setting and Participants We interviewed vulnerable older adults (low income/health literacy, and/or Limited English Proficiency) who were enrolled in a larger discharge interventional study within 30 days of discharge from an urban public hospital. All participants were interviewed in their native language (English, Spanish, or Chinese). Results We interviewed 24 patients: mean age 63 (55–84), 66% male, 67% Non-white, 16% Spanish-speaking, 16% Chinese-speaking. We identified an overarching theme of “missing pieces” in the plan for post-discharge recovery at home from which three specific sub-themes emerged: (1) functional limitations and difficulty with mobility and self-care tasks; (2) social isolation and lack of support from family and friends; (3) challenges from poverty and the built environment at home. In contrast, patients described mostly supportive experiences with traditional focuses of transition care such as following prescribed medication and diet regimens. Conclusion Hospital-based discharge interventions that focus on traditional aspects of care may overlook social and functional gaps in post-discharge care at home for vulnerable older adults. Post-discharge interventions that address these challenges may be necessary to reduce readmissions in this population. PMID:24934494

Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan

PubMed Central

Birnkrant, David J; Bushby, Katharine; Bann, Carla M; Apkon, Susan D; Blackwell, Angela; Colvin, Mary K; Cripe, Linda; Herron, Adrienne R; Kennedy, Annie; Kinnett, Kathi; Naprawa, James; Noritz, Garey; Poysky, James; Street, Natalie; Trout, Christina J; Weber, David R; Ward, Leanne M

2018-01-01

Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy. PMID:29398641

Lessons Learned from Testing the Quality Cost Model of Advanced Practice Nursing (APN) Transitional Care

PubMed Central

Brooten, Dorothy; Naylor, Mary D.; York, Ruth; Brown, Linda P.; Munro, Barbara Hazard; Hollingsworth, Andrea O.; Cohen, Susan M.; Finkler, Steven; Deatrick, Janet; Youngblut, JoAnne M.

2013-01-01

Purpose To describe the development, testing, modification, and results of the Quality Cost Model of Advanced Practice Nurses (APNs) Transitional Care on patient outcomes and health care costs in the United States over 22 years, and to delineate what has been learned for nursing education, practice, and further research. Organizing Construct The Quality Cost Model of APN Transitional Care. Methods Review of published results of seven randomized clinical trials with very low birth-weight (VLBW) infants; women with unplanned cesarean births, high risk pregnancies, and hysterectomy surgery; elders with cardiac medical and surgical diagnoses and common diagnostic related groups (DRGs); and women with high risk pregnancies in which half of physician prenatal care was substituted with APN care. Ongoing work with the model is linking the process of APN care with the outcomes and costs of care. Findings APN intervention has consistently resulted in improved patient outcomes and reduced health care costs across groups. Groups with APN providers were rehospitalized for less time at less cost, reflecting early detection and intervention. Optimal number and timing of postdischarge home visits and telephone contacts by the APNs and patterns of rehospitalizations and acute care visits varied by group. Conclusions To keep people well over time, APNs must have depth of knowledge and excellent clinical and interpersonal skills that are the hallmark of specialist practice, an in-depth understanding of systems and how to work within them, and sufficient patient contact to effect positive outcomes at low cost. PMID:12501741

Economic evaluation of a multifactorial, interdisciplinary intervention versus usual care to reduce frailty in frail older people.

PubMed

Fairhall, Nicola; Sherrington, Catherine; Kurrle, Susan E; Lord, Stephen R; Lockwood, Keri; Howard, Kirsten; Hayes, Alison; Monaghan, Noeline; Langron, Colleen; Aggar, Christina; Cameron, Ian D

2015-01-01

To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention versus usual care for older people who are frail. Cost-effectiveness study embedded within a randomized controlled trial. Community-based intervention in Sydney, Australia. A total of 241 community-dwelling people 70 years or older who met the Cardiovascular Health Study criteria for frailty. A 12-month multifactorial, interdisciplinary intervention targeting identified frailty characteristics versus usual care. Health and social service use, frailty, and health-related quality of life (EQ-5D) were measured over the 12-month intervention period. The difference between the mean cost per person for 12 months in the intervention and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in the intervention group compared with the control group at 12 months (95% CI 2.4%-27.0%; P = .02). There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to transition out of frailty was $A15,955 (at 2011 prices). In the "very frail" subgroup (participants met >3 Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from frailty. In the very frail subpopulation, this reduced to $25,000. For frail older people residing in the community, a 12-month multifactorial intervention provided better value for money than usual care, particularly for the very frail, in whom it has a high probability of being cost saving, as well as effective. Trial registration: ACTRN12608000250336. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Feasibility of "Standardized Clinician" Methodology for Patient Training on Hospital-to-Home Transitions.

PubMed

Wehbe-Janek, Hania; Hochhalter, Angela K; Castilla, Theresa; Jo, Chanhee

2015-02-01

Patient engagement in health care is increasingly recognized as essential for promoting the health of individuals and populations. This study pilot tested the standardized clinician (SC) methodology, a novel adaptation of standardized patient methodology, for teaching patient engagement skills for the complex health care situation of transitioning from a hospital back to home. Sixty-seven participants at heightened risk for hospitalization were randomly assigned to either simulation exposure-only or full-intervention group. Both groups participated in simulation scenarios with "standardized clinicians" around tasks related to hospital discharge and follow-up. The full-intervention group was also debriefed after scenario sets and learned about tools for actively participating in hospital-to-home transitions. Measures included changes in observed behaviors at baseline and follow-up and an overall program evaluation. The full-intervention group showed increases in observed tool possession (P = 0.014) and expression of their preferences and values (P = 0.043). The simulation exposure-only group showed improvement in worksheet scores (P = 0.002) and fewer engagement skills (P = 0.021). Both groups showed a decrease in telling an SC about their hospital admission (P < 0.05). Open-ended comments from the program evaluation were largely positive. Both groups benefited from exposure to the SC intervention. Program evaluation data suggest that simulation training is feasible and may provide a useful methodology for teaching patient skills for active engagement in health care. Future studies are warranted to determine if this methodology can be used to assess overall patient engagement and whether new patient learning transfers to health care encounters.

Outcomes of an Interdisciplinary Transitional Care Quality Improvement Project on Self-Management and Health Care Use in Patients With Heart Failure.

PubMed

Hoover, Carrie; Plamann, Joy; Beckel, Jean

2017-01-01

Heart failure (HF) accounts for most U.S. Medicare hospital admissions. The purpose of the current study was to evaluate the effectiveness of a care transitions quality improvement (QI) intervention on self-management and readmission rates in older adults with HF. A quasi-experimental, descriptive study was conducted with 66 patients with HF in three medical units in a 489-bed Midwestern acute care hospital. The intervention included a nurse coach visit and follow up, pharmacy medication education and reconciliation, and HF clinic referral. Outcomes were assessed within 48 hours of admission and 30 days after discharge using the Self-Care of Heart Failure Index and medical record review. Following implementation, readmission rates decreased from 24% to 13%. Participants demonstrated a greater improvement in use of self-management strategies to control symptoms than the non-intervention group (p < 0.02) and more readily identified their symptoms of HF (p < 0.04). The evolution of population health, with increasing numbers of older adults living at home with complex chronic conditions, will require establishment of active partnerships among pharmacists, physicians, nurse specialists, home care nurses, and patients. [Journal of Gerontological Nursing, 43(1), 23-31.]. Copyright 2016, SLACK Incorporated.

Improving Outcomes After Hospitalization: A Prospective Observational Multicenter Evaluation of Care Coordination Strategies for Reducing 30-Day Readmissions to Maryland Hospitals.

PubMed

Hoyer, Erik H; Brotman, Daniel J; Apfel, Ariella; Leung, Curtis; Boonyasai, Romsai T; Richardson, Melissa; Lepley, Diane; Deutschendorf, Amy

2018-05-01

Patients frequently experience suboptimal transitions from the hospital to the community, which can increase the likelihood of readmission. It is not known which care coordination services can lead to improvements in readmission rates. To evaluate the effects of two care coordination interventions on 30-day readmission rates. Prospective multicenter observational study of hospitalized patients eligible for two care coordination services between January 1, 2013, and October 31, 2015. Readmission rates were compared for patients who received each care coordination intervention versus those who did not using multivariable generalized estimating equation logistic regression models. A total of 25,628 patients hospitalized in medicine, neurosciences, or surgical sciences units. Patients discharged home and deemed to be at high risk for readmission were assigned a nurse Transition Guide (TG) for 30 days post-discharge. All other patients were assigned the Patient Access Line (PAL) intervention, which provided a post-discharge phone call from a registered nurse. Two large academic hospitals in Baltimore, MD. Thirty-day all-cause readmission to any Maryland hospital. Among all patients, 14.2% (2409/16,993) of those referred for the PAL intervention and 22.8% (1973/8635) of those referred for the TG intervention were readmitted. PAL-referred patients who did not receive the intervention had an adjusted odds ratio (aOR) for readmission of 1.27 (95% confidence interval [95% CI] 1.12-1.44, p < 0.001) compared with patients who did. TG-referred patients who did not receive the TG intervention had an aOR of 1.83 (95% CI 1.60-2.10, p < 0.001) compared with patients who received the intervention. Younger age, male sex, having more comorbidities, and being discharged from a medicine unit were associated with not receiving an assigned intervention. These characteristics were also associated with higher readmission rates. PAL and TG care coordination interventions were associated with lower rates of 30-day readmission. Our findings underscore the importance of determining the appropriate intervention for the hardest-to-reach patients, who are also at the highest risk of being readmitted.

A systematic review of interventions to improve postpartum retention of women in PMTCT and ART care

PubMed Central

Geldsetzer, Pascal; Yapa, H Manisha N; Vaikath, Maria; Ogbuoji, Osondu; Fox, Matthew P; Essajee, Shaffiq M; Negussie, Eyerusalem K; Bärnighausen, Till

2016-01-01

Introduction The World Health Organization recommends lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV. Effective transitioning from maternal and child health to ART services, and long-term retention in ART care postpartum is crucial to the successful implementation of lifelong ART for pregnant women. This systematic review aims to determine which interventions improve (1) retention within prevention of mother-to-child HIV transmission (PMTCT) programmes after birth, (2) transitioning from PMTCT to general ART programmes in the postpartum period, and (3) retention of postpartum women in general ART programmes. Methods We searched Medline, Embase, ISI Web of Knowledge, the regional World Health Organization databases and conference abstracts for data published between 2002 and 2015. The quality of all included studies was assessed using the GRADE criteria. Results and Discussion After screening 8324 records, we identified ten studies for inclusion in this review, all of which were from sub-Saharan Africa except for one from the United Kingdom. Two randomized trials found that phone calls and/or text messages improved early (six to ten weeks) postpartum retention in PMTCT. One cluster-randomized trial and three cohort studies found an inconsistent impact of different levels of integration between antenatal care/PMTCT and ART care on postpartum retention. The inconsistent results of the four identified studies on care integration are likely due to low study quality, and heterogeneity in intervention design and outcome measures. Several randomized trials on postpartum retention in HIV care are currently under way. Conclusions Overall, the evidence base for interventions to improve postpartum retention in HIV care is weak. Nevertheless, there is some evidence that phone-based interventions can improve retention in PMTCT in the first one to three months postpartum. PMID:27118443

The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission.

PubMed

Kirkham, Heather S; Clark, Bobby L; Paynter, Jacquelyn; Lewis, Geraint H; Duncan, Ian

2014-05-01

The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission was evaluated. This retrospective cohort study was conducted in two acute care hospitals within the same hospital system in the southeastern United States. One hospital initiated a care transition program in January 2011; the other hospital did not have such a program. All patients who were discharged from either hospital to home from January 1, 2010, through December 31, 2011, were included in the study. The two key program components included bedside delivery of postdischarge medications and follow-up telephone calls two to three days after discharge. The likelihood of readmission was assessed using multiple logistic regression. Over the 2-year study period, 19,659 unique patients had 26,781 qualifying index admissions, 2,523 of which resulted in a readmission within 30 days of discharge. After adjusting for various demographic and clinical characteristics, the usual care group (i.e., patients who did not participate in the program) had nearly twice the odds of readmission within 30 days (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.35-2.67), compared with the intervention group (i.e., program participants). For patients age 65 years or older, those in the usual care group had a sixfold increase in the odds of a 30-day readmission (OR, 6.05; 95% CI, 1.92-19.00) relative to those in the intervention group. A care transition program was associated with a lower likelihood of readmission and had a greater effect on older patients.

Challenges associated with transition to caregiver role following diagnostic disclosure of Alzheimer disease: a descriptive study.

PubMed

Ducharme, Francine; Lévesque, Louise; Lachance, Lise; Kergoat, Marie-Jeanne; Coulombe, Renée

2011-09-01

The prevalence of Alzheimer's disease is rising. The large number of new cases identified each year means that many new families will set upon a long trajectory of caring for a relative with dementia. Diagnostic disclosure of Alzheimer's disease marks the official transition to the caregiver role, yet this early period of the caregiver career have rarely been studied. Based on Meleis's theoretical framework for role transition, the objectives of this study were to document the characteristics of the caregiving context during the transition to the caregiver role following diagnostic disclosure of Alzheimer's disease and to compare these characteristics by caregiver gender and kinship tie to the relative. A descriptive design was used. Data were collected using standardized measures selected in accordance with the role transition theoretical framework. The sample recruited in Quebec (Canada) cognition clinics comprised 122 caregivers of an elderly relative diagnosed with Alzheimer's disease in the past nine months. Findings reveal the context of care to be marked by several challenges for caregivers. The majority of caregivers receives little informal support, has poor knowledge of available formal services, and has difficulty planning ahead for the relative's future care needs. Caregivers themselves report a lack of preparedness to provide care. Compared with men caregivers, women seem to have more problems controlling disturbing thoughts about their new caregiver role and to experience more family conflicts and psychological distress. Compared with offspring caregivers, spouse caregivers are less able to respond to the relative's disruptive behaviors, make less use of problem-solving strategies, and report fewer family conflicts. The challenges faced by caregivers during the transition to the caregiver role are sensitive to nursing interventions. Pro-active interventions from the outset of the caregiving career, such as early assessment of caregiver needs for support and of caregiver preparedness to provide care as well as early psycho-educational interventions, are essential to foster positive caregiver responses to the challenges of their new role. Copyright © 2011 Elsevier Ltd. All rights reserved.

Story sharing: restoring the reciprocity of caring in long-term care.

PubMed

Heliker, Diane

2007-07-01

Residents in long-term care facilities often experience an interruption in the reciprocity of caring, inadvertently cut off when they enter the unfamiliar surroundings of a residential health care system. This transition from the give and take of caring to being completely cared for often leads to a breakdown of meaning, a loss of identity, and loneliness. This article addresses how an intervention called story sharing can restore the reciprocity of caring. Beginning with a review of the significance and functions of storytelling and listening, a specific story sharing intervention-the mutual sharing of everyday experiences among nurse aides and the nursing home residents for whom they care-is described. The theoretical and practice implications of story sharing are discussed.

A motivational counseling approach to improving heart failure self-care: mechanisms of effectiveness.

PubMed

Riegel, Barbara; Dickson, Victoria V; Hoke, Linda; McMahon, Janet P; Reis, Brendali F; Sayers, Steven

2006-01-01

Self-care is an integral component of successful heart failure (HF) management. Engaging patients in self-care can be challenging. Fifteen patients with HF enrolled during hospitalization received a motivational intervention designed to improve HF self-care. A mixed method, pretest posttest design was used to evaluate the proportion of patients in whom the intervention was beneficial and the mechanism of effectiveness. Participants received, on average, 3.0 +/- 1.5 home visits (median 3, mode 3, range 1-6) over a three-month period from an advanced practice nurse trained in motivational interviewing and family counseling. Quantitative and qualitative data were used to judge individual patients in whom the intervention produced a clinically significant improvement in HF self-care. Audiotaped intervention sessions were analyzed using qualitative methods to assess the mechanism of intervention effectiveness. Congruence between quantitative and qualitative judgments of improved self-care revealed that 71.4% of participants improved in self-care after receiving the intervention. Analysis of transcribed intervention sessions revealed themes of 1) communication (reflective listening, empathy); 2) making it fit (acknowledging cultural beliefs, overcoming barriers and constraints, negotiating an action plan); and, 3) bridging the transition from hospital to home (providing information, building skills, activating support resources). An intervention that incorporates the core elements of motivational interviewing may be effective in improving HF self-care, but further research is needed.

Clinician roles and responsibilities during care transitions of older adults.

PubMed

Schoenborn, Nancy L; Arbaje, Alicia I; Eubank, Kathryn J; Maynor, Kenric; Carrese, Joseph A

2013-02-01

To identify the perceived roles and responsibilities of clinicians during care transitions of older adults. Qualitative study involving 1-hour in-depth semistructured interviews. Audiotapes of interviews were transcribed, coded, and analyzed, and themes and subthemes were generated. An acute care hospital, a skilled nursing facility, two community-based outpatient practices, and one home healthcare agency. Forty healthcare professionals directly involved in care transitions of older adults (18 physicians, 11 home healthcare administrative and field staff, four social workers, three nurse practitioners, three physician assistants, and one hospital case manager). Perspectives of healthcare professionals regarding clinicians' roles and responsibilities during care transitions were examined and described. Content analysis revealed several themes: components of clinicians' roles during care transitions; congruence between self- and others' perceived ideal roles but incongruence between ideal and routine roles; ambiguity in accountability in the postdischarge period; factors prompting clinicians to act closer to ideal roles; and barriers to performing ideal roles. A conceptual framework was created to summarize clinicians' roles during care transitions. This study reports differences between what healthcare professionals perceive as ideal roles of clinicians during care transitions and what clinicians actually do routinely. Certain patient and clinician factors prompt clinicians to act closer to the ideal roles. Multiple barriers interfere with consistent practice of ideal roles. Future investigations could evaluate interventions targeting various components of the conceptual framework and relevant outcomes. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): study protocol for a randomized controlled trial.

PubMed

McWilliams, Andrew; Roberge, Jason; Moore, Charity G; Ashby, Avery; Rossman, Whitney; Murphy, Stephanie; McCall, Stephannie; Brown, Ryan; Carpenter, Shannon; Rissmiller, Scott; Furney, Scott

2016-12-19

Hospital readmissions remain highly prevalent despite being the target of policies and financial penalties. Evidence comparing the effectiveness and costs of interventions to reduce readmissions is lacking, leaving healthcare systems with little guidance on how to improve quality and avoid costly penalties. Effective interventions likely need to bridge inpatient and outpatient settings, incorporate information technology, and use dedicated providers. Such complex innovations will require rigorous evaluation. The framework of quality improvement research provides an approach that both improves care locally and contributes to closing the current knowledge gaps for readmissions. In this trial, we will study a comprehensive intervention that incorporates these recommendations into an integrated practice unit, called transition services, with an aim of reducing 30-day readmission rates. We describe a nonblinded, pragmatic, controlled trial with two parallel groups comprising an evaluation of the effect of referral to a provider-led integrated practice unit, inclusive of comprehensive multidisciplinary care, dedicated paramedicine providers, and virtual visits, on 30-day readmission rates for high-risk hospitalized patients. An automated risk-scoring system will randomly generate referrals to either transition services or usual care for 1520 hospitalized patients who score as high-risk for readmission. Transition services will then engage with patients in the hospital setting using a patient navigator and provide bridging outpatient services for the 30 days following discharge. All outcome data are retrieved electronically from administrative medical records. After reapplication of inclusion and exclusion criteria at the time of hospital discharge, analyses will follow the intention-to-treat principle such that patients will be analyzed on the basis of the referral group to which they were initially randomized. The hospital transition program under study is complex and integrates the latest recommendations for readmission reduction strategies. As healthcare systems innovate to address readmissions through such complex interventions, there is significant benefit for stakeholders to have a clear understanding of the potential reach, cost, and real-world effectiveness. The pragmatic methods described here provide a template for conducting quality improvement research that fits seamlessly into existing care delivery and improvement efforts, leading to better-informed strategic decisions and the investments necessary to transform care and value for patients. ClinicalTrials.gov, NCT02763202 . Registered 3 March 2016 (retrospectively registered).

Not feeling ready to go home: a qualitative analysis of chronically ill patients' perceptions on care transitions.

PubMed

Verhaegh, Kim J; Jepma, Patricia; Geerlings, Suzanne E; de Rooij, Sophia E; Buurman, Bianca M

2018-06-25

Unplanned hospital readmissions frequently occur and have profound implications for patients. This study explores chronically ill patients' experiences and perceptions of being discharged to home and then acutely readmitted to the hospital to identify the potential impact on future care transition interventions. Twenty-three semistructured interviews were conducted with chronically ill patients who had an unplanned 30-day hospital readmission at a university teaching hospital in the Netherlands. A constructive grounded theory approach was used for data analysis. The core category identified was 'readiness for hospital discharge,' and the categories related to the core category are 'experiencing acute care settings' and 'outlook on the recovery period after hospital discharge.' Patients' readiness for hospital discharge was influenced by the organization of hospital care, patients' involvement in decision-making and preparation for discharge. The experienced difficulties during care transitions might have influenced patients' ability to cope with challenges of recovery and dependency on others. The results demonstrated the importance of assessing patients' readiness for hospital discharge. Health care professionals are recommended to recognize patients and guide them through transitions of care. In addition, employing specifically designated strategies that encourage patient-centered communication and shared decision-making can be vital in improving care transitions and reduce hospital readmissions. We suggest that health care professionals pay attention to the role and capacity of informal caregivers during care transitions and the recovery period after hospital discharge to prevent possible postdischarge problems.

Clinicians’ views on improving inter-organizational care transitions

PubMed Central

2013-01-01

Background Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians’ perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations. Methods A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. Results Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients’ readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. Conclusion Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient’s status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients. PMID:23899326

Women in Transition to Health: A Theory-Based Intervention to Increase Engagement in Care for Women Recently Released From Jail or Prison.

PubMed

Colbert, Alison M; Durand, Vanessa

2016-01-01

The time after incarceration is widely regarded as tenuous and stressful, and for women living with chronic illness, self-management is yet another stressor. Intervening before the individual is overwhelmed is critical to ensuring success. In this article the Women in Transition to Health, a nurse-led intervention based on Lazarus and Folkman's Transactional Model of Stress and Coping, designed to improve health outcomes in women recently released from jail or prison is described. Motivational interviewing and case management are used to strengthen coping skills and encourage engagement in care. Using the stress model to address the unique needs of this population holds promise for improving health and quality of life.

Effect of Pharmacy-Supported Transition-of-Care Interventions on 30-Day Readmissions: A Systematic Review and Meta-analysis.

PubMed

Rodrigues, Claire R; Harrington, Amanda R; Murdock, Nicole; Holmes, John T; Borzadek, Eliza Z; Calabro, Kristin; Martin, Jennifer; Slack, Marion K

2017-10-01

To describe pharmacy-supported transition-of-care (TOC) interventions and determine their effect on 30-day all-cause readmissions. MEDLINE/PubMed, EMBASE, International Pharmaceutical Abstracts, ABI Inform Complete, PsychINFO, Web of Science, Academic Search Complete, CINHAL, Cochrane library, OIASTER, ProQuest Dissertations & Theses, ClinicalTrials.gov , and relevant websites were searched from January 1, 1995, to December 31, 2015. PICOS+E criteria were utilized. Eligible studies reported pharmacy-supported TOC interventions compared with usual care in adult patients discharged to home within the United States. Studies were required to evaluate postdischarge outcomes (eg, rate of readmissions, hospital utilization). Randomized controlled trials, cohort studies, or controlled before-and-after studies were included. Two reviewers independently extracted data and evaluated study quality. A total of 56 articles were included in the systematic review (n = 61 858), of which 32 reported 30-day all-cause readmissions and were included in the meta-analysis. A taxonomy was developed to categorize targeted patients, intervention types, and pharmacy personnel as sole intervener. The meta-analysis demonstrated about a 32% reduction in the odds of readmission (odds ratio [OR] = 0.68; 95% CI = 0.61 to 0.75) observed for pharmacy-supported TOC interventions compared with usual care. Heterogeneity was identified ( I 2 = 55%; P < 0.001). A stratified meta-analysis showed that interventions with patient-centered follow-up reduced 30-day readmissions relative to studies without follow-up (OR = 0.70; CI = 0.63 to 0.78). Pharmacy-supported TOC programs were associated with a significant reduction in the odds of 30-day readmissions.

Interprofessional simulation to improve patient participation in transitional care.

PubMed

Dyrstad, Dagrunn Nåden; Storm, Marianne

2017-06-01

Educating and training healthcare professionals is known to improve the quality of transitional care for older adults. Arranging interprofessional meetings for healthcare professionals might be useful to improve patient participation skills in transitional care. To describe the learning activities used in The Meeting Point programme, focusing on patient participation in transitional care, and assess whether they increase healthcare professionals' awareness of and competencies relating to patient participation in the transitional care of older patients. Data were collected as part of an educational intervention programme, The Meeting Point, including three seminars on 'Patient participation in the transitional care of older patients' and four follow-up meetings. Participants were nurses, care assistants, doctors, physiotherapists, patient coordinators and administrative personnel from hospital, nursing homes and home-based care services. The Meeting Point was organised around four pillars: introduction, teaching session, group work activity and plenary discussion. Qualitative data included log reports, summaries of meetings, notes from group work activities, and reports from participants and from follow-up meetings. Feedback from participants shows that they were satisfied with meeting healthcare professionals from other units of care. A film scenario was perceived relevant for group work activity and useful in focusing participants' attention to patient participation. Follow-up meetings show that some nursing home wards, the emergency department and one medical ward at the hospital continued with ongoing work to improve quality of care. Efforts included implementation of an observational waiting room with comfortable chairs, planning for discharge in hospital admission, a daily patient flow registration system and motivational interviewing during admission to nursing home. The description of the learning activities used at The Meeting Point seminars shows that they were useful to increase awareness of and competencies on patient participation in transitional care. © 2016 Nordic College of Caring Science.

The impact of transitional care programs on health services utilization in community-dwelling older adults: a systematic review.

PubMed

Weeks, Lori E; Macdonald, Marilyn; Martin-Misener, Ruth; Helwig, Melissa; Bishop, Andrea; Iduye, Damilola F; Moody, Elaine

2018-02-01

The objective was to identify and synthesize the best available evidence on the impact of transitional care programs on various forms of health services utilization in community-dwelling older adults. There is growing evidence that transitional care programs can help address important challenges facing health care systems and our increasing older adult population in many countries by reducing unnecessary health service utilization. There is a need for a systematic review of the research evaluating the impact of transitional care programs on hospital and other health service usage. The review included studies on community-dwelling adults age 60 and over with at least one medical diagnosis, and which evaluated the outcomes of transitional care programs on health system utilization of older adults. The outcomes for this review were hospital usage including admissions and readmissions, emergency department usage, primary care/physician usage, nursing home usage, and home health care usage. The review considered experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, and case-control studies. A three-step search was utilized to find published and unpublished studies conducted in any country but reported in English. Six electronic databases were searched from inception of the database to May, 2016. A search for unpublished studies was also conducted. Methodological quality was assessed independently by two reviewers using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research synthesis. Quantitative data were extracted from included studies independently by the two reviewers using the standardized Joanna Briggs Institute data extraction tools. Due to the methodological heterogeneity of the included studies, a comprehensive meta-analysis for all outcomes was not possible. Meta-analysis was conducted for rehospitalization at 30, 90 and 180 days. A narrative summary of other quantitative findings was conducted. Twenty-three studies met the inclusion criteria and were included in the review. Nineteen of the studies were randomized controlled trials and four were case control studies, involving 20,997 participants in total with a mean age of 76. Meta-analysis found that transitional care significantly reduced hospital readmission rates at 30 days (odds ratio [OR] 0.75, 95% confidence intervals [CIs] 0.62-0.91, p < 0.01), 90 days (OR 0.77, 95% CIs 0.59-1.02, p = 0.04), and 180 days (OR 0.67, 95% CIs 0.46-0.99, p < 0.01). Narrative synthesis indicated little impact of transitional care on emergency department and nursing home usage, increased use of primary care/physician usage, and decreased home health care usage. Based on a review of 23 studies conducted in the USA, Hong Kong, Canada, Germany, the Netherlands, Sweden and Switzerland, we identified four major conclusions. First, transitional care reduces rehospitalization rates over time, with the largest effects seen at 30 days. Second, transitional care may increase the utilization of primary care services and thus have a favourable impact on preventative care. Third, transitional care may reduce home health usage. Fourth, transitional care interventions of one month or less appear to be as effective as longer interventions in reducing hospital usage.

Limitations of self-care in reducing the risk of lymphedema: supportive-educative systems.

PubMed

Armer, Jane M; Brooks, Constance W; Stewart, Bob R

2011-01-01

The purpose of this study was to examine patient perceptions of limitations related to self-care measures to reduce lymphedema risk following breast cancer surgery. Secondary analysis of survey data from a companion study to a study piloting a behavioral-educational intervention was conducted to examine the specific limitations in performing lymphedema risk-reduction self-care measures. Findings suggest a more comprehensive approach is needed if patients are to engage in self-care actions to reduce lymphedema risk. Understanding the concepts of self-care and personal support interventions that include motivational interviewing can help nurses design supportive-educative care systems that assist patients in overcoming limitations in the estimative, transitional, and productive phases of self-care necessary to reduce lymphedema risk.

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

PubMed

Rochester-Eyeguokan, Charmaine D; Pincus, Kathleen J; Patel, Roshni S; Reitz, Shirley J

2016-01-01

Transitions of care (TOC) are a set of actions to ensure patient coordination and continuity of care as patients transfer between different locations or levels. During transitions associated with chronic or acute illness, vulnerable patients may be placed at risk with fragmented systems compromising their health and safety. In addition, poor care transitions also have an enormous impact on health care spending. The primary objective of this scoping review is to summarize the current landscape of practice models that deliver TOC services in the United States. The secondary objective is to use the information to characterize the current state of best practice models. A search of the PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, International Pharmaceutical Abstracts, National Center for Biotechnology Information at the U.S. National Library of Medicine, and Cochrane Library databases (January 1, 2000-April 13, 2015) for articles pertaining to TOC models, limited to U.S. studies published in the English language with human subjects, gleaned 1362 articles. An additional 26 articles were added from the gray literature. Articles meeting inclusion criteria underwent a second review and were categorized into four groups: background information, original TOC research articles not evaluating practice model interventions, original TOC research articles describing practice models, and systematic or Cochrane reviews. The reviewers met weekly to discuss the challenges and resolve disagreements regarding literature reviews with consensus before progressing. A total of 188 articles describing TOC practice models met the inclusion criteria. Despite the strengths of several quality TOC models, none satisfied all the components recommended by leading experts. Multimodal interventions by multidisciplinary teams appear to represent a best practice model for TOC to improve patient outcomes and reduce readmissions, but one size does not fit all. Best model TOC services must include services along the TOC continuum: pretransition and posttransition, as well as at home and in outpatient health care settings. Studies clearly show that single-modal interventions are rarely successful in reducing readmissions and that successful TOC services must be multimodal and multidisciplinary, and continue throughout the care transition. Utilizing best practice TOC models described in this article as a starting point, practitioners interested in developing their own TOC program should test these tools in new practice environments and add to the body of literature by publishing their findings. © 2016 Pharmacotherapy Publications, Inc.

Reducing hospital readmission rates: current strategies and future directions.

PubMed

Kripalani, Sunil; Theobald, Cecelia N; Anctil, Beth; Vasilevskis, Eduard E

2014-01-01

New financial penalties for institutions with high readmission rates have intensified efforts to reduce rehospitalization. Several interventions that involve multiple components (e.g., patient needs assessment, medication reconciliation, patient education, arranging timely outpatient appointments, and providing telephone follow-up) have successfully reduced readmission rates for patients discharged to home. The effect of interventions on readmission rates is related to the number of components implemented; single-component interventions are unlikely to reduce readmissions significantly. For patients discharged to postacute care facilities, multicomponent interventions have reduced readmissions through enhanced communication, medication safety, advanced care planning, and enhanced training to manage medical conditions that commonly precipitate readmission. To help hospitals direct resources and services to patients with greater likelihood of readmission, risk-stratification methods are available. Future work should better define the roles of home-based services, information technology, mental health care, caregiver support, community partnerships, and new transitional care personnel.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device.

PubMed

Iseler, Jackeline; Fox, John; Wierenga, Kelly

2018-06-01

The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%. Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices. Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team. The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%. Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

An evidence-based strategy for transitioning patients from the hospital to the community.

PubMed

Watkins, Lynn

2012-01-01

Improving transitional care from hospital to home requires comprehensive and highly coordinated intervention during the immediate days following discharge. The Hospital to Home Program addresses both medical and social needs, prevents unnecessary readmissions, promotes improvements in patient perceptions of physical and mental health, and results in excellent patient satisfaction.

Girls in Foster Care: Risk and Promotive Factors for School Adjustment Across the Transition to Middle School.

PubMed

Pears, Katherine C; Kim, Hyoun K; Leve, Leslie D

2012-01-01

Girls in foster care may face difficulties across the transition to middle school. Latent growth curve modeling was employed to examine trajectories and predictors of academic competence and aggression from and against peers for 75 girls in foster care from the end of elementary school to the 2(nd) year of middle school. Across the transition to middle school, academic competence increased. Poor self-regulation was associated with decreased academic competence, and higher caregiver support was associated with increased academic competence. Frequency of aggression from peers decreased across the transition, with perceived school competence predicting smaller decreases. Aggression against peers dropped initially and then increased to pretransition levels by the end of the 2(nd) year of middle school. Lower caregiver support was associated with higher rates of aggression against peers at the end of the 1(st) year of middle school. The results are discussed in terms of implications for interventions for girls in foster care.

Girls in Foster Care: Risk and Promotive Factors for School Adjustment Across the Transition to Middle School

PubMed Central

Pears, Katherine C.; Kim, Hyoun K.; Leve, Leslie D.

2011-01-01

Girls in foster care may face difficulties across the transition to middle school. Latent growth curve modeling was employed to examine trajectories and predictors of academic competence and aggression from and against peers for 75 girls in foster care from the end of elementary school to the 2nd year of middle school. Across the transition to middle school, academic competence increased. Poor self-regulation was associated with decreased academic competence, and higher caregiver support was associated with increased academic competence. Frequency of aggression from peers decreased across the transition, with perceived school competence predicting smaller decreases. Aggression against peers dropped initially and then increased to pretransition levels by the end of the 2nd year of middle school. Lower caregiver support was associated with higher rates of aggression against peers at the end of the 1st year of middle school. The results are discussed in terms of implications for interventions for girls in foster care. PMID:22389543

An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients.

PubMed

Saleh, Shadi S; Freire, Chris; Morris-Dickinson, Gwendolyn; Shannon, Trip

2012-06-01

To investigate the business case of postdischarge care transition (PDCT) among Medicare beneficiaries by conducting a cost-benefit analysis. Randomized controlled trial. A general hospital in upstate New York State. Elderly Medicare beneficiaries being treated from October 2008 through December 2009 were randomly selected to receive services as part of a comprehensive PDCT program (intervention--173 patients) or regular discharge process (control--160 patients) and followed for 12 months. The intervention comprised five activities: development of a patient-centered health record, a structured discharge preparation checklist of critical activities, delivery of patient self-activation and management sessions, follow-up appointments, and coordination of data flow. Cost-benefit ratio of the PDCT program; self-management skills and abilities. The 1-year readmission analysis revealed that control participants were more likely to be readmitted than intervention participants (58.2% vs 48.2%; P = .08); with most of that difference observed in the 91 to 365 days after discharge. Findings from the cost-benefit analysis revealed a cost-benefit ratio of 1.09, which indicates that, for every $1 spent on the program, a saving of $1.09 was realized. In addition, participating in a care transition program significantly enhanced self-management skills and abilities. Postdischarge care transition programs have a dual benefit of enhancing elderly adults' self-management skills and abilities and producing cost savings. This study builds a case for the inclusion of PDCT programs as a reimbursable service in benefit packages. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Transitioning from pediatric to adult health care with familial hypercholesterolemia: Listening to young adult and parent voices.

PubMed

Sliwinski, Samantha K; Gooding, Holly; de Ferranti, Sarah; Mackie, Thomas I; Shah, Supriya; Saunders, Tully; Leslie, Laurel K

Young adults with familial hypercholesterolemia (FH) are at a critical period for establishing behaviors to promote future cardiovascular health. To examine challenges transitioning to adult care for young adults with FH and parents of FH-affected young adults in the context of 2 developmental tasks, transitioning from childhood to early adulthood and assuming responsibility for self-management of a chronic disorder. Semistructured, qualitative interviews were conducted with 12 young adults with FH and 12 parents of affected young adults from a pediatric subspecialty preventive cardiology program in a northeastern academic medical center. Analyses were conducted using a modified grounded theory framework. Respondents identified 5 challenges: (1) recognizing oneself as a decision maker, (2) navigating emerging independence, (3) prioritizing treatment for a chronic disorder with limited signs and symptoms, (4) managing social implications of FH, and (5) finding credible resources for guidance. Both young adults and parents proposed similar recommendations for addressing these challenges, including the need for family and peer involvement to establish and maintain diet and exercise routines and to provide medication reminders. Systems-level recommendations included early engagement of adolescents in shared decision-making with health care team; providing credible, educational resources regarding FH; and using blood tests to track treatment efficacy. Young adults with FH transitioning to adult care may benefit from explicit interventions to address challenges to establishing healthy lifestyle behaviors and medication adherence as they move toward being responsible for their medical care. Further research should explore the efficacy of recommended interventions. Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.

The Preventable Admissions Care Team (PACT): A Social Work-Led Model of Transitional Care.

PubMed

Basso Lipani, Maria; Holster, Kathleen; Bussey, Sarah

2015-10-01

In 2010, the Preventable Admissions Care Team (PACT), a social work-led transitional care model, was developed at Mount Sinai to reduce 30-day readmissions among high-risk patients. PACT begins with a comprehensive bedside assessment to identify the psychosocial drivers of readmission. In partnership with the patient and family, a patient-centered action plan is developed and carried out through phone calls, accompaniments, navigations and home visits, as needed, in the first 30 days following discharge. 620 patients were enrolled during the pilot from September 2010-August 2012. Outcomes demonstrated a 43% reduction in inpatient utilization and a 54% reduction in emergency department visits among enrollees. In addition, 93% of patients had a follow-up appointment within 7-10 days of discharge and 90% of patients attended the appointment. The success of PACT has led to additional funding from the Centers for Medicare and Medicaid Services under the Community-based Care Transitions Program and several managed care companies seeking population health management interventions for high risk members.

TransitionRx: Impact of community pharmacy postdischarge medication therapy management on hospital readmission rate.

PubMed

Luder, Heidi R; Frede, Stacey M; Kirby, James A; Epplen, Kelly; Cavanaugh, Teresa; Martin-Boone, Jill E; Conrad, Wayne F; Kuhlmann, Diane; Heaton, Pamela C

2015-01-01

To determine if a community pharmacy-based transition of care (TOC) program that included the full scope of medication therapy management (MTM) services (TransitionRx) decreased hospital readmissions, resolved medication-related problems, and increased patient satisfaction. Prospective, quasi-experimental study. Nine Kroger Pharmacies located in Western Cincinnati. Patients older than 18 years of age and discharged from two local hospitals with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. Patients were recruited from two local hospitals and referred to the community pharmacy for MTM services with the pharmacist within 1 week of discharge. Pharmacists reconciled the patients' medications, identified drug therapy problems, recommended changes to therapy, and provided self-management education. At 30 days after discharge, research personnel conducted telephone surveys, using a previously validated survey instrument, to assess hospital readmissions and patient satisfaction. Pharmacist interventions and medication-related problems were documented. A total of 90 patients completed the study. Of these, 20% of patients in the usual care group were admitted to the hospital within 30 days compared with 6.9% of patients in the intervention group (P = 0.019). In the 30 patients who received MTM services from the pharmacist, 210 interventions were made. The overall mean patient satisfaction with the TOC process was not significantly different between patients who were seen by the pharmacist and those who were not seen by the pharmacist. Community pharmacies successfully collaborated with hospitals to develop a referral process for TOC interventions. Patients who received MTM services from the pharmacist experienced significantly fewer readmissions than patients who received usual care.

Changes in Classes of Injury-Related Risks and Consequences of Risk-Level Drinking: a Latent Transition Analysis.

PubMed

Cochran, Gerald; Field, Craig; Caetano, Raul

2015-07-01

Risk-level drinking, drinking and driving, and alcohol-related violence are risk factors that result in injuries. The current study sought to identify which subgroups of patients experience the most behavioral change following a brief intervention. A secondary analysis of data from a brief alcohol intervention study was conducted. The sample (N = 664) includes at-risk drinkers who experienced an injury and were admitted for care to a Level 1 trauma center. Injury-related items from the Short Inventory of Problems+6 were used to perform a latent transition analysis to describe class transitions participants experienced following discharge. Four classes emerged for the year before and after the current injury. Most individuals transitioned from higher-risk classes into those with lower risk. Some participants maintained risky profiles, and others increased risks and consequences. Drinking and driving remained a persistent problem among the study participants. Although a large portion of intervention recipients improved risks and consequences of alcohol use following discharge, more intensive intervention services may be needed for a subset of patients who showed little or no improvement.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions.

PubMed

De Regge, Melissa; De Pourcq, Kaat; Meijboom, Bert; Trybou, Jeroen; Mortier, Eric; Eeckloo, Kristof

2017-08-09

Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies. Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy. Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital's side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients. Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

Reducing menopausal symptoms for women during the menopause transition using group education in a primary health care setting-a randomized controlled trial.

PubMed

Rindner, Lena; Strömme, Gunilla; Nordeman, Lena; Hange, Dominique; Gunnarsson, Ronny; Rembeck, Gun

2017-04-01

Women's physical and mental ill-health shows a marked increase during menopause, which usually occurs between 45 and 55 years of age. Mental illness and somatic symptoms are common causes of long-term sick leave. Women suffer from a lack of knowledge about the menopause transition and its associated symptoms. The aim of the study was to investigate whether group education for women in primary health care (PHC) about the menopause transition can improve their physical and mental ill-health. This randomized controlled study was conducted in PHC and aimed to evaluate a group education programme for women aged 45-55 years, around the menopause transition. A total of 131 women were randomized to group education or no intervention. The group intervention included two education sessions with topics related to menopause. They answered two questionnaires at baseline and at four-month follow-up: the Menopause Rating Scale (MRS) and the Montgomery-Asberg Depression Rating Scale (MADRS). Change in MRS and MADRS scores over the four months. The intervention group experienced a slight reduction in symptoms while the control group mostly experienced the opposite. This study showed that it was feasible to implement group education on menopause for women aged 45-55 years. NTC02852811. Copyright © 2017 Elsevier B.V. All rights reserved.

Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study.

PubMed

Leonard, Chelsea; Lawrence, Emily; McCreight, Marina; Lippmann, Brandi; Kelley, Lynette; Mayberry, Ashlea; Ladebue, Amy; Gilmartin, Heather; Côté, Murray J; Jones, Jacqueline; Rabin, Borsika A; Ho, P Michael; Burke, Robert

2017-10-23

Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP. This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA. The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a novel approach to engaging sites in adapting interventions while promoting fidelity to the intervention. Our application of PRISM to pre-implementation and midline evaluation, as well as documentation of adaptations, provides an opportunity to identify and address contextual factors that may impede or enhance implementation and sustainability of health interventions and inform dissemination.

Comparative Effectiveness of Risk-Stratified Care Management in Reducing Readmissions in Medicaid Adults With Chronic Disease.

PubMed

Hewner, Sharon; Wu, Yow-Wu Bill; Castner, Jessica

2016-01-01

Hospitalized adult Medicaid recipients with chronic disease are at risk for rehospitalization within 90 days of discharge, but most research has focused on the Medicare population. The purpose of this study is to examine the impact of population-based care management intensity on inpatient readmissions in Medicaid adults with pre-existing chronic disease. Retrospective analyses of 2,868 index hospital admissions from 2012 New York State Medicaid Data Warehouse claims compared 90-day post-discharge utilization in populations with and without transitional care management interventions. High intensity managed care organization interventions were associated with higher outpatient and lower emergency department post-discharge utilization than low intensity fee-for-service management. However, readmission rates were higher for the managed care cases. Shorter time to readmission was associated with managed care, diagnoses that include heart and kidney failure, shorter length of stay for index hospitalization, and male sex; with no relationship to age. This unexpected result flags the need to re-evaluate readmission as a quality indicator in the complex Medicaid population. Quality improvement efforts should focus on care continuity during transitions and consider population-specific factors that influence readmission. Optimum post-discharge utilization in the Medicaid population requires a balance between outpatient, emergency and inpatient services to improve access and continuity.

Enhancing Infant-Toddler Adjustment during Transitions to Child Care: A Screening and Intervention Tool for Practitioners

ERIC Educational Resources Information Center

Fernandez, Mari T.; Marfo, Kofi

2005-01-01

Children's successful adjustment to child care involves effectively managing their separation from parents. Persistent problems with separation interfere with other relationships and with learning opportunities. The authors of this article developed a tool that caregivers can use to identify adjustment difficulties in young children who are …

Conditions, components and outcomes of Integrative Validation Therapy in a long-term care facility for people with dementia. A qualitative evaluation study.

PubMed

Erdmann, Anke; Schnepp, Wilfried

2016-09-01

In this study, the practical application of Integrative Validation Therapy (IVA) in a nursing home for people with dementia was investigated and evaluated from the perspectives of professionals and relatives by using Fourth Generation Evaluation. IVA, a complex intervention frequently applied in Germany's long-term care settings, is a modification of Feil's Validation Therapy and contains a specific attitude and several components of action. The findings demonstrate that professionals as well as relatives of nursing home residents gave the intervention a positive rating. From the perspective of the participating professionals, the application of IVA results in less agitated residents which also has an influence on the consumption of benzodiazepine and neuroleptics. The authors conclude that IVA is a beneficial nursing intervention helping to facilitate the illness-related transition process of people with dementia. IVA is able to support them to cope with emotional distress during transition (e.g. irritability, anxiety, depression, changes in self-esteem). Another conclusion is that IVA supports person-centred care because, with IVA, professionals react to typical needs people with dementia have: comfort, inclusion, attachment and identity (Kitwood, 2012). © The Author(s) 2014.

Transitional care for formerly incarcerated persons with HIV: protocol for a realist review.

PubMed

Tsang, Jenkin; Mishra, Sharmistha; Rowe, Janet; O'Campo, Patricia; Ziegler, Carolyn; Kouyoumdjian, Fiona G; Matheson, Flora I; Bayoumi, Ahmed M; Zahid, Shatabdy; Antoniou, Tony

2017-02-13

Little is known about the mechanisms that influence the success or failure of programs to facilitate re-engagement with health and social services for formerly incarcerated persons with HIV. This review aims to identify how interventions to address such transitions work, for whom and under what circumstances. We will use realist review methodology to conduct our analysis. We will systematically search electronic databases and grey literature for English language qualitative and quantitative studies of interventions. Two investigators will independently screen citations and full-text articles, abstract data, appraise study quality and synthesize the literature. Data analysis will include identifying context-mechanism-outcome configurations, exploring and comparing patterns in these configurations, making comparisons across contexts and developing explanatory frameworks. This review will identify mechanisms that influence the success or failure of transition interventions for formerly incarcerated individuals with HIV. The findings will be integrated with those from complementary qualitative and quantitative studies to inform future interventions. PROSPERO CRD42016040054.

Managing Cancer Care: a psycho-educational intervention to improve knowledge of care options and breast cancer self-management.

PubMed

Schulman-Green, Dena; Jeon, Sangchoon

2017-02-01

We tested the feasibility and acceptability of a psycho-educational self-management intervention, Managing Cancer Care: A Personal Guide (MCC), to improve knowledge of care options (curative, palliative, and hospice care) among a range of breast cancer self-management skills. We conducted a one-group, pre-post-test study among women with non-metastatic breast cancer (n = 105). We gave participants the printed, self-guided, seven-module intervention following enrollment. At baseline and 2  months, we measured knowledge of care options, desired and actual role in self-management, medical communication skills, experience and management of transitions, anxiety, depression, uncertainty, and self-efficacy. We conducted interviews to obtain module ratings and qualitative data on strengths and limitations of MCC. Knowledge of care options (δ = 0.40 (1.11), p = 0.0005) and desired role in self-management (δ = -0.28 (1.08), p = 0.0177) significantly improved. Less skilled medical communicators significantly improved their communication (δ = 3.47, standard deviation = 6.58, p = 0.0449). Multivariate modeling showed that changes in our primary outcomes of medical communication and management of transitions seemed to drive positive changes in our secondary outcomes of anxiety, depression, uncertainty, and self-efficacy. Participants highly rated MCC and reported the importance of understanding care options despite non-metastatic disease. MCC is a feasible and acceptable means of improving knowledge of care options and other aspects of breast cancer self-management. The combination of modules offered in MCC appears to have beneficial interactive effects. We are currently testing MCC more rigorously in a randomized controlled trial to explore mediating and moderating relationships. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

A Lean Six Sigma quality improvement project to increase discharge paperwork completeness for admission to a comprehensive integrated inpatient rehabilitation program.

PubMed

Neufeld, Nathan J; Hoyer, Erik H; Cabahug, Philippines; González-Fernández, Marlís; Mehta, Megha; Walker, N Colbey; Powers, Richard L; Mayer, R Samuel

2013-01-01

Lean Six Sigma (LSS) process analysis can be used to increase completeness of discharge summary reports used as a critical communication tool when a patient transitions between levels of care. The authors used the LSS methodology as an intervention to improve systems process. Over the course of the project, 8 required elements were analyzed in the discharge paperwork. The authors analyzed the discharge paperwork of patients (42 patients preintervention and 143 patients postintervention) of a comprehensive integrated inpatient rehabilitation program (CIIRP). Prior to this LSS project, 61.8% of required discharge elements were present. The intervention improved the completeness to 94.2% of the required elements. The percentage of charts that were 100% complete increased from 11.9% to 67.8%. LSS is a well-established process improvement methodology that can be used to make significant improvements in complex health care workflow issues. Specifically, the completeness of discharge documentation required for transition of care to CIIRP can be improved.

Working With Socially and Medically Complex Patients: When Care Transitions Are Circular, Overlapping, and Continual Rather Than Linear and Finite.

PubMed

Roberts, Shauna R; Crigler, Jane; Ramirez, Cristina; Sisco, Deborah; Early, Gerald L

2015-01-01

The care coordination program described here evolved from 5 years of trial and learning related to how to best serve our high-cost, high-utilizing, chronically ill, urban core patient population. In addition to medical complexity, they have daily challenges characteristic of persons served by Safety-Net health systems. Many have unstable health insurance status. Others have insecure housing. A number of patients have a history of substance use and mental illness. Many have fractured social supports. Although some of the best-known care transition models have been successful in reducing rehospitalizations and cost among patients studied, these models were developed for a relatively high functioning patient population with social support. We describe a successful approach targeted at working with patients who require a more intense and lengthy care coordination intervention to self-manage and reduce the cost of caring for their medical conditions. Using a diverse team and a set of replicable processes, we have demonstrated statistically significant reduction in the use of hospital and emergency services. Our intervention leverages the strengths and resilience of patients, focuses on trust and self-management, and targets heterogeneous "high-utilizer" patients with medical and social complexity.

The Relationship of Transition Readiness, Self-Efficacy, and Adherence to Preferred Health Learning Method by Youths with Chronic Conditions.

PubMed

Johnson, Meredith A J; Javalkar, Karina; van Tilburg, Miranda; Haberman, Cara; Rak, Eniko; Ferris, Maria E

2015-01-01

Health care transition preparation, medication adherence, and self-efficacy are important skills to achieve optimal health outcomes. It is unclear how pediatric patients with chronic conditions obtain health information that may impact the acquisition of these skills. In this cross-sectional study, we determined the preferred sources/methods for health information among youths with chronic conditions and their relationship to health care transition readiness (STARx Questionnaire), self-efficacy (Iannotti's Diabetes Management Self-efficacy Scale), and medication adherence (Morisky Medication Adherence Scale). Youths with various chronic health conditions attending Victory Junction, a therapeutic camp, were invited to complete these online surveys. A total of 160 youths with different chronic conditions from multiple institutions, ages 6 to 16 years participated. Most commonly preferred sources of medical information were family/parents (n=122, 76.3%) and health care providers (n=88, 55.0%). Youths who favored family/parents had the highest medication adherence rates. In turn, youths who favored health care providers over other sources, scored highest on self-efficacy and transition readiness of all groups. Our novel findings represent important areas of intervention to improve transition readiness, self-efficacy, and medication adherence. Ascertaining the patients' preferred method of learning about the disease and its management is important in order to customize and enhance health care transition readiness, self-efficacy, and medication adherence. Copyright © 2015 Elsevier Inc. All rights reserved.

Adolescents with Hearing Loss and the International Classification of Functioning, Health, and Disability: Children & Youth Version

PubMed Central

English, Kris; Pajevic, Emily

2016-01-01

In 2007, the World Health Organization published a set of International Classification of Functioning, Disability and Health (ICF) codes designed for children and youth (ICF-CY version). The ICF-CY considers typical developmental changes associated with childhood while describing health status and the effects of intervention. In this article we will describe how a specific intervention (transition planning for adolescents) can be documented with the ICF-CY. Transition planning in health care prepares adolescents and their families for the transfer from pediatric to adult health services and has been demonstrated to be an effective practice for adolescents with many types of chronic health conditions (e.g., cystic fibrosis, epilepsy, diabetes). Audiology has not yet addressed transition planning for adolescents with hearing loss; therefore, we propose using the ICF-CY to design a pathway of care. The ICF-CY can standardize transition planning to the benefit of both teen patients and audiologists: teens and their families would gradually acquire necessary knowledge and skills, and audiologists would develop a meaningful data set to help further inform our pediatric practices, as well as give more structure, depth, and accountability to our role in rehabilitation. PMID:27489402

Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions.

PubMed

Strand, Monica; Gammon, Deede; Ruland, Cornelia M

2017-04-07

The Internet is transforming mental health care services by increasing access to, and potentially improving the quality of, care. Internet-based interventions in mental health can potentially play a role in transitions from biomedical to recovery-oriented research and practices, but an overview of what this may entail, current work, and issues that need addressing, is lacking. The objective of this study is to describe Internet-based recovery-oriented interventions (referred to as e-recovery) and current research, and to identify gaps and issues relevant to advancing recovery research and practices through opportunities provided by the Internet. Five iterative stages of a scoping review framework were followed in searching and analyzing the literature. A recovery framework with four domains and 16 themes was used to deductively code intervention characteristics according to their support for recovery-oriented practices. Only Internet-based interventions used in conjunction with ongoing care were included. Twenty studies describing six e-recovery interventions were identified and originated in Australia, Finland, the Netherlands, Norway and USA. The domain supporting personal recovery was most clearly reflected in interventions, whereas the last three domains, i.e., promoting citizenship, organizational commitment and working relationship were less evident. Support for the formulation and follow-up of personal goals and preferences, and in accessing peer-support, were the characteristics shared by most interventions. Three of the six studies that employed a comparison group used randomization, and none presented definitive findings. None used recovery-oriented frameworks or specific recovery outcome measures. Four of the interventions were specific to a diagnosis. Research about how technologies might aid in illuminating and shaping recovery processes is in its formative stages. We recommend that future e-recovery research and innovation attend to four dimensions: evidence-supported interventions, new knowledge about personal recovery, values-based approaches and Internet as a facilitator for organizational transformation. The incremental changes facilitated by e-recovery may help propel a shift in mental health care toward recovery-oriented practices.

Measurement tools and outcome measures used in transitional patient safety; a systematic review.

PubMed

van Melle, Marije A; van Stel, Henk F; Poldervaart, Judith M; de Wit, Niek J; Zwart, Dorien L M

2018-01-01

Patients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed. To identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection. First, publications about validation of measurement tools were appraised for quality following COSMIN criteria. Second, we inventoried all measurement tools and outcome measures found in our search that assessed current transitional patient safety or the effect of interventions targeting transitional patient safety. The initial search yielded 8288 studies, of which 18 assessed validity of measurement tools of different aspects of transitional safety, and 191 assessed current transitional patient safety or effect of interventions. In the validated measurement tools, the overall quality of content and structural validity was acceptable; other COSMIN criteria, such as reliability, measurement error and responsiveness, were mostly poor or not reported. In our outcome inventory, the most frequently used validated outcome measure was the Care Transition Measure (n = 9). The most frequently used non-validated outcome measures were: medication discrepancies (n = 98), hospital readmissions (n = 55), adverse events (n = 34), emergency department visits (n = 33), (mental or physical) health status (n = 28), quality and timeliness of discharge summary, and patient satisfaction (n = 23). Although no validated measures exist that assess all aspects of transitional patient safety, we found validated measurement tools on specific aspects. Reporting of validity of transitional measurement tools was incomplete. Numerous outcome measures with unknown measurement properties are used in current studies on safety of care transitions, which makes interpretation or comparison of their results uncertain.

Transition readiness skills acquisition in adolescents and young adults with inflammatory bowel disease: findings from integrating assessment into clinical practice.

PubMed

Gray, Wendy N; Holbrook, Erin; Morgan, Pamela J; Saeed, Shehzad A; Denson, Lee A; Hommel, Kevin A

2015-05-01

Almost 80% of adult gastroenterologists report inadequacies in the preparation of patients transferred from pediatrics. To improve transition to adult care, it is important to identify the specific deficits that patients are demonstrating before transfer. We present data from a clinic-wide assessment of transition readiness skill acquisition in adolescents/young adults with IBD. A total of 195 patients (age, 16-25 yr) with IBD completed the Transition Readiness Assessment Questionnaire. Patient age, diagnosis, time since diagnosis, physician global assessment, and patient and parent disease management confidence ratings were extracted from the medical record. Transition Readiness Assessment Questionnaire scores were compared with a benchmark established by an interdisciplinary, multi-institutional Transition Task Force. Only 5.6% of older adolescents/young adults on the verge of transfer to adult care met our institutional benchmark (3.5% of adolescents, 7.3% of young adults). Patients reported mastery of 9.10 ± 4.68 out of 20 Transition Readiness Assessment Questionnaire items. Transition readiness was associated with older age (r = 0.27, P < 0.001) and female gender (F(1,192) = 13.81, P < 0.001) but not time since diagnosis, physician global assessment, or confidence ratings. Deficits in health care utilization/self-advocacy (e.g., understanding insurance, scheduling appointments/following up on referrals), and self-management (e.g., filling/reordering prescriptions) were observed. Most patients on the verge of transferring to adult care are not demonstrating transition readiness. Deficits observed represent modifiable behaviors. Using data-driven assessments to guide interventions to enhance transition readiness may minimize the retention of young adult patients in pediatrics and result in patients who are better prepared for adult care.

A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial.

PubMed

Black, Jeanne T; Romano, Patrick S; Sadeghi, Banafsheh; Auerbach, Andrew D; Ganiats, Theodore G; Greenfield, Sheldon; Kaplan, Sherrie H; Ong, Michael K

2014-04-13

Heart failure is a prevalent health problem associated with costly hospital readmissions. Transitional care programs have been shown to reduce readmissions but are costly to implement. Evidence regarding the effectiveness of telemonitoring in managing the care of this chronic condition is mixed. The objective of this randomized controlled comparative effectiveness study is to evaluate the effectiveness of a care transition intervention that includes pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight, blood pressure, heart rate, and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure. A multi-center, randomized controlled trial is being conducted at six academic health systems in California. A total of 1,500 patients aged 50 years and older will be enrolled during a hospitalization for treatment of heart failure. Patients in the intervention group will receive intensive patient education using the 'teach-back' method and receive instruction in using the telemonitoring equipment. Following hospital discharge, they will receive a series of nine scheduled health coaching telephone calls over 6 months from nurses located in a centralized call center. The nurses also will call patients and patients' physicians in response to alerts generated by the telemonitoring system, based on predetermined parameters. The primary outcome is readmission for any cause within 180 days. Secondary outcomes include 30-day readmission, mortality, hospital days, emergency department (ED) visits, hospital cost, and health-related quality of life. BEAT-HF is one of the largest randomized controlled trials of telemonitoring in patients with heart failure, and the first explicitly to adapt the care transition approach and combine it with remote telemonitoring. The study population also includes patients with a wide range of demographic and socioeconomic characteristics. Once completed, the study will be a rich resource of information on how best to use remote technology in the care management of patients with chronic heart failure. ClinicalTrials.gov # NCT01360203.

Acute Care Utilization by Patients After Graduation of Their Resident Primary Care Physicians.

PubMed

Solomon, Sonja R; Gooding, Holly C; Reyes Nieva, Harry; Linder, Jeffrey A

2015-11-01

The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes. Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients. This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012. We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating. Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31). Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.

Partners at Care Transitions (PACT)—exploring older peoples’ experiences of transitioning from hospital to home in the UK: protocol for an observation and interview study of older people and their families to understand patient experience and involvement in care at transitions

PubMed Central

Birks, Yvonne; Murray, Jenni; Sheard, Laura; Hughes, Lesley; Heyhoe, Jane; Cracknell, Alison; Lawton, Rebecca

2017-01-01

Introduction Length of hospital inpatient stays have reduced. This benefits patients, who prefer to be at home, and hospitals, which can treat more people when stays are shorter. Patients may, however, leave hospital sicker, with ongoing care needs. The transition period from hospital to home can be risky, particularly for older patients with complex health and social needs. Improving patient experience, especially through greater patient involvement, may improve outcomes for patients and is a key indicator of care quality and safety. In this research, we aim to: capture the experiences of older patients and their families during the transition from hospital to home, and identify opportunities for greater patient involvement in care, particularly where this contributes to greater individual-level and organisational-level resilience. Methods and analysis A ‘focused ethnography’ comprising observations, ‘Go-Along’ and semistructured interviews will be used to capture patient and carer experiences during different points in the care transition from admission to 90 days after discharge. We will recruit 30 patients and their carers from six hospital departments across two National Health Service (NHS) Trusts. Analysis of observations and interviews will use a framework approach to identify themes to understand the experience of transitions and generate ideas about how patients could be more actively involved in their care. This will include exploring what ‘good’ care at transitions looks like and seeking out examples of success, as well as recommendations for improvement. Ethics and dissemination Ethical approval was received from the NHS Research Ethics Committee in Wales. The research findings will add to a growing body of knowledge about patient experience of transitions, in particular providing insight into the experiences of patients and carers throughout the transitions process, in ‘real time’. Importantly, the data will be used to inform the development of a patient-centred intervention to improve the quality and safety of transitions. PMID:29196483

Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition -- Heart Failure (BEAT-HF) Randomized Clinical Trial.

PubMed

Ong, Michael K; Romano, Patrick S; Edgington, Sarah; Aronow, Harriet U; Auerbach, Andrew D; Black, Jeanne T; De Marco, Teresa; Escarce, Jose J; Evangelista, Lorraine S; Hanna, Barbara; Ganiats, Theodore G; Greenberg, Barry H; Greenfield, Sheldon; Kaplan, Sherrie H; Kimchi, Asher; Liu, Honghu; Lombardo, Dawn; Mangione, Carol M; Sadeghi, Bahman; Sadeghi, Banafsheh; Sarrafzadeh, Majid; Tong, Kathleen; Fonarow, Gregg C

2016-03-01

It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. clinicaltrials.gov Identifier: NCT01360203.

Promoting a positive transition to parenthood: a randomized clinical trial of couple relationship education.

PubMed

Halford, W Kim; Petch, Jemima; Creedy, Debra K

2010-03-01

The transition to parenthood is often associated with a decline in couple relationship adjustment. Couples (n = 71) expecting their first child were randomly assigned to either: (a) Becoming a Parent (BAP), a maternal parenting education program; or (b) Couple CARE for Parents (CCP), a couple relationship and parenting education program. Couples were assessed pre-intervention (last trimester of pregnancy), post-intervention (5 months postpartum), and follow-up (12 months postpartum). Relative to BAP, CCP reduced negative couple communication from pre- to post-intervention, and prevented erosion of relationship adjustment and self-regulation in women but not men from pre-intervention to follow-up. Mean parenting stress reflected positive adjustment to parenthood with no differences between BAP and CCP. CCP shows promise as a brief program that can enhance couple communication and women's adjustment to parenthood.

Family-centred approaches to healthcare interventions in chronic diseases in adults: a quantitative systematic review.

PubMed

Deek, Hiba; Hamilton, Sandra; Brown, Nicola; Inglis, Sally C; Digiacomo, Michelle; Newton, Phillip J; Noureddine, Samar; MacDonald, Peter S; Davidson, Patricia M

2016-05-01

Increasingly there is a focus on self-care strategies for both malignant and non-malignant conditions. Models of self-care interventions have focussed on the individual and less on the broader context of family and society. In many societies, decision-making and health seeking behaviours, involve family members. To identify elements of effective family-centred self-care interventions that are likely to improve outcomes of adults living with chronic conditions. Review paper. MEDLINE (Ovid), CINAHL, Academic Search Complete, PsychInfo and Scopus between 2000-2014. Quantitative studies targeting patient outcomes through family-centred interventions in adults were retrieved using systematic methods in January, 2015. Search terms used were: 'family', 'spouse', 'carer', 'caregiver', 'chronic', 'chronic disease', 'self-care', 'self-management' and 'self-efficacy'. Reference lists were reviewed. Risk of bias assessment was performed using the Cochrane Collaboration's tool. Data were reported using a narrative summary approach. Ten studies were identified. Improvements were noted in readmission rates, emergency department presentations, and anxiety levels using family-centred interventions compared with controls. Elements of effective interventions used were a family-centred approach, active learning strategy and transitional care with appropriate follow-up. Involving the family in self-care has shown some positive results for patients with chronic conditions. The benefits of family-centred care may be more likely in specific socio-cultural contexts. The review has year limits and further research needs to identify support for both the patients and family caregivers. © 2016 John Wiley & Sons Ltd.

Modeling Trajectories and Transitions: Results from the New York University Caregiver Intervention

PubMed Central

Gaugler, Joseph; Roth, David L.; Haley, William E.; Mittelman, Mary S.

2011-01-01

Background Current research fails to capture the temporal dynamics of chronic disease in favor of cross-sectional snapshots of symptoms and outcomes. Objective To estimate the effects of comprehensive psychosocial support on trajectories of spouse caregivers’ well-being related to the nursing home placement transition. Method Data from the New York University Caregiver Intervention, a randomized controlled trial of a comprehensive support program for spouse caregivers of persons with Alzheimer’s disease, were utilized. A convenience sample of 406 spouse caregivers of community-dwelling persons with Alzheimer’s disease was enrolled over a 9.5-year time period in an Alzheimer’s disease research center in New York City. Outcome measures, including the Zarit Burden Inventory and Geriatric Depression Scale, were used to assess differential effects of nursing home placement and the Intervention on spouse caregivers. In-person interviews of spouse caregivers took place every 4 months during the first year of participation and every 6 months thereafter for up to 16 years; 385 caregivers provided sufficient follow-up data for all analyses. Results Longitudinal models found that wives were more likely than husbands to indicate reductions in burden in the months following placement in an institution. Wives also reported greater decreases in depressive symptoms after placement in an institution when compared to husbands. Discussion The inclusion of transitions and health trajectories in a randomized controlled trial offers an intriguing picture of how comprehensive psychosocial interventions can help families navigate the challenges of chronic disease care. The results also demonstrate how advances in nursing science can facilitate future research in the modeling of trajectories and transitions in the dementia care context. PMID:21543959

The Effects of Project APPLE (Autistic Preadolescent Proactive Learning Environments) on Academic, Behavioral, and Transitional Needs of Students with Autism Spectrum Disorder

ERIC Educational Resources Information Center

Cayce, Robin M.

2012-01-01

This study addressed the effects of Project APPLE, an intervention created by the researcher and supported by the Guide to Project APPLE, a handbook which provided research-based teaching strategies, modificaitons to the learning environment, and transitional supports for students with ASD, and the teachers with whom their care and education is…

Individuals motivated to participate in adherence, care and treatment (imPACT): development of a multi-component intervention to help HIV-infected recently incarcerated individuals link and adhere to HIV care.

PubMed

Golin, Carol E; Knight, Kevin; Carda-Auten, Jessica; Gould, Michele; Groves, Jennifer; L White, Becky; Bradley-Bull, Steve; Amola, Kemi; Fray, Niasha; Rosen, David L; Mugavaro, Michael J; Pence, Brian W; Flynn, Patrick M; Wohl, David

2016-09-06

Policy-makers promote a seek, test, treat and retain (STTR) strategy to expand HIV testing, support linkage and engagement in care, and enhance the continuous use of antiretroviral therapy for those HIV-infected. This HIV prevention strategy is particularly appropriate in correctional settings where HIV screening and treatment are routinely available yet many HIV-infected individuals have difficulty sustaining sufficient linkage and engagement in care, disease management, and viral suppression after prison release. Our research team developed Project imPACT (individuals motivated to Participate in Adherence, Care and Treatment), a multi-component approach for HIV-Infected recently incarcerated individuals that specifically targets their care linkage, retention, and medication adherence by addressing multiple barriers to care engagement after release. The ultimate goals of this intervention are to improve the health of HIV-infected individuals recently released from prison and reduce HIV transmission to their communities by maintaining viral suppression. This paper describes the intervention and technology development processes, based on best practices for intervention development and process evaluation. These processes included: 1) identifying the target population; 2) clarifying the theoretical basis for intervention design; 3) describing features of its foundational interventions; 4) conducting formative qualitative research; 5) integrating and adapting foundational interventions to create and refine intervention content based on target audience feedback. These stages along with the final intervention product are described in detail. The intervention is currently being evaluation and a two arm randomized, controlled trial in two US state prison systems. Based on a literature review, qualitative research, integration of proven interventions and behavioral theory, the final imPACT intervention focused on the transition period two to three months before and three months after prison release. It emphasized pre-release readiness, pre- and post-release supportive non-judgmental counseling, linking individuals to a HIV care clinic and technological supports through videos and text messages. This article provides a useful model for how researchers can develop, test, and refine multi-component interventions to address HIV care linkage, retention and adherence. NCT01629316 , first registered 6-4-2012; last updated 6-9-2015.

Telephone calls postdischarge from hospital to home: a literature review.

PubMed

Hand, Kristin E; Cunningham, Regina S

2014-02-01

The oncology population is particularly affected by hospital readmissions because hospitalized patients with cancer often have complex needs. The complexity and diversity of care requirements create substantial challenges in planning for appropriate postdischarge support. Implementing postdischarge telephone calls in the population of patients with cancer could offer a low-cost intervention to address the complex needs of patients during the transition from hospital to home. The goal of the current literature review is to provide an understanding about postdischarge telephone calls in patients with cancer. Findings from this review support the notion that discharge phone calls could improve care continuity for patients transitioning from hospital to home. The literature review outlines information related to telephone call content, timing, and structure for healthcare systems that want to use a postdischarge telephone intervention for patients with cancer. However, additional research is needed to develop and test cancer-specific protocols.

Innovative approach to patient-centered care coordination in primary care practices.

PubMed

Clarke, Robin; Bharmal, Nazleen; Di Capua, Paul; Tseng, Chi-Hong; Mangione, Carol M; Mittman, Brian; Skootsky, Samuel A

2015-09-01

Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients. Matched case-control differences-in-differences. Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity. CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001). Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

Anticipation of Local Epidemics Management

NASA Astrophysics Data System (ADS)

Krivy, Ivan

2008-10-01

Local epidemics are systems where temporary elements (infected ones) are distributed over a hexagonal or rectangular network of permanent elements (humans). Their relation of being neighbors is considered to be constant. The systems of this type can occur in rest homes, institutes of social care, nursery schools, summer camps, prisons, etc. The process of the infection propagation depends on the neighborhood relation and on the actual distance of the neighbors. It is influenced by delays during the transitive affecting the people and by random effects, the size of which can be diminished by the intervention of health care service. The anticipation of the health care intervention effects was supported by simulation models implemented by means of the object-oriented programming.

Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework.

PubMed

Kerstenetzky, Luiza; Birschbach, Matthew J; Beach, Katherine F; Hager, David R; Kennelty, Korey A

2018-02-01

Patients transitioning from the hospital to a skilled nursing home (SNF) are susceptible to medication-related errors resulting from fragmented communication between facilities. Through continuous process improvement efforts at the hospital, a targeted needs assessment was performed to understand the extent of medication-related issues when patients transition from the hospital into a SNF, and the gaps between the hospital's discharge process, and the needs of the SNF and long-term care (LTC) pharmacy. We report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to SNF and LTC pharmacy staff. Applying the Intervention Mapping (IM) framework, a targeted needs assessment was performed using quantitative and qualitative methods. Using the hospital discharge medication list as reference, medication discrepancies in the SNF and LTC pharmacy lists were identified. SNF and LTC pharmacy staffs were also interviewed regarding the continuity of medication information post-discharge from the hospital. At least one medication discrepancy was discovered in 77.6% (n = 45/58) of SNF and 76.0% (n = 19/25) of LTC pharmacy medication lists. A total of 191 medication discrepancies were identified across all SNF and LTC pharmacy records. Of the 69 SNF staff interviewed, 20.3% (n = 14) reported patient care delays due to omitted documents during the hospital-to-SNF transition. During interviews, communication between the SNF/LTC pharmacy and the discharging hospital was described by facility staff as unidirectional with little opportunity for feedback on patient care concerns. The targeted needs assessment guided by the IM framework has lent to several planned process improvements initiatives to help reduce medication discrepancies during the hospital-to-SNF transition as well as improve communication between healthcare entities. Opening lines of communication along with aligning healthcare entity goals may help prevent medication-related errors. Copyright © 2017 Elsevier Inc. All rights reserved.

Changes in Relatives' Perspectives on Quality of Death, Quality of Care, Pain Relief, and Caregiving Burden Before and After a Region-Based Palliative Care Intervention.

PubMed

Maeda, Isseki; Miyashita, Mitsunori; Yamagishi, Akemi; Kinoshita, Hiroya; Shirahige, Yutaka; Izumi, Noriko; Yamaguchi, Takuhiro; Igarashi, Miyuki; Kato, Masashi; Morita, Tatsuya

2016-11-01

A region-based palliative care intervention (Outreach Palliative Care Trial of Integrated Regional Model Study) increased home death, access to specialist palliative care, quality of care, and quality of death and dying. The objective of this study was to examine changes in palliative care outcomes in different care settings (hospitals, palliative care units, and home) and obtain insights into how to improve region-level palliative care. The intervention program was implemented from April 2008 to March 2011. Two bereavement surveys were conducted before and after intervention involving 4228 family caregivers of deceased cancer patients. Family-perceived quality of care (range 1-6), quality of death and dying (1-7), pain relief (1-7), and caregiver burden (1-7) were measured. Response rates were 69% (preintervention) and 66% (postintervention), respectively. Family-perceived quality of care (adjusted mean 4.89, 95% CI 4.54-5.23) and quality of death and dying (4.96, 4.72-5.20) at home were the highest and sustained throughout the study. Palliative care units were at the intermediate level between home and hospitals. In hospitals, both quality of care and quality of death and dying were low at baseline but significantly improved after intervention (quality of care: 4.24, 4.13-4.34 to 4.43, 4.31-4.54, P = 0.002; quality of death and dying: 4.22, 4.09-4.36 to 4.36, 4.22-4.50, P = 0.012). Caregiver burden did not significantly increase after intervention, regardless of place of death. The dual strategies of transition of place of death to home and improving quality of care in hospitals should be recognized as important targets for improving region-level palliative care. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

PubMed

Bleijenberg, Nienke; Drubbel, Irene; Ten Dam, Valerie H; Numans, Mattijs E; Schuurmans, Marieke J; de Wit, Niek J

2012-04-25

Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinary intervention program (U-CARE). The U-PROFIT trial was designed to evaluate the effectiveness of these interventions. The aim of this paper is to describe the U-PROFIT trial design and to discuss methodological issues and challenges. The effectiveness of U-PRIM and U-CARE is being tested in a three-armed, cluster randomized trial in 58 general practices in the Netherlands, with approximately 5000 elderly individuals expected to participate. The primary outcome is the effect on activities of daily living as measured with the Katz ADL index. Secondary outcomes are quality of life, mortality, nursing home admission, emergency department and out-of-hours General Practice (GP), surgery visits, and caregiver burden. In a large, pragmatic trial conducted in daily clinical practice with frail older patients, several challenges and methodological issues will occur. Recruitment and retention of patients and feasibility of the interventions are important issues. To enable broad generalizability of results, careful choices of the design and outcome measures are required. Taking this into account, the U-PROFIT trial aims to provide robust evidence for a structured and integrated approach to provide care for frail older people in primary care. NTR2288.

Developing a Policy Flight Simulator to Facilitate the Adoption of an Evidence-Based Intervention

PubMed Central

Yu, Zhongyuan; Hirschman, Karen B.; Pepe, Kara; Pauly, Mark V.; Naylor, Mary D.; Rouse, William B.

2018-01-01

While the use of evidence-based interventions (EBIs) has been advocated by the medical research community for quite some time, uptake of these interventions by healthcare providers has been slow. One possible explanation is that it is challenging for providers to estimate impacts of a specific EBI on their particular organization. To address that concern, we developed and evaluated a type of simulation called a policy flight simulator to determine if it could improve the adoption decision about a specific EBI, the transitional care model (TCM). The TCM uses an advanced practice nurse-led model of care to transition older adults with multiple chronic conditions from a hospitalization to home. An evaluation by a National Advisory Committee, made up of senior representatives from various stakeholders in the U.S. healthcare system, found the policy flight simulator to be a useful tool that has the potential to better inform adoption decisions. This paper describes the simulation development effort and documents lessons learned that may be useful to the healthcare modeling community and those interested in using simulation to support decisions based on EBIs. PMID:29805921

Stakeholder validation of a model of readiness for transition to adult care.

PubMed

Schwartz, Lisa A; Brumley, Lauren D; Tuchman, Lisa K; Barakat, Lamia P; Hobbie, Wendy L; Ginsberg, Jill P; Daniel, Lauren C; Kazak, Anne E; Bevans, Katherine; Deatrick, Janet A

2013-10-01

That too few youth with special health care needs make the transition to adult-oriented health care successfully may be due, in part, to lack of readiness to transfer care. There is a lack of theoretical models to guide development and implementation of evidence-based guidelines, assessments, and interventions to improve transition readiness. To further validate the Social-ecological Model of Adolescent and Young Adult Readiness to Transition (SMART) via feedback from stakeholders (patients, parents, and providers) from a medically diverse population in need of life-long follow-up care, survivors of childhood cancer. Mixed-methods participatory research design. A large Mid-Atlantic children's hospital. Adolescent and young adult survivors of childhood cancer (n = 14), parents (n = 18), and pediatric providers (n = 10). Patients and parents participated in focus groups; providers participated in individual semi-structured interviews. Validity of SMART was assessed 3 ways: (1) ratings on importance of SMART components for transition readiness using a 5-point scale (0-4; ratings >2 support validity), (2) nominations of 3 "most important" components, and (3) directed content analysis of focus group/interview transcripts. Qualitative data supported the validity of SMART, with minor modifications to definitions of components. Quantitative ratings met criteria for validity; stakeholders endorsed all components of SMART as important for transition. No additional SMART variables were suggested by stakeholders and the "most important" components varied by stakeholders, thus supporting the comprehensiveness of SMART and need to involve multiple perspectives. SMART represents a comprehensive and empirically validated framework for transition research and program planning, supported by survivors of childhood cancer, parents, and pediatric providers. Future research should validate SMART among other populations with special health care needs.

Parenting a child with chronic illness as they transition into adulthood: A systematic review and thematic synthesis of parents' experiences.

PubMed

Heath, Gemma; Farre, Albert; Shaw, Karen

2017-01-01

To understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services. Five databases were systematically searched for qualitative articles examining parents' views and experiences of their child's healthcare transition. Papers were quality assessed and thematically synthesised. Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child's progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child's readiness, wellness, competence and long-term condition impacted on the child' progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child's growing independence. Parents can be key facilitators of their child's healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers. Interventions are needed which address the transitional care needs of parents as well as young people. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking.

PubMed

Nieder, Timo O; Elaut, Els; Richards, Christina; Dekker, Arne

2016-01-01

Since the beginning of contemporary transition-related care at the outset of the 20th century, sexual orientation has ben considered to be closely connected with gender identity and the developmental trajectories of trans people. Specifically, health professionals have regarded the anticipated post-transitional heterosexual behaviour of trans adults as predictive of a good outcome of cross-sex hormones and gender-confirming surgeries. This article reviews the current literature according to the question of whether the sexual orientation of trans people is linked to outcome measures following transition-related interventions. A comprehensive review was undertaken using the Medline database, searching for empirical studies published between 2010 and 2015. Out of a total of 474 studies, only 10 studies reported a follow-up of trans adults and assessed sexual orientation in the study protocol at all. Sexual orientation was predominantly assessed as homosexual versus non-homosexual related to sex assigned at birth. Only one 1 of 10 follow-up studies found a significant association according to the outcome between groups differentiated by sexual orientation. Empirically there is no link between sexual orientation and outcome of transition-related health care for trans adults. In order to provide comprehensive health care, we recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions; however, this knowledge should not drive, but simply inform, such comprehensive care.

Perspectives of Youth in Foster Care on Essential Ingredients for Promoting Self-determination and Successful Transition to Adult Life: My Life Model.

PubMed

Powers, Laurie E; Fullerton, Ann; Schmidt, Jessica; Geenen, Sarah; Oberweiser-Kennedy, Molly; Dohn, JoAnn; Nelson, May; Iavanditti, Rosemary; Blakeslee, Jennifer

2018-02-01

Research clearly documents the serious challenges and poor outcomes experienced by many young people exiting foster care, as well as compounded disparities for the high percentage of youth in care who are identified with disabilities and/or mental health challenges. However, very little research has been conducted to specify or validate effective models for improving the transition trajectories of youth exiting care. Evidence suggests the My Life self-determination enhancement model offers a promising approach for supporting youths' self-determined and positive transition to adulthood. The model includes youth-directed, experientially oriented coaching in the application of self-determination skills to achieve youth-identified transition goals, coupled with peer mentoring workshops that provide opportunities for learning, networking and fun. This in depth qualitative study of 10 youth who completed the My Life intervention focused on investigating coaching and mentoring elements and processes that youth participants identify as most important to their success, with the intention of informing the further development of youth-directed approaches to supporting young people who are transitioning to adulthood. Themes emerged around the centrality of youth self-direction, important processes in the coaching relationship, the essential value of experiential activities and self-determination skill development, and peer mentoring experiences that youth identified as fostering their success. Implications are discussed for research and practice in supporting youth exiting foster care.

CAREGIVER-CHILD INTERACTION, CAREGIVER TRANSITIONS, AND GROUP SIZE AS MEDIATORS BETWEEN INTERVENTION CONDITION AND ATTACHMENT AND PHYSICAL GROWTH OUTCOMES IN INSTITUTIONALIZED CHILDREN.

PubMed

Warner, Hilary A; McCall, Robert B; Groark, Christina J; Kim, Kevin H; Muhamedrahimov, Rifkat J; Palmov, Oleg I; Nikiforova, Natalia V

2017-09-01

This report describes a secondary analysis of data from a comprehensive intervention project which included training and structural changes in three Baby Homes in St. Petersburg, Russian Federation. Multiple mediator models were tested according to the R.M. Baron and D.A. Kenny () causal-steps approach to examine whether caregiver-child interaction quality, number of caregiver transitions, and group size mediated the effects of the intervention on children's attachment behaviors and physical growth. The study utilized a subsample of 163 children from the original Russian Baby Home project, who were between 11 and 19 months at the time of assessment. Results from comparisons of the training and structural changes versus no intervention conditions are presented. Caregiver-child interaction quality and number of caregiver transitions fully mediated the association between intervention condition and attachment behavior. No other mediation was found. Results suggest that the quality of interaction between caregivers and children in institutional care is of primary importance to children's development, but relationship context may play a less direct mediational role, supporting caregiver-child interactions. © 2017 Michigan Association for Infant Mental Health.

Automation is key to managing a population's health.

PubMed

Matthews, Michael B; Hodach, Richard

2012-04-01

Online tools for automating population health management can help healthcare organizations meet their patients' needs both during and between encounters with the healthcare system. These tools can facilitate: The use of registries to track patients' health status and care gaps. Outbound messaging to notify patients when they need care. Care team management of more patients at different levels of risk. Automation of workflows related to case management and transitions of care. Online educational and mobile health interventions to engage patients in their care. Analytics programs to identify opportunities for improvement.

Preparing childhood cancer survivors for transition to adult care: The young adult perspective.

PubMed

Frederick, Natasha N; Bober, Sharon L; Berwick, Lexie; Tower, Mary; Kenney, Lisa B

2017-10-01

Childhood cancer survivors (CCSs) remain at risk for developing treatment-associated health conditions as they age; however, many do not obtain recommended follow-up, putting them at unnecessary risk for morbidity. Educational interventions targeted at providing survivors with the knowledge and skills necessary for healthcare independence might improve adherence and outcomes as they transition care to the adult medical system. To identify informational needs, educational preferences, and support that young adult CCSs perceive as beneficial for transition from pediatric to adult medical care. Sixteen young adult CCSs (ages 22-39 years) who have transitioned to adult care participated in focus groups led by a trained moderator and analyzed using a thematic analysis approach. Four major themes emerged: (1) education preferences-pediatric oncology provider as the primary source of information and guidance, enhanced by other formats, and early and ongoing engagement in education; (2) family role in transition-desire for independence and acknowledgement of need for ongoing parental support; (3) expectations for adult providers, such as close relationships, open communication, and care coordination; and (4) knowledge deficits regarding disease/treatment history, risk for long-term complications, and navigation of the adult medical system. Transition education as described by young adult CCSs should be a developmentally appropriate process beginning in early adolescents, primarily administered by pediatric oncology providers, and delivered in multiple formats. While healthcare independence is a goal for young adult CCSs, all stakeholders must recognize that families and providers continue to have an important role supporting survivors with transition logistics and medical decision-making. © 2017 Wiley Periodicals, Inc.

A transitional care service for elderly chronic disease patients at risk of readmission.

PubMed

Brand, Caroline A; Jones, Catherine T; Lowe, Adrian J; Nielsen, David A; Roberts, Carol A; King, Bellinda L; Campbell, Donald A

2004-12-13

Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. A quasi-experimental controlled trial. A large tertiary metropolitan teaching hospital. 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

The Process and Impact of Stakeholder Engagement in Developing a Pediatric Intensive Care Unit Communication and Decision-Making Intervention.

PubMed

Michelson, Kelly N; Frader, Joel; Sorce, Lauren; Clayman, Marla L; Persell, Stephen D; Fragen, Patricia; Ciolino, Jody D; Campbell, Laura C; Arenson, Melanie; Aniciete, Danica Y; Brown, Melanie L; Ali, Farah N; White, Douglas

2016-12-01

Stakeholder-developed interventions are needed to support pediatric intensive care unit (PICU) communication and decision-making. Few publications delineate methods and outcomes of stakeholder engagement in research. We describe the process and impact of stakeholder engagement on developing a PICU communication and decision-making support intervention. We also describe the resultant intervention. Stakeholders included parents of PICU patients, healthcare team members (HTMs), and research experts. Through a year-long iterative process, we involved 96 stakeholders in 25 meetings and 26 focus groups or interviews. Stakeholders adapted an adult navigator model by identifying core intervention elements and then determining how to operationalize those core elements in pediatrics. The stakeholder input led to PICU-specific refinements, such as supporting transitions after PICU discharge and including ancillary tools. The resultant intervention includes navigator involvement with parents and HTMs and navigator-guided use of ancillary tools. Subsequent research will test the feasibility and efficacy of our intervention.

Parents' early healthcare transition experiences with preterm and acutely ill infants: a scoping review.

PubMed

Ballantyne, M; Orava, T; Bernardo, S; McPherson, A C; Church, P; Fehlings, D

2017-11-01

Parents undergo multiple transitions following the birth of an ill infant: their infant's illness-health trajectory, neonatal intensive care unit hospitalization and transfers from one healthcare setting to another, while also transitioning to parenthood. The objective of this review was to map and synthesize evidence on the experiences and needs of parents of preterm or ill infants as they transition within and between healthcare settings following birth. The scoping review followed Arskey and O'Malley's () framework, enhanced by Levac et al. (). Relevant studies were identified through a comprehensive search strategy of scientific and grey literature databases, online networks, Web of Science and citation lists of relevant articles. Inclusion criteria encompassed a focus on infants undergoing a healthcare transition, and the experiences and needs of parents during transition. Studies were appraised for design quality, and data relevant to parent experiences were extracted and underwent thematic analysis. A total of 7773 records were retrieved, 90 full texts reviewed and 11 articles synthesized that represented a total sample of 435 parents of preterm or ill infants. Parents reported on their experiences in response to their infant's transition within and between hospitals and across levels of neonatal intensive care unit, intermediate and community hospital care. Ten studies used qualitative research methods, while one employed quantitative survey methods. Four key themes were identified: that of parent distress throughout transition, parenting at a distance, sources of stress and sources of support. Parents' stress resulted from not being informed or involved in the transition decision, inadequate communication and perceived differences in cultures of care across healthcare settings. Opportunities to improve parents' early transition experiences include enhanced engagement, communication, information-sharing and shared decision-making between health care providers and parents. Future areas of research should focus on early transition interventions to advance parent capacity, confidence and closeness as the primary nurturer. © 2017 John Wiley & Sons Ltd.

Methodology for a Community Based Stroke Preparedness Intervention: The ASPIRE Study

PubMed Central

Boden-Albala, Bernadette; Edwards, Dorothy F.; Clair, Shauna St; Wing, Jeffrey J; Fernandez, Stephen; Gibbons, Chris; Hsia, Amie W.; Morgenstern, Lewis B.; Kidwell, Chelsea S.

2014-01-01

Background and Purpose Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. Methods The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multi-level program utilizing a community engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia (DC). This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue plasminogen activator (IV tPA) utilization for acute ischemic stroke. Results Phase 1 included: 1) enhancement of EMS focus on acute stroke; 2) hospital collaborations to implement and/or enrich acute stroke protocols and transition DC hospitals toward Primary Stroke Center certification; and 3) pre-intervention acute stroke patient data collection in all 7 acute care DC hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted with over 10,256 participants reached; 3289 intervention evaluations were performed, and 19,000 preparedness bracelets and 14,000 stroke warning magnets were distributed. Phase 3 included an evaluation of EMS and hospital processes for acute stroke care and a yearlong post-intervention acute stroke data collection period to assess changes in IV tPA utilization. Conclusions We report the methods, feasibility, and pre-intervention data collection efforts of the ASPIRE intervention. PMID:24876243

Supporting long-term follow-up of young adult survivors of childhood cancer: Correlates of healthcare self-efficacy

PubMed Central

Miller, Kimberly A.; Wojcik, Katherine Y.; Ramirez, Cynthia N.; Ritt-Olson, Anamara; Freyer, David R.; Hamilton, Ann S.; Milam, Joel E.

2017-01-01

Background Healthcare self-efficacy (HCSE), the perceived confidence to manage one’s health care, has been identified as a critical component in the transition process from pediatric to adult-oriented care for childhood cancer survivors (CCSs). HCSE is amenable to intervention and associated with long-term follow-up care among CCSs. However, factors associated with HCSE have not been fully explored among CCSs. Procedure We identified correlates of HCSE among a sample of CCSs (n = 193). Descriptive statistics and linear regression methods were used in this cross-sectional analysis. Results In univariate analyses, higher physical and psychosocial quality of life, posttraumatic growth, and religious/spiritual importance were associated with higher HCSE. Attendance at a survivorship clinic, having a regular source of care (both noncancer and oncologist), and any type of health insurance were also associated with HCSE. Hispanic ethnicity was negatively associated with HCSE relative to non-Hispanics. In a multivariable model, psychosocial quality of life, religious/spiritual importance, survivorship clinic attendance, having a regular oncologist, and Hispanic ethnicity remained significantly associated with HCSE. Conclusions CCSs who reported greater well-being, who rated religion and spirituality of high importance, and who accessed specialized cancer services expressed greater HCSE. Hispanic CCSs, however, reported less HCSE than non-Hispanics. Interventions that attend to the quality of life and spiritual needs of CCSs have potential to build HCSE to support the healthcare transition process. Because Hispanic CCSs may be at risk of lower perceived confidence to navigate their health care, culturally competent, efficacy-enhancing interventions are needed for this population. PMID:27567026

Supporting long-term follow-up of young adult survivors of childhood cancer: Correlates of healthcare self-efficacy.

PubMed

Miller, Kimberly A; Wojcik, Katherine Y; Ramirez, Cynthia N; Ritt-Olson, Anamara; Freyer, David R; Hamilton, Ann S; Milam, Joel E

2017-02-01

Healthcare self-efficacy (HCSE), the perceived confidence to manage one's health care, has been identified as a critical component in the transition process from pediatric to adult-oriented care for childhood cancer survivors (CCSs). HCSE is amenable to intervention and associated with long-term follow-up care among CCSs. However, factors associated with HCSE have not been fully explored among CCSs. We identified correlates of HCSE among a sample of CCSs (n = 193). Descriptive statistics and linear regression methods were used in this cross-sectional analysis. In univariate analyses, higher physical and psychosocial quality of life, posttraumatic growth, and religious/spiritual importance were associated with higher HCSE. Attendance at a survivorship clinic, having a regular source of care (both noncancer and oncologist), and any type of health insurance were also associated with HCSE. Hispanic ethnicity was negatively associated with HCSE relative to non-Hispanics. In a multivariable model, psychosocial quality of life, religious/spiritual importance, survivorship clinic attendance, having a regular oncologist, and Hispanic ethnicity remained significantly associated with HCSE. CCSs who reported greater well-being, who rated religion and spirituality of high importance, and who accessed specialized cancer services expressed greater HCSE. Hispanic CCSs, however, reported less HCSE than non-Hispanics. Interventions that attend to the quality of life and spiritual needs of CCSs have potential to build HCSE to support the healthcare transition process. Because Hispanic CCSs may be at risk of lower perceived confidence to navigate their health care, culturally competent, efficacy-enhancing interventions are needed for this population. © 2016 Wiley Periodicals, Inc.

Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis.

PubMed

Suijkerbuijk, Yvonne B; Schaafsma, Frederieke G; van Mechelen, Joost C; Ojajärvi, Anneli; Corbière, Marc; Anema, Johannes R

2017-09-12

People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions. To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness. In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials. We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only. Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE. We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions. Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.

The Youth Health Care measure-satisfaction, utilization, and needs (YHC-SUN)-development of a self-report version of the Child Health Care (CHC-SUN) proxy-measure.

PubMed

Schmidt, Silke; Thyen, Ute; Herrmann-Garitz, Carsten; Bomba, Franziska; Muehlan, Holger

2016-05-20

The transition of health care of youth (age 15-25) with chronic conditions requires the assessment of adolescents' access, use and needs as well as satisfaction with the health services they use. The aim of this study was to test the adolescent adaptation of the parent version "Child Health Care Questionnaire - Satisfaction, Utilization and Needs" (CHC-SUN) concerning its psychometric performance and appropriateness for adolescents and young adults. The Youth Health Care Measure (YHC-SUN) was designed to allow self-report of youth and it was pilot-tested in a small sample using cognitive debriefing. A cross-sectional survey in a sample of youth with chronic conditions in the transition period was carried out. One hundred eighty-two ambulatory care patients with three conditions participated in the survey. The subscales of the section on satisfaction with care showed excellent internal consistencies, uni-dimensionality and fit to the model of the parent version. There was no impact of gender and education on satisfaction with care. Associations with age, diagnosis, experiences with care and health literacy affecting the satisfaction with care indicate discriminatory and content validity. Potential applications of the new instrument are evaluations of health care services for adolescents and young adults using self-reports and evaluations of transition programs and interventions such as patient education.

Optimizing care transitions: the role of the community pharmacist

PubMed Central

Melody, Karleen T; McCartney, Elizabeth; Sen, Sanchita; Duenas, Gladys

2016-01-01

Transitions of care (TOC) refer to the movement of patients across institutions, among providers, between different levels of care, and to and from home. Medication errors that occur during TOC have the potential to result in medical complications that are serious for the patient and costly to the health care system. Positive outcomes have been demonstrated when pharmacists are involved in providing TOC services, including reducing preventable adverse drug reactions, medication-related problems, and rehospitalizations, as well as improving the discharge process. This review explores TOC models involving community pharmacy practice, the current impact of pharmacist interventions in TOC, and patient satisfaction with TOC services provided by community pharmacists. Common barriers and potential solutions to TOC services provided in the community pharmacy, such as patient identification, information gathering, standardization of services, administrative support, reimbursement, and time restraints, are also discussed. PMID:29354539

Coaching Older Adults and Carers to have their preferences Heard (COACH): A randomised controlled trial in an intermediate care setting (study protocol).

PubMed

Masters, Stacey; Gordon, Jason; Whitehead, Craig; Davies, Owen; Giles, Lynne C; Ratcliffe, Julie

2012-01-01

Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria. This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made. This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health-related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, 'red flags', end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician. The costs and outcomes of the intervention are compared with usual care. Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).

The mourning before: can anticipatory grief theory inform family care in adult intensive care?

PubMed

Coombs, Maureen A

2010-12-01

Although anticipatory grief is a much-debated and critiqued bereavement concept, it does offer a way of understanding and exploring expected loss that may be helpful in certain situations. In end-of-life care in adult intensive care units, families often act as proxy decision makers for patients in the transition from curative treatment efforts to planned treatment withdrawal. Despite there being a developed evidence base to inform care of families at this time, few of the clinical studies that provided this evidence were underpinned by bereavement theory. Focusing on end-of-life intensive care practices, this paper integrates work on anticipatory grief and family interventions to present a family-centred framework of care. Through this it is argued that the complex needs of families must be more comprehensively understood by doctors and nurses and that interventions must be more systematically planned to improve quality end-of-life care for families in this setting.

77 FR 35396 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-13

... on transitional care, including needs assessment, discharge planning, post-discharge intervention... test modifications to address the particular circumstances related to Medicaid readmissions and safety... and test existing strategies to reduce avoidable readmissions for their adequacy and applicability to...

The Family Perspective on Hospital to Home Transitions: A Qualitative Study.

PubMed

Solan, Lauren G; Beck, Andrew F; Brunswick, Stephanie A; Sauers, Hadley S; Wade-Murphy, Susan; Simmons, Jeffrey M; Shah, Samir S; Sherman, Susan N

2015-12-01

Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families' experiences with hospital-to-home transitions. Four main concepts resulted: (1) "In a fog" (barriers to processing and acting on information), (2) "What I wish I had" (desired information and suggestions for improvement), (3) "Am I ready to go home?" (discharge readiness), and (4) "I'm home, now what?" (confidence and postdischarge care). Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home. Copyright © 2015 by the American Academy of Pediatrics.

Substance Use and Delinquency among Middle School Girls in Foster Care: A Three-Year Follow-Up of a Randomized Controlled Trial

ERIC Educational Resources Information Center

Kim, Hyoun K.; Leve, Leslie D.

2011-01-01

Objective: The present study evaluated the efficacy of the Middle School Success intervention (MSS) for reducing substance use and delinquency among girls in foster care, using a randomized controlled trial design. The program was designed to fill a service gap during the summer prior to the middle school transition and to prevent delinquency,…

A Hybrid Web-Based and In-Person Self-Management Intervention to Prevent Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): Protocol for a Pilot Single-Blind Randomized Controlled Trial

PubMed Central

2017-01-01

Background Acute pain frequently transitions to chronic pain after major lower extremity trauma (ET). Several modifiable psychological risk and protective factors have been found to contribute to, or prevent, chronic pain development. Some empirical evidence has shown that interventions, including cognitive and behavioral strategies that promote pain self-management, could prevent chronic pain. However, the efficacy of such interventions has never been demonstrated in ET patients. We have designed a self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma). Objective This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and research methods of the intervention, as well as the potential effects of iPACT-E-Trauma, on pain intensity and pain interference with daily activities. Methods A 2-arm single-blind pilot RCT will be conducted. Participants will receive the iPACT-E-Trauma intervention (experimental group) or an educational pamphlet (control group) combined with usual care. Data will be collected at baseline, during iPACT-E-Trauma delivery, as well as at 3 and 6 months post-injury. Primary outcomes are pain intensity and pain interference with daily living activities at 6 months post-injury. Secondary outcomes are pain self-efficacy, pain acceptance, pain catastrophizing, pain-related fear, anxiety and depression symptoms, health care service utilization, and return to work. Results Fifty-three patients were recruited at the time of manuscript preparation. Comprehensive data analyses will be initiated in July 2017. Study results are expected to be available in 2018. Conclusions Chronic pain is an important problem after major lower ET. However, no preventive intervention has yet been successfully proven in these patients. This study will focus on developing a feasible intervention to prevent acute to chronic pain transition in the context of ET. Findings will allow for the refinement of iPACT-E-Trauma and methodological parameters in prevision of a full-scale multi-site RCT. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6rR8G2vMs) PMID:28652226

Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients.

PubMed

Aboumatar, H; Naqibuddin, M; Chung, S; Adebowale, H; Bone, L; Brown, T; Cooper, L A; Gurses, A P; Knowlton, A; Kurtz, D; Piet, L; Putcha, N; Rand, C; Roter, D; Shattuck, E; Sylvester, C; Urteaga-Fuentes, A; Wise, R; Wolff, J L; Yang, T; Hibbard, J; Howell, E; Myers, M; Shea, K; Sullivan, J; Syron, L; Wang, Nae-Yuh; Pronovost, P

2017-11-01

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home. In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors. Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.

Using Tablet Computers to Increase Patient Engagement With Electronic Personal Health Records: Protocol For a Prospective, Randomized Interventional Study

PubMed Central

Magan Mendoza, Yimdriuska; Rosenthal, Jaime; Jacolbia, Ronald; Rajkomar, Alvin; Lee, Herman; Auerbach, Andrew

2016-01-01

Background Inadequate patient engagement in care is a major barrier to successful transitions from the inpatient setting and can lead to preventable adverse events after discharge, particularly for older adults. While older adults may be less familiar with mobile devices and applications, they may benefit from focused bedside training to engage them in using their Personal Health Record (PHR). Mobile technologies such as tablet computers can be used in the hospital to help bridge this gap in experience by teaching older, hospitalized patients to actively manage their medication list through their PHR during hospitalization and continue to use their PHR for other post-discharge tasks such as scheduling follow-up appointments, viewing test results, and communicating with providers. Bridging this gap is especially important for older, hospitalized adults as they are at higher risk than younger populations for low engagement in transitions of care and poor outcomes such as readmission. Greater understanding of the advantages and limitations of mobile devices for older adults may be important for improving transitions of care. Objective To better understand the effective use of mobile technologies to improve transitions in care for hospitalized, older adults and leverage these technologies to improve inpatient and postdischarge care for older adults. Methods We will compare an intervention group with tablet-based training to engage effectively with their PHR to a control group also receiving tablets and basic access to their PHR but no additional training on how to engage with their PHR. Results Patient enrollment is ongoing. Conclusions Through this grant, we will further develop our preliminary dataset and practical experience with these mobile technologies to catalyze patient engagement during hospitalization. ClinicalTrial ClinicalTrials.gov NCT02109601; https://clinicaltrials.gov/ct2/show/NCT02109601 (Archived by WebCite at http://www.webcitation.org/6jpXjkwM8) PMID:27599452

Permanency and the Foster Care System.

PubMed

Lockwood, Katie K; Friedman, Susan; Christian, Cindy W

2015-10-01

Each year over 20,000 youth age out of the child welfare system without reaching a permanent placement in a family. Certain children, such as those spending extended time in foster care, with a diagnosed disability, or adolescents, are at the highest risk for aging out. As young adults, this population is at and increased risk of incarceration; food, housing, and income insecurity; unemployment; educational deficits; receipt of public assistance; and mental health disorders. We reviewed the literature on foster care legislation, permanency, outcomes, and interventions. The outcomes of children who age out of the child welfare system are poor. Interventions to increase permanency include training programs for youth and foster parents, age extension for foster care and insurance coverage, an adoption tax credit, and specialized services and programs that support youth preparing for their transition to adulthood. Future ideas include expanding mentoring, educational support, mental health services, and post-permanency services to foster stability in foster care placements and encourage permanency planning. Children in the child welfare system are at a high risk for physical, mental, and emotional health problems that can lead to placement instability and create barriers to achieving permanency. Failure to reach the permanency of a family leads to poor outcomes, which have negative effects on the individual and society. Supporting youth in foster care throughout transitions may mediate the negative outcomes that have historically followed placement in out-of-home care. Copyright © 2015 Mosby, Inc. All rights reserved.

Reducing depression during the menopausal transition with health coaching: Results from the healthy menopausal transition randomised controlled trial.

PubMed

Almeida, Osvaldo P; Marsh, Kylie; Murray, Karen; Hickey, Martha; Sim, Moira; Ford, Andrew; Flicker, Leon

2016-10-01

To determine if health coaching (HC) decreases the incidence of depression, reduces the severity of symptoms, and increases quality of life during the menopausal transition (MT). Parallel, single-blinded, randomised controlled trial of 6 sessions of phone-delivered HC compared with usual care. Participants were 351 community-dwelling women free of major depression going through the MT, of whom 180 were assigned the intervention and 171 usual care. The primary outcome of interest was the incidence of clinically significant depressive symptoms over 52 weeks. Other study measures included the Hospital Anxiety and Depression Scale, quality of life (SF-12), the Menopause Rating Scale (MRS), diet, body mass index, alcohol use, smoking and physical activity. We considered that women with Patient Health Questionnaire (PHQ-9) scores between 5 and 14 (inclusive) had sub-threshold depressive symptoms. Nine women developed clinically significant symptoms of depression during the study-2 had been assigned HC (odds ratio, OR=0.26, 95%CI=0.05, 1.29; p=0.099). Intention-to-treat showed that, compared with usual care, the intervention led to a greater decline in depressive scores, most markedly for participants with sub-threshold depressive symptoms. Similar, but less pronounced, benefits were noticed for anxiety scores and the mental component summary of the SF-12. The intervention led to a decline in MRS scores by week 26 and subtle improvements in body mass, consumption of vegetables and smoking. HC addressing relevant risk factors for depression during the MT improves mental health measures. Our findings indicate that women with sub-threshold depressive symptoms may benefit the most from such interventions, and suggest that HC could play a useful role in minimizing mental health disturbance for women going through the MT. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Communication interventions to improve adherence to infection control precautions: a randomised crossover trial.

PubMed

Ong, Mei-Sing; Magrabi, Farah; Post, Jeffrey; Morris, Sarah; Westbrook, Johanna; Wobcke, Wayne; Calcroft, Ross; Coiera, Enrico

2013-02-06

Ineffective communication of infection control requirements during transitions of care is a potential cause of non-compliance with infection control precautions by healthcare personnel. In this study, interventions to enhance communication during inpatient transfers between wards and radiology were implemented, in the attempt to improve adherence to precautions during transfers. Two interventions were implemented, comprising (i) a pre-transfer checklist used by radiology porters to confirm a patient's infectious status; (ii) a coloured cue to highlight written infectious status information in the transfer form. The effectiveness of the interventions in promoting adherence to standard precautions by radiology porters when transporting infectious patients was evaluated using a randomised crossover trial at a teaching hospital in Australia. 300 transfers were observed over a period of 4 months. Compliance with infection control precautions in the intervention groups was significantly improved relative to the control group (p < 0.01). Adherence rate in the control group was 38%. Applying the coloured cue resulted in a compliance rate of 73%. The pre-transfer checklist intervention achieved a comparable compliance rate of 71%. When both interventions were applied, a compliance rate of 74% was attained. Acceptability of the coloured cue was high, but adherence to the checklist was low (40%). Simple measures to enhance communication through the provision of a checklist and the use a coloured cue brought about significant improvement in compliance with infection control precautions by transport personnel during inpatient transfers. The study underscores the importance of effective communication in ensuring compliance with infection control precautions during transitions of care.

The effect of a nurse-led telephone-based care coordination program on the follow-up and control of cardiovascular risk factors in patients with coronary artery disease.

PubMed

Wong, Ningyan; Chua, Siang Jin Terrance; Gao, Fei; Sim, Sok Tiang Rosalind; Matchar, David; Wong, Sung Lung Aaron; Yeo, Khung Keong; Tan, Wei Chieh Jack; Chin, Chee Tang

2016-12-01

We sought to analyse the impact of a care coordination protocol on transiting patients with coronary artery disease who had undergone percutaneous coronary intervention (PCI) to primary care and its effect on cardiovascular risk factor control. A prospective observational study involving 492 patients who had undergone PCI either electively or after an acute coronary syndrome. A tertiary institution in Singapore. Patients who had undergone a PCI either electively or after an acute coronary syndrome. The SCORE (Standardized Care for Optimal Outcomes, Right-Siting and Rapid Re-evaluation) program was a nurse-led, telephone-based, care coordination protocol. Transition to primary care within 1 year of enrolment, the achievement of low-density lipoprotein (LDL) level of <2.6 mmol/l within 1 year and hospital admissions related to cardiovascular causes within 1 year were studied. Under the SCORE protocol, a significantly higher number of patients transited to primary care and achieved the LDL target within 1 year, as compared with non-SCORE patients. Discharge to primary care and achievement of target LDL continued to be higher among those under the SCORE protocol even after multivariate analysis. Rates of hospital admission due to cardiovascular causes were not significantly different. Care coordination improved the rate of transition of post-PCI patients to primary care and improved LDL control, with no difference in the rate of hospital admissions due to cardiovascular causes. These findings support the implementation of a standardized follow-up protocol in patients who have undergone PCI. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

[Economics of health system transformation].

PubMed

González Pier, Eduardo

2012-01-01

Health conditions in Mexico have evolved along with socioeconomic conditions. As a result, today's health system faces several problems characterized by four overlapping transitions: demand, expectations, funding and health resources. These transitions engender significant pressures on the system itself. Additionally, fragmentation of the health system creates disparities in access to services and generates problems in terms of efficiency and use of available resources. To address these complications and to improve equity in access and efficiency, thorough analysis is required in how the right to access health care should be established at a constitutional level without differentiating across population groups. This should be followed by careful discussion about what rules of health care financing should exist, which set of interventions ought to be covered and how services must be organized to meet the health needs of the population.

Transition from children's to adult services for young adults with life-limiting conditions: A realist review of the literature.

PubMed

Kerr, Helen; Price, Jayne; Nicholl, Honor; O'Halloran, Peter

2017-11-01

Improvements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, which means they must make the transition from children's to adult services. This has proved a challenging process for both young adults and service providers, with complex transition interventions interacting in unpredictable ways with local contexts. To explain how intervention processes interact with contextual factors to help transition from children's to adult services for young adults with life-limiting conditions. Systematic realist review of the literature. Literature was sourced from four electronic databases: Embase, MEDLINE, Science Direct and Cochrane Library from January 1995 to April 2016. This was supplemented with a search in Google Scholar and articles sourced from reference lists of included papers. Data were extracted using an adapted standardised data extraction tool which included identifying information related to interventions, mechanisms, contextual influences and outcomes. Two reviewers assessed the relevance of papers based on the inclusion criteria. Methodological rigor was assessed using the relevant Critical Appraisal Skills Programme tools. 78 articles were included in the review. Six interventions were identified related to an effective transition to adult services. Contextual factors include the need for children's service providers to collaborate with adult service providers to prepare an environment with knowledgeable staff and adequate resources. Mechanisms triggered by the interventions include a sense of empowerment and agency amongst all stakeholders. Early planning, collaboration between children's and adult service providers, and a focus on increasing the young adults' confidence in decision-making and engaging with adult services, are vital to a successful transition. Interventions should be tailored to their context and focused not only on organisational procedures but on equipping young adults, parents/carers and staff to engage with each other effectively. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Intervention time until discharge for newborns on transition from gavage to exclusive oral feeding.

PubMed

Medeiros, Andréa Monteiro Correia; Ramos, Blenda Karen Batista; Bomfim, Déborah Letticia Santana Santos; Alvelos, Conceição Lima; Silva, Talita Cardoso da; Barreto, Ikaro Daniel de Carvalho; Santos, Felipe Batista; Gurgel, Ricardo Queiroz

2018-01-01

Purpose Measure the intervention time required for transition from gavage to exclusive oral feeding, comparing newborns exposed exclusively to the mother's breast with those who, in addition to breastfeeding, received supplementation using a cup or baby bottle. Methods Analytical, longitudinal, cohort study conducted with 165 newborns (NB) divided into groups according to severity of medical complications (G1-with no complications; G2-with significant complications), and into subgroups according to feeding mechanism (A and B). All NBs were low birth weight, on Kangaroo Mother Care, and breast stimulated according to medical prescription and hospital routine. Regarding feeding pattern, subgroup A comprised NBs exclusively breastfed at hospital discharge, whereas subgroup B was composed of NBs fed through cup/bottle at some time during hospitalization. The number of days spent in each stage of transition was recorded for each NB. Results History of clinical complications significantly influenced total intervention time. Study participants in subgroups G1-A (10 days), G1-B (9 days), and G2-A (12 days) displayed greater chances of early discharge compared with those in subgroup G2-B (16 days). Conclusion NBs with no important history of clinical complications displayed greater chances of early hospital discharge. NBs with significant history of clinical complications that underwent gavage to exclusive breastfeeding transition presented smaller intervention time than those that required supplementation using cup/bottle. Feeding transition using the gavage-to-exclusive oral feeding technique is recommended for Speech-language Pathology practice in Neonatology.

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives

PubMed Central

Eisen, Jeffrey C.; Marko-Holguin, Monika; Fogel, Joshua; Cardenas, Alonso; Bahn, My; Bradford, Nathan; Fagan, Blake; Wiedmann, Peggy

2013-01-01

Objective: To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007. Method: The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention). Results: While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses. Conclusion: Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings. Trial Registration: ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912 PMID:24800110

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives.

PubMed

Eisen, Jeffrey C; Marko-Holguin, Monika; Fogel, Joshua; Cardenas, Alonso; Bahn, My; Bradford, Nathan; Fagan, Blake; Wiedmann, Peggy; Van Voorhees, Benjamin W

2013-01-01

To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007. The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention). While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses. Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings. ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912.

Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI): protocol for a cluster-randomised clinical trial of a complex intervention

PubMed Central

Richards-Belle, Alvin; Mouncey, Paul R; Wade, Dorothy; Brewin, Chris R; Emerson, Lydia M; Grieve, Richard; Harrison, David A; Harvey, Sheila; Howell, David; Mythen, Monty; Sadique, Zia; Smyth, Deborah; Weinman, John; Welch, John; Rowan, Kathryn M

2018-01-01

Introduction Acute psychological stress, as well as unusual experiences including hallucinations and delusions, are common in critical care unit patients and have been linked to post-critical care psychological morbidity such as post-traumatic stress disorder (PTSD), depression and anxiety. Little high-quality research has been conducted to evaluate psychological interventions that could alleviate longer-term psychological morbidity in the critical care unit setting. Our research team developed and piloted a nurse-led psychological intervention, aimed at reducing patient-reported PTSD symptom severity and other adverse psychological outcomes at 6 months, for evaluation in the POPPI trial. Methods and analysis This is a multicentre, parallel group, cluster-randomised clinical trial with a staggered roll-out of the intervention. The trial is being carried out at 24 (12 intervention, 12 control) NHS adult, general, critical care units in the UK and is evaluating the clinical effectiveness and cost-effectiveness of a nurse-led preventative psychological intervention in reducing patient-reported PTSD symptom severity and other psychological morbidity at 6 months. All sites deliver usual care for 5 months (baseline period). Intervention group sites are then trained to carry out the POPPI intervention, and transition to delivering the intervention for the rest of the recruitment period. Control group sites deliver usual care for the duration of the recruitment period. The trial also includes a process evaluation conducted independently of the trial team. Ethics and dissemination This protocol was reviewed and approved by the National Research Ethics Service South Central - Oxford B Research Ethics Committee (reference: 15/SC/0287). The first patient was recruited in September 2015 and results will be disseminated in 2018. The results will be presented at national and international conferences and published in peer reviewed medical journals. Trial registration number ISRCTN53448131; Pre-results. PMID:29439083

Transitions to Care in the Community for Prison Releasees with HIV: a Qualitative Study of Facilitators and Challenges in Two States.

PubMed

Hammett, Theodore M; Donahue, Sara; LeRoy, Lisa; Montague, Brian T; Rosen, David L; Solomon, Liza; Costa, Michael; Wohl, David; Rich, Josiah D

2015-08-01

One in seven people living with HIV in the USA passes through a prison or jail each year, and almost all will return to the community. Discharge planning and transitional programs are critical but challenging elements in ensuring continuity of care, maintaining treatment outcomes achieved in prison, and preventing further viral transmission. This paper describes facilitators and challenges of in-prison care, transitional interventions, and access to and continuity of care in the community in Rhode Island and North Carolina based on qualitative data gathered as part of the mixed-methods Link Into Care Study of prisoners and releasees with HIV. We conducted 65 interviews with correctional and community-based providers and administrators and analyzed the transcripts using NVivo 10 to identify major themes. Facilitators of effective transitional systems in both states included the following: health providers affiliated with academic institutions or other entities independent of the corrections department; organizational philosophy emphasizing a patient-centered, personal, and holistic approach; strong leadership with effective "champions"; a team approach with coordination, collaboration and integration throughout the system, mutual respect and learning between corrections and health providers, staff dedicated to transitional services, and effective communication and information sharing among providers; comprehensive transitional activities and services including HIV, mental health and substance use services in prisons, timely and comprehensive discharge planning with specific linkages/appointments, supplies of medications on release, access to benefits and entitlements, case management and proactive follow-up on missed appointments; and releasees' commitment to transitional plans. These elements were generally present in both study states but their absence, which also sometimes occurred, represent ongoing challenges to success. The qualitative findings on the facilitators and challenges of the transitional systems were similar in the two states despite differences in context, demographics of target population, and system organization. Recommendations for improved transitional systems follow from the analysis of the facilitators and challenges.

[The transition process from the intensive care unit to the ward: a review of the literature].

PubMed

Vázquez Calatayud, M; Portillo, M C

2013-01-01

The optimum transition process from the ICU to the ward is key to avoiding the appearance of anxiety in the patient and family, increase of re-admissions in the ICU with the consequent increase in costs and jeopardization to the patient's safety. 1) To identify, study and give a critical presentation of the existing evidence on how patients, families and nurses experience the transition from ICU to the ward; 2) to analyze the possible interventions available for the development of an optimum transition process. A review was made of the evidence available in the main databases. In addition, several journals specialized in Intensive Care were reviewed. Studies with a qualitative, quantitative or mixed approach and reviews on the subject with a systematic methodology or narrative reviews were included. A total of 23 papers were selected for review, 10 of which were qualitative studies, 11 quantitative and two had combined methodology. «Transfer anxiety» was identified after the analysis of these articles as one of the recurring aspects. Discrepancies regarding who should take responsibility for the preparation of the transition process and when it should be performed were also found. In the literature reviewed, several interventions have been proposed to facilitate an optimal transition process such as developing information brochures, creating a profile of practicing nursing liaison between the ICU and the ward and ICU discharge report. This review emphasizes the importance of taking into account the perspectives of patients, families and nurses to perform optimal planning of the transition of the patient from the ICU to the ward to ensure their safety. Copyright © 2012 Elsevier España, S.L. y SEEIUC. All rights reserved.

Predictors of Retention in a Homeless Veteran Intervention Program

DTIC Science & Technology

2012-12-01

Educational Development /High School GPD Grant and Per Diem HCHV Health Care for Homeless Veterans HEARTH Homeless Emergency Assistance and...Planning and Public Affairs, University of Illinois at Chicago. The Homeless Emergency Assistance and Rapid Transition to Housing ( HEARTH ) Act (P.L. 111

Comparing the Effects of Aromatherapy With Rose Oils and Warm Foot Bath on Anxiety in the First Stage of Labor in Nulliparous Women

PubMed Central

Kheirkhah, Massomeh; Vali Pour, Nassimeh Setayesh; Nisani, Leila; Haghani, Hamid

2014-01-01

Background: Anxiety is the most common emotional response in women during delivery, which can be accompanied with adverse effects on fetus and mother. Objectives: This study was conducted to compare the effects of aromatherapy with rose oil and warm foot bath on anxiety in the active phase of labor in nulliparous women in Tehran, Iran. Patients and Methods: This clinical trial study was performed after obtaining informed written consent on 120 primigravida women randomly assigned into three groups. The experimental group 1 received a 10-minute inhalation and footbath with oil rose. The experimental group 2 received a 10-minute warm water footbath. Both interventions were applied at the onset of active and transitional phases. Control group, received routine care in labor. Anxiety was assessed using visual analogous scale (VASA) at onset of active and transitional phases before and after the intervention. Statistical comparison was performed using SPSS software version 16 and P < 0.05 was considered significant. Results: Anxiety scores in the intervention groups in active phase after intervention were significantly lower than the control group (P < 0.001). Anxiety scores before and after intervention in intervention groups in transitional phase was significantly lower than the control group (P < 0.001). Conclusions: Using aromatherapy and footbath reduces anxiety in active phase in nulliparous women. PMID:25593713

Feasibility and Acceptability of Nurse-Led Primary Palliative Care for Older Adults with Chronic Conditions: A Pilot Study.

PubMed

Izumi, Shigeko Seiko; Basin, Basilia; Presley, Margo; McCalmont, Jean; Furuno, Jon P; Noble, Brie; Baggs, Judith G; Curtis, J Randall

2018-05-24

Many older adults live with serious illness for years before their death. Nurse-led primary palliative care could improve their quality of life and ability to stay in their community. To assess feasibility and acceptability of a nurse-led Transitional Palliative Care (TPC) program for older adults with serious illness. The study was a pilot trial of the TPC program in which registered nurses assisted patients with symptom management, communication with care providers, and advance care planning. Forty-one older adults with chronic conditions were enrolled in TPC or standard care groups. Feasibility was assessed through enrollment and attrition rates and degree of intervention execution. Acceptability was assessed through surveys and exit interviews with participants and intervention nurses. Enrollment rate for those approached was 68%, and completion rate for those enrolled was 71%. The TPC group found the intervention acceptable and helpful and was more satisfied with care received than the control group. However, one-third of participants perceived that TPC was more than they needed, despite the number of symptoms they experienced and the burdensomeness of their symptoms. More than half of the participants had little to no difficulty participating in daily activities. This study demonstrated that the nurse-led TPC program is feasible, acceptable, and perceived as helpful. However, further refinement is needed in selection criteria to identify the population who would most benefit from primary palliative care before future test of the efficacy of this intervention.

Association between quality domains and health care spending across physician networks

PubMed Central

Rahman, Farah; Guan, Jun; Glazier, Richard H.; Brown, Adalsteinn; Bierman, Arlene S.; Croxford, Ruth; Stukel, Therese A.

2018-01-01

One of the more fundamental health policy questions is the relationship between health care quality and spending. A better understanding of these relationships is needed to inform health systems interventions aimed at increasing quality and efficiency of care. We measured 65 validated quality indicators (QI) across Ontario physician networks. QIs were aggregated into domains representing six dimensions of care: screening and prevention, evidence-based medications, hospital-community transitions (7-day post-discharge visit with a primary care physician; 30-day post-discharge visit with a primary care physician and specialist), potentially avoidable hospitalizations and emergency department (ED) visits, potentially avoidable readmissions and unplanned returns to the ED, and poor cancer end of life care. Each domain rate was computed as a weighted average of QI rates, weighting by network population at risk. We also measured overall and sector-specific per capita healthcare network spending. We evaluated the associations between domain rates, and between domain rates and spending using weighted correlations, weighting by network population at risk, using an ecological design. All indicators were measured using Ontario health administrative databases. Large variations were seen in timely hospital-community transitions and potentially avoidable hospitalizations. Networks with timely hospital-community transitions had lower rates of avoidable admissions and readmissions (r = -0.89, -0.58, respectively). Higher physician spending, especially outpatient primary care spending, was associated with lower rates of avoidable hospitalizations (r = -0.83) and higher rates of timely hospital-community transitions (r = 0.81) and moderately associated with lower readmission rates (r = -0.46). Investment in effective primary care services may help reduce burden on the acute care sector and associated expenditures. PMID:29614131

The Use of Text Messaging to Improve the Hospital-to-Community Transition in Acute Coronary Syndrome Patients (Txt2Prevent): Intervention Development and Pilot Randomized Controlled Trial Protocol.

PubMed

Ross, Emily S; Sakakibara, Brodie M; Mackay, Martha H; Whitehurst, David Gt; Singer, Joel; Toma, Mustafa; Corbett, Kitty K; Van Spall, Harriette Gc; Rutherford, Kimberly; Gheorghiu, Bobby; Code, Jillianne; Lear, Scott A

2017-05-23

Acute coronary syndrome, including acute myocardial infarction (AMI), is one of the leading causes for hospitalization, with AMI 30-day readmission rates around 20%. Supporting patient information needs and increasing adherence to recommended self-management behaviors during transition from hospital to home has the potential to improve patient outcomes. Text messages have been effective in other interventions and may be suitable to provide support to patients during this transition period. The goal of this study is to pilot test a text messaging intervention program (Txt2Prevent) that supports acute coronary syndrome patients for 60 days postdischarge. The primary objective is to compare self-management, as measured by the Health Education Impact Questionnaire, between patients receiving only usual care versus those who receive usual care plus the Txt2Prevent intervention. The secondary objectives are to compare medication adherence, health-related quality of life, self-efficacy, health care resource use (and associated costs), all-cause and cardiovascular disease (CVD) readmission, and all-cause and CVD mortality rates between the 2 groups. The third objective is to assess acceptability of the text messaging intervention and feasibility of the study protocol. This is a randomized controlled trial with blinding of outcome assessors. The Txt2Prevent program includes automated text messages to patients about standard follow-up care, general self-management, and healthy living. The content of the text messages was informed by and developed based on interviews with patients, discharge materials, theoretical domains of behavior, and a clinical advisory group composed of patients, clinicians, and researchers. We will recruit 76 consecutive cardiac in-patients with acute coronary syndrome who are treated with either medical management or percutaneous coronary intervention from a hospital in Vancouver, Canada. Assessments at baseline will include measures for demographic information, self-management, health-related quality of life, and self-efficacy. Assessments at follow-up will include medication adherence, readmissions, health care resource use, and mortality in addition to the reassessment of baseline measures. Baseline assessments are done in-person while follow-up assessments are completed through a combination of mailed packages and phone calls. Semistructured interviews with participants will also be performed to better understand participant experiences managing their condition and with the text messages. This study will determine preliminary efficacy, feasibility, and acceptability of the Txt2Prevent program to support acute coronary syndrome patients in the transition to home following hospital discharge. The results of this study will be used to inform a larger trial. ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919 (Archived by WebCite at http://www.webcitation.org/6qMjEqo6O). ©Emily S Ross, Brodie M Sakakibara, Martha H Mackay, David GT Whitehurst, Joel Singer, Mustafa Toma, Kitty K Corbett, Harriette GC Van Spall, Kimberly Rutherford, Bobby Gheorghiu, Jillianne Code, Scott A Lear. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 23.05.2017.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department.

PubMed

Dahlquist, Robert T; Reyner, Karina; Robinson, Richard D; Farzad, Ali; Laureano-Phillips, Jessica; Garrett, John S; Young, Joseph M; Zenarosa, Nestor R; Wang, Hao

2018-05-01

Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change. We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS. The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05). Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS.

Improving Caregivers' Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team.

PubMed

Wessman, Brian T; Sona, Carrie; Schallom, Marilyn

2017-01-01

With population aging and growth, use of critical care medicine at the end of life continues to rise, while many critical care providers are not adequately trained regarding goals of care/end-of-life (GOC/EOL) issues. A multidisciplinary intensive care unit (ICU) team intervention regarding GOC/EOL communication will enhance the clinical abilities of all critical care providers when discussing GOC/EOL issues and increase ICU staff comfort level while improving transitions for patients to a comfort care approach. This study was a preintervention/postintervention survey evaluation. This study was conducted at an academic tertiary surgical burn trauma ICU. The intervention was provided to nursing, ancillary staff, house staff, and attending physicians. An initial survey was circulated among the critical care staff for baseline expectations, satisfaction, and understanding of GOC/EOL care. A robust intervention was begun including the creation of a multidisciplinary GOC/EOL team, communication tools for providers, patient-family pamphlets, standardized EOL order sets, and formalized didactic sessions. Subsequently, the same survey was circulated and compared to baseline data. Preintervention/postintervention survey data were reviewed and statistically analyzed. Our survey response rate for preintervention/postintervention was 50.4% and 36.1%, respectively. The intervention generated heightened interest in improving family communication and provided focal direction to foster this growth. Based on the serial surveys regarding our intervention, statistically significant staff improvements were seen in "work stress" (P = .04), "EOL information" (P = .006), and "space allotment" (P = .001). Improved congruence of families and health care providers regarding decision over intensity of care was also noted. We created a novel unit-based multidisciplinary program for improved EOL/GOC approaches in the critical care setting. A similarly formatted program could be adapted by other ICUs. Benefits of such a program include improving caregivers' perceptions regarding EOL/GOC issues and fostering critical care team growth. © The Author(s) 2015.

Holistic concerns of Chinese stroke survivors during hospitalization and in transition to home.

PubMed

Yeung, Siu Ming; Wong, Frances Kam Yuet; Mok, Esther

2011-11-01

This article is a report of a study conducted to explore the phenomenon of concerns as experienced by Chinese stroke survivors during hospitalization and in transition to home. Stroke is characterized by its sudden onset and prolonged residual problems, which affect survivors' holistic well-being. Many studies have focused on stroke consequences and their correlates with psychosocial outcomes. Very little is known about holistic concerns of stroke survivors, particularly in the transition from hospital to home. We used purposive sampling of 15 stroke survivors who participated in semi-structured interviews after being discharged from stroke wards of a general hospital in Hong Kong from November 2008 to February 2009. The interviews were transcribed verbatim and analysed using Giorgi's phenomenological techniques. Stroke survivors' physical, psychological, socio-cultural and spiritual concerns in hospital and transition to home emerged from the data analysis. The four major themes identified were: (a) dynamic interplay of holistic concerns, (b) cultural expression of illness experiences, (c) social support 'paradox' and (d) caring gaps in clinical management. Understanding the interwoven holistic concerns for the stroke survivors in hospital and after discharged home can help nurses to identify their health needs and plan for appropriate nursing interventions. The findings provide guidance for the development of culture-sensitive holistic care interventions with family involvement in Chinese stroke populations. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

The costs and benefits of enhanced depression care to employers.

PubMed

Wang, Philip S; Patrick, Amanda; Avorn, Jerry; Azocar, Francisca; Ludman, Evette; McCulloch, Joyce; Simon, Gregory; Kessler, Ronald

2006-12-01

Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment. To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives. Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature. Hypothetical cohort of 40-year-old workers. Intervention Enhanced depression care consisting of a depression screen and care management for those depressed vs usual care. Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer's perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon. From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19 976 per quality-adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer's perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In 1-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions. If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers.

International practice settings, interventions and outcomes of nurse practitioners in geriatric care: A scoping review.

PubMed

Chavez, Krista S; Dwyer, Andrew A; Ramelet, Anne-Sylvie

2018-02-01

To identify and summarize the common clinical settings, interventions, and outcomes of nurse practitioner care specific to older people. Scoping review of the international published and grey literature. A structured literature search was conducted of CINAHL, EMBASE, MEDLINE, Google Scholar, and Cochrane Collaboration and Joanna Briggs Institute databases. Following the Arksey and O'Malley framework, randomized controlled and quasi-experimental studies of Masters-prepared nurse practitioners providing care for patients over 65 years were included. Studies were reviewed independently by two investigators. Data were extracted, collated by setting, summarized in tables and synthesized for analysis. In total, 56 primary research studies from four countries and 23 systematic reviews were identified. Primary studies were conducted in primary care (n=13), home care (n=14), long-term care (n=10), acute/hospital care (n=9), and transitional care (n=10). Nurse practitioner interventions included substitutive as well as a supplementation NP role elements to meet specific unmet patient care needs. Studies examined six main outcome measures: service utilization (n=41), cost (n=24), length of stay (n=14), health indices (n=44), satisfaction (n=14) and quality of life (n=7). Cumulatively, nurse practitioners demonstrated enhanced results in 83/144 (58%) of outcomes compared to physician-only or usual care. The most commonly measured financial-related outcome was service utilization (n=41) and benefits were frequently reported in home care (8/9, 89%) and long-term care (7/10, 70%) settings. Among patient and care-related outcomes health indices were most frequently measured (n=44). Primary care most frequently reported improved health indices (11/13, 85%). Transitional care reported improved outcomes across all measures, except for service utilization. This review demonstrates improved or non-inferiority results of nurse practitioner care in older people across settings. More well-designed, rigorous studies are needed particularly in relation to costs. The results of this review could be used for future systemic review of effectiveness of NP care specific to older people. Despite the demonstrated NP role value, barriers to implementing the nurse practitioner role persist internationally and more work is needed to develop and promote these roles. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Mobile integrated health to reduce post-discharge acute care visits: A pilot study.

PubMed

Siddle, Jennica; Pang, Peter S; Weaver, Christopher; Weinstein, Elizabeth; O'Donnell, Daniel; Arkins, Thomas P; Miramonti, Charles

2018-05-01

Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). In this pilot before/after study, MIH significantly reduces acute care hospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.

Cost-effectiveness of a health-social partnership transitional program for post-discharge medical patients.

PubMed

Wong, Frances Kam Yuet; Chau, June; So, Ching; Tam, Stanley Ku Fu; McGhee, Sarah

2012-12-24

Readmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap. Cost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1. The readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY. Previous studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.

[The development and effects of an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention].

PubMed

Son, Youn-Jung

2008-04-01

This study was conducted to develop and to determine the effects of an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention. Subjects consisted of 58 CAD patients (experimental group: 30, control group: 28). The experimental group participated in an integrated symptom management program for 6 months which was composed of tailored education, stress management, exercise, diet, deep breathing, music therapy, periodical telephone monitoring and a daily log. The control group received the usual care. The experimental group significantly decreased symptom experiences and the level of LDL compared to the control group. The experimental group significantly increased self care activity and quality of life compared to the control group. Although no significant difference was found in cardiac recurrence, the experimental group had fewer recurrences. These results suggest that an integrated symptom management program for prevention of recurrent cardiac events after percutaneous coronary intervention can improve symptom aggravation, recurrent rate, self care activity and quality of life. Nursing interventions are needed to maintain and further enhance the quality of life of these patients and the interventions should be implemented in the overall transition period.

Technology use in linking criminal justice reentrants to HIV care in the community: a qualitative formative research study.

PubMed

Peterson, James; Cota, Michelle; Gray, Holly; Bazerman, Lauri; Kuo, Irene; Kurth, Ann; Beckwith, Curt

2015-01-01

Innovative interventions increasing linkage, adherence, and retention in care among HIV-infected persons in the criminal justice system are needed. The authors conducted a qualitative study to investigate technology-based tools to facilitate linkage to community-based care and viral suppression for HIV-infected jail detainees on antiretroviral medications being released to the community. The authors conducted 24 qualitative interview-12 in Rhode Island and 12 in Washington, DC-among recently incarcerated HIV-infected persons to elicit their perceptions on the use of technology tools to support linkage to HIV care among criminal justice populations. This article discusses participants' perceptions of the acceptability of technological tools such as (a) a computer-based counseling and (b) text messaging interventions. The participants reported positive experiences when previewing the technology-based tools to facilitate linkage to HIV care and adherence to HIV medications. Successful linkage to care has been shown to improve HIV-associated and non-HIV-associated health outcomes, as well as prevent criminal recidivism and facilitate reentrants' successful and meaningful transition. These findings can be used to inform the implementation of interventions aimed at promoting adherence to antiretroviral medications and linkage to care for HIV-infected persons being released from the correctional setting.

Treatment issues for children with epilepsy transitioning to adult care.

PubMed

Nabbout, Rima; Camfield, Carol S; Andrade, Danielle M; Arzimanoglou, Alexis; Chiron, Catherine; Cramer, Joyce A; French, Jacqueline A; Kossoff, Eric; Mula, Marco; Camfield, Peter R

2017-04-01

This is the third of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper focuses on treatment issues that arise during the course of childhood epilepsy and make the process of transition to adult care more complicated. Some AEDs used during childhood, such as stiripentol, vigabatrin, and cannabidiol, are unfamiliar to adult epilepsy specialists. In addition, new drugs are being developed for treatment of specific childhood onset epilepsy syndromes and have no indication yet for adults. The ketogenic diet may be effective during childhood but is difficult to continue in adult care. Regional adult epilepsy diet clinics could be helpful. Polytherapy is common for patients transitioning to adult care. Although these complex AED regimes are difficult, they are often possible to simplify. AEDs used in childhood may need to be reconsidered in adulthood. Rescue medications to stop prolonged seizures and clusters of seizures are in wide home use in children and can be continued in adulthood. Adherence/compliance is notoriously difficult for adolescents, but there are simple clinical approaches that should be helpful. Mental health issues including depression and anxiety are not always diagnosed and treated in children and young adults even though effective treatments are available. Attention deficit hyperactivity disorder and aggressive behavior disorders may interfere with transition and successful adulthood but these can be treated. For the majority, the adult social outcome of children with epilepsy is unsatisfactory with few proven interventions. The interface between pediatric and adult care for children with epilepsy is becoming increasingly complicated with a need for more comprehensive transition programs and adult epileptologists who are knowledgeable about special treatments that benefit this group of patients. Copyright © 2016 Elsevier Inc. All rights reserved.

A patient navigation intervention for drug-involved former prison inmates.

PubMed

Binswanger, Ingrid A; Whitley, Elizabeth; Haffey, Paul-Ryan; Mueller, Shane R; Min, Sung-Joon

2015-01-01

Former prison inmates experience high rates of hospitalizations and death during the transition from prison to the community, particularly from drug-related causes and early after release. The authors designed a randomized controlled trial (RCT) of patient navigation to reduce barriers to health care and hospitalizations for former prison inmates. Forty former prison inmates with a history of drug involvement were recruited and randomized within 15 days after prison release. Participants were randomized to receive 3 months of patient navigation (PN) with facilitated enrollment into an indigent care discount program (intervention) or facilitated enrollment into an indigent care discount program alone (control). Structured interviews were conducted at baseline, 3 months, and 6 months. Outcomes were measured as a change in self-reported barriers to care and as the rate of health service use per 100 person-days. The mean number of reported barriers to care was reduced at 3 and 6 months in both groups. At 6 months, the rate of emergency department/urgent care visits per 100 person-days since baseline was 1.1 among intervention participants and 0.5 among control participants (P = .04), whereas the rate of hospitalizations per 100 person-days was 0.2 in intervention participants and 0.6 in control participants (P = .04). Recruitment of former inmates into an RCT of patient navigation was highly feasible, but follow-up was limited by rearrests. Results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved. Patient navigation is a promising, pragmatic intervention that may be effective at reducing high-cost health care utilization in former prison inmates.

The Journey to Interprofessional Collaborative Practice: Are We There Yet?

PubMed

Golom, Frank D; Schreck, Janet Simon

2018-02-01

Interprofessional collaborative practice (IPCP) is a service delivery approach that seeks to improve health care outcomes and the patient experience while simultaneously decreasing health care costs. The current article reviews the core competencies and current trends associated with IPCP, including challenges faced by health care practitioners when working on interprofessional teams. Several conceptual frameworks and empirically supported interventions from the fields of organizational psychology and organization development are presented to assist health care professionals in transitioning their teams to a more interprofessionally collaborative, team-based model of practice. Copyright © 2017 Elsevier Inc. All rights reserved.

Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review.

PubMed

Samal, Lipika; Dykes, Patricia C; Greenberg, Jeffrey O; Hasan, Omar; Venkatesh, Arjun K; Volk, Lynn A; Bates, David W

2016-04-22

Health information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States. We performed a qualitative study with clinicians and information technology professionals from six regions of the U.S. which were chosen as national leaders in HIT. We analyzed data through a two person consensus approach, assigning responses to each of nine care coordination activities. We also conducted a literature review of MEDLINE®, CINAHL®, and Embase, analyzing results of studies that examined interventions to improve information transfer during transitions of care. We enrolled 29 respondents from 17 organizations and conducted six focus groups. Respondents reported how HIT is currently used for care coordination activities. HIT is currently used to monitor patients and to align systems-level resources with population needs. However, we identified multiple areas where the lack of interoperability leads to inefficient processes and missing data. Additionally, the literature review identified ten intervention studies that address information transfer, seven of which employed HIT and three of which utilized other communication methods such as telephone calls, faxed records, and nurse case management. Significant care coordination gaps exist due to the lack of interoperability across the United States. We must design, evaluate, and incentivize the use of HIT for care coordination. We should focus on the domains where we found the largest gaps: information transfer, systems to monitor patients, tools to support patients' self-management goals, and tools to link patients and their caregivers with community resources.

HOME-BASED BLOOD PRESSURE INTERVENTIONS FOR AFRICAN AMERICANS

PubMed Central

Feldman, Penny H.; McDonald, Margaret V.; Mongoven, Jennifer M.; Peng, Timothy R.; Gerber, Linda M.; Pezzin, Liliana E.

2009-01-01

Background Efforts to increase blood pressure (BP) control rates in African Americans, a traditionally underserved, high risk population must address both provider practice and patient adherence issues. The Home-Based BP Intervention for African Americans study is a three-arm randomized controlled trial designed to test two strategies to improve HTN management and outcomes in a decentralized service setting serving a vulnerable and complex home care population. The primary study outcomes are systolic BP, diastolic BP, and BP control; secondary outcomes are nurse adherence to HTN management recommendations, and patient adherence to medication, healthy diet and other self-management strategies. Methods and Results Nurses (N=312) in a nonprofit Medicare-certified home health agency are randomized along with their eligible hypertensive patients (N=845). The two interventions being tested are: (i) a “basic” intervention delivering key evidence-based reminders to home care nurses and patients while the patient is receiving traditional post-acute home health care; and (ii) an “augmented” intervention that includes that same as the basic intervention, plus transition to an ongoing HTN Home Support Program that extends support for 12 months. Outcomes are measured at 3 and 12 months post baseline interview. The interventions will be assessed relative to usual care and to each other. Conclusions Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact. Results from this trial will provide important information on potential strategies to improve BP control in a low income, chronically ill patient population. PMID:20031844

Survivorship education for Latina breast cancer survivors: Empowering Survivors through education

PubMed Central

Juarez, Gloria; Mayorga, Lina; Hurria, Arti; Ferrell, Betty

2013-01-01

Objectives Nueva Luz is an English and Spanish quality of life (QOL) intervention developed to address the educational needs of Latina breast cancer survivors and provide strategies to assist in their transition into survivorship. Methods A qualitative approach was used to evaluate the English and Spanish educational intervention (Nueva Luz). A purposive sample of eight Latina breast cancer survivors was selected from the group who received the intervention to participate in a digitally recorded interview. Data was analyzed using thematic analysis. Results Findings provide evidence that the one-on-one tailored approach is a feasible and acceptable method of providing a bilingual psychosocial intervention. The provision of printed bilingual information along with the verbal instruction from a bilingual and culturally competent health care provider can be effective in helping Latina breast cancer survivor’s transition successfully into survivorship, improve QOL and contribute to better patient outcomes Conclusions The study informs our understanding of the cultural context in patient education content and delivery of psychosocial interventions. The findings may also have relevance for other ethnic minority cancer survivors. PMID:24416043

Better futures: a randomized field test of a model for supporting young people in foster care with mental health challenges to participate in higher education.

PubMed

Geenen, Sarah; Powers, Laurie E; Phillips, Lee Ann; Nelson, May; McKenna, Jessica; Winges-Yanez, Nichole; Blanchette, Linda; Croskey, Adrienne; Dalton, Lawrence D; Salazar, Amy; Swank, Paul

2015-04-01

The purpose of the study was to conduct a preliminary efficacy evaluation of the Better Futures model, which is focused on improving the postsecondary preparation and participation of youth in foster care with mental health challenges. Sixty-seven youth were randomized to either a control group that received typical services or an intervention group, which involved participation in a Summer Institute, individual peer coaching, and mentoring workshops. Findings indicate significant gains for the intervention group on measures of postsecondary participation, postsecondary and transition preparation, hope, self-determination, and mental health empowerment, as compared to the control group. Youth in the intervention group also showed positive trends in the areas of mental health recovery, quality of life, and high school completion. Implications for future research and practice are discussed, while emphasizing the capacities of youth in foster care with mental health conditions to successfully prepare for and participate fully in high education.

How Oncology Fellows Discuss Transitions in Goals of Care: A Snapshot of Approaches Used Prior to Training

PubMed Central

Michaelsen, Kate; Alexander, Stewart; Hopley, Elizabeth; Edwards, Kelly; Arnold, Robert M.

2010-01-01

Abstract Introduction The moment when a physician raises the possibility of discontinuing palliative chemotherapy at the end of life is a critical moment in the illness, and a difficult conversation. Expert recommendations cite the importance of giving bad news in these situations but there is limited research addressing how physicians should discuss transitions in goals of care from disease-modifying therapy to end-of-life care. While existing research includes survey data and observational studies of oncologist outpatient visits with patient who have advanced cancer, there are no studies that characterize actual physician communication behaviors when the physician tried to initiate a transitions conversation with a patient who has advanced cancer. Method In this study, we examined the communication approaches used by oncology fellows discussing transitions with a standardized patient using audiorecordings collected prior to an intensive communication skills workshop. In this preworkshop encounter, each oncology fellow had the task of discussing a transition in goals of care with a patient who was experiencing cancer progression despite treatment with existing evidence-based therapies. We used qualitative methodology to characterize the approaches used by oncology fellows in 20 of these pre-workshop conversations. Results We identified two themes in the approaches that fellows used: (1) the limitations of biomedical disease-modifying treatments and (2) the possibility of a new direction for medical care when disease-modifying treatments have been exhausted. Conclusion We found that for each theme, fellows tended to emphasize a logical frame or an experiential frame. Understanding these frames could be useful in designing future communication skills training interventions. PMID:20307195

How oncology fellows discuss transitions in goals of care: a snapshot of approaches used prior to training.

PubMed

Back, Anthony L; Michaelsen, Kate; Alexander, Stewart; Hopley, Elizabeth; Edwards, Kelly; Arnold, Robert M

2010-04-01

The moment when a physician raises the possibility of discontinuing palliative chemotherapy at the end of life is a critical moment in the illness, and a difficult conversation. Expert recommendations cite the importance of giving bad news in these situations but there is limited research addressing how physicians should discuss transitions in goals of care from disease-modifying therapy to end-of-life care. While existing research includes survey data and observational studies of oncologist outpatient visits with patient who have advanced cancer, there are no studies that characterize actual physician communication behaviors when the physician tried to initiate a transitions conversation with a patient who has advanced cancer. In this study, we examined the communication approaches used by oncology fellows discussing transitions with a standardized patient using audiorecordings collected prior to an intensive communication skills workshop. In this preworkshop encounter, each oncology fellow had the task of discussing a transition in goals of care with a patient who was experiencing cancer progression despite treatment with existing evidence-based therapies. We used qualitative methodology to characterize the approaches used by oncology fellows in 20 of these pre-workshop conversations. We identified two themes in the approaches that fellows used: (1) the limitations of biomedical disease-modifying treatments and (2) the possibility of a new direction for medical care when disease-modifying treatments have been exhausted. We found that for each theme, fellows tended to emphasize a logical frame or an experiential frame. Understanding these frames could be useful in designing future communication skills training interventions.

Rationale of the BREAst cancer e-healTH [BREATH] multicentre randomised controlled trial: An Internet-based self-management intervention to foster adjustment after curative breast cancer by decreasing distress and increasing empowerment

PubMed Central

2012-01-01

Background After completion of curative breast cancer treatment, patients go through a transition from patient to survivor. During this re-entry phase, patients are faced with a broad range of re-entry topics, concerning physical and emotional recovery, returning to work and fear of recurrence. Standard and easy-accessible care to facilitate this transition is lacking. In order to facilitate adjustment for all breast cancer patients after primary treatment, the BREATH intervention is aimed at 1) decreasing psychological distress, and 2) increasing empowerment, defined as patients’ intra- and interpersonal strengths. Methods/design The non-guided Internet-based self-management intervention is based on cognitive behavioural therapy techniques and covers four phases of recovery after breast cancer (Looking back; Emotional processing; Strengthening; Looking ahead). Each phase of the fully automated intervention has a fixed structure that targets consecutively psychoeducation, problems in everyday life, social environment, and empowerment. Working ingredients include Information (25 scripts), Assignment (48 tasks), Assessment (10 tests) and Video (39 clips extracted from recorded interviews). A non-blinded, multicentre randomised controlled, parallel-group, superiority trial will be conducted to evaluate the effectiveness of the BREATH intervention. In six hospitals in the Netherlands, a consecutive sample of 170 will be recruited of women who completed primary curative treatment for breast cancer within 4 months. Participants will be randomly allocated to receive either usual care or usual care plus access to the online BREATH intervention (1:1). Changes in self-report questionnaires from baseline to 4 (post-intervention), 6 and 10 months will be measured. Discussion The BREATH intervention provides a psychological self-management approach to the disease management of breast cancer survivors. Innovative is the use of patients’ own strengths as an explicit intervention target, which is hypothesized to serve as a buffer to prevent psychological distress in long-term survivorship. In case of proven (cost) effectiveness, the BREATH intervention can serve as a low-cost and easy-accessible intervention to facilitate emotional, physical and social recovery of all breast cancer survivors. Trial registration This study is registered at the Netherlands Trial Register (NTR2935) PMID:22958799

Comprehensive Strategies to Reduce Readmissions in Older Patients With Cardiovascular Disease.

PubMed

Dharmarajan, Kumar

2016-11-01

Older adults are frequently readmitted to the hospital soon after hospitalization for common cardiovascular conditions. Yet there are few high-quality data on the best strategies to reduce short-term readmissions because most studies have involved small numbers of participants, single-centre design, and strong susceptibility to bias. Despite these limitations in the literature, a clear signal exists that most studies involving a singular type of intervention, a singular type of health provider, or a low intensity of intervention have failed to reduce readmissions. In contrast, interventions that are most likely to lower readmissions have used comprehensive approaches, including combined hospital and postacute care, multimodal interventions, multidisciplinary teams, or frequent longitudinal contact. Components of a comprehensive approach with the highest level of evidence include high-quality, disease-specific care; multiple transitional care interventions; involvement of multidisciplinary teams; early and frequent outpatient follow-up; and, when possible, home visits. These findings are consistent with data demonstrating that older adults have multiple sources of vulnerability and experience elevated readmission risk from a broad spectrum of medical conditions for an extended time after hospital discharge. Because readmission reduction is difficult and requires new ways of conceptualizing links between inpatient and postacute care, financial incentives may ultimately be required to motivate hospitals and health systems to redesign care processes, deploy new resources, and collaborate with out-of-hospital providers and organizations. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Exploring barriers to remaining physically active: a case report of a person with multiple sclerosis.

PubMed

Zalewski, Kathryn

2007-03-01

Physical therapy intervention for those with chronic disabling conditions typically follows an episode of care approach: therapists provide services when a decrement in functional performance occurs such that individuals require intervention to return to baseline performance. Attention to the psychosocial supports required for successful transition can be unintentionally minimized when the focus of an episode of care follows a change in physical function. The purpose of this case report is to present and discuss the challenges to successful community reintegration following physical therapy intervention with an emphasis on developing independent exercise habits in management of a person with multiple sclerosis. RW, presented in this case study, is a 52-year-old man diagnosed with progressive multiple sclerosis five years before self-referral to a pro bono physical therapy clinic.

Psychometric Evaluation of the Hospital Culture of Transitions Survey.

PubMed

McClelland, Mark; Bena, James; Albert, Nancy M; Pines, Jesse M

2017-10-01

Ineffective or inefficient transitions threaten patient safety, hinder communication, and worsen patient outcomes. The Hospital Culture of Transitions (H-CulT) survey was designed to assess a hospital's organizational culture related to within-hospital transitions in care involving patient movement. In this article, psychometric properties of the H-CulT survey were examined to assess and refine the hospital culture of transitions. A cross-sectional, multicenter, multidisciplinary correlational design and survey methods were used to examine the psychometric properties of the H-CulT survey. Exploratory factor analysis was used to quantify the accuracy of the previously identified structure. Specifically, the analysis involved the principal axis factor method with an oblique rotation, based on a polychoric correlation matrix. A sample of 492 respondents from 13 diverse hospitals participated. Cronbach's alpha for the instrument was 0.88, indicating strong internal consistency. Seven subscales emerged and were labeled: Hospital Leadership, Unit Leadership, My Unit's Culture, Other Units' Culture, Busy Workload, Priority of Patient Care, and Use of Data. Correlations between subscales ranged from 0.07 to 0.52, providing evidence that the subscales did not measure the same construct. Subscale correlations with the total score were near or above 0.50 (p <0.001). Use of a factor-loading cutoff of 0.40 resulted in the elimination of 12 items because of weak associations with the topic. The H-CulT is a psychometrically sound and practical survey for assessing hospital culture related to patient flow during transitions in care. Survey results may prompt quality improvement interventions that enhance in-hospital transitions and improve staff satisfaction and patient satisfaction with care. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use.

PubMed

Al-Hashar, Amna; Al-Zakwani, Ibrahim; Eriksson, Tommy; Sarakbi, Alaa; Al-Zadjali, Badriya; Al Mubaihsi, Saif; Al Zaabi, Mohammed

2018-05-12

Background Adverse drug events from preventable medication errors can result in patient morbidity and mortality, and in cost to the healthcare system. Medication reconciliation can improve communication and reduce medication errors at transitions in care. Objective Evaluate the impact of medication reconciliation and counselling intervention delivered by a pharmacist for medical patients on clinical outcomes 30 days after discharge. Setting Sultan Qaboos University Hospital, Muscat, Oman. Methods A randomized controlled study comparing standard care with an intervention delivered by a pharmacist and comprising medication reconciliation on admission and discharge, a medication review, a bedside medication counselling, and a take-home medication list. Medication discrepancies during hospitalization were identified and reconciled. Clinical outcomes were evaluated by reviewing electronic health records and telephone interviews. Main outcome measures Rates of preventable adverse drug events as primary outcome and healthcare resource utilization as secondary outcome at 30 days post discharge. Results A total of 587 patients were recruited (56 ± 17 years, 57% female); 286 randomized to intervention; 301 in the standard care group. In intervention arm, 74 (26%) patients had at least one discrepancy on admission and 100 (35%) on discharge. Rates of preventable adverse drug events were significantly lower in intervention arm compared to standard care arm (9.1 vs. 16%, p = 0.009). No significant difference was found in healthcare resource use. Conclusion The implementation of an intervention comprising medication reconciliation and counselling by a pharmacist has significantly reduced the rate of preventable ADEs 30 days post discharge, compared to the standard care. The effect of the intervention on healthcare resource use was insignificant. Pharmacists should be included in decentralized, patient-centred roles. The findings should be interpreted in the context of the study's limitations.

Substance Use and Delinquency Among Middle School Girls in Foster Care: A Three-Year Follow-up of a Randomized Controlled Trial

PubMed Central

Kim, Hyoun K.; Leve, Leslie D.

2011-01-01

Objective The present study evaluated the efficacy of the Middle School Success intervention (MSS) for reducing substance use and delinquency among girls in foster care, using a randomized controlled trial (RCT) design. The program was designed to fill a service gap during the summer prior to the middle school transition and to prevent delinquency, substance use, and related problems. Method One hundred girls in foster care and their caregivers were randomly assigned either to the intervention (n = 48) or to a regular foster care control (n = 52) condition. The girls completed a baseline (T1) assessment and follow-up assessments at 6 months (T2), 12 months (T3), 24 months (T4), and 36 months (T5) postbaseline. Caregivers participated in assessments from T1 through T4. This study is a follow up to Smith et al. (2011)’s study, which examined immediate outcomes at T2. Results Girls in the intervention condition showed significantly lower levels of substance use than did girls in the control condition at 36-months postbaseline. The group difference was only marginally significant for delinquency. Further analyses indicated significant indirect effects of the intervention through increased prosocial behaviors which led to decreased internalizing and externalizing symptoms and then to lower levels of substance use. The direct effect of the intervention on substance use remained significant in the presence of the indirect effects. For delinquency, the intervention had positive effects mainly through increased prosocial skills. Conclusions Findings highlight the importance of providing preventive intervention services for early adolescent girls in foster care. PMID:22004305

Transition Needs of Adolescents With Sickle Cell Disease

PubMed Central

Abel, Regina A.; Cho, Esther; Chadwick-Mansker, Kelley R.; D’Souza, Natalia; Housten, Ashley J.

2015-01-01

OBJECTIVE. This article describes how adolescents with sickle cell disease (SCD) perceive their ability to perform everyday tasks required for transition to adult health care and independent living. METHOD. The Adolescent Autonomy Checklist (AAC) was adapted to include skills associated with managing SCD (AAC–SCD) and was administered to adolescents during clinic visits. Participants indicated “can do already” or “needs practice” for 100 activities in 12 categories. RESULTS. Of 122 patients, the percentage of adolescents who needed practice was greatest in living arrangements (38.7%), money management (35.8%), vocational skills (29.6%), and health care skills (25.5%). We found a significant effect of age and of cerebrovascular injury on the percentage of those who reported “needs practice” in multiple categories. We found no effect of gender and limited effect of hemoglobin phenotype on any skill category. CONCLUSION. Findings support the need for educational intervention to improve transition skills in adolescents with SCD. PMID:26122692

Transition from patient to survivor in African American breast cancer survivors.

PubMed

Mollica, Michelle; Nemeth, Lynne

2015-01-01

Breast cancer is the most common cancer among African American (AA) women, with a survival rate of 79%, lower than for other ethnic and racial groups in the United States. Minorities experience disparities in timeliness of care, delivery of culturally sensitive care, and outcomes. Transition from active treatment to survivorship presents an opportunity for exploration. This qualitative, grounded theory study examined the experiences and coping of AA women as they transition from being a breast cancer patient to being a breast cancer survivor. This study included 15 community-based AA women aged 35 to 75 years in Charleston, South Carolina, and Buffalo, New York, who had completed treatment for primary breast cancer between 6 and 18 months prior. A semistructured interview explored experiences as they finished treatment, support from family, role of spirituality, physical and emotional concerns, needs of the survivor, as well as suggestions for possible interventions for other survivors. Two investigators reviewed transcripts and coding to confirm and refine the findings. Four main themes were identified: perseverance through struggles supported by reliance on faith, persistent physical issues, anticipatory guidance needed after treatment, and emotional needs as important as physical. The transition from cancer patient to survivor is a pervasive time filled with stress, loss of safety net, and significant coping measures. Participants expressed the need to have support from another AA breast cancer survivor as they complete treatment. Nurses and providers can assess and address stressors in transition. Nurses should design patient-centered interventions using peers as direct support to promote effective coping strategies.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial.

PubMed

Balaban, Richard B; Galbraith, Alison A; Burns, Marguerite E; Vialle-Valentin, Catherine E; Larochelle, Marc R; Ross-Degnan, Dennis

2015-07-01

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals. To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. Randomized controlled trial. General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up. A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions among younger patients. Care transition strategies should be evaluated among diverse populations, and younger high risk patients may require novel strategies.

ProvenCare: Geisinger's Model for Care Transformation through Innovative Clinical Initiatives and Value Creation.

PubMed

2009-04-01

Geisinger's system of care can be seen as a microcosm of the national delivery of healthcare, with implications for decision makers in other health plans. In this interview, Dr Ronald A. Paulus focuses on Geisinger's unique approach to patient care. In its core, this approach represents a system of quality and value initiatives based on 3 major programs-Proven Health Navigation (medical home); the ProvenCare model; and transitions of care. The goal of such an approach is to optimize disease management by using a rational reimbursement paradigm for appropriate interventions, providing innovative incentives, and engaging patients in their own care as part of any intervention. Dr Paulus explains the reasons why, unlike Geisinger, other stakeholders, including payers, providers, patients, and employers, have no intrinsic reasons to be concerned with quality and value initiatives. In addition, he says, an electronic infrastructure that could be modified as management paradigms evolve is a necessary tool to ensure the healthcare delivery system's ability to adapt to new clinical realities quickly to ensure the continuation of delivering best value for all stakeholders.

Medication Therapy Management after Hospitalization in CKD: A Randomized Clinical Trial.

PubMed

Tuttle, Katherine R; Alicic, Radica Z; Short, Robert A; Neumiller, Joshua J; Gates, Brian J; Daratha, Kenn B; Barbosa-Leiker, Celestina; McPherson, Sterling M; Chaytor, Naomi S; Dieter, Brad P; Setter, Stephen M; Corbett, Cynthia F

2018-02-07

CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization. The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization. Baseline characteristics of participants ( n =141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m 2 (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P =0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P =0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP, hemoglobin, phosphorus, or parathyroid hormone. Acute care utilization after hospitalization was not reduced by a pharmacist-led medication therapy management intervention at the transition from hospital to home. Copyright © 2018 by the American Society of Nephrology.

Integrating transition theory and bioecological theory: a theoretical perspective for nurses supporting the transition to adulthood for young people with medical complexity.

PubMed

Joly, Elizabeth

2016-06-01

To present a discussion of a theoretical perspective developed through integrating Meleis' Transition Theory and Bronfenbrenner's Bioecological Theory of Human Development to inform nursing and advanced nursing practice supporting the transition to adulthood for young people with medical complexity. Theoretical perspectives to inform nursing practice in supporting successful transition are limited, yet nurses frequently encounter young people with medical complexity during the transition to adulthood. Discussion paper. A literature search of CINAHL and Medline was conducted in 2014 and included articles from 2003-2014; informal discussions with families; the author's experiences in a transition program. The integrated theoretical perspective described in this paper can inform nurses and advanced practice nurses on contextual influences, program and intervention development across spheres of influence and outcomes for the transition to adulthood for young people with medical complexity. Young people and their families require effective reciprocal interactions with individuals and services across sectors to successfully transition to adulthood and become situated in the adult world. Intervention must also extend beyond the young person to include providers, services and health and social policy. Nurses can take a leadership role in supporting the transition to adulthood for young people with medical complexity through direct care, case management, education and research. It is integral that nurses holistically consider developmental processes, complexity and contextual conditions that promote positive outcomes during and beyond the transition to adulthood. © 2016 John Wiley & Sons Ltd.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department

PubMed Central

Dahlquist, Robert T.; Reyner, Karina; Robinson, Richard D.; Farzad, Ali; Laureano-Phillips, Jessica; Garrett, John S.; Young, Joseph M.; Zenarosa, Nestor R.; Wang, Hao

2018-01-01

Background Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change. Methods We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS. Results The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05). Conclusions Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS. PMID:29581808

Decreasing handoff-related care failures in children's hospitals.

PubMed

Bigham, Michael T; Logsdon, Tina R; Manicone, Paul E; Landrigan, Christopher P; Hayes, Leslie W; Randall, Kelly H; Grover, Purva; Collins, Susan B; Ramirez, Dana E; O'Guin, Crystal D; Williams, Catherine I; Warnick, Robin J; Sharek, Paul J

2014-08-01

Patient handoffs in health care require transfer of information, responsibility, and authority between providers. Suboptimal patient handoffs pose a serious safety risk. Studies demonstrating the impact of improved patient handoffs on care failures are lacking. The primary objective of this study was to evaluate the effect of a multihospital collaborative designed to decrease handoff-related care failures. Twenty-three children's hospitals participated in a quality improvement collaborative aimed at reducing handoff-related care failures. The improvement was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Handoff-related care failures were compared between baseline and 3 intervention periods. Secondary outcomes measured compliance to specific change package elements and balancing measure of staff satisfaction. Twenty-three children's hospitals evaluated 7864 handoffs over the 12-month study period. Handoff-related care failures decreased from baseline (25.8%) to the final intervention period (7.9%) (P < .05). Significant improvement was observed in every handoff type studied. Compliance to change package elements improved (achieving a common understanding about the patient from 86% to 96% [P < .05]; clear transition of responsibility from 92% to 96% [P < .05]; and minimized interruptions and distractions from 84% to 90% [P < .05]) as did overall satisfaction with the handoff (from 55% to 70% [P < .05]). Implementation of a standardized evidence-based handoff process across 23 children's hospitals resulted in a significant decrease in handoff-related care failures, observed over all handoff types. Compliance to critical components of the handoff process improved, as did provider satisfaction. Copyright © 2014 by the American Academy of Pediatrics.

Extended Foster Care for Transition-Age Youth: An Opportunity for Pregnancy Prevention and Parenting Support.

PubMed

Putnam-Hornstein, Emily; Hammond, Ivy; Eastman, Andrea Lane; McCroskey, Jacquelyn; Webster, Daniel

2016-04-01

This analysis examined California county birth rate variations among girls in foster care. The objective was to generate data to assess potential intervention points tied to federal legislation extending foster care beyond age 18 years. Child protection records for all adolescent girls in foster care at age 17 years between 2003 and 2007 (N = 20,222) were linked to vital birth records through 2011. The cumulative percentage of girls who had given birth by age 21 years was calculated by county and race/ethnicity. One in three (35.2%) adolescent girls in foster care had given birth at least once before age 21 years. Although significant birth rate variations emerged, even at the low end of the county range, more than one in four girls had given birth by age 21 years. Child welfare systems are now charged with coordinating transitional services for foster youth beyond age 18 years. Extended foster care provides new opportunities for pregnancy prevention work and targeted parenting support. Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Longitudinal trajectories of subjective care stressors: the role of personal, dyadic, and family resources.

PubMed

Bangerter, Lauren R; Liu, Yin; Zarit, Steven H

2017-11-24

Stressors are critical to the caregiver stress process, yet little work has examined resources that contribute to longitudinal changes in subjective stressors. The present study examines a variety of factors that contribute to changes in subjective stressors across time. Dementia caregivers (N = 153) completed an in-person interview and eight daily telephone interviews at baseline, and follow up interviews at 6 and 12 months. Growth curve analyses examine how care- and non-care stressors, respite, dyadic relationship quality, family support/conflict and care transitions (e.g. nursing home placement) are associated with changes in role overload and role captivity across 12 months. Caregivers who transitioned out of their role had higher overload and captivity at baseline. Among caregivers who transitioned out of caregiving, higher captivity at baseline was associated with declines in captivity and overload; more non-care stressors at baseline was linked to increased captivity and greater overload across time. Adult day service use and family support were associated with lesser captivity over time; taking more breaks from caregiving was linked to lower overload. Higher dyadic relationship quality was associated with lower captivity and overload. Findings contribute to caregiver intervention efforts by highlighting important resources associated with subjective stressors across time.

The effect of childhood adversity on 4-year outcome in individuals at ultra high risk for psychosis in the Dutch Early Detection Intervention Evaluation (EDIE-NL) Trial.

PubMed

Kraan, Tamar C; Ising, Helga K; Fokkema, Marjolein; Velthorst, Eva; van den Berg, David P G; Kerkhoven, Margot; Veling, Wim; Smit, Filip; Linszen, Don H; Nieman, Dorien H; Wunderink, Lex; Boonstra, Nynke; Klaassen, Rianne M C; Dragt, Sara; Rietdijk, Judith; de Haan, Lieuwe; van der Gaag, Mark

2017-01-01

Childhood adversity is associated with a range of mental disorders, functional impairment and higher health care costs in adulthood. In this study we evaluated if childhood adversity was predictive of adverse clinical and functional outcomes and health care costs in a sample of patients at ultra-high risk (UHR) for developing a psychosis. Structural Equation Modeling was used to examine the effect of childhood adversity on depression, anxiety, transition to psychosis and overall functioning at 4-year follow-up. In addition, we evaluated economic costs of childhood adversity in terms of health care use and productivity loss. Data pertain to 105 UHR participants of the Dutch Early Detection and Intervention Evaluation (EDIE-NL). Physical abuse was associated with higher depression rates (b=0.381, p=0.012) and lower social functional outcome (b=-0.219, p=0.017) at 4-year follow-up. In addition, emotional neglect was negatively associated with social functioning (b=-0.313, p=0.018). We did not find evidence that childhood adversity was associated with transition to psychosis, but the experience of childhood adversity was associated with excess health care costs at follow-up. The data indicate long-term negative effects of childhood adversity on depression, social functioning and health care costs at follow-up in a sample of UHR patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

The effectiveness of critical time intervention for abused women leaving women's shelters: a randomized controlled trial.

PubMed

Lako, Danielle A M; Beijersbergen, Mariëlle D; Jonker, Irene E; de Vet, Renée; Herman, Daniel B; van Hemert, Albert M; Wolf, Judith R L M

2018-05-01

To examine the effectiveness of critical time intervention (CTI)-an evidence-based intervention-for abused women transitioning from women's shelters to community living. A randomized controlled trial was conducted in nine women's shelters across the Netherlands. 136 women were assigned to CTI (n = 70) or care-as-usual (n = 66). Data were analyzed using intention-to-treat three-level mixed-effects models. Women in the CTI group had significant fewer symptoms of post-traumatic stress (secondary outcome) (adjusted mean difference - 7.27, 95% CI - 14.31 to - 0.22) and a significant fourfold reduction in unmet care needs (intermediate outcome) (95% CI 0.06-0.94) compared to women in the care-as-usual group. No differences were found for quality of life (primary outcome), re-abuse, symptoms of depression, psychological distress, self-esteem (secondary outcomes), family support, and social support (intermediate outcomes). This study shows that CTI is effective in a population of abused women in terms of a reduction of post-traumatic stress symptoms and unmet care needs. Because follow-up ended after the prescribed intervention period, further research is needed to determine the full long-term effects of CTI in this population.

Pharmacists’ Recommendations to Improve Care Transitions

PubMed Central

Haynes, Katherine Taylor; Oberne, Alison; Cawthon, Courtney

2013-01-01

Background Increasingly, hospitals are implementing multi-faceted programs to improve medication reconciliation and transitions of care, often involving pharmacists. Objective To help delineate the optimal role of pharmacists in this context, this qualitative study assessed pharmacists’ views on their roles in hospital-based medication reconciliation and discharge counseling. We also provide pharmacists’ recommendations for improving care transitions. Methods Eleven study pharmacists at two hospitals who participated in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study completed semi-structured one-on-one interviews, which were coded systematically in NVivo. Pharmacists provided their perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (e.g., pill box, illustrated daily medication schedule), and telephone follow-up. Results Pharmacists considered medication reconciliation, though time-consuming, to be their most important role in improving care transitions, particularly through detection of errors in the admission medication history that required correction. They also identified patients with poor understanding of their medications, who required additional counseling. Providing adherence aids was felt to be highly valuable for patients with low health literacy, though less useful for patients with adequate health literacy. Pharmacists noted that having trained administrative staff conduct the initial post-discharge follow-up call to screen for issues and triage which patients needed pharmacist follow-up was helpful and an efficient use of resources. Pharmacists’ recommendations for improving care transitions included clear communication among team members, protected time for discharge counseling, patient and family engagement in discharge counseling, and provision of patient education materials. Conclusion Pharmacists are well-positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care. Additional studies are needed to confirm these findings in other settings, and to determine the efficacy and cost-effectiveness of different models of pharmacist involvement. PMID:22872752

Strategies to Reduce Hospitalizations of Children With Medical Complexity Through Complex Care: Expert Perspectives.

PubMed

Coller, Ryan J; Nelson, Bergen B; Klitzner, Thomas S; Saenz, Adrianna A; Shekelle, Paul G; Lerner, Carlos F; Chung, Paul J

Interventions to reduce disproportionate hospital use among children with medical complexity (CMC) are needed. We conducted a rigorous, structured process to develop intervention strategies aiming to reduce hospitalizations within a complex care program population. A complex care medical home program used 1) semistructured interviews of caregivers of CMC experiencing acute, unscheduled hospitalizations and 2) literature review on preventing hospitalizations among CMC to develop key drivers for lowering hospital utilization and link them with intervention strategies. Using an adapted version of the RAND/UCLA Appropriateness Method, an expert panel rated each model for effectiveness at impacting each key driver and ultimately reducing hospitalizations. The complex care program applied these findings to select a final set of feasible intervention strategies for implementation. Intervention strategies focused on expanding access to familiar providers, enhancing general or technical caregiver knowledge and skill, creating specific and proactive crisis or contingency plans, and improving transitions between hospital and home. Activities aimed to facilitate family-centered, flexible implementation and consideration of all of the child's environments, including school and while traveling. Tailored activities and special attention to the highest utilizing subset of CMC were also critical for these interventions. A set of intervention strategies to reduce hospitalizations among CMC, informed by key drivers, can be created through a structured, reproducible process. Both this process and the results may be relevant to clinical programs and researchers aiming to reduce hospital utilization through the medical home for CMC. Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Delivering team training to medical home staff to impact perceptions of collaboration.

PubMed

Treadwell, Janet; Binder, Brenda; Symes, Lene; Krepper, Rebecca

2015-01-01

The purpose of this study was to explore whether an evidence-based educational and experiential intervention to develop team skills in medical homes would positively affect team members' perceptions of interprofessional collaboration. The study population consisted of primary care medical home practices associated with the health plan sponsor of this research. All practices were located within the greater Houston region of Texas and had more than 500 patients. A cluster design experimental study was conducted between August 2013 and June 2014. Fifty medical home practices, 25 intervention and 25 attention control, were recruited as study sites. Results indicate that individual team members in the medical homes receiving the intervention were significantly more likely than the individual team members in the attention control groups to report higher levels of positive perception of team collaboration after the 12-week intervention. This research indicates that educating teams about interprofessional collaboration tools and supporting technique use may be an effective strategy to assist medical homes in developing collaborative environments. Case management experience in collaboration supports the role facilitating team training. Transforming culture from hierarchical to team-based care supports the case management approach of collaborative practice. In addition, role satisfaction attained through the respect and communication of team-based care delivery may influence retention within the case management profession. As case managers in primary care settings assume roles of embedded care coordinators, program leaders, and transition facilitators, an understanding of collaboration techniques is needed to support the entire care team to achieve desired outcomes.

Challenges to HIV prevention in psychiatric settings: Perceptions of South African mental health care providers

PubMed Central

Collins, Pamela Y.

2009-01-01

Mental health services in South Africa increasingly feel the brunt of the AIDS epidemic. Despite the high prevalence of infection in the psychiatric setting, HIV risk reduction interventions targeting South Africans with psychiatric illness remain few and far between. The attitudes of mental health care providers about sexual relations and HIV among people with mental illness continue to influence the extent to which these issues are addressed in care settings. This study examines these attitudes through the use of a semi-structured interview administered to 46 mental health care providers in four provinces of South Africa. I found that personal, contextual and political factors in the clinic and the hospital create barriers to integrating prevention activities. In particular, providers face at least three challenges to intervening in the epidemic among their patients: their own views of psychiatric illness, the transitions occurring in the mental health care system, and shifting social attitudes toward sexuality. Barriers operate at the individual level, the institutional level, and the societal level. At the individual level providers’ perceptions of psychiatric symptoms shape their outlook on intervention with psychiatric patients. At the institutional level disruptive transitions in service delivery relegate HIV services to lesser importance. At the societal level, personal beliefs about sexuality and mental illness have remained slow to change despite major political changes. Minimizing barriers to implementing HIV prevention services requires institutional and health care policies that ensure adequate resources for treating people with mental illness and for staff development and support. PMID:16647793

Agent-based human-robot interaction of a combat bulldozer

NASA Astrophysics Data System (ADS)

Granot, Reuven; Feldman, Maxim

2004-09-01

A small-scale supervised autonomous bulldozer in a remote site was developed to experience agent based human intervention. The model is based on Lego Mindstorms kit and represents combat equipment, whose job performance does not require high accuracy. The model enables evaluation of system response for different operator interventions, as well as for a small colony of semiautonomous dozers. The supervising human may better react than a fully autonomous system to unexpected contingent events, which are a major barrier to implement full autonomy. The automation is introduced as improved Man Machine Interface (MMI) by developing control agents as intelligent tools to negotiate between human requests and task level controllers as well as negotiate with other elements of the software environment. Current UGVs demand significant communication resources and constant human operation. Therefore they will be replaced by semi-autonomous human supervisory controlled systems (telerobotic). For human intervention at the low layers of the control hierarchy we suggest a task oriented control agent to take care of the fluent transition between the state in which the robot operates and the one imposed by the human. This transition should take care about the imperfections, which are responsible for the improper operation of the robot, by disconnecting or adapting them to the new situation. Preliminary conclusions from the small-scale experiments are presented.

Case management redesign in an urban facility.

PubMed

Almaden, Stefany; Freshman, Brenda; Quaye, Beverly

2011-01-01

To explore strategies for improving patient throughput and to redesign case management processes to facilitate level of care transitions and safe discharges. Large Urban Medical Center in South Los Angeles County, with 384 licensed beds that services poor, underserved communities. Both qualitative and quantitative methods were applied. Combined theoretical frameworks were used for needs assessment, intervention strategies, and change management. Observations, interviews, surveys, and database extraction methods were used. The sample consisted of case management staff members and several other staff from nursing, social work, and emergency department staff. Postintervention measures indicated improvement in reimbursements for services, reduction in length of stay, increased productivity, improved patients' access to care, and avoiding unnecessary readmission or emergency department visits. Effective change management strategies must consider multiple factors that influence daily operations and service delivery. Creating accountability by using performance measures associated with patient transitions is highlighted by the case study results. The authors developed a process model to assist in identifying and tracking outcome measures related to patient throughput, front-end assessments, and effective patient care transitions. This model can be used in future research to further investigate best case management practices.

Type 1 Diabetes in Young Adulthood

PubMed Central

Monaghan, Maureen; Helgeson, Vicki; Wiebe, Deborah

2015-01-01

Type 1 diabetes has traditionally been studied as a chronic illness of childhood. However, young adulthood is a critical time for the development and integration of lifelong diabetes management skills, and research is starting to identify unique challenges faced by youth with diabetes as they age into adulthood. Most young adults experience multiple transitions during this unstable developmental period, including changes in lifestyle (e.g., education, occupation, living situation), changes in health care, and shifting relationships with family members, friends, and intimate others. Young adults with type 1 diabetes must navigate these transitions while also assuming increasing responsibility for their diabetes care and overall health. Despite these critical health and psychosocial concerns, there is a notable lack of evidence-based clinical services and supports for young adults with type 1 diabetes. We review relevant evolving concerns for young adults with type 1 diabetes, including lifestyle considerations, health care transitions, psychosocial needs, and changes in supportive networks, and how type 1 diabetes impacts and is impacted by these key developmental considerations. Specific avenues for intervention and future research are offered. PMID:25901502

Identifying transitions in terminal illness trajectories: a critical factor in hospital-based palliative care.

PubMed

Dalgaard, Karen Marie; Thorsell, Georg; Delmar, Charlotte

2010-02-01

This article describes the significance of the identification and explicit communication of the different clinical phases in incurable illness trajectories in a hospital setting. The article is part of a qualitative study carried out in a Danish haematology department. The data were obtained through a total of 157 hours of participant observation and informal interviews with patients, families, doctors and nurses and four focus group interviews with doctors and nursing staff. Grounded theory was applied for the data analysis. The findings outline how the unpredictability of certain haematological malignancies and barriers in professional practice tended to postpone identifications of transitions between clinical phases. The study has identified ten barriers including personal, professional, time-related, cultural and organizational-for an open dialogue between staff, patients and families about illness progression. The quality of palliative care was affected as different clinical phases require different treatment and care strategies. Complex intervention is called for.

Nurturing Care for Young Children under Conditions of Fragility and Conflict

ERIC Educational Resources Information Center

Richter, Linda M.; Lye, Stephen J.; Proulx, Kerrie

2018-01-01

Forced displacement worldwide is at its highest in decades and millions of young children are living in conflict zones, in transitional or enduring refugee contexts, and in demographically diverse marginalized and informal settlements. There is a huge unmet need for delivering early childhood development interventions to ensure the safety and…

Physical therapy interventions for patients with movement disorders due to cerebral palsy.

PubMed

Barry, M J

1996-11-01

The purpose of this paper is to present evidence of the efficacy of physical therapy interventions for patients with cerebral palsy and identify goals for these patients. Studies suggest that neurodevelopmental treatment and Vojta techniques improve postural control. Little evidence supports the efficacy of early intervention, but researchers have not yet studied effects on the family. Strengthening, electrical stimulation, the use of orthoses, and seating show positive effects in studies of small numbers of subjects. For severely involved children, ease of care and comfort are important goals, as well as prevention of deformity, which is important for all children. To the extent possible, therapy should prepare a child for independent adult life. In early intervention through school age, therapy focuses on promoting communication, self-care, and mobility. Independence is a key issue for adolescents transitioning into adulthood. The rehabilitation and health needs of adults with cerebral palsy need to be addressed. Research needs to determine the effects of physical therapy not only on impairment but also on function and disability.

Every team needs a coach: Training for interprofessional clinical placements.

PubMed

Grymonpre, Ruby; Bowman, Susan; Rippin-Sisler, Cathy; Klaasen, Kathleen; Bapuji, Sunita B; Norrie, Ola; Metge, Colleen

2016-09-01

Despite growing awareness of the benefits of interprofessional education and interprofessional collaboration (IPC), understanding how teams successfully transition to IPC is limited. Student exposure to interprofessional teams fosters the learners' integration and application of classroom-based interprofessional theory to practice. A further benefit might be reinforcing the value of IPC to members of the mentoring team and strengthening their IPC. The research question for this study was: Does training in IPC and clinical team facilitation and mentorship of pre-licensure learners during interprofessional clinical placements improve the mentoring teams' collaborative working relationships compared to control teams? Statistical analyses included repeated time analysis multivariate analysis of variance (MANOVA). Teams on four clinical units participated in the project. Impact on intervention teams pre- versus post-interprofessional clinical placement was modest with only the Cost of Team score of the Attitudes Towards Healthcare Team Scale improving relative to controls (p = 0.059) although reflective evaluations by intervention team members noted many perceived benefits of interprofessional clinical placements. The significantly higher group scores for control teams (geriatric and palliative care) on three of four subscales of the Assessment of Interprofessional Team Collaboration Scale underscore our need to better understand the unique features within geriatric and palliative care settings that foster superior IPC and to recognise that the transition to IPC likely requires a more diverse intervention than the interprofessional clinical placement experience implemented in this study. More recently, it is encouraging to see the development of innovative tools that use an evidence-based, multi-dimensional approach to support teams in their transition to IPC.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres.

PubMed

Gotlib Conn, Lesley; Zwaiman, Ashley; DasGupta, Tracey; Hales, Brigette; Watamaniuk, Aaron; Nathens, Avery B

2018-01-01

Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences. A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach. Twenty-four interviews included 19 patients and 7 family members. Participants' experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities' ability to care for injured patients. The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention. Copyright © 2017 Elsevier Ltd. All rights reserved.

Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit.

PubMed

Park, Yong Eun; Park, Soo Jung; Park, Yehyun; Cheon, Jae Hee; Kim, Tae Il; Kim, Won Ho

2017-12-01

Nutritional support has become an important intervention for critically ill patients. Many studies have reported on the effects of nutritional support for the patients within the intensive care unit (ICU); however, no studies have specifically assessed patients with gastrointestinal diseases who may have difficulty absorbing enteral nutrition (EN) in the ICU.Sixty-two patients with gastrointestinal disease were admitted to the ICU between August 2014 and August 2016 at a single tertiary university hospital. We analyzed 2 different patient groups in a retrospective cohort study: those who received nutritional support team (NST) intervention and those who did not.Forty-four (71.0%) patients received nutritional support in ICU and 18 (29.0%) did not. Variables including male sex, high albumin or prealbumin level at the time of ICU admission, and short transition period into EN showed statistically significant association with lower mortality on the univariate analysis (all P < .05). Multivariate analysis revealed that longer length of hospital stay (P = .013; hazard ratio [HR], 0.972; 95% confidence interval [CI], 0.951-0.994), shorter transition into EN (P = .014; HR, 1.040; 95% CI, 1.008-1.072), higher prealbumin level (P = .049; HR, 0.988; 95% CI, 0.976-1.000), and NST intervention (P = .022; HR, 0.356; 95% CI, 0.147-0.862) were independent prognostic factors for lower mortality.In conclusion, NST intervention related to early initiated EN, and high prealbumin levels are beneficial to decrease mortality in the acutely ill patients with GI disease.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

PubMed

Lau, Hunter Singh; Hollander, Matthew M; Cushman, Jeremy T; DuGoff, Eva H; Jones, Courtney M C; Kind, Amy J H; Lohmeier, Michael T; Coleman, Eric A; Shah, Manish N

2018-02-12

The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

A Family-Centered Rounds Checklist, Family Engagement, and Patient Safety: A Randomized Trial

PubMed Central

Jacobsohn, Gwen C.; Rajamanickam, Victoria P.; Carayon, Pascale; Kelly, Michelle M.; Wetterneck, Tosha B.; Rathouz, Paul J.; Brown, Roger L.

2017-01-01

BACKGROUND AND OBJECTIVES: Family-centered rounds (FCRs) have become standard of care, despite the limited evaluation of FCRs’ benefits or interventions to support high-quality FCR delivery. This work examines the impact of the FCR checklist intervention, a checklist and associated provider training, on performance of FCR elements, family engagement, and patient safety. METHODS: This cluster randomized trial involved 298 families. Two hospital services were randomized to use the checklist; 2 others delivered usual care. We evaluated the performance of 8 FCR checklist elements and family engagement from 673 pre- and postintervention FCR videos and assessed the safety climate with the Children’s Hospital Safety Climate Questionnaire. Random effects regression models were used to assess intervention impact. RESULTS: The intervention significantly increased the number of FCR checklist elements performed (β = 1.2, P < .001). Intervention rounds were significantly more likely to include asking the family (odds ratio [OR] = 2.43, P < .05) or health care team (OR = 4.28, P = .002) for questions and reading back orders (OR = 12.43, P < .001). Intervention families’ engagement and reports of safety climate were no different from usual care. However, performance of specific checklist elements was associated with changes in these outcomes. For example, order read-back was associated with significantly more family engagement. Asking families for questions was associated with significantly better ratings of staff’s communication openness and safety of handoffs and transitions. CONCLUSIONS: The performance of FCR checklist elements was enhanced by checklist implementation and associated with changes in family engagement and more positive perceptions of safety climate. Implementing the checklist improves delivery of FCRs, impacting quality and safety of care. PMID:28557720

Person-centred transition programme to empower adolescents with congenital heart disease in the transition to adulthood: a study protocol for a hybrid randomised controlled trial (STEPSTONES project)

PubMed Central

Acuña Mora, Mariela; Sparud-Lundin, Carina; Bratt, Ewa-Lena; Moons, Philip

2017-01-01

Introduction When a young person grows up, they evolve from an independent child to an empowered adult. If an individual has a chronic condition, this additional burden may hamper adequate development and independence. Transition programmes for young persons with chronic disorders aim to provide the necessary skills for self-management and participation in care. However, strong evidence on the effects of these interventions is lacking. Therefore, as part of the STEPSTONES project (Swedish Transition Effects Project Supporting Teenagers with chrONic mEdical conditionS), we propose a trial to assess the effectiveness of a structured, person-centred transition programme to empower adolescents with congenital heart disease in the transition to adulthood. Methods/design STEPSTONES will use a hybrid experimental design in which a randomised controlled trial is embedded in a longitudinal, observational study. It will be conducted in 4 paediatric cardiology centres in Sweden. 2 centres will be allocated to the randomised controlled trial group, assigning patients randomly to the intervention group (n=63) or the comparison group (n=63). The other 2 centres will form the intervention-naïve control group (n=63). The primary outcome is the level of patient empowerment, as measured by the Gothenburg Young Persons Empowerment Scale (GYPES). Ethics and dissemination The study has been approved by the Regional Ethical Board of Gothenburg, Sweden. Findings will be reported following the CONSORT statement and disseminated at international conferences and as published papers in peer-reviewed journals. Trial registration number NCT02675361; pre-results. PMID:28420661

Motivational Interviewing to Increase Postdischarge Antibiotic Adherence in Older Adults with Pneumonia.

PubMed

Eyler, Rachel; Shvets, Kristina; Blakely, Michelle L

2016-01-01

To evaluate the impact of a pharmacist-led, motivational interviewing on antibiotic adherence following discharge in older adults with pneumonia. Inpatient medical wards in a large tertiary academic medical center. Older adults diagnosed with pneumonia were enrolled from December 1, 2013, to August 1, 2014, at Yale-New Haven Hospital. Motivational interviewing-a patient-centered method of communication-has gained recognition as a tool that can aid pharmacists in addressing negative health behaviors (e.g., medication adherence, health screenings, substance abuse during counseling sessions). However, the potential role of motivational interviewing in older adults to improve medication adherence during transitions of care is not clear. In this study, in addition to standard discharge care, older adults hospitalized with pneumonia who were randomized to the intervention group received enhanced care: pharmacist-led motivational interviewing. Evaluation of adherence to prescribed antibiotic regimens and patient satisfaction with the motivational interviewing, enhanced-care session. Ultimately, 87% of patients in the intervention group (n = 16) compared with 64% of patients in the control group (n = 14) were adherent to their antibiotic regimens. Patient satisfaction with the motivational interviewing intervention was high. Pharmacist-led motivational interviewing sessions have the potential to positively influence antibiotic adherence rates and patient satisfaction.

Transition to Adulthood and Antiretroviral Adherence Among HIV-Positive Young Black Men Who Have Sex With Men

PubMed Central

Andes, Karen; Gilliard, Danielle; Chakraborty, Rana; del Rio, Carlos; Malebranche, David J.

2015-01-01

Objectives. We conducted a qualitative study of HIV-positive young Black men who have sex with men (YBMSM) to explore their experiences of living with HIV and adhering to antiretroviral medications (ARVs) within the developmental context of their transition to adulthood. Methods. We conducted life history interviews with 20 HIV-positive YBMSM in Atlanta, Georgia, engaged in outpatient HIV care. We addressed these questions: (1) How do YBMSM living with HIV experience the transition to adulthood? and (2) What are the important sociocontextual influences on ARV adherence for YBMSM? Results. Successful transition to adulthood and optimal ARV adherence were inextricably linked. HIV’s detrimental impact on development was moderated by the degree of physical illness at diagnosis. Many participants described resilient trajectories while coping with HIV. Adherence problems occurred primarily among participants who were not meeting their developmental goals. Conclusions. Our findings support the need for early diagnosis and linkage to care, as well as the need to develop holistic, resilience-based interventions focusing on transition to adulthood. These findings have implications for individual clinical outcomes as well as ARV-based prevention efforts among YBMSM. PMID:24922167

Improving care planning and coordination for service users with medical co-morbidity transitioning between tertiary medical and primary care services.

PubMed

Cranwell, K; Polacsek, M; McCann, T V

2017-08-01

WHAT IS KNOWN ON THE SUBJECT?: Mental health service users with medical co-morbidity frequently experience difficulties accessing and receiving appropriate treatment in emergency departments. Service users frequently experience fragmented care planning and coordinating between tertiary medical and primary care services. Little is known about mental health nurses' perspectives about how to address these problems. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Emergency department clinicians' poor communication and negative attitudes have adverse effects on service users and the quality of care they receive. The findings contribute to the international evidence about mental health nurses' perspectives of service users feeling confused and frustrated in this situation, and improving coordination and continuity of care, facilitating transitions and increasing family and caregiver participation. Intervention studies are needed to evaluate if adoption of these measures leads to sustainable improvements in care planning and coordination, and how service users with medical co-morbidity are treated in emergency departments in particular. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Effective planning and coordination of care are essential to enable smooth transitions between tertiary medical (emergency departments in particular) and primary care services for service users with medical co-morbidity. Ongoing professional development education and support is needed for emergency department clinicians. There is also a need to develop an organized and systemic approach to improving service users' experience in emergency departments. Introduction Mental health service users with medical co-morbidity frequently experience difficulties accessing appropriate treatment in medical hospitals, and often there is poor collaboration within and between services. Little is known about mental health nurses' perspectives on how to address these problems. Aim To explore mental health nurses' perspectives of the experience of service users with medical co-morbidity in tertiary medical services, and to identify how to improve care planning and coordination for service users transitioning between tertiary medical and primary care services. Method Embedded within an experience-based co-design study, focus group discussions were conducted with 17 emergency department nurses and other clinicians, in Melbourne, Australia. Results Three main themes were abstracted from the data: feeling confused and frustrated, enhancing service users' transition and experience and involving families and caregivers. Participants perceived the service user experience to be characterized by fear, confusion and a sense of not being listened to. They highlighted that service users' transition and experience could be enhanced by facilitating transitions and improving coordination and continuity of care. They also emphasized the need to increase family and caregiver participation. Conclusion Our findings contribute to knowledge about improving the way service users are treated in emergency departments and improving care planning and coordination; in particular, facilitating transitions, improving coordination and continuity of care and increasing family and caregiver participation. © 2016 The Authors. Journal of Psychiatric and Mental Health Nursing Published by John Wiley & Sons Ltd.

Economic evaluation of interventions for problem drinking and alcohol dependence: cost per QALY estimates.

PubMed

Mortimer, Duncan; Segal, Leonie

2005-01-01

To compare the performance of competing and complementary interventions for prevention or treatment of problem drinking and alcohol dependence. To provide an example of how health maximising decision-makers might use performance measures such as cost per quality adjusted life year (QALY) league tables to formulate an optimal package of interventions for problem drinking and alcohol dependence. A time-dependent state-transition model was used to estimate QALYs gained per person for each intervention as compared to usual care in the relevant target population. Cost per QALY estimates for each of the interventions fall below any putative funding threshold for developed economies. Interventions for problem drinkers appear to offer better value than interventions targeted at those with a history of severe physical dependence. Formularies such as Australia's Medicare should include a comprehensive package of interventions for problem drinking and alcohol dependence.

A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond.

PubMed

Lovelace, Derenda; Hancock, Diane; Hughes, Sabrina S; Wyche, Phyllis R; Jenkins, Claire; Logan, Cindy

In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%. To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs. Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay. The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits. Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in this program compared with the 90 days prior to participation. This produced an estimated net savings of $3,823,673 in medical center costs. In addition, registered nurse case managers (RN CMs) noted improved patient compliance and satisfaction with care and the licensed clinical social worker noted reduced caregiver burden. The results of this program demonstrate how using an interdisciplinary approach to develop patient-centered transition plans of care through intensive case management interventions improves resource utilization with substantial financial savings. This program represents a feasible option for other VAMCs as well as civilian hospitals seeking to provide cost-effective transitional care to patients upon discharge and prevent untimely readmissions. With an RN CM at the hub of patient care, this program successfully demonstrates the value of smooth care transitions.

Treatment Considerations and the Role of the Clinical Pharmacist Throughout Transitions of Care for Patients With Acute Heart Failure.

PubMed

McNeely, Elizabeth B

2017-08-01

Heart failure is associated with increased risk of morbidity and mortality, resulting in substantial health-care costs. Clinical pharmacists have an opportunity to reduce health-care costs and improve disease management as patients transition from inpatient to outpatient care by leading interventions to develop patient care plans, educate patients and clinicians, prevent adverse drug reactions, reconcile medications, monitor drug levels, and improve medication access and adherence. Through these methods, clinical pharmacists are able to reduce rates of hospitalization, readmission, and mortality. In addition, care by clinical pharmacists can improve dosing levels and adherence to guideline-directed therapies. A greater benefit in patient management occurs when clinical pharmacists collaborate with other members of the health-care team, emphasizing the importance of heart failure treatment by a multidisciplinary health-care team. Education is a key area in which clinical pharmacists can improve care of patients with heart failure and should not be limited to patients. Clinical pharmacists should provide education to all members of the health-care team and introduce them to new therapies that may further improve the management of heart failure. The objective of this review is to detail the numerous opportunities that clinical pharmacists have to improve the management of heart failure and reduce health-care costs as part of a multidisciplinary health-care team.

Public-private partnerships improve health outcomes in individuals with early stage Alzheimer's disease.

PubMed

Galvin, James E; Tolea, Magdalena I; George, Nika; Wingbermuehle, Cheryl

2014-01-01

In a collaborative effort between the Missouri Department of Health, Area Agencies on Aging (AAA), Alzheimer Association, and academic researchers, we tested whether early dementia detection and comprehensive care consultations would improve health outcomes in care receivers (CRs) and their family caregivers (FCGs), therefore addressing an important public health concern. A total of 244 community-dwelling older adults screened for early-stage dementia by the AAA field staff were referred to the Alzheimer Association and participated in Project Learn MORE (Missouri Outreach and Referral Expanded) (PLM) - a 2-year, nonrandomized multisite intervention consisting of comprehensive care consultations to improve coping skills. PLM participants were compared against 96 controls receiving the Alzheimer Association's "usual services" between January 2011 and December 2012. We examined CR and FCG outcomes, including burden, care confidence, and mood, as effects of PLM, on delaying transitions in level of care. CRs showed improved knowledge (P=0.002) and reduced depression (P=0.007), while FCGs demonstrated improved knowledge (P=0.003) and ability to identify sources of support for the CR (P=0.032) and for themselves (P=0.043). However, FCGs were more burdened after PLM (P=0.02), due to increased awareness of Alzheimer's disease. PLM delayed transitions in care (odds ratio [OR] 3.32, 95% confidence level [CI]: 1.25-8.83) with the number needed to treat =6.82. PLM was successful in improving detection of incident cases of dementia in the community and in connecting patients and their families with needed services. Our findings support the use of state agencies and community service partners to detect dementia. Early implementation of psychosocial interventions could have significant impact in improving patient- and family-centered outcomes, potentially providing a cost-efficient alternative to pharmacotherapy.

Multicentre randomised study of the effect and experience of an early inhome programme (PreHomeCare) for preterm infants using video consultation and smartphone applications compared with inhospital consultations: protocol of the PreHomeCare study

PubMed Central

Hägi-Pedersen, Mai-Britt

2017-01-01

Introduction Although premature infants and their parents are discharged earlier to inhomecare programmes, how to optimally support parents during this transition remains unknown. The aim of this study is to compare the effects of early inhomecare (PreHomeCare) including video consultations and mobile applications with those of inhospital consultations regarding breast feeding, parental confidence and parent–infant interactions. Methods and analysis A randomised controlled intervention study will be conducted in four neonatal departments offering PreHomeCare (ie, premature infant inhomecare) in Denmark. Parents of hospitalised premature infants who fulfil the inclusion criteria for PreHomeCare will be randomised during hospitalisation to either the intervention (n=80) or control group (n=80) using 1:1 block randomisation. During PreHomeCare, the intervention group will receive a smartphone application with a video system and an infant scale, and the control group will receive usual care (ie, hospital consultations). Additionally, both groups will have planned nurse consultations two to three times a week: the intervention group through video consultations and the control group through inhospital consultations. Data collection will occur at inclusion/baseline, at the end of PreHomeCare and 1 month after discharge using questionnaires and hospital records. The primary outcome is the proportion of exclusively breastfed infants 1 month after discharge/end of PreHomeCare, the secondary outcomes are parent–infant interactions measured by the Mother and baby interaction scale and family confidence in caring for infants measured by the Karitane Parenting Confidence Scale. The process evaluation will consist of two qualitative studies: a field study and an interview study. Data collection will initially involve field observations of three scheduled video consultations with six families from the intervention group. These families will also be interviewed 1 month after PreHomeCare has ended. Ethics and dissemination The project has been approved by the Regional Ethics Committee and the Danish Data Protection Agency. Trial registration number NCT02581800. PMID:28279994

Spreading improvements for advanced COPD care through a Canadian Collaborative.

PubMed

Rocker, Graeme M; Amar, Claudia; Laframboise, Wendy L; Burns, Jane; Verma, Jennifer Y

2017-01-01

A year-long pan-Canadian quality improvement collaborative (QIC) led by the Canadian Foundation for Healthcare Improvement (CFHI) supported the spread of the successful Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ to 19 teams in the 10 Canadian provinces. We describe QIC results, addressing two main questions: 1) Can the results of the Nova Scotia INSPIRED model be replicated elsewhere in Canada? 2) How did the teams implement and evaluate their versions of the INSPIRED program? Collaborative faculty selected measures that were evidence-based, relatively simple to collect, and relevant to local context. Chosen process and outcome measures are related to four quality domains: 1) patient- and family-centeredness, 2) coordination, 3) efficiency, and 4) appropriateness. Evaluation of a complex intervention followed a mixed-methods approach. Most participants were nurse managers and/or COPD educators. Only 8% were physicians. Fifteen teams incorporated all core INSPIRED interventions. All teams carried out evaluation. Thirteen teams actively involved patients and families in customized, direct care planning, eg, asking them to complete evaluative surveys and/or conducting interviews. Patients consistently reported greater self-confidence in symptom management, a return to daily activities, and improvements to quality of life. Twelve teams collected data on care transitions using the validated three-item Care Transitions Measure (CTM-3). Twelve teams used the Lung Information Needs Questionnaire (LINQ). Admissions, emergency room visits, and patient-related costs fell substantially for two teams described in detail (combined enrollment 208 patients). Most teams reported gaining deeper knowledge around complexities of COPD care, optimizing patient care through action plans, self-management support, psychosocial support, advance care planning, and coordinating community partnerships. Quality-of-care gains are achievable in the short term among different teams across diverse geographical and social contexts. A well-designed, adequately funded public-private partnership can deliver widespread beneficial outcomes for the health care system and for those living with advanced COPD.

Transition Needs of Adolescents With Sickle Cell Disease.

PubMed

Abel, Regina A; Cho, Esther; Chadwick-Mansker, Kelley R; D'Souza, Natalia; Housten, Ashley J; King, Allison A

2015-01-01

This article describes how adolescents with sickle cell disease (SCD) perceive their ability to perform everyday tasks required for transition to adult health care and independent living. The Adolescent Autonomy Checklist (AAC) was adapted to include skills associated with managing SCD (AAC-SCD) and was administered to adolescents during clinic visits. Participants indicated "can do already" or "needs practice" for 100 activities in 12 categories. Of 122 patients, the percentage of adolescents who needed practice was greatest in living arrangements (38.7%), money management (35.8%), vocational skills (29.6%), and health care skills (25.5%). We found a significant effect of age and of cerebrovascular injury on the percentage of those who reported "needs practice" in multiple categories. We found no effect of gender and limited effect of hemoglobin phenotype on any skill category. Findings support the need for educational intervention to improve transition skills in adolescents with SCD. Copyright © 2015 by the American Occupational Therapy Association, Inc.

Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses.

PubMed

Wilson, Melissa A; Goettemoeller, Diana M; Bevan, Nancy A; McCord, Jennifer M

2013-05-01

To examine the level and frequency of moral distress in staff nurses working in two types of units in an acute care hospital and to gather information for future interventions addressing moral distress. In 2008, the American Association of Critical Care Nurses published a Position Statement on Moral Distress. Nurses working in units where critically ill patients are admitted may encounter distressing situations. Moral distress is the painful feelings and/or psychological disequilibrium that may occur when taking care of patients. An exploratory, descriptive design study was used to identify the type and frequency of moral distress experienced by nurses. The setting was an acute care hospital in which the subjects were sampled from two groups of nurses based on their unit assignment. A descriptive, questionnaire study was used. Nurses completed the 38-item moral distress scale, a coping questionnaire, and indicated their preferred methods for institutional support in managing distressing situations. A convenience sample of staff nurses was approached to complete the moral distress questionnaire. Overall, the nurses reported low levels of moral distress. Situations creating the highest levels of moral distress were those related to futile care. A significance between group differences was found in the physician practice dimension. Specific resources were identified to help guide future interventions to recognise and manage moral distress. Nurses reported lower levels and frequency of moral distress in these units but their open-ended responses appeared to indicate moral distress. Nurses identified specific resources that they would find helpful to alleviate moral distress. There are numerous studies that identify the situations and the impact of moral distress, but not many studies explore treatments and interventions for moral distress. This study attempted to identify nurse preferences for lessening the impact of moral distress. © 2013 Blackwell Publishing Ltd.

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach.

PubMed

Werner, Nicole E; Tong, Michelle; Borkenhagen, Amy; Holden, Richard J

2018-01-03

Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success. This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload. Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process. © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Four-Year Cost-effectiveness of Cognitive Behavior Therapy for Preventing First-episode Psychosis: The Dutch Early Detection Intervention Evaluation (EDIE-NL) Trial.

PubMed

Ising, Helga K; Lokkerbol, Joran; Rietdijk, Judith; Dragt, Sara; Klaassen, Rianne M C; Kraan, Tamar; Boonstra, Nynke; Nieman, Dorien H; van den Berg, David P G; Linszen, Don H; Wunderink, Lex; Veling, Wim; Smit, Filip; van der Gaag, Mark

2017-03-01

This study aims to evaluate the long-term cost-effectiveness of add-on cognitive behavior therapy (CBT) for the prevention of psychosis for individuals at ultrahigh risk (UHR) of psychosis. The Dutch Early Detection and Intervention randomized controlled trial was used, comparing routine care (RC; n = 101) with routine care plus CBT for UHR (here called CBTuhr; n = 95). A cost-effectiveness analysis was conducted with treatment response (defined as proportion of averted transitions to psychosis) as an outcome and a cost-utility analysis with quality-adjusted life years (QALYs) gained as a secondary outcome. The proportion of averted transitions to psychosis was significantly higher in the CBTuhr condition (with a risk difference of 0.122; b = 1.324, SEb = 0.017, z = 7.99, P < 0.001). CBTuhr showed an 83% probability of being more effective and less costly than RC by -US$ 5777 (savings) per participant. In addition, over the 4-year follow-up period, cumulative QALY health gains were marginally (but not significantly) higher in CBTuhr than for RC (2.63 vs. 2.46) and the CBTuhr intervention had a 75% probability of being the superior treatment (more QALY gains at lower costs) and a 92% probability of being cost-effective compared with RC at the Dutch threshold value (US$ 24 560; €20 000 per QALY). Add-on preventive CBTuhr had a high likelihood (83%) of resulting in more averted transitions to psychosis and lower costs as compared with RC. In addition, the intervention had a high likelihood (75%) of resulting in more QALY gains and lower costs as compared to RC. © The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com

The family in Italy: cultural changes and implications for treatment.

PubMed

Luciano, Mario; Sampogna, Gaia; del Vecchio, Valeria; Giacco, Domenico; Mulè, Alice; de Rosa, Corrado; Fiorillo, Andrea; Maj, Mario

2012-04-01

In Italy family is characterized by strong ties and is based on mutual aid of all its members. In the last 20 years, the structure of families has been significantly influenced by demographic, economic and professional changes, determining a transition from a patriarchal to a nuclear family model, with a higher number of single-parent families, single-person households, childless couples, same-sex couples. However, this transition has been slower than that occurring in other countries, probably as an ongoing impact of prevalent Catholic ideology. Major demographic changes in Italian families include, 1) a decrease in the number of marriages, delays in getting married and an high number of civil ceremonies, 2) a reduced birth rate; Italy is becoming one of the European countries with lowest growth rate, and with an increasing number of births out of wedlock, 3) an increased marital instability, with a constantly growing number of legal separations. Like many countries, relatives in Italy are highly involved in the care of patients with physical and mental disorders. There are a number of psychosocial interventions used in Italy including the 'Milan Systemic Approach' and family psycho-educational interventions. However, there are difficulties in implementing these interventions which are highlighted in this paper. We recommend research strategies to identify the best options to involve families in the care of mentally ill patients and to adequately support them.

Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups.

PubMed

Brooten, Dorothy; Youngblut, JoAnne M; Deatrick, Janet; Naylor, Mary; York, Ruth

2003-01-01

To describe patient problems and APN interventions in each of five clinical trials and to establish links among patient problems, APN interventions, APN time and number of contacts, patient outcomes, and health care costs. Analysis of 333 interaction logs created by APNs during five randomized controlled trials: (a) very low birthweight infants (n = 39); (b) women with unplanned cesarean birth (n = 61), (c) high-risk pregnancy (n = 44), and (d) hysterectomy (n = 53); and (e) elders with cardiac medical and surgical diagnoses (n = 139). Logs containing recordings of all APN interactions with participants, APN time and type of patient contact were content analyzed with the smallest phrase or sentence representing a "unit." These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Groups were compared concerning total amount of APN time, number of contacts per patient, and mean length of time per APN contact. All studies were conducted in the United States. Groups with greater mean APN time and contacts per patient had greater improvements in patients' outcomes and greater health care cost savings. Of the 150,131 APN interventions, surveillance was the predominant APN function in all five patient groups. Health teaching, guidance, and counseling was the second most frequent category of APN intervention in four of the five groups. In all five groups, treatments and procedures accounted for < 1% of total APN interventions. Distribution of patient problems (N = 150,131) differed across groups reflecting the health care problems common to the group. Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessing, teaching, counseling, communicating, collaborating, knowing health behaviors, negotiating systems, and having condition-specific knowledge about different patient problems.

Nursing perception of patient transitions from hospitals to home with home health.

PubMed

Smith, Shannon Bright; Alexander, Judith W

2012-01-01

The study's purpose was to determine nurses' opinions of sending patients from the hospital to home with home health services. The study occurred in the Charleston, South Carolina, Tricounty area (Berkeley, Charleston, and Dorchester counties). Home health agencies and hospitals were invited to participate. The study used a survey design to gather information on nursing perceptions of current practices and needed changes to improve transition of patients. The population was nurses (licensed practical nurses (LPNs) and registered nurses (RNs)) employed at inpatient hospitals or home health agencies in the area. Thirty-four RNs responded with no LPNs respondents. Agency administrators/chief nursing officers agreed for their agencies to participate and distributed the survey using a Research Electronic Data Capture (REDCap) Internet-based survey tool. Using the survey results and information from a literature review, the study developed a list of propositions, which participating administrators reviewed, for improving transitions to home. Both home health and hospital nurses reported a need to improve the process of sending patients from hospital to home with home health services. This study provides hospitals and home health agencies with propositions to facilitate the establishment of a process to communicate effectively patients care needs and streamline the discharging patients from the hospital to home health care; thus, improving patient transition. Case managers and discharge planners will need interagency collaboration along with evidence-based interventions to transition patients from the hospital to home with home health services with various populations. Direct patient care nurses in both hospital and home health settings should share the same accountability as case managers to ensure successful transitions.

Quality Improvement Initiative on Pain Knowledge, Assessment, and Documentation Skills of Pediatric Nurses.

PubMed

Margonary, Heather; Hannan, Margaret S; Schlenk, Elizabeth A

2017-01-01

Pain treatment begins with a nurse’s assessment, which relies on effective assessment skills. Hospital settings have implemented pain assessment education, but there is limited evidence in pediatric transitional care settings. The purpose of this quality improvement (QI) initiative was to develop, implement, and evaluate an evidence-based pain education session with 20 nurses in a pediatric specialty hospital that provides transitional care. Specific aims were to assess nurses’ knowledge and attitudes of pain, and evaluate assessment skills based on nurses’ documentation. A prospective pre-post design with three assessments (baseline, post-intervention, and one-month follow-up) was used. The Shriner’s Pediatric Nurses’ Knowledge and Attitudes Regarding Pain questionnaire and an electronic health record review were completed at each assessment. There was significant improvement in nurses’ knowledge and attitudes of pain after the education session (F[2,6] = 50.281, p < 0.0001) from baseline to post-intervention (p < 0.0001), which was maintained at follow-up (p = 0.009). Pain assessment frequency by nurses significantly increased from 43.1% at baseline to 64.8% at post-intervention, and 67.7% at follow-up (χ²[2] = 20.55, p < 0.0001). Developmentally appropriate pain scale usage increased significantly, from 13.1% at baseline to 77.4% at post-intervention, and 81.8% at follow-up (χ²[2] = 169.19, p < 0.0001). Nursing interventions for pain increased significantly, from 33.3% at baseline to 84.0% at post-intervention, and stabilized at 80.0% at follow-up (χ²[2] = 8.91, p = 0.012). Frequency of pain reassessments did not show a statistically significant change, decreasing from 77.8% at baseline to 44.0% at post-intervention and 40.0% at follow-up (χ²[2]= 3.538, p = 0.171). Nurses’ pain knowledge and documentation of assessment skills were improved in this QI initiative.

Lives in Motion: A Review of Former Foster Youth in the Context of their Experiences in the Child Welfare System

PubMed Central

Havlicek, Judy

2011-01-01

In light of the poor prospects facing many former foster youth during the transition to adulthood, it is surprising that so little attention has been given to substitute care contexts during child welfare system involvement. A review of child welfare research finds that many former foster youth go through an alarming number of placement changes and report a high rate of placement into congregate care settings and other unplanned events. Future research should take explicit account of substitute care contexts in designing and carrying out studies examining the adult outcomes of aging out foster care populations. Interventions intended to circumvent high rates of movement in foster care should also be broadened to target multiple aspects of substitute care contexts. PMID:21643470

Person-centred transition programme to empower adolescents with congenital heart disease in the transition to adulthood: a study protocol for a hybrid randomised controlled trial (STEPSTONES project).

PubMed

Acuña Mora, Mariela; Sparud-Lundin, Carina; Bratt, Ewa-Lena; Moons, Philip

2017-04-17

When a young person grows up, they evolve from an independent child to an empowered adult. If an individual has a chronic condition, this additional burden may hamper adequate development and independence. Transition programmes for young persons with chronic disorders aim to provide the necessary skills for self-management and participation in care. However, strong evidence on the effects of these interventions is lacking. Therefore, as part of the STEPSTONES project (Swedish Transition Effects Project Supporting Teenagers with chrONic mEdical conditionS), we propose a trial to assess the effectiveness of a structured, person-centred transition programme to empower adolescents with congenital heart disease in the transition to adulthood. STEPSTONES will use a hybrid experimental design in which a randomised controlled trial is embedded in a longitudinal, observational study. It will be conducted in 4 paediatric cardiology centres in Sweden. 2 centres will be allocated to the randomised controlled trial group, assigning patients randomly to the intervention group (n=63) or the comparison group (n=63). The other 2 centres will form the intervention-naïve control group (n=63). The primary outcome is the level of patient empowerment, as measured by the Gothenburg Young Persons Empowerment Scale (GYPES). The study has been approved by the Regional Ethical Board of Gothenburg, Sweden. Findings will be reported following the CONSORT statement and disseminated at international conferences and as published papers in peer-reviewed journals. NCT02675361; pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Community leaders' perceptions of Hispanic, single, low-income mothers' needs, concerns, social support, and interactions with health care services.

PubMed

Campbell-Grossman, Christie; Hudson, Diane Brage; Keating-Lefler, Rebecca; Yank, Jodell R; Obafunwa, Titilola

2009-01-01

Hispanic, single, low-income mothers are a vulnerable population who are often identified as having difficult transitioning to motherhood and successfully using the U.S. health care system. The purpose of this study was to examine needs, concerns, and social support of Hispanic, single, low-income mothers during the transition to motherhood through the eyes of community leaders serving this population in the U.S. Two focus groups were conducted, and 16 Midwestern community leaders working or volunteering with the Hispanic population expressed their opinions. Two investigators and two graduate nursing students evaluated the data. The process of word and context interpretation was completed using a combination of Tesch (1990) and Creswell (2007) techniques. Data were compared to field notes and debriefing summaries were completed during focus group discussions. Four themes and 12 subthemes evolved from the group discussions. Themes were (a) mothers' social support, (b) interactions with health care providers, (c) barriers in trust, and (d) practical life issues. A conclusion was drawn from these data that these women have difficulty accessing social support and information regarding care of themselves and their newborn infants due to limited social networks and barriers to health care. Nurses are in key positions to offer culturally sensitive social support and identify health care barriers with Hispanic, single, low-income mothers during the transition to motherhood. Further research is needed on interventions that effectively deliver information, lower health care barriers, and meet social support needs of Hispanic, single, low-income mothers and their infants.

Social-support needs among adolescents living with HIV in transition from pediatric to adult care in Cambodia: findings from a cross-sectional study.

PubMed

Toth, Graham; Mburu, Gitau; Tuot, Sovannary; Khol, Vohith; Ngin, Chanrith; Chhoun, Pheak; Yi, Siyan

2018-03-28

Understanding the circumstances of adolescents living with HIV is critical in designing adolescent-friendly services that will facilitate successful transition from pediatric to adult care. This study describes access, utilization and ongoing social support needs among adolescents living with HIV aged 15-17 in transition from pediatric to adult HIV care in Cambodia. A cross-sectional study was conducted among 328 adolescents, randomly selected from 11 antiretroviral therapy (ART) clinics across the country. Descriptive analyses were conducted to summarize their characteristics, access to social support and ongoing support needs among male and female adolescents. Mean age of the study participants was 15.8 (SD = 0.8) years. Just over half (55.2%) were male. Most had at least one deceased parent (mother 50.9%; father 60.5%), and majority were living with biological parents (40.8%) or relatives (49.3%). A third came from families with an ID poor card, and 21.0% were working for pay. Almost half (46.6%) reported that their family had received social support for their health care, including food support (76.5%), school allowance (62.1%), transport allowance to ART clinics (53.6%), psychosocial counseling (35.3%), vocational training (22.9%) or home visits (11.1%). Several ongoing social support needs were identified, including ongoing inability to cover health expenses unless they are supported by health insurance or health equity fund (55.0%). In addition, adolescents reported having been asked to come back earlier than their scheduled appointment (13.7%), having had to purchase their own drugs (2.7%), experiencing HIV stigma (32.0%), having been denied housing or food due to HIV (8.2%) or failing to attend school within the past month partly because of HIV (16.8%). Two-thirds did not have access to peer support groups. Social protection mechanisms are reaching some adolescents in need, while other remain without social support due to discontinuities in health and social care. Multi-sectoral interventions, supporting school attendance, adolescent-friendly clinic scheduling, reductions in child employment, mitigation of HIV-related stigma and strengthening of peer-to-peer support are required to improve coverage of social protection interventions for adolescents in transition.

"Every Family": A Population Approach to Reducing Behavioral and Emotional Problems in Children Making the Transition to School

ERIC Educational Resources Information Center

Sanders, Matthew R.; Ralph, Alan; Sofronoff, Kate; Gardiner, Paul; Thompson, Rachel; Dwyer, Sarah; Bidwell, Kerry

2008-01-01

A large-scale population trial using the Triple P-Positive Parenting Program (TPS) was evaluated. The target population was all parents of 4- to 7-year-old children residing in ten geographical catchment areas in Brisbane (intervention communities) and ten sociodemographically matched catchment areas from Sydney (5) and Melbourne (5), care as…

The art of letting go: referral to palliative care and its discontents.

PubMed

Broom, Alex; Kirby, Emma; Good, Phillip; Wootton, Julia; Adams, Jon

2013-02-01

Accompanying patients from active treatment towards specialist palliative care is a complex sphere of clinical practice that can be fraught with interpersonal and emotional challenges. While medical specialists are expected to break 'bad news' to their patients and ease their transitions to specialist palliative care if required, few have received formal training in such interpersonal complexities. Furthermore, there also often exists clinical ambiguity around whether to continue active treatment vis-à-vis refocusing on quality of life and palliation. In this paper we explore the experiences of twenty Australian medical specialists, focussing on issues such as: dilemmas around when and how to talk about dying and palliation; the art of referral and practices of representation; and, accounts of emotion and subjective influences on referral. The results illustrate how this transitional realm can be embedded in emotions, relationships and the allure of potentially life-prolonging intervention. We argue that the practice of referral should be understood as a relational and contextually-bound process. Copyright © 2012 Elsevier Ltd. All rights reserved.

Empowering certified nurse's aides to improve quality of work life through a team communication program.

PubMed

Howe, Erin E

2014-01-01

The purpose of this pilot study was to explore the impact of a certified nurse's aide (CNA)-led interdisciplinary teamwork and communication intervention on perceived quality of work environment and six-month job intentions. CNAs are frequently excluded from team communication and decision-making, which often leads to job dissatisfaction with high levels of staff turnover. Using a mixed quantitative and qualitative approach with pre- post-program design, the intervention utilized the strategy of debriefing from the national patient safety initiative, TeamSTEPPS. Inherent in the program design, entitled Long Term Care (LTC) Team Talk, was the involvement of the CNAs in the development of the intervention as an empowering process on two wings of a transitional care unit in a long-term care facility in upstate NY. CNAs' perceptions of work environment quality were measured using a Quality of Work Life (QWL) instrument. Additionally, job turnover intent within six months was assessed. Results indicated improved scores on nearly all QWL subscales anticipated to be impacted, and enhanced perceived empowerment of the CNAs on each wing albeit through somewhat different experiential processes. The program is highly portable and can potentially be implemented in a variety of long-term care settings. Copyright © 2014 Mosby, Inc. All rights reserved.

Effects of a Community-Based, Post-Rehabilitation Exercise Program in COPD: Protocol for a Randomized Controlled Trial With Embedded Process Evaluation.

PubMed

Desveaux, Laura; Beauchamp, Marla K; Lee, Annemarie; Ivers, Noah; Goldstein, Roger; Brooks, Dina

2016-05-11

This manuscript (1) outlines the intervention, (2) describes how its effectiveness is being evaluated in a pragmatic randomized controlled trial, and (3) summarizes the embedded process evaluation aiming to understand key barriers and facilitators for implementation in new environments. Participating centers refer eligible individuals with COPD following discharge from their local PR program. Consenting patients are assigned to a year-long community exercise program or usual care using block randomization and stratifying for supplemental oxygen use. Patients in the intervention arm are asked to attend an exercise session at least twice per week at their local community facility where their progress is supervised by a case manager. Each exercise session includes a component of aerobic exercise, and activities designed to optimize balance, flexibility, and strength. All study participants will have access to routine follow-up appointments with their respiratory physician, and additional health care providers as part of their usual care. Assessments will be completed at baseline (post-PR), 6, and 12 months, and include measures of functional exercise capacity, quality of life, self-efficacy, and health care usage. Intervention effectiveness will be assessed by comparing functional exercise capacity between intervention and control groups. A mixed-methods process evaluation will be conducted to better understand intervention implementation, guided by Normalization Process Theory and the Consolidated Framework for Implementation Research. Based on results from our pilot work, we anticipate a maintenance of exercise capacity and improved health-related quality of life in the intervention group, compared with a decline in exercise capacity in the usual care group. Findings from this study will improve our understanding of the effectiveness of community-based exercise programs for maintaining benefits following PR in patients with COPD and provide information on how best to implement them. If effective, the intervention represents an opportunity to transition patients from institutionally-based rehabilitative management to community-based care. The results of the process evaluation will contribute to the science of translating evidence-based programs into regular practice.

Cost-effectiveness of a transitional home-based palliative care program for patients with end-stage heart failure.

PubMed

Wong, Frances Kam Yuet; So, Ching; Ng, Alina Yee Man; Lam, Po-Tin; Ng, Jeffrey Sheung Ching; Ng, Nancy Hiu Yim; Chau, June; Sham, Michael Mau Kwong

2018-02-01

Studies have shown positive clinical outcomes of specialist palliative care for end-stage heart failure patients, but cost-effectiveness evaluation is lacking. To examine the cost-effectiveness of a transitional home-based palliative care program for patients with end-stage heart failure patients as compared to the customary palliative care service. A cost-effectiveness analysis was conducted alongside a randomized controlled trial (Trial number: NCT02086305). The costs included pre-program training, intervention, and hospital use. Quality of life was measured using SF-6D. The study took place in three hospitals in Hong Kong. The inclusion criteria were meeting clinical indicators for end-stage heart failure patients including clinician-judged last year of life, discharged to home within the service area, and palliative care referral accepted. A total of 84 subjects (study = 43, control = 41) were recruited. When the study group was compared to the control group, the net incremental quality-adjusted life years gain was 0.0012 (28 days)/0.0077 (84 days) and the net incremental costs per case was -HK$7935 (28 days)/-HK$26,084 (84 days). The probability of being cost-effective was 85% (28 days)/100% (84 days) based on the cost-effectiveness thresholds recommended both by National Institute for Health and Clinical Excellence (£20,000/quality-adjusted life years) and World Health Organization (Hong Kong gross domestic product/capita in 2015, HK$328117). Results suggest that a transitional home-based palliative care program is more cost-effective than customary palliative care service. Limitations of the study include small sample size, study confined to one city, clinic consultation costs, and societal costs including patient costs and unpaid care-giving costs were not included.

Grip on health: A complex systems approach to transform health care.

PubMed

van Wietmarschen, Herman A; Wortelboer, Heleen M; van der Greef, Jan

2018-02-01

This article addresses the urgent need for a transition in health care to deal with the increasing prevalence of chronic diseases and associated rapid rise of health care costs. Chronic diseases evolve and are predominantly related to lifestyle and environment. A shift is needed from a reductionist repair mode of thinking, toward a more integrated biopsychosocial way of thinking about health. The aim of this article is to discuss the opportunities that complexity science offer for transforming health care toward optimal treatment and prevention of chronic lifestyle diseases. Health and health care is discussed from a complexity science perspective. The benefits of concepts developed in the field of complexity science for stimulating transitions in health care are explored. Complexity science supports the elucidation of the essence of health processes. It provides a unique perspective on health with a focus on the relationships within networks of dynamically interacting factors and the emergence of health out of the organization of those relationships. Novel types of complexity science-based intervention strategies are being developed. The first application in practice is the integrated obesity treatment program currently piloted in the Netherlands, focusing on health awareness and healing relationships. Complexity science offers various theories and methods to capture the path toward unhealthy and healthy states, facilitating the development of a dynamic integrated biopsychosocial perspective on health. This perspective offers unique insights into health processes for patients and citizens. In addition, dynamic models driven by personal data provide simulations of health processes and the ability to detect transitions between health states. Such models are essential for aligning and reconnecting the many institutions and disciplines involved in the health care sector and evolve toward an integrated health care ecosystem. © 2016 John Wiley & Sons, Ltd.

Complex Case Conferences Associated with Reduced Hospital Admissions for High-Risk Patients with Multiple Comorbidities

PubMed Central

Tuso, Philip; Watson, Heather L; Garofalo-Wright, Lynn; Lindsay, Gail; Jackson, Ana; Taitano, Maria; Koyama, Sandra; Kanter, Michael

2014-01-01

Objectives: Reducing avoidable hospital readmissions presents an opportunity to improve health care quality and reduce avoidable costs. We studied the effect person-focused care may have on reducing avoidable admissions to the hospital. Methods: Among patients with heart failure discharged from the hospital, we evaluated the effect on 30-day readmissions of transitions-in-care interventions: home health visits, follow-up phone calls, and physician office visits. We also used a standardized diagnostic tool to interview readmitted patients to identify social reasons that may have contributed to the readmission. Finally, we used the learnings from both interventions to develop a new intervention: a single complex disease case conference that included the entire health care team. We measured hospital admissions for 21 patients during the 6 months before and after their complex case conferences. Results: Observed-over-expected hospital readmission rates were lowest for patients receiving a postdischarge visit with a home health nurse and a follow-up visit with their physician (0.54), compared with solely a physician visit (0.81), home health visit (1.2), or phone call (1.55). Various social issues may contribute to hospital readmissions, including caregiver knowledge, ability to care for oneself at home, and issues related to medications (adherence, ability to pay, and knowledge about potential side effects). Substantially fewer hospital admissions occurred after complex case conferences. Conclusions: Complex case conferences with disease-focused and person-focused interventions may be associated with reduced hospital admissions for patients with heart failure and multiple comorbidities. PMID:24626071

Depression in adolescents: review of a nursing research report.

PubMed

Bauman, Jennifer G

2013-01-01

The research findings from the McCann et al.'s (2012) study are important to evidence-based nursing practice (EBNP) as they highlight the need to improve mental health literacy for health care professionals, including nurses, so that nurses are more aware of the signs of depression, young people's experiences of depression, and how to respond appropriately to their needs (McCann et al., 2012, p. 339). The findings that government funding, along with knowledgeable health care professionals, improved community awareness, and support of young people with depression, played a vital role in strengthening young people's ability to counteract the stigma while promoting self-empowerment, indicate the need for the identification and implementation of EBNP interventions incorporating their finding. (McCann et al., 2012, p. 339). One suggestion for future research would be to develop EBNP interventions designed to promote a smooth transition from youth to adulthood in those with depression and to conduct a research study evaluating the effectiveness of interventions implemented.

EARLY PARENTING SUPPORT AND INFORMATION: A CONSUMER PERSPECTIVE.

PubMed

Morawska, Alina; Weston, Kate; Bowd, Courtney

2018-03-01

The transition to parenthood is a period of both joy and challenge for most parents. There is a recognized need to support parents during this period, yet existing interventions have shown limited evidence of efficacy. This study takes a consumer-focused approach to examine the needs and preferences of parents both prenatally (n = 77) and postnatally (n = 123) for parenting support. The study used a cross-sectional design with a purpose-built online survey. Parents were recruited via online forums, Facebook and parenting blogs, childcare centers, and playgroups. In general, all parents were satisfied with their current levels of both formal and informal support, and about one fourth of parents had accessed a parenting intervention. Parents expressed a moderate level of interest in additional parenting information, and parents expecting their first baby indicated preferences for information about basic baby care needs whereas postnatally, parents expressed more interest in topics around self-care and behavior management. The implications for developing interventions and engaging families are discussed. © 2018 Michigan Association for Infant Mental Health.

Effective process or dangerous precipice: qualitative comparative embedded case study with young people with epilepsy and their parents during transition from children’s to adult services

PubMed Central

2013-01-01

Background Transition from children’s to adult epilepsy services is known to be challenging. Some young people partially or completely disengage from contact with services, thereby risking their health and wellbeing. We conducted a mixed-method systematic review that showed current epilepsy transition models enabling information exchange and developing self-care skills were not working well. We used synthesised evidence to develop a theoretical framework to inform this qualitative study. The aim was to address a critical research gap by exploring communication, information needs, and experiences of knowledge exchange in clinical settings by young people and their parents, during transition from children’s to adult epilepsy services. Method Qualitative comparative embedded Case study with 2 'transition’ cases (epilepsy services) in two hospitals. Fifty-eight participants: 30 young people (13–19 years) and 28 parents were interviewed in-depth (individual or focus group). Clinical documents/guidelines were collated. 'Framework’ thematic analysis was used. The theoretical framework was tested using themes, pattern matching and replication logic. Theory-based evaluation methods were used to understand how and why different models of service delivery worked. Results A joint epilepsy clinic for young people 14–17 years coordinated by children’s and adult services was more likely to influence young people’s behaviour by facilitating more positive engagement with adult healthcare professionals and retention of epilepsy-related self-care information. Critical success factors were continuity of care, on-going and consistent age-appropriate and person centred communication and repeated information exchange. Three young people who experienced a single handover clinic disengaged from services. Psychosocial care was generally inadequate and healthcare professionals lacked awareness of memory impairment. Parents lacked knowledge, skills and support to enable their child to independently self-care. Translation of transition policies/guidelines into practice was weak. Conclusion Findings make a significant contribution to understanding why young people disengage from epilepsy services, why some parents prevent independent self-care, and what constitutes good communication and transition from the perspective of young people and parents. The type of service configuration, delivery and organisation influenced the behaviours of young people at transition to adult services. The novel theoretical framework was substantially supported, underwent further post-hoc development and can be used in future practice/intervention development and research. PMID:24131769

Safety in the operating theatre--a transition to systems-based care.

PubMed

Weiser, Thomas G; Porter, Michael P; Maier, Ronald V

2013-03-01

All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.

OC24 - An algorithm proposal to oral feeding in premature infants.

PubMed

Neto, Florbela; França, Ana Paula; Cruz, Sandra

2016-05-09

Theme: Transition of care. Oral feeding is one of the hardest steps for premature infants after respiratory independence and is a challenge for nurses in neonatology. To know the characteristics of preterm infants, essential for oral feeding; to know the nurses' opinion on nursing interventions, that promote the transition of gavage feeding for oral feeding in preterm infants. An exploratory, descriptive study with a qualitative approach was used. Semi-structured interviews with neonatal nurses were conducted and data was submitted to content analysis. Weight, gestational age, physiological stability, sucking coordination, swallowing and breathing, and the overall look and feeding involvement are fundamental parameters to begin oral feeding. Positioning the baby, reflexes stimulation, control stress levels, monitoring the temperature and the milk flow are nursing interventions that promote the development of feeding skills. An algorithm for the oral feeding of preterm infants was developed grounded in the opinions of nurses.

A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents.

PubMed

Kennedy, David P; Osilla, Karen Chan; Hunter, Sarah B; Golinelli, Daniela; Maksabedian Hernandez, Ervant; Tucker, Joan S

2018-03-01

This article presents findings of a pilot test of a Motivational Interviewing social network intervention (MI-SNI) to enhance motivation to reduce high risk alcohol and other drug (AOD) use among formerly homeless individuals transitioning to housing. Delivered in-person by a facilitator trained in MI, this four-session computer-assisted intervention provides personalized social network visualization feedback to help participants understand the people in their network who trigger their alcohol and other drug (AOD) use and those who support abstinence. If ready, participants are encouraged to make changes to their social network to help reduce their own high-risk behavior. Participants were 41 individuals (33 male, 7 female, 1 other; 23 African-American, 5 non-Latino White, 6 Latino, 7 other, mean age 48) who were transitioning from homelessness to permanent supportive housing. They were randomly assigned to either the MI-SNI condition or usual care. Readiness to change AOD use, AOD abstinence self-efficacy, and AOD use were assessed at baseline and shortly after the final intervention session for the MI-SNI arm and around 3-months after baseline for the control arm. Acceptability of the intervention was also evaluated. MI-SNI participants reported increased readiness to change AOD use compared to control participants. We also conducted a subsample analysis for participants at one housing program and found a significant intervention effect on readiness to change AOD use, AOD abstinence self-efficacy, and alcohol use compared to control participants. Participants rated the intervention as highly acceptable. We conclude that a brief computer-assisted Motivational Interviewing social network intervention has potential to efficaciously impact readiness to change AOD use, AOD abstinence self-efficacy, and AOD use among formerly homeless individuals transitioning to permanent supportive housing, and warrants future study in larger clinical trials. Copyright © 2017 Elsevier Inc. All rights reserved.

Family-focused interventions and resources for veterans and their families.

PubMed

Sherman, Michelle D; Larsen, Jessica L

2018-05-01

Accelerated by the decreasing military presence in Iraq and Afghanistan, many military members are currently transitioning out of active duty into civilian life. Many of these new veterans have recently experienced combat deployment(s), and some are struggling with the aftermath of combat exposure, separation from family, and reintegration stressors. These challenges often follow these military families as they enter the civilian world, a time with its own major life changes vocationally, socially, and interpersonally. Although numerous resources have been developed to assist service members during their transition to the civilian world, relatively fewer exist for partners, children, and broader family systems. Family psychoeducation is a nonpathologizing, strengths-focused model of care that has documented benefits in the arena of mental illness. This article describes some manualized family psychoeducational programs and online and phone-based resources that may be useful to veteran families during this time of change. The programs and resources described herein are all available for free, primarily online. Because of a wide variety of barriers and limitations for family based care in the Veterans Affairs health care system, veteran families are and will continue to seek mental health care in public sector settings. Community providers can enhance their military culture competence by familiarizing themselves with these resources and drawing upon them in working with transitioning military families. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Integrated and Gender-Affirming Transgender Clinical Care and Research.

PubMed

Reisner, Sari L; Radix, Asa; Deutsch, Madeline B

2016-08-15

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested "best practices" for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

Integrated and Gender-Affirming Transgender Clinical Care and Research

PubMed Central

Radix, Asa; Deutsch, Madeline B.

2016-01-01

Abstract: Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment). PMID:27429189

What can artefact analysis tell us about patient transitions between the hospital and primary care? Lessons from the HANDOVER project.

PubMed

Johnson, Julie K; Arora, Vineet M; Barach, Paul R

2013-09-01

Hospital discharge often faces breakdowns in information, communication, and coordination. The European Union FP7 Health Research Programme commissioned the European HANDOVER Project in 2008, a three year, 3.5 million Euro programme to examine transitions of patient care from the hospital to the community care settings. Six European countries--Italy, the Netherlands, Poland, United Kingdom, Spain, and Sweden--participated in this collaborative study. This paper highlights a multi-centre, multi-national research programme. We describe how HANDOVER participants conducted an 'artefact analysis' as one element of the mixed methods study to inform opportunities to make patient handovers between hospital and community care more effective. The artefact analysis consisted of a four-step process to assess different tools used in communication and treatment and their effects on the communication processes between the hospital and general practice settings. Four themes emerged from our analysis: (a) The inpatient care of a patient is 'hospital centric' whereby the hospital 'pulls' information regarding a patient's family physician (b) There are rich cognitive artefacts that support the patient clinician encounter; c) The use of information technology does not necessarily improve the communication process; and (d) There is a role for the patient, albeit not particularly well-defined or explicit, as a conduit for essential information communication. Cognitive artefact analysis is an innovative method to provide insights into transitions of patient care. It may be most useful to think about interventions at both the individual patient and the system levels that more fully address and overcome the system issues at work.

Economic evaluation of the differential benefits of home visits with telephone calls and telephone calls only in transitional discharge support.

PubMed

Wong, Frances Kam Yuet; So, Ching; Chau, June; Law, Antony Kwan Pui; Tam, Stanley Ku Fu; McGhee, Sarah

2015-01-01

home visits and telephone calls are two often used approaches in transitional care, but their differential economic effects are unknown. to examine the differential economic benefits of home visits with telephone calls and telephone calls only in transitional discharge support. cost-effectiveness analysis conducted alongside a randomised controlled trial (RCT). patients discharged from medical units randomly assigned to control (control, N = 210), home visits with calls (home, N = 196) and calls only (call, N = 204). cost-effectiveness analyses were conducted from the societal perspective comparing monetary benefits and quality-adjusted life years (QALYs) gained. the home arm was less costly but less effective at 28 days and was dominating (less costly and more effective) at 84 days. The call arm was dominating at both 28 and 84 days. The incremental QALY for the home arm was -0.0002/0.0008 (28/84 days), and the call arm was 0.0022/0.0104 (28/84 days). When the three groups were compared, the call arm had a higher probability being cost-effective at 84 days but not at 28 days (home: 53%, call: 35% (28 days) versus home: 22%, call: 73% (84 days)) measuring against the NICE threshold of £20,000. the original RCT showed that the bundled intervention involving home visits and calls was more effective than calls only in the reduction of hospital readmissions. This study adds a cost perspective to inform policymakers that both home visits and calls only are cost-effective for transitional care support, but calls only have a higher chance of being cost-effective for a sustained period after intervention. © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society.

Women in Transition: Experiences of Health and Health Care for Recently Incarcerated Women Living in Community Corrections Facilities.

PubMed

Colbert, Alison M; Goshin, Lorie S; Durand, Vanessa; Zoucha, Rick; Sekula, L Kathleen

2016-12-01

Health priorities of women after incarceration remain poorly understood, constraining development of interventions targeted at their health during that time. We explored the experience of health and health care after incarceration in a focused ethnography of 28 women who had been released from prison or jail within the past year and were living in community corrections facilities. The women's outlook on health was rooted in a newfound core optimism, but this was constrained by their pressing health-related issues; stress and uncertainty; and the pressures of the criminal justice system. These external forces threatened to cause collapse of women's core optimism. Findings support interventions that capitalize on women's optimism and address barriers specific to criminal justice contexts. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces.

PubMed

Robinson, C A; Bottorff, J L; Lilly, M B; Reid, C; Abel, S; Lo, M; Cummings, G G

2012-12-01

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population. Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.

Drug therapy problems and medication discrepancies during care transitions in super-utilizers.

PubMed

Surbhi, Satya; Munshi, Kiraat D; Bell, Paula C; Bailey, James E

First, to investigate the prevalence and types of drug therapy problems and medication discrepancies among super-utilizers, and associated patient characteristics. Second, to examine the outcomes of pharmacist recommendations and estimated cost avoidance through care transitions support focused on medication management. Retrospective analysis of the pharmacist-led interventions as part of the SafeMed Program. A large nonprofit health care system serving the major medically underserved areas in Memphis, Tennessee. Three hundred seventy-four super-utilizing SafeMed participants with multiple chronic conditions and polypharmacy. Comprehensive medication review, medication therapy management, enhanced discharge planning, home visits, telephone follow-up, postdischarge medication reconciliation, and care coordination with physicians. Types of drug therapy problems, outcomes of pharmacist recommendations, estimated cost avoided, medication discrepancies, and self-reported medication adherence. Prevalence of drug therapy problems and postdischarge medication discrepancies was 80.7% and 75.4%, respectively. The most frequently occurring drug therapy problems were enrollee not receiving needed medications (33.4%), underuse of medications (16.9%), and insufficient dose or duration (11.2%). Overall 50.8% of the pharmacist recommendations were accepted by physicians and patients, resulting in an estimated cost avoidance of $293.30 per drug therapy problem identified. Multivariate analysis indicated that participants with a higher number of comorbidities were more likely to have medication discrepancies (odds ratio 1.23 [95% CI 1.05-1.44]). Additional contributors to postdischarge medication discrepancies were difficulty picking up and paying for medications and not being given necessary prescriptions before discharge. Drug therapy problems and medication discrepancies are common in super-utilizers with multiple chronic conditions and polypharmacy during transitions of care, and greater levels of comorbidity magnify risk. Pharmacist-led interventions in the SafeMed Program have demonstrated success in resolving enrollees' medication-related issues, resulting in substantial estimated cost savings. Preliminary evidence suggests that the SafeMed model's focus on medication management has great potential to improve outcomes while reducing costs for vulnerable super-utilizing populations nationwide. Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Roles and identities in transition: boundaries of work and inter-professional relationships at the interface between telehealth and primary care.

PubMed

Segar, Julia; Rogers, Anne; Salisbury, Chris; Thomas, Clare

2013-11-01

Shifting the balance of care towards home and community is viewed as requiring interventions which enhance or complement primary care. Technology-based interventions are seen as key to the future in this work. Telehealthcare implicates a new agenda for inter-professional working across boundaries of healthcare. One such interface is between telehealthcare professionals and professionals located in primary care. This study reports the findings from a qualitative study forming part of a broader project examining the potential of developing and implementing telehealth interventions to support patients with long-term conditions. Semi-structured interviews were undertaken with telehealth nurse care managers, practice nurses and general practitioners in their respective work settings (39 interviews with 62 participants). Observation was undertaken at a telehealth call centre. The research took place between April 2010 and March 2011. Thematic analysis of qualitative data was undertaken. Telehealth nurse care managers' interviews suggested narrative constructions of new roles and identities to fit telehealth work, combining a holistic ideal and retro-appeal with 'traditional' values of nursing, which distinguished and distanced them from counterparts in general practices. Practice nurses and general practitioners were ambivalent and often sceptical about the contribution of telehealth to long-term condition work. Practice nurses' accounts suggested a sense of protectiveness about maintaining boundaries around established remits of managing long-term conditions; general practitioners, having devolved much of the care of long-term conditions to nurses, were keen to retain their positions as gatekeepers to resources. Perceptions of shifts of professional roles, new ways of working and how they are valued form a relevant contextual element to the introduction of telehealth interventions. A pre-emptive view and response to how professionals understand and approach increasingly complex and multi-faceted roles within primary care is likely to prepare and facilitate the introduction and integration of telehealth innovations into existing patient services. © 2013 John Wiley & Sons Ltd.

Effects of a home care mobile app on the outcomes of discharged patients with a stoma: a randomized controlled trial.

PubMed

Wang, Qing-Qing; Zhao, Jing; Huo, Xiao-Rong; Wu, Ling; Yang, Li-Fang; Li, Ju-Yun; Wang, Jie

2018-05-18

The aim of this study is to explore the effects of a home care mobile app on the outcomes of stoma patients who discharged from hospital. Patients with a newly formed stoma experience many difficulties after surgery. Mobile application (app) has the potential to help patients self-manage their diseases and adjust to the changes in their lives and is a convenient way to ensure the continuity of care. However, there is a lack of studies about the effects of a mobile app on the transitional care for improving discharged stoma-related health outcomes. A randomized controlled trial. 203 patients with a permanent stoma in tertiary hospitals in China were randomly assigned into two groups. Patients in the control group (n=103) received routine discharge care. Patients in the intervention group (n=100) received home care via a mobile app besides routine care. The psychosocial adjustment level, self-efficacy scale and stoma complications incidence were measured in the follow-up period and compared between the two groups. Data was collected at four time points: before intervention (baseline), at 1, 3 and 6 months after discharge. The psychosocial adjustment level and stoma self-efficacy score of the intervention group were significantly higher than those of the control group respectively at 1, 3 and 6-month follow-up (all P<0.05). The incidence of stoma complications in the intervention group were tending to reduce at 1, 3 and 6 months after discharge. The findings indicated that follow-up care at home via a mobile app can effectively improve the psychosocial adjustment level, self-efficacy scale and other related outcomes of stoma patients. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Parents, Peers, and Sexual Values Influence Sexual Behavior During the Transition to College

PubMed Central

Neal, Dan J.; Fromme, Kim

2018-01-01

Several decades of research have identified the contributions of psychosocial influences on adolescent and young adult sexual behavior; however, few studies have examined parental and peer influence and sexual values during the transition from high school to college. The current study tested the influence of sexual values and perceived awareness and caring (PAC), or beliefs about how much parents and peers know and care about students’ behavior, on sexual behavior during this transitional period. Using data from a longitudinal study, generalized estimating equations and the generalized linear model were used to examine the associations among sexual values, parental and peer PAC, and sexual behavior, both cross-sectionally and longitudinally. Participants (N = 1,847; 61% female) completed web-based surveys the summer before college matriculation and at the end of the first semester in college. Results indicated that individuals with high levels of both parental and peer PAC engaged in less frequent sexual behaviors and that PAC moderated the effect of sexual values on sexual behaviors. Furthermore, both PAC variables decreased during the transition from high school to college, and high school sexual values, parental PAC, and their interaction predicted the number of sexual partners during the first semester of college. Only sexual values and high school unsafe sexual behaviors predicted unsafe sexual behavior in college. Findings suggest that complex associations exist among perceived awareness and caring, sexual values, and sexual behaviors, and that the transition from high school to college may be an ideal time for safer-sex interventions. PMID:19291385

Supportive care for older people with frailty in hospital: An integrative review.

PubMed

Nicholson, Caroline; Morrow, Elizabeth M; Hicks, Allan; Fitzpatrick, Joanne

2017-01-01

Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care. To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation. An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken. Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes. Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings. The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Well-being, health, and productivity improvement after an employee well-being intervention in large retail distribution centers.

PubMed

Rajaratnam, Augustine S; Sears, Lindsay E; Shi, Yuyan; Coberley, Carter R; Pope, James E

2014-12-01

To evaluate changes in well-being, biometric, and productivity indicators after a well-being intervention. Biometric and self-reported outcomes were assessed among 677 retail distribution center employees before and after a 6-month well-being intervention. Despite lower well-being at baseline compared to an independent random sample of workers, program participants' well-being, productivity, body mass index, systolic blood pressure, and total cholesterol improved significantly after the intervention, whereas the decline in diastolic blood pressure was not significant. Moreover, participants' specific transition across well-being segments over the intervention period demonstrated more improvement than decline. There is evidence that programs designed to improve well-being within a workforce can be used to significantly and positively impact employee health and productivity, which should result in reduced health care costs, improved employee productivity, and increased overall profitability.

Multicentre randomised study of the effect and experience of an early inhome programme (PreHomeCare) for preterm infants using video consultation and smartphone applications compared with inhospital consultations: protocol of the PreHomeCare study.

PubMed

Hägi-Pedersen, Mai-Britt; Norlyk, Annelise; Dessau, Ram; Stanchev, Hristo; Kronborg, Hanne

2017-03-09

Although premature infants and their parents are discharged earlier to inhomecare programmes, how to optimally support parents during this transition remains unknown. The aim of this study is to compare the effects of early inhomecare (PreHomeCare) including video consultations and mobile applications with those of inhospital consultations regarding breast feeding, parental confidence and parent-infant interactions. A randomised controlled intervention study will be conducted in four neonatal departments offering PreHomeCare (ie, premature infant inhomecare) in Denmark. Parents of hospitalised premature infants who fulfil the inclusion criteria for PreHomeCare will be randomised during hospitalisation to either the intervention (n=80) or control group (n=80) using 1:1 block randomisation. During PreHomeCare, the intervention group will receive a smartphone application with a video system and an infant scale, and the control group will receive usual care (ie, hospital consultations). Additionally, both groups will have planned nurse consultations two to three times a week: the intervention group through video consultations and the control group through inhospital consultations. Data collection will occur at inclusion/baseline, at the end of PreHomeCare and 1 month after discharge using questionnaires and hospital records. The primary outcome is the proportion of exclusively breastfed infants 1 month after discharge/end of PreHomeCare, the secondary outcomes are parent-infant interactions measured by the Mother and baby interaction scale and family confidence in caring for infants measured by the Karitane Parenting Confidence Scale. The process evaluation will consist of two qualitative studies: a field study and an interview study. Data collection will initially involve field observations of three scheduled video consultations with six families from the intervention group. These families will also be interviewed 1 month after PreHomeCare has ended. The project has been approved by the Regional Ethics Committee and the Danish Data Protection Agency. NCT02581800. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Feasibility and Preliminary Effects of an Intervention Targeting Schema Development for Caregivers of Newly Admitted Hospice Patients

PubMed Central

Mazurek Melnyk, Bernadette

2013-01-01

Abstract Background The transition to hospice care is a stressful experience for caregivers, who report high anxiety, unpreparedness, and lack of confidence. These sequelae are likely explained by the lack of an accurate cognitive schema, not knowing what to expect or how to help their loved one. Few interventions exist for this population and most do not measure preparedness, confidence, and anxiety using a schema building a conceptual framework for a new experience. Objective The purpose of this study was to test the feasibility and preliminary effects of an intervention program, Education and Skill building Intervention for Caregivers of Hospice patients (ESI-CH), using an innovative conceptual design that targets cognitive schema development and basic skill building for caregivers of loved ones newly admitted to hospice services. Design A pre-experimental one-group pre- and post-test study design was used. Eighteen caregivers caring for loved ones in their homes were recruited and twelve completed the pilot study. Depression, anxiety, activity restriction, preparedness, and beliefs/confidence were measured. Results Caregivers reported increased preparedness, more helpful beliefs, and more confidence about their ability to care for their loved one. Preliminary trends suggested decreased anxiety levels for the intervention group. Caregivers who completed the intervention program rated the program very good or excellent, thought the information was helpful and timely, and would recommend it to friends. Conclusions Results show promise that the ESI-CH program may assist as an evidence-based program to support caregivers in their role as a caregiver to a newly admitted hospice patient. PMID:23384244

Essential Elements of Early Post Discharge Care of Patients with Heart Failure.

PubMed

Soucier, Richard J; Miller, P Elliott; Ingrassia, Joseph J; Riello, Ralph; Desai, Nihar R; Ahmad, Tariq

2018-06-01

Heart failure is associated with an enormous burden on both patients and health care systems in the USA. Several national policy initiatives have focused on improving the quality of heart failure care, including reducing readmissions following hospitalization, which are common, costly, and, at least in part, preventable. The transition from inpatient to ambulatory care setting and the immediate post-hospitalization period present an opportunity to further optimize guideline concordant medical therapy, identify reversible issues related to worsening heart failure, and evaluate prognosis. It can also provide opportunities for medication reconciliation and optimization, consideration of device-based therapies, appropriate management of comorbidities, identification of individual barriers to care, and a discussion of goals of care based on prognosis. Recent studies suggest that attention to detail regarding patient comorbidities, barriers to care, optimization of both diuretic and neurohormonal therapies, and assessment of prognosis improve patient outcomes. Despite the fact that the transition period appears to be an optimal time to address these issues in a comprehensive manner, most patients are not referred to programs specializing in this approach post hospital discharge. The objective of this review is to provide an outline for early post discharge care that allows clinicians and other health care providers to care for these heart failure patients in a manner that is both firmly rooted in the guidelines and patient-centered. Data regarding which intervention is most likely to confer benefit to which subset of patients with this disease is lacking and warrants further study.

Study protocol: pragmatic randomized control trial of an internet-based intervention (My tools 4 care) for family carers.

PubMed

Duggleby, Wendy; Ploeg, Jenny; McAiney, Carrie; Fisher, Kathryn; Swindle, Jenny; Chambers, Tracey; Ghosh, Sunita; Peacock, Shelley; Markle-Reid, Maureen; Triscott, Jean; Williams, Allison; Forbes, Dorothy; Pollard, Lori

2017-08-14

Family carers of older persons with Alzheimer's' disease and related dementia (ADRD) and multiple chronic conditions (MCC) experience significant, complex, and distressing transitions such as changes to their environment, roles and relationships, physical health, and mental health. An online intervention (My Tools 4 Care) was developed for family carers of persons with ADRD and MCC living at home, with the aim of supporting these carers through transitions and increasing their self-efficacy, hope, and health related quality of life (HRQoL). This study will evaluate My Tools 4 Care (MT4C) by asking the following research questions: 1. Does use of MT4C result in a 3 month (immediately post intervention) and 6-month (3 months after intervention) increase in HRQoL, self-efficacy, and hope, in carers of persons with ADRD and MCC compared to an educational control group? 2. Does use of MT4C help carers of community-dwelling older adults with ADRD and MCC deal with significant changes they experience as carers? and 3. Are the effects/benefits of the MT4C intervention achieved at no additional cost compared to an educational control group? Using a pragmatic mixed methods randomized controlled trial design, 180 family carers of community dwelling older persons (65 years of age and older) with ADRD and MCC will participate in the study. Data will be collected from the intervention and an educational control group at four time points: baseline, 1 month, 3 and 6 months. We expect to find that family carers using MT4C will show greater improvement in hope, self-efficacy and HRQoL, at no additional cost from a societal perspective, compared to those in the educational control group. General estimating equations will be used to determine differences between groups and over time. Data collection began in Ontario and Alberta Canada in June 2015 and is expected to be completed in June 2017. The results will inform policy and practice as MT4C can be easily revised for local contexts and is scalable in terms of posting on websites such as those hosted by the Alzheimer Society. ClinicalTrials.gov Identifier: NCT02428387.

Caregiver informational support in different patient care settings at end of life.

PubMed

Lavalley, Susan A

2018-01-01

Caregivers of the terminally ill face many complicated tasks including providing direct patient care, communicating with clinicians, and managing the logistical demands of daily activities. They require instructive information at all points in the illness process and across several settings where patients receive end-of-life care. This study examines how the setting where a patient receives end-of-life care affects caregivers' informational support needs by thematically analyzing data from caregiver interviews and clinical observations. Caregivers providing care for patients at home received informational support related to meeting patients' mobility, medication, and nutritional needs. Caregivers who provided care remotely received informational support to navigate transitions between patient care settings or long-term care arrangements, including financial considerations and insurance logistics. The findings document that interventions designed to enhance information for caregivers should account for caregiving context and that health care providers should proactively and repeatedly assess caregiver information needs related to end-of-life patient care.

Palliative care for patients with Parkinson's disease: study protocol for a mixed methods study.

PubMed

Lennaerts, Herma; Groot, Marieke; Steppe, Maxime; van der Steen, Jenny T; Van den Brand, Marieke; van Amelsvoort, Dorian; Vissers, Kris; Munneke, Marten; Bloem, Bastiaan R

2017-11-25

Parkinson's disease (PD) is a chronic, progressive neurological disorder with many intractable consequences for patients and their family caregivers. Little is known about the possibilities that palliative care could offer to patients and their proxies. Guidelines strongly recommend palliative care to improve the quality of life and - if needed - the quality of dying. However, providing palliative care to persons with PD involves specific challenges. For example, a timely initiation of palliative interventions is difficult because due to the gradually progressive nature of PD, there is often no clear marker for the transition from curative towards palliative care. Furthermore, there is little evidence to indicate which palliative care interventions are effective. Here, we describe the contours of a study that aims to examine the experiences of patients, (bereaved) family caregivers and professionals, with the aim of improving our knowledge about palliative care needs in PD. We will perform a mixed methods study to evaluate the experiences of patients, (bereaved) family caregivers and palliative care professionals. In this study, we focus on Quality of Life, Quality of Care, perceived symptoms, caregiver burden and collaboration between professionals. In phase 1, we will retrospectively explore the views of bereaved family caregivers and professionals by conducting individual interviews and focus group interviews. In phase 2, 5-15 patients with PD and their family caregiver will be followed prospectively for 8-12 months. Data collection will involve semi-structured interviews and questionnaires at three consecutive contact moments. Qualitative data will be audio recorded, transcribed and analyzed using CAQDAS. If patients pass away during the study period, a bereavement interview will be done with the closest family caregiver. This study will offer a broad perspective on palliative care, and the results can be used to inform a palliative care protocol for patients with PD. By describing the experiences of patients, (bereaved) family caregivers and professionals with palliative care, this investigation will also establish an important ground for future intervention research.

Navigating a new health culture: experiences of immigrant Hispanic women.

PubMed

Sanchez-Birkhead, Ana C; Kennedy, Holly Powell; Callister, Lynn Clark; Miyamoto, Teresa Paredes

2011-12-01

According to many reports, time in the United States negatively affects the health of Hispanic immigrants. However, little is known about the role of traditional health beliefs and practices in immigrants' underutilization of the US health care system. This descriptive, qualitative study utilized narrative interviews with 20 foreign-born Hispanic women of childbearing age to gain a better understanding of their existing health beliefs, health promotion practices, past health care experiences, and transition into a new society and health care system. Demographic data and scores on the short acculturation scale for Hispanics were also analyzed. Results highlight the importance of female social support for Hispanic women in making health care decisions; their dual use of US medical intervention and home and herbal remedies; and perceived racial discrimination on their health-care seeking behaviors and adherence to treatment modalities. Recommendations are included for professionals who provide health care to immigrant Hispanic women and their families.

Integrative Review: Delivery of Healthcare Services to Adolescents and Young Adults During and After Foster Care.

PubMed

Collins, Jennifer L

The purpose of this integrative review is to summarize evidence describing delivery of healthcare services to adolescents while in foster care and to young adults after they exit foster care. The long-term, deleterious effect of abuse and/or neglect by caregivers among youth who have been placed in foster care is grounded in empirical evidence demonstrating the relationship between long-term health needs and exposure to trauma in childhood. Evidence is needed to provide culturally-specific care and also to identify knowledge gaps in the care of adolescents and young adults who have been in the foster care system. Peer-reviewed research studies published between 2004 and 2014 that include samples of youth 12 to 30 years of age are included in the review. Eighteen studies met inclusion criteria for the review. Physical and behavioral healthcare needs among youth with foster care experience are significant. The ability to adequately meet health needs are inextricable from the ability to negotiate resources and to successfully interact with adults. Challenges that youth with foster care histories experience when transitioning into young adulthood are comparable to other populations of vulnerable youth not in foster care. Nurses must use each healthcare encounter to assess how the social determinants of health facilitate or impede optimal health among youth with foster care experience. The development of integrated intervention strategies to inform best practice models is a priority for current and former foster care youth as they transition into young adulthood. Copyright © 2016 Elsevier Inc. All rights reserved.

The clinical impact of a brief transition programme for young people with juvenile idiopathic arthritis: results of the DON'T RETARD project.

PubMed

Hilderson, Deborah; Moons, Philip; Van der Elst, Kristien; Luyckx, Koen; Wouters, Carine; Westhovens, René

2016-01-01

To investigate the clinical impact of a brief transition programme for young people with JIA. The Devices for Optimization of Transfer and Transition of Adolescents with Rheumatic Disorders (DON'T RETARD) project is a mixed method project in which we first conducted a quasi-experimental study employing a one-group pre-test-post-test with a non-equivalent post-test-only comparison group design. In this quantitative study, we investigated clinical outcomes in patients with JIA and their parents who participated in the transition programme (longitudinal analyses). The post-test scores of this intervention group were compared with those of patients who received usual care (comparative analyses). Second, a qualitative study was conducted to explore the experiences of adolescents with JIA and their parents regarding their participation in the transition programme. The primary hypothesis of improved physical (effect size 0.11), psychosocial (effect size 0.46) and rheumatic-specific health status (effect size ranging from 0.21 to 0.33), was confirmed. With respect to the secondary outcomes, improved quality of life (effect size 0.51) and an optimized parenting climate (effect size ranging from 0.21 to 0.28) were observed. No effect was measured in medication adherence (odds ratio 1.46). Implementation of a transition programme as a brief intervention can improve the perceived health and quality of life of adolescents with JIA during the transition process, as well as the parenting behaviours of their parents. Based on the present study, a randomized controlled trial can be designed to evaluate the effectiveness of the transition programme. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Effectiveness and cost-effectiveness of a self-management training for patients with chronic and treatment resistant anxiety or depressive disorders: design of a multicenter randomized controlled trial.

PubMed

Zoun, Maringa H H; Koekkoek, Bauke; Sinnema, Henny; Muntingh, Anna D T; van Balkom, Anton J L M; Schene, Aart H; Smit, Filip; Spijker, Jan

2016-07-07

Many patients with anxiety or depressive disorders achieve no remission of their symptoms after evidence-based treatment algorithms. They develop a chronic course of the disorder. Current care for these patients usually consists of long-term supportive contacts with a community psychiatric nurse and pharmacological management by a psychiatrist. Data on the effectiveness of these treatments is lacking. A psychosocial rehabilitation approach, where self-management is an increasingly important part, could be more suitable. It focuses on the restoration of functioning and enhancement of patients' autonomy and responsibility. Treatment with this focus, followed by referral to primary care, may be more (cost-)effective. A multicenter randomized controlled trial is designed for twelve participating specialized outpatient mental health services in the Netherlands. Patients with chronic and treatment resistant anxiety or depressive disorders, currently receiving supportive care in specialized outpatient mental health care, are asked to participate. After inclusion, patients receive the baseline questionnaire and are randomized to the intervention group or the usual care control group. The intervention focuses on rehabilitation and self-management and is provided by a trained community psychiatric nurse, followed by referral to primary care. Measurements take place at 6, 12, and 18 months after baseline. This study evaluates both the effectiveness (on quality of life, symptom severity, and empowerment), and cost-effectiveness of the intervention compared to usual care. In addition, a questionnaire is designed to get insight in which self-management strategies patients use to manage their disorder, and in the experiences of patients with the change of care setting. In this study we evaluate the effectiveness and cost-effectiveness of a self-management intervention for patients with chronic and treatment resistant anxiety or depressive disorders in specialized outpatient mental health care. The results of this study may provide a first 'proof-of-concept' in this under-researched but important field, and might be relevant for a large group of patients in the context of a transition of the Dutch health care system. Netherlands Trial Register: NTR3335 , registered 7 March 2012.

“Don't let the world become too small” – How patients with advanced cancer and their significant others cope with transitions during the last year of life. A qualitative study

PubMed

Chabloz-Süssenbach, Christiane; Sailer Schramm, Monique; Stoll, Hansruedi; Spirig, Rebecca

2016-07-01

Background: In the last year of life, persons with advanced cancer and their significant others are affected by several transitions. They perform psychological adjustment processes during transformation. This requires strategies for patients and their significant others. Research in German about this theme is missing. Aim: We explored the experiences with illness management during transitions in the last year of life of patients with advanced cancer and their significant others. Method: In this qualitative study, we conducted structured interviews with five dyads, consisting of persons with Karnofsky Index ≥ 60 % and life expectancy of six to twelve months as well as their significant others. To interpret the interviews, we used qualitative content analysis according to Mayring. Results: The main theme “Don't let the world become too small” expresses that limitations diminished the lifeworld and the participants struggled against this process. This is revealed in three categories: “Being shocked by diagnosis – realigning again”, “Bearing limitations and loss – finding new ways in daily life”, “Living in uncertainty – holding out together”. Conclusions: Patients and significant others live in changing lifeworlds caused by transitions. Health care professionals should be attentive and may gain deeper knowledge about transitions. Further research in German-speaking contexts will help to improve nursing care and psychooncological interventions.

The effectiveness of telehealth care on caregiver burden, mastery of stress, and family function among family caregivers of heart failure patients: a quasi-experimental study.

PubMed

Chiang, Li-Chi; Chen, Wan-Chou; Dai, Yu-Tzu; Ho, Yi-Lwun

2012-10-01

Telehealth care was developed to provide home-based monitoring and support for patients with chronic disease. The positive effects on physical outcome have been reported; however, more evidence is required concerning the effects on family caregivers and family function for heart failure patients transitioning from the hospital to home. To evaluate the effectiveness of nursing-led transitional care combining discharge plans and telehealth care on family caregiver burden, stress mastery and family function in family caregivers of heart failure patients compared to those receiving traditional discharge planning only. This is a quasi-experimental study design. Sixty-three patients with heart failure were assessed for eligibility and invited to participate in either telehealth care or standard care in a medical centre from May to October 2010. Three families refused to participate in data collection. Thirty families who chose telehealth care after discharge from the hospital to home comprised the experimental group; the others families receiving discharge planning only comprised the comparison group. Telenursing specialist provided the necessary family nursing interventions by 24-h remote monitoring of patients' health condition and counselling by telephone, helping the family caregivers successfully transition from hospital to home. Data on caregiver burden, stress mastery and family function were collected before discharge from the hospital and one month later at home. Effects of group, time, and group×time interaction were analysed using Mixed Model in SPSS (17.0). Family caregivers in both groups had significantly lower burden, higher stress mastery, and better family function at one-month follow-up compared to before discharge. The total score of caregiver burden, stress mastery and family function was significantly improved for the family caregivers in the experimental group compared to the comparison group at posttest. Two subscales of family function-Relationships between family and subsystems and Relationships between family and society were improved in the experimental group compared to the comparison group, but Relationships between family and family members was not different. The results provide evidence that telehealth care combined with discharge planning could reduce family caregiver burden, improve stress mastery, and improve family function during the first 30 days at home after heart failure patients are discharged from the hospital. Telenursing specialists cared caregivers with the concepts of providing transitional care to help them successful cross the critical transition stage. Copyright © 2012 Elsevier Ltd. All rights reserved.

A Clinical Trial of Translation of Evidence Based Interventions to Mobile Tablets and Illness Specific Internet Sites.

PubMed

Smith, Carol E; Piamjariyakul, Ubolrat; Werkowitch, Marilyn; Yadrich, Donna Macan; Thompson, Noreen; Hooper, Dedrick; Nelson, Eve-Lynn

2016-03-01

This article describes a method to translate an evidence based health care intervention to the mobile environment. This translation assisted patient participants to: avoid life threatening infections; monitor emotions and fatigue; keep involved in healthy activities. The mobile technology also decreased costs by reducing for example travel to visit health care providers. Testing of this translation method and its use by comparison groups of patients adds to the knowledge base for assessing technology for its impact on health outcome measures. The challenges and workflow of designing materials for the mobile format are described. Transitioning clinical trial verified interventions, previously provided in person to patients, onto tablet and internet platforms is an important process that must be evaluated. In this study, our evidence based guide's intravenous (IV) homeCare interventions (IVhomeCare) were delivered via Apple iPad mini™ tablet audiovisual instruction / discussion sessions and on a website. Each iPad audiovisual session (n = 41), included three to five families, a mental health specialist, and healthcare professionals. Patients and their family caregivers readily learned to use the wireless mobile tablets, and the IVhomeCare interventions, as described here, were successfully translated onto these mobile technology platforms. Using Likert scale responses on a questionnaire (1 = not helpful and 5 = very helpful) participants indicated that they gained problem solving skills for home care through iPad group discussion ( M = 4.60, SD = 0.60). The firewall protected videoconferencing in real time with multiple healthcare professionals effectively allowed health history taking and visual inspection of the patient's IV insertion site for signs of infection. Supportive interactions with peer families on videoconferencing were documented during discussions. Discussion topics included low moods, fatigue, infection worry, how to maintain independence, and need for support from others with their same lifelong IV experiences. The visual family interactions, discussions with professionals, and the iPad internet links were highly rated. Mobile distance care delivery can result in saved time and money for both healthcare professionals and families.

A Clinical Trial of Translation of Evidence Based Interventions to Mobile Tablets and Illness Specific Internet Sites

PubMed Central

Smith, Carol E; Piamjariyakul, Ubolrat; Werkowitch, Marilyn; Yadrich, Donna Macan; Thompson, Noreen; Hooper, Dedrick; Nelson, Eve-Lynn

2016-01-01

This article describes a method to translate an evidence based health care intervention to the mobile environment. This translation assisted patient participants to: avoid life threatening infections; monitor emotions and fatigue; keep involved in healthy activities. The mobile technology also decreased costs by reducing for example travel to visit health care providers. Testing of this translation method and its use by comparison groups of patients adds to the knowledge base for assessing technology for its impact on health outcome measures. The challenges and workflow of designing materials for the mobile format are described. Transitioning clinical trial verified interventions, previously provided in person to patients, onto tablet and internet platforms is an important process that must be evaluated. In this study, our evidence based guide’s intravenous (IV) homeCare interventions (IVhomeCare) were delivered via Apple iPad mini™ tablet audiovisual instruction / discussion sessions and on a website. Each iPad audiovisual session (n = 41), included three to five families, a mental health specialist, and healthcare professionals. Patients and their family caregivers readily learned to use the wireless mobile tablets, and the IVhomeCare interventions, as described here, were successfully translated onto these mobile technology platforms. Using Likert scale responses on a questionnaire (1 = not helpful and 5 = very helpful) participants indicated that they gained problem solving skills for home care through iPad group discussion (M = 4.60, SD = 0.60). The firewall protected videoconferencing in real time with multiple healthcare professionals effectively allowed health history taking and visual inspection of the patient’s IV insertion site for signs of infection. Supportive interactions with peer families on videoconferencing were documented during discussions. Discussion topics included low moods, fatigue, infection worry, how to maintain independence, and need for support from others with their same lifelong IV experiences. The visual family interactions, discussions with professionals, and the iPad internet links were highly rated. Mobile distance care delivery can result in saved time and money for both healthcare professionals and families. PMID:27182451

Team-Based Palliative and End-of-Life Care for Heart Failure

PubMed Central

Fendler, Timothy J.; Swetz, Keith M.; Allen, Larry A.

2015-01-01

SYNOPSIS Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is no longer seen as “giving up” or “accepting death,” but is now conceptualized as “supportive care” afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, we will comment on the current state of multidisciplinary care for such patients, explore evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identify high-priority areas for research. Ultimately, patients require a “heart failure medical home”, where various specialties may take a more central role in coordination of patient care at different times in the disease span, sometimes transitioning leadership from primary care to cardiology to palliative care. PMID:26142643

Medical care transition planning and dental care use for youth with special health care needs during the transition from adolescence to young adulthood: a preliminary explanatory model

PubMed Central

Chi, Donald L.

2013-01-01

Objectives To test the hypotheses that youth with special health care needs (YSHCN) with a medical care transition plan are more likely to use dental care during the transition from adolescence to young adulthood and that different factors are associated with dental utilization for YSHCN with and YSHCN without functional limitations. Methods National Survey of CSHCN (2001) and Survey of Adult Transition and Health (2007) data were analyzed (N=1,746). The main predictor variable was having a medical care transition plan, defined as having discussed with a doctor how health care needs might change with age and having developed a transition plan. The outcome variable was dental care use in 2001 (adolescence) and 2007 (young adulthood). Multiple variable Poisson regression models with robust standard errors were used to estimate covariate-adjusted relative risks (RR). Results About 63% of YSHCN had a medical care transition plan and 73.5% utilized dental care. YSHCN with a medical care transition plan had a 9% greater relative risk (RR) of utilizing dental care than YSHCN without a medical care transition plan (RR:1.09; 95% CI:1.03–1.16). In the models stratified by functional limitation status, having a medical care transition plan was significantly associated with dental care use, but only for YSHCN without functional limitations (RR:1.11; 95% CI:1.04–1.18). Conclusions Having a medical care transition plan is significantly associated with dental care use, but only for YSHCN with no functional limitation. Dental care should be an integral part of the comprehensive health care transition planning process for all YSHCN. PMID:23812799

Psychosocial Pathways to Sexually Transmitted Infection (STI) Risk Among Youth Transitioning Out of Foster Care: Evidence from a Longitudinal Cohort Study

PubMed Central

McCarty, Cari; Simoni, Jane; Dworsky, Amy; Courtney, Mark E.

2013-01-01

Purpose To test the fit of a theoretically driven conceptual model of pathways to STI risk among foster youth transitioning to adulthood. The model included: 1) historical abuse and foster care experiences, 2) mental health and attachment style in late adolescence, and 3) STI risk in young adulthood. Methods We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Covariates included gender, race and an inverse probability weight. We also performed moderation analyses comparing models constrained and unconstrained by gender. Results Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Squared Residual of 0.026). Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use. There was also a borderline association with having greater than 5 partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 decreased STI risk. Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models. Conclusions Interventions/policies that: 1) address externalizing trauma sequelae, 2) promote close, stable substitute caregiver relationships, and 3) extend care to age 21 years have the potential to decrease STI risk in this population. PMID:23859955

Towards interruption of schistosomiasis transmission in sub-Saharan Africa: developing an appropriate environmental surveillance framework to guide and to support 'end game' interventions.

PubMed

Stothard, J Russell; Campbell, Suzy J; Osei-Atweneboana, Mike Y; Durant, Timothy; Stanton, Michelle C; Biritwum, Nana-Kwadwo; Rollinson, David; Ombede, Dieudonné R Eloundou; Tchuem-Tchuenté, Louis-Albert

2017-01-14

Schistosomiasis is a waterborne parasitic disease in sub-Saharan Africa, particularly common in rural populations living in impoverished conditions. With the scale-up of preventive chemotherapy, national campaigns will transition from morbidity- to transmission-focused interventions thus formal investigation of actual or expected declines in environmental transmission is needed as 'end game' scenarios arise. Surprisingly, there are no international or national guidelines to do so in sub-Saharan Africa. Our article therefore provides an introduction to key practicalities and pitfalls in the development of an appropriate environmental surveillance framework. In this context, we discuss how strategies need to be adapted and tailored to the local level to better guide and support future interventions through this transition. As detection of egg-patent infection in people becomes rare, careful sampling of schistosome larvae in freshwater and in aquatic snails with robust species-specific DNA assays will be required. Appropriate metrics, derived from observed prevalence(s) as compared with predetermined thresholds, could each provide a clearer insight into contamination- and exposure-related dynamics. Application could be twofold, first to certify areas currently free from schistosomiasis transmission or second to red-flag recalcitrant locations where extra effort or alternative interventions are needed.

Evolution and Initial Experience of a Statewide Care Transitions Quality Improvement Collaborative: Preventing Avoidable Readmissions Together.

PubMed

Axon, R Neal; Cole, Laura; Moonan, Aunyika; Foster, Richard; Cawley, Patrick; Long, Laura; Turley, Christine B

2016-02-01

Increasing scrutiny of hospital readmission rates has spurred a wide variety of quality improvement initiatives. The Preventing Avoidable Readmissions Together (PART) initiative is a statewide quality improvement learning collaborative organized by stakeholder organizations in South Carolina. This descriptive report focused on initial interventions with hospitals. Eligible participants included all acute care hospitals plus home health organizations, nursing facilities, hospices, and other health care organizations. Measures were degree of statewide participation, curricular engagement, adoption of evidence-based improvement strategies, and readmission rate changes. Fifty-nine of 64 (92%) acute care hospitals and 9 of 10 (90%) hospital systems participated in collaborative events. Curricular engagement included: webinars and coaching calls (49/59, 83%), statewide in-person meetings (35/59, 59%), regional in-person meetings (44/59, 75%), and individualized consultations (46/59, 78%). Among 34 (58%) participating hospitals completing a survey at the completion of Year 1, respondents indicated complete implementation of multidisciplinary rounding (58%), post-discharge telephone calls (58%), and teach-back (32%), and implementation in process of high-quality transition records (52%), improved discharge summaries (45%), and timely follow-up appointments (39%). A higher proportion of hospitals had significant decreases (≥10% relative change) in all-cause readmission rates for acute myocardial infarction (55.6% vs. 30.4%, P=0.01), heart failure (54.2% vs. 31.7%, P=0.09), and chronic obstructive pulmonary disease (41.7% vs. 33.3%, P=0.83) between 2011-2013 compared to earlier (2009-2011) trends. Focus on reducing readmissions is driving numerous, sometimes competing, quality improvement initiatives. PART successfully engaged the majority of acute care facilities in one state to harmonize and accelerate adoption of evidence-based care transitions strategies.

Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies.

PubMed

Tremblay, Dominique; Prady, Catherine; Bilodeau, Karine; Touati, Nassera; Chouinard, Maud-Christine; Fortin, Martin; Gaboury, Isabelle; Rodrigue, Jean; L'Italien, Marie-France

2017-12-16

Cancer is now viewed as a chronic disease, presenting challenges to follow-up and survivorship care. Models to shift from haphazard, suboptimal and fragmented episodes of care to an integrated cancer care continuum must be developed, tested and implemented. Numerous studies demonstrate improved care when follow-up is assured by both oncology and primary care providers rather than either group alone. However, there is little data on the roles assumed by specialized oncology teams and primary care providers and the extent to which they work together. This study aims to develop, pilot test and measure outcomes of an innovative risk-based coordinated cancer care model for patients transitioning from specialized oncology teams to primary care providers. This multiple case study using a sequential mixed-methods design rests on a theory-driven realist evaluation approach to understand how transitions might be improved. The cases are two health regions in Quebec, Canada, defined by their geographic territory. Each case includes a Cancer Centre and three Family Medicine Groups selected based on differences in their determining characteristics. Qualitative data will be collected from document review (scientific journal, grey literature, local documentation), semi-directed interviews with key informants, and observation of care coordination practices. Qualitative data will be supplemented with a survey to measure the outcome of the coordinated model among providers (scope of practice, collaboration, relational coordination, leadership) and patients diagnosed with breast, colorectal or prostate cancer (access to care, patient-centredness, communication, self-care, survivorship profile, quality of life). Results from descriptive and regression analyses will be triangulated with thematic analysis of qualitative data. Qualitative, quantitative, and mixed methods data will be interpreted within and across cases in order to identify context-mechanism associations that explain outcomes. The study will provide empirical data on a risk-based coordinated model of cancer care to guide actions at different levels in the health system. This in-depth multiple case study using a realist approach considers both the need for context-specific intervention research and the imperative to address research gaps regarding coordinated models of cancer care.

Developing a Brief Suicide Prevention Intervention and Mobile Phone Application: a Qualitative Report.

PubMed

Kennard, Beth D; Biernesser, Candice; Wolfe, Kristin L; Foxwell, Aleksandra A; Craddock Lee, Simon J; Rial, Katie V; Patel, Sarita; Cheng, Carol; Goldstein, Tina; McMakin, Dana; Blastos, Beatriz; Douaihy, Antoine; Zelazny, Jamie; Brent, David A

2015-10-01

Suicide is the second leading cause of death among youth and has become a serious public health problem. There has been limited research on strategies to decrease the likelihood of reattempt in adolescents. As phase one of a treatment development study, clinicians, parents and adolescents participated in qualitative interviews in order to gain new perspectives on developing a targeted intervention and a safety plan phone application for suicide prevention. Participants indicated that transition of care, specific treatment targets and safety planning were important parts of treatment. In addition, all participants endorsed the use of a smartphone application for these purposes.

Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color.

PubMed

Hill, Brandon J; Crosby, Richard; Bouris, Alida; Brown, Rayna; Bak, Trevor; Rosentel, Kris; VandeVusse, Alicia; Silverman, Michael; Salazar, Laura

2018-03-01

The purpose of this exploratory study was to examine the effects of legal name change on socioeconomic factors, general and transgender-related healthcare access and utilization, and transgender-related victimization in a sample of young transgender women (transwomen) of color. A cross-sectional group comparison approach was used to assess the potential effects of legal name change. A convenience sample of young transwomen enrolled in a no-cost legal name change clinic were recruited to complete a 30-minute interviewer-guided telephone survey including sociodemographic and socioeconomic factors, health and well-being, health care utilization, transgender transition-related health care, and transgender-related victimization. Sixty-five transgender women of color (37 = pre-name change group; 28 = post-name change group) completed the survey. Results indicated that the transwomen in the post-name change group were significantly older than the pre-name change group. In age-adjusted analyses, the post-name change group was significantly more likely to have a higher monthly income and stable housing than the pre-name change group. No significant differences were observed for general healthcare utilization; however, a significantly greater percentage of transwomen in the pre-name change group reported postponing medical care due to their gender identity. In addition, a significantly larger proportion of transwomen in the pre-name change group reported using non-prescribed hormones injected by friends and experiencing verbal harassment by family and friends compared to transwomen in the post-name change group. Findings suggest that legal name change may be an important structural intervention for low-income transwomen of color, providing increased socioeconomic stability and improved access to primary and transition-related health care.

The hepatitis C cascade of care: identifying priorities to improve clinical outcomes.

PubMed

Linas, Benjamin P; Barter, Devra M; Leff, Jared A; Assoumou, Sabrina A; Salomon, Joshua A; Weinstein, Milton C; Kim, Arthur Y; Schackman, Bruce R

2014-01-01

As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals. We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.

The Hepatitis C Cascade of Care: Identifying Priorities to Improve Clinical Outcomes

PubMed Central

Linas, Benjamin P.; Barter, Devra M.; Leff, Jared A.; Assoumou, Sabrina A.; Salomon, Joshua A.; Weinstein, Milton C.; Kim, Arthur Y.; Schackman, Bruce R.

2014-01-01

Background As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them. Methods We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation. Main measures Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs). Results We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals. Conclusions We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points. PMID:24842841

Stressors in Teens with Type 1 Diabetes and Their Parents: Immediate and Long-Term Implications for Transition to Self-Management.

PubMed

Ersig, Anne L; Tsalikian, Eva; Coffey, Julie; Williams, Janet K

2016-01-01

Teens with Type 1 diabetes and their parents experience every day and illness-related stress; however, understanding of how these stressors relate to the transition to adulthood is limited. The purpose of this study was to identify stressors of teens with Type 1 diabetes (T1DM) and their parents related to the impending transition to adulthood. This study used open-ended questions to identify every day and illness-related stressors among 15 teens with T1DM and 25 parents seen in one pediatric diabetes clinic. Qualitative descriptive analysis identified themes in interview transcripts. The primary teen stressor related to impending transition centered on ineffective self-management, often when they were taking over responsibility for T1DM management. Parents' concerns included immediate and long-term negative outcomes of teen self-management as well as financial resources and health insurance for the teen. Teens and parents both expressed specific concerns about outcomes and prevention of nocturnal hypoglycemia, and identified uncertainties related to teen health and diabetes-focused health care when no longer living in the parent's home. Teens with Type 1 diabetes and their parents understand that independent teen self-management is a component of transition to adulthood, but worry about teen self-management outcomes. Concerns specific to health care transition included health insurance, T1DM resources, and teens' abilities to handle new situations. Identifying current and future self-management concerns of individuals and families can facilitate targeted education and interventions to support successful transition to adulthood. Copyright © 2016 Elsevier Inc. All rights reserved.

Primary care and youth mental health in Ireland: qualitative study in deprived urban areas

PubMed Central

2013-01-01

Background Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15–24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people’s unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals’ experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16–25 years) in primary care in deprived urban settings in Ireland. Methods The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres. Results We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care’s longitudinal nature as a key asset in promoting treatment engagement. Conclusions Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people’s experience and developing complex interventions that promote early intervention are priorities. (350 words) PMID:24341616

Universal Health Coverage for Schizophrenia: A Global Mental Health Priority

PubMed Central

Patel, Vikram

2016-01-01

The growing momentum towards a global consensus on universal health coverage, alongside an acknowledgment of the urgency and importance of a comprehensive mental health action plan, offers a unique opportunity for a substantial scale-up of evidence-based interventions and packages of care for a range of mental disorders in all countries. There is a robust evidence base testifying to the effectiveness of drug and psychosocial interventions for people with schizophrenia and to the feasibility, acceptability and cost-effectiveness of the delivery of these interventions through a collaborative care model in low resource settings. While there are a number of barriers to scaling up this evidence, for eg, the finances needed to train and deploy community based workers and the lack of agency for people with schizophrenia, the experiences of some upper middle income countries show that sustained political commitment, allocation of transitional financial resources to develop community services, a commitment to an integrated approach with a strong role for community based institutions and providers, and a progressive realization of coverage are the key ingredients for scale up of services for schizophrenia. PMID:26245942

TRANSFER FROM PEDIATRIC TO ADULT ENDOCRINOLOGY.

PubMed

Jones, Marybeth R; Robbins, Brett W; Augustine, Marilyn; Doyle, Jackie; Mack-Fogg, Jean; Jones, Heather; White, Patience H

2017-07-01

Adult and pediatric endocrinologists share responsibility for the transition of youth with type 1 diabetes from pediatric to adult healthcare. This study aimed to increase successful transfers to adult care in subspecialty practices by establishing a systematic health care transition (HCT) process. Providers from the adult and pediatric endocrinology divisions at the University of Rochester Medical Center met monthly to customize and integrate the Six Core Elements (6CEs) of HCT into clinical workflows. Young adult patients with type 1 diabetes having an outpatient visit during a 34-month pre-post intervention period were eligible (N = 371). Retrospective chart review was performed on patients receiving referrals to adult endocrinology (n = 75) to obtain (1) the proportion of patients explicitly tracked during transfer from the pediatric to adult endocrinology practice, (2) the providers' documentation of the use of the 6CEs, and (3) the patients' diabetes control and healthcare utilization during the transition period. The percent of eligible patients with type 1 diabetes who were explicitly tracked in their transfer more than doubled compared to baseline (11% vs. 27% of eligible patients; P<.01). Pediatric providers started to use transition readiness assessments and create medical summaries, and adult providers increased closed-loop communication with pediatric providers after a patient's first adult visit. Glycemic control and healthcare utilization remained stable. Successful implementation of the 6CEs into pediatric and adult subspecialty practices can result in improvements of planned transfers of pediatric patients with type 1 diabetes to adult subspecialty providers. 6CEs = six core elements; AYA = adolescent and young adult; DKA = diabetic ketoacidosis; ED = emergency department; HbA1c = hemoglobin A1c; HCT = health care transition.

The Healthy Moms Study: the efficacy of brief alcohol intervention in postpartum women.

PubMed

Fleming, Michael F; Lund, Michael R; Wilton, Georgiana; Landry, Mary; Scheets, Dawn

2008-09-01

The prevention and treatment of alcohol use disorders among women of reproductive age have been well described. However, there is limited information on women specifically during the postpartum period. This period in a woman's life is a time of transition and it provides an ideal opportunity for primary care providers to intervene. The goal of this report was to present the results of a brief alcohol intervention conducted in 34 obstetrical practices with women seeking routine postpartum care. A randomized clinical trial was conducted from 2002 to 2005 in a diverse sample of women located in 15 Wisconsin counties. This report presents 6-month follow-up data. A total of 8,706 women were screened for high-risk alcohol use during routine postpartum care with 997 (12%) of these women testing positive for at-risk drinking. A total of 235 women met inclusion criteria and were randomized to either "usual care" or "brief intervention." The 4-session intervention was delivered by outpatient obstetrical nurses and research staff. The mean age of the women in the sample was 28, 19.3% were from minority groups, 60.8% were married, 53.2% reported current tobacco use, and 17.9% had used marijuana in the previous 30 days. At the 6 month follow-up appointment, there were significant reductions in mean number of total drinks in the previous 28 days (p < 0.013), number of drinking days (p < 0.024) and heavy drinking days (p < 0.019). In addition to a statistical difference between groups, there was a 19% difference in the mean number of drinks and number of drinking days, and a 36% difference in the number of heavy drinking days in favor of the intervention group. The findings of the Healthy Moms Trial support the implementation of brief alcohol intervention during the postpartum period.

Navigating the Health Care System: An Adolescent Health Literacy Unit for High Schools.

PubMed

Hughes, Denise; Maiden, Kristin

2018-05-01

Currently, no intervention concerning transition of health care responsibilities from parents to teens exists for adolescents in the general population. The purpose of this intervention was to evaluate teacher satisfaction and student knowledge gain of a health unit developed for adolescents on becoming their own health care advocates. Throughout the 2014-2015 school year, 13 health and career technical education teachers in 11 Delaware high schools taught the unit to 948 students in 2 90-minute classes in 35 classrooms. Assessments included teacher reflections and student pre- and posttests to measure knowledge transfer and gain and gather feedback. Teacher and student feedback indicated the materials were appropriate and useful in teaching students to navigate the health care system. Student knowledge increased from pretest (64%) to posttest (82%), (p < .001). The educational background of the teacher did not influence this outcome. Students reported they will know what to do better at their next doctor's appointment because of this unit and indicated support for peers to learn this information. The unit resulted in content knowledge increase for students. It was consistently effective throughout all schools regardless of social and demographic characteristics, teacher type, or experience teaching the unit. © 2018, American School Health Association.

From Adversary to Partner: Have Quality Improvement Organizations Made the Transition?

PubMed Central

Bradley, Elizabeth H; Carlson, Melissa DA; Gallo, William T; Scinto, Jeanne; Campbell, Miriam K; Krumholz, Harlan M

2005-01-01

Objective To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. Data Source Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. Study Design We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. Principle Findings More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. Conclusions Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians. PMID:15762902

The menopause transition experiences of Chinese Singaporean women: an exploratory qualitative study.

PubMed

Lim, Hui-Koon; Mackey, Sandra

2012-06-01

Menopause, a developmental occurrence that takes place in midlife, marks the end of a woman's fertile phase. Cultural norms, social influences, and personal perceptions related to menopause may influence its meaning and how each woman experiences this transition. Little is known about the menopausal experiences of Asian women. This study explores the menopause transition experiences of ethnic Chinese women in Singapore. Using a qualitative design, the researchers conducted audio-taped interviews in 2010 with 14 menopausal and postmenopausal Chinese Singaporean women aged 40-60 years. Thematic analysis was used to analyze interviews. Two main themes were identified: (a) experiencing symptoms and (b) managing symptoms during menopause transition. The most commonly reported symptoms were abnormal bleeding, hot flushes, and emotional changes. Most participants described their transition to be uneventful and ordinary and reported two significant symptoms at most. The strategies women used to manage their transition included using Western and traditional Chinese medical interventions and seeking support from family and friends. This study provides new insights into how ethnic Chinese women in Singapore experience menopause transition. Findings can assist nurses and healthcare workers in the local context to better understand menopausal women's needs and guide nurses to implement suitable health promotional strategies for women under their care in both hospital and community settings. Although ethnicity is not necessarily a determinant of symptom experience during menopause transition, health education for menopausal women should be based on knowledge of culture-specific practices. Nurses caring for menopausal women in hospital and community settings in Singapore should evaluate the use of medications prescribed by Western and Chinese herbal medical professionals as well as those that are self-prescribed.

Differential effect of a patient-education transition intervention in adolescents with IBD vs. diabetes.

PubMed

Schmidt, Silke; Markwart, Henriette; Bomba, Franziska; Muehlan, Holger; Findeisen, Annette; Kohl, Martina; Menrath, Ingo; Thyen, Ute

2018-04-01

Patient education programs (PEPs) to improve disease management are part of standard and regular treatment in adolescents with diabetes. In Germany, youth with inflammatory bowel disease (IBD) receive individual counseling but not PEPs in group settings. Generic PEPs have been developed in order to improve transition from child-centered to adolescent health services. The aim of the study was to investigate the effects of a transition-oriented PEP on quality of life (QoL) and self-management in young patients with IBD (PEP naive), compared to patients with diabetes (familiar with PEPs). A 2-day transition workshop was oriented at improving psychosocial skills and addressed both generic as well as specific aspects of the condition. A controlled trial on the outcomes of a generic transition-oriented PEP was conducted in 14- to 20-year-old patients with IBD (n = 99) and diabetes (n = 153). Transition competence and QoL were assessed at baseline and 6-month follow-up. Results show that the intervention lead to a significant increase in QoL only in patients with IBD. The PEP significantly improved transition competence in both groups, however to a higher extent in subjects with IBD. Transition-oriented PEPs can have differential effects in different patient groups. However, this needs further longitudinal investigations. What is Known: • To date, evidence has accumulated concerning the effectiveness of patient education programs (PEPs) in pediatric health care for chronic conditions such as type 1 diabetes, asthma, atopic dermatitis, or obesity but is less documented in inflammatory bowel disease (IBD). In particular, PEPs in the transition period have not been investigated in youth with IBD. • The current study focuses on evaluating a PEP for transition preparation and management designed to be generically used across different chronic conditions since many aspects of managing chronic conditions share commonalities across conditions. The 2-day workshop included condition-specific modules adapted to the specific medical needs but was otherwise similar in quality and organization among different conditions. What is New: • The transition-oriented PEP was effective in enhancing self-management and transition management skills in both patients with IBD and diabetes; however, effects were higher in youth with IBD. A significant impact of the intervention on patients' QoL compared to the control group was only identified in youth with IBD. • We recommend that patients with IBD have access to PEP as a standard treatment as well as to a transition program during the course of illness.

The impact of care management information technology model on quality of care after percutaneous coronary intervention: "Bridging the Divides".

PubMed

Weintraub, William S; Fanari, Zaher; Elliott, Daniel; Ostertag-Stretch, Jennifer; Muther, Ann; Lynahan, Margaret; Kerzner, Roger; Salam, Tabassum; Scherrer, Herbert; Anderson, Sharon; Russo, Carla A; Kolm, Paul; Steinberg, Terri H

2017-07-03

Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions. CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care. The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community. Copyright © 2017 Elsevier Inc. All rights reserved.

Exposing Baccalaureate Nursing Students to Transitional Care.

PubMed

OʼConnor, Melissa; Arcamone, Angelina; Amorim, Frances; Hoban, Mary Beth; Boyd, Regina M; Fowler, Lauren; Marcelli, Theresa; Smith, Jacalyn; Nassar, Kathleen; Fitzpatrick, M Louise

2016-10-01

Management and facilitation of care transitions from hospital to alternative settings requires skill and attention to avoid adverse events. Several interprofessional organizations and nurse leaders have called for the expansion and redesign of undergraduate nursing curricula to include care transitions. Yet there is little evidence describing how undergraduate baccalaureate nursing students are educated on this critical topic or how successful they are in improving student knowledge about care transitions. To address this gap, an in-classroom and clinical experience was implemented to prepare students to manage and facilitate care transitions from the hospital to alternative settings-including the home. Perceptions of undergraduate nursing students and home healthcare nurse preceptors were assessed via an electronic survey that was emailed to participants. Forty-eight responses to the survey were received. Students agreed this experience contributed to their understanding of caring for adults and older adults who are experiencing a care transition and they had a good understanding of care transitions to apply to their future nursing courses. Home healthcare nurse preceptors agreed they were able to demonstrate transitional care and that students were engaged. Future work should include expanding transitional care immersion to other care settings as well as the inclusion of additional healthcare disciplines in care transition education.

Leaving Homelessness Behind: Housing Decisions among Families Exiting Shelter1

PubMed Central

Fisher, Benjamin W.; Mayberry, Lindsay; Shinn, Marybeth; Khadduri, Jill

2014-01-01

Because homelessness assistance programs are designed to help families, it is important for policymakers and practitioners to understand how families experiencing homelessness make housing decisions, particularly when they decide not to use available services. This study explores those decisions using in-depth qualitative interviews with 80 families recruited in shelters across four sites approximately six months after they were assigned to one of four conditions (permanent housing subsidies, project-based transitional housing, community-based rapid re-housing, and usual care). Familiar neighborhoods near children’s schools, transportation, family and friends, and stability were important to families across conditions. Program restrictions on eligibility constrained family choices. Subsidized housing was the most desired intervention and families leased up at higher rates than in other studies of poor families. Respondents were least comfortable in and most likely to leave transitional housing. Uncertainty associated with community-based rapid re-housing generated considerable anxiety. Across interventions, many families had to make unhappy compromises, often leading to further moves. Policy recommendations are offered. PMID:25258503

Alcohol withdrawal management in adult patients in a high acuity medical surgical transitional care unit: a best practice implementation project.

PubMed

Sukhenko, Olga

2016-01-15

Excessive alcohol consumption, a major health problem worldwide, affects about 6% of the United States population. Caring for patients with alcohol withdrawal syndrome in a hospital ward presents complex physiologic and psycho-social challenges which are best met with evidence-based practices. An academic medical center in the United States has been experiencing an increase in patients with alcohol withdrawal syndrome. However, gaps in clinician knowledge and infrastructure supporting the management of these patients still existed. The aim of this project was to improve the continuity of care of patients undergoing alcohol withdrawal in a medical surgical high acuity transitional care unit by incorporating evidence-based practices, and thereby to positively impact on patient outcomes. Specific objectives were related to standardized assessments and pharmacologic management strategies. The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting change in health practice. A baseline clinical audit was conducted to assess compliance with best practices for managing alcohol withdrawal syndrome, which was followed by several interventions targeted at nurses and providers. A follow-up audit was conducted to assess compliance with the implemented strategies. The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. A non-probabilistic, convenience sampling approach was used. A sample size of 15 patients was used for both the baseline and follow-up audits. The baseline audit revealed a high compliance rate for four of the five audit criteria concerning risk assessment and pharmacologic strategies. There was sub-optimal compliance (53%) with the criterion regarding use of the Clinical Institute Withdrawal Assessment of Alcohol Scale (revised) (CIWA-Ar) scale to assess patients with alcohol withdrawal. After the interventions were implemented this criterion recorded an improvement to 100% compliance. None of the patients in the pilot were transferred to the intensive care unit (ICU) for reasons relating to alcohol withdrawal. The outcomes of this project demonstrated alcohol withdrawal management can be safely undertaken outside the ICU when the patients are appropriately assessed and treated for the severity of their withdrawal symptoms. This new clinical program significantly impacted on continuity of care. Challenges were resolved using an interdisciplinary team approach. The project resulted in plans for further areas of work concerning alcohol withdrawal management, including adoption of similar approaches by other acute and transitional care units. The Joanna Briggs Institute.

Safety threats and opportunities to improve interfacility care transitions: insights from patients and family members.

PubMed

Jeffs, Lianne; Kitto, Simon; Merkley, Jane; Lyons, Renee F; Bell, Chaim M

2012-01-01

To explore patients' and family members' perspectives on how safety threats are detected and managed across care transitions and strategies that improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. Poorly executed care transitions can result in additional health care spending due to adverse outcomes and delays as patients wait to transfer from acute care to facilities providing different levels of care. Patients and their families play an integral role in ensuring they receive safe care, as they are the one constant in care transitions processes. However, patients' and family members' perspectives on how safety threats are detected and managed across care transitions from health care facility to health care facility remain poorly understood. This qualitative study used semistructured interviews with patients (15) and family members (seven) who were transferred from an acute care hospital to a complex continuing care/rehabilitation care facility. Data were analyzed using a directed content analytical approach. OUR RESULTS REVEALED THREE KEY OVERARCHING THEMES IN THE PERCEPTIONS: lacking information, getting "funneled through" too soon, and difficulty adjusting to the shift from total care to almost self-care. Several patients and families described their expectations and experiences associated with their interfacility care transitions as being uninformed about their transfer or that transfer happened too early. In addition, study participants identified the need for having a coordinated approach to care transitions that engages patients and family members. Study findings provide patients' and family members' perspectives on key safety threats and how to improve care transitions. Of particular importance is the need for patients and family members to play a more active role in their care transition planning and self-care management.

Reducing hospital readmission through team-based primary care: A 7-week pilot study integrating behavioral health and pharmacy.

PubMed

DeCaporale-Ryan, Lauren N; Ahmed-Sarwar, Nabila; Upham, Robbyn; Mahler, Karen; Lashway, Katie

2017-06-01

A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients' mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model. Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems' costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Transitional Care for Older Adults with Chronic Illnesses as a Vulnerable Population: Theoretical Framework and Future Directions in Nursing.

PubMed

Son, Youn Jung; You, Mi Ae

2015-12-01

Effective transitional care is needed to improve the quality of life in older adult patients with chronic illness and avoid discontinuity of care and adverse events. The aim of this article is to provide an overview of the key features, broader implications, and the utility of Meleis' transition theory intended for the transitional care of older adults with chronic illnesses. We present the role of nurse in the context of transitional care and propose future directions to increase the quality of nursing care. The online databases Cumulative Index of Nursing and Allied Health Literature, MEDLINE, and Science Direct were searched for relevant literature published since 1970 along with textbooks regarding nursing theory. An evaluation of the usefulness of transition theory based on transitional care in older adult patients with chronic illnesses is provided. Healthy transition should be the expected standard of nursing care for older adults across all healthcare settings. Nurses need to contribute to the development of transitional care for vulnerable populations; however, transition theory needs to be enhanced through additional theoretical work and repeated evaluations of the applicability in areas of transitional care.

'The horse has bolted I suspect': A qualitative study of clinicians' attitudes and perceptions regarding palliative rehabilitation.

PubMed

Runacres, Fiona; Gregory, Heidi; Ugalde, Anna

2017-07-01

Palliative care patients have numerous rehabilitation needs that increase with disease progression. Palliative rehabilitation practices and perceptions of palliative medicine physicians towards the role of rehabilitation are largely unstudied. To explore palliative medicine physicians' attitudes and perceptions towards rehabilitation delivered within inpatient palliative care units. Qualitative study utilizing semi-structured interviews. Transcribed interviews were analysed using thematic analysis and major themes reported as results. Australian palliative medicine physicians working in inpatient palliative care units. In total, 20 physicians participated, representing specialist palliative care services across Australia. A total of 11 (55%) were males with an average of 12.5 years' experience working in palliative care. Most participants believed rehabilitation was an important aspect of palliative care; however, few felt adequate rehabilitation programmes were available. Participants varied in their concepts of what palliative rehabilitation entailed. The term rehabilitation was seen by some as helpful (fostering hope and aiding transitions) and by others to be misleading (creating unrealistic expectations). Four key themes emerged when describing physicians' attitudes, including (1) integrating rehabilitation within palliative care, (2) the intervention, (3) possibilities and (4) the message of rehabilitation. A lack of consensus exists among palliative medicine specialists regarding the definition and scope of palliative rehabilitation. Participants generally expressed a wish to offer enhanced rehabilitation interventions, however described resource and skill-set limitations as significant barriers. Further research is required to establish an evidence base for palliative rehabilitation, to support its acceptance and widespread integration within specialist inpatient palliative care.

4th generation HIV screening in Massachusetts: a partnership between laboratory and program.

PubMed

Goodhue, Tammy; Kazianis, Arthur; Werner, Barbara G; Stiles, Tracy; Callis, Barry P; Dawn Fukuda, H; Cranston, Kevin

2013-12-01

The Massachusetts Department of Public Health's (MDPH) Office of HIV/AIDS (OHA) and Hinton State Laboratory Institute (HSLI) have offered HIV screening since 1985. Point-of-care screening and serum collection for laboratory-based testing is conducted at clinic and non-clinic-based sites across Massachusetts as part of an integrated communicable disease screening intervention. MDPH aimed to transition to a 4th generation HIV screening-based algorithm for testing all serum specimens collected at OHA-funded programs and submitted to the HSLI to detect acute HIV infections, detect and differentiate HIV-1 and HIV-2 infections, eliminate indeterminate results, reduce cost and turnaround time, and link newly diagnosed HIV+ individuals to care. The HSLI and OHA created a joint project management team to plan and lead the transition. The laboratory transitioned successfully to a 4th generation screening assay as part of a revised diagnostic algorithm. In the 12 months since implementation, a total of 7984 serum specimens were tested with 258 (3.2%) positive for HIV-1 and one positive for HIV-2. Eight were reported as acute HIV-1 infections. These individuals were linked to medical care and partner services in a timely manner. Turnaround time was reduced and the laboratory realized an overall cost savings of approximately 15%. The identification of eight acute HIV infections in the first year underscores the importance of using the most sensitive screening tests available. A multi-disciplinary program and laboratory team was critical to the success of the transition, and the lessons learned may be useful for other jurisdictions. Published by Elsevier B.V.

Stakeholders' Voices: Defining Needs of Students with Emotional and Behavioral Disorders Transitioning between School Settings.

PubMed

Buchanan, Rohanna; Nese, Rhonda N T; Clark, Miriam

2016-05-01

Students with emotional and behavioral disorders (EBD) too often do not receive adequate services or care in their school settings, particularly during transitions in educational placements. In addition, school support teams often struggle with creating transition plans that honor the needs of students with input from key stakeholders responsible for supporting student success. This article presents findings from the information-gathering phase of an iterative project that aims to develop a support program for students with EBD transitioning from day-treatment schools to district schools. We conducted 5 semistructured, qualitative focus groups with parents and teachers to explore needs during students' transitions between school settings. Five themes emerged from the focus groups: (a) consistent, behavior-specific feedback and positive reinforcement are vital to sustaining learned prosocial skills; (b) students benefit from regular opportunities to learn and practice social skills; (c) transition programming should emphasize communication between school and home; (d) routines at home and school should be coordinated; and (e) parents need support at school meetings. We will use findings from this study to develop a multifaceted intervention that aims to support students, their caregivers, and their teachers during transitions between the aforementioned types of schools.

Stakeholders’ Voices: Defining Needs of Students with Emotional and Behavioral Disorders Transitioning between School Settings

PubMed Central

Buchanan, Rohanna; Nese, Rhonda N. T.; Clark, Miriam

2017-01-01

Students with emotional and behavioral disorders (EBD) too often do not receive adequate services or care in their school settings, particularly during transitions in educational placements. In addition, school support teams often struggle with creating transition plans that honor the needs of students with input from key stakeholders responsible for supporting student success. This article presents findings from the information-gathering phase of an iterative project that aims to develop a support program for students with EBD transitioning from day-treatment schools to district schools. We conducted 5 semistructured, qualitative focus groups with parents and teachers to explore needs during students’ transitions between school settings. Five themes emerged from the focus groups: (a) consistent, behavior-specific feedback and positive reinforcement are vital to sustaining learned prosocial skills; (b) students benefit from regular opportunities to learn and practice social skills; (c) transition programming should emphasize communication between school and home; (d) routines at home and school should be coordinated; and (e) parents need support at school meetings. We will use findings from this study to develop a multifaceted intervention that aims to support students, their caregivers, and their teachers during transitions between the aforementioned types of schools. PMID:29706679

Mental health challenges among adolescents living with HIV.

PubMed

Vreeman, Rachel C; McCoy, Brittany M; Lee, Sonia

2017-05-16

Mental health is a critical and neglected global health challenge for adolescents infected with HIV. The prevalence of mental and behavioural health issues among HIV-infected adolescents may not be well understood or addressed as the world scales up HIV prevention and treatment for adolescents. The objective of this narrative review is to assess the current literature related to mental health challenges faced by adolescents living with HIV, including access to mental health services, the role of mental health challenges during transition from paediatric to adult care services and responsibilities, and the impact of mental health interventions. For each of the topics included in this review, individual searches were run using Medline and PubMed, accompanied by scans of bibliographies of relevant articles. The topics on which searches were conducted for HIV-infected adolescents include depression and anxiety, transition from paediatric to adult HIV care and its impact on adherence and mental health, HIV-related, mental health services and interventions, and the measurement of mental health problems. Articles were included if the focus was consistent with one of the identified topics, involved HIV-infected adolescents, and was published in English. Mental and behavioural health challenges are prevalent in HIV-infected adolescents, including in resource-limited settings where most of them live, and they impact all aspects of HIV prevention and treatment. Too little has been done to measure the impact of mental health challenges for adolescents living with HIV, to evaluate interventions to best sustain or improve the mental health of this population, or to create healthcare systems with personnel or resources to promote mental health. Mental health issues should be addressed proactively during adolescence for all HIV-infected youth. In addition, care systems need to pay greater attention to how mental health support is integrated into the care management for HIV, particularly throughout lifespan changes from childhood to adolescence to adulthood. The lack of research and support for mental health needs in resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed.

Mental health challenges among adolescents living with HIV

PubMed Central

Vreeman, Rachel C.; McCoy, Brittany M.; Lee, Sonia

2017-01-01

Abstract Introduction: Mental health is a critical and neglected global health challenge for adolescents infected with HIV. The prevalence of mental and behavioural health issues among HIV-infected adolescents may not be well understood or addressed as the world scales up HIV prevention and treatment for adolescents. The objective of this narrative review is to assess the current literature related to mental health challenges faced by adolescents living with HIV, including access to mental health services, the role of mental health challenges during transition from paediatric to adult care services and responsibilities, and the impact of mental health interventions. Methods: For each of the topics included in this review, individual searches were run using Medline and PubMed, accompanied by scans of bibliographies of relevant articles. The topics on which searches were conducted for HIV-infected adolescents include depression and anxiety, transition from paediatric to adult HIV care and its impact on adherence and mental health, HIV-related, mental health services and interventions, and the measurement of mental health problems. Articles were included if the focus was consistent with one of the identified topics, involved HIV-infected adolescents, and was published in English. Results and Discussion: Mental and behavioural health challenges are prevalent in HIV-infected adolescents, including in resource-limited settings where most of them live, and they impact all aspects of HIV prevention and treatment. Too little has been done to measure the impact of mental health challenges for adolescents living with HIV, to evaluate interventions to best sustain or improve the mental health of this population, or to create healthcare systems with personnel or resources to promote mental health. Conclusions: Mental health issues should be addressed proactively during adolescence for all HIV-infected youth. In addition, care systems need to pay greater attention to how mental health support is integrated into the care management for HIV, particularly throughout lifespan changes from childhood to adolescence to adulthood. The lack of research and support for mental health needs in resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed. PMID:28530045

A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes.

PubMed

Donovan, Jennifer L; Kanaan, Abir O; Gurwitz, Jerry H; Tjia, Jennifer; Cutrona, Sarah L; Garber, Lawrence; Preusse, Peggy; Field, Terry S

2016-04-01

Older adults are often transferred from hospitals to skilled nursing facilities (SNFs) for post-acute care. Patients may be at risk for adverse outcomes after SNF discharges, but little research has focused on this period. Assessment of the feasibility of a transitional care intervention based on a combination of manual information transmission and health information technology to provide automated alert messages to primary care physicians and staff; pre-post analysis to assess potential impact. A multispecialty group practice. Adults aged 65 and older, discharged from SNFs to home; comparison group drawn from SNF discharges during the previous 1.5 years, matched on facility, patient age, and sex. For the pre-post analysis, we tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days. The intervention was developed and implemented with manual transmission of information between 8 SNFs and the group practice followed by entry into the electronic health record. The process required a 5-day delay during which a large portion of the adverse events occurred. Over a 1-year period, automated alert messages were delivered to physicians and staff for the 313 eligible patients discharged from the 8 SNFs to home. We compared outcomes to those of individually matched discharges from the previous 1.5 years and found similar percentages with 30-day rehospitalizations (31% vs 30%, adjusted HR 1.06, 95% CI 0.80-1.4). Within the adverse drug event (ADE) study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days. Older adults discharged from SNFs are at high risk of adverse outcomes immediately following discharge. Simply providing alerts to outpatient physicians, especially if delivered multiple days after discharge, is unlikely to have any impact on reducing these rates. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Comparative effectiveness of post-discharge interventions for hospitalized smokers: study protocol for a randomized controlled trial

PubMed Central

2012-01-01

Background A hospital admission offers smokers an opportunity to quit. Smoking cessation counseling provided in the hospital is effective, but only if it continues for more than one month after discharge. Providing smoking cessation medication at discharge may add benefit to counseling. A major barrier to translating this research into clinical practice is sustaining treatment during the transition to outpatient care. An evidence-based, practical, cost-effective model that facilitates the continuation of tobacco treatment after discharge is needed. This paper describes the design of a comparative effectiveness trial testing a hospital-initiated intervention against standard care. Methods/design A two-arm randomized controlled trial compares the effectiveness of standard post-discharge care with a multi-component smoking cessation intervention provided for three months after discharge. Current smokers admitted to Massachusetts General Hospital who receive bedside smoking cessation counseling, intend to quit after discharge and are willing to consider smoking cessation medication are eligible. Study participants are recruited following the hospital counseling visit and randomly assigned to receive Standard Care or Extended Care after hospital discharge. Standard Care includes a recommendation for a smoking cessation medication and information about community resources. Extended Care includes up to three months of free FDA-approved smoking cessation medication and five proactive computerized telephone calls that use interactive voice response technology to provide tailored motivational messages, offer additional live telephone counseling calls from a smoking cessation counselor, and facilitate medication refills. Outcomes are assessed at one, three, and six months after hospital discharge. The primary outcomes are self-reported and validated seven-day point prevalence tobacco abstinence at six months. Other outcomes include short-term and sustained smoking cessation, post-discharge utilization of smoking cessation treatment, hospital readmissions and emergency room visits, and program cost per quit. Discussion This study tests a disseminable smoking intervention model for hospitalized smokers. If effective and widely adopted, it could help to reduce population smoking rates and thereby reduce tobacco-related mortality, morbidity, and health care costs. Trial registration United States Clinical Trials Registry NCT01177176. PMID:22852832

A systematic review of the cost and cost-effectiveness of electronic discharge communications

PubMed Central

Sevick, Laura K; Esmail, Rosmin; Tang, Karen; Lorenzetti, Diane L; Ronksley, Paul; James, Matthew; Santana, Maria; Ghali, William A; Clement, Fiona

2017-01-01

Background The transition between acute care and community care can be a vulnerable period in a patients’ treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. Objective To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. Methods We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. Results One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. Discussion Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care. PMID:28674136

Clinical care of adult Turner syndrome--new aspects.

PubMed

Trolle, Christian; Mortensen, Kristian Havmand; Hjerrild, Britta E; Cleemann, Line; Gravholt, Claus H

2012-05-01

Turner syndrome (TS) is characterized by numerous medical challenges during adolescence and adulthood. Puberty has to be induced in most cases, and female sex hormone replacement therapy (HRT) should continue during adult years. These issues are normally dealt with by the paediatrician, but once a TS female enters adulthood it is less clear who should be the primary care giver. Morbidity and mortality is increased, especially due to the risk of dissection of the aorta and other cardiovascular diseases, as well as the risk of type 2 diabetes, hypertension, osteoporosis, thyroid disease and other diseases. The proper dose of HRT with female sex steroids has not been established, and, likewise, benefits and/or drawbacks from HRT have not been thoroughly evaluated. The transition period from paediatric to adult care seems to be especially vulnerable and the proper framework for transition has not yet been established. Likewise, no framework is in place for continuous follow-up during adult years in many countries. Today, most treatment recommendations are based on expert opinion and are unfortunately not evidence based, although more areas, such as growth hormone and oxandrolone treatment for increasing height, are becoming well founded. Osteoporosis, diabetes, both type 1 and 2, hypothyroidism, obesity and a host of other endocrine diseases and conditions are seen more frequently in TS. Prevention, intervention and proper treatment is only just being recognized. Hypertension is frequent and can be a forerunner of cardiovascular disease. The description of adult life with TS has been broadened and medical, social and psychological aspects are being added at a compelling pace. Proper care during adulthood should be studied and a framework for care should be in place, since most morbidity potentially is amenable to intervention. In summary, TS is a condition associated with a number of diseases and conditions which need the attention of a multi-disciplinary team during adulthood.

Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial.

PubMed

Richter, Kimber P; Faseru, Babalola; Mussulman, Laura M; Ellerbeck, Edward F; Shireman, Theresa I; Hunt, Jamie J; Carlini, Beatriz H; Preacher, Kristopher J; Ayars, Candace L; Cook, David J

2012-08-01

Post-discharge support is a key component of effective treatment for hospitalized smokers, but few hospitals provide it. Many hospitals and care settings fax-refer smokers to quitlines for follow-up; however, less than half of fax-referred smokers are successfully contacted and enrolled in quitline services. "Warm handoff" is a novel approach to care transitions in which health care providers directly link patients with substance abuse problems with specialists, using face-to-face or phone transfer. Warm handoff achieves very high rates of treatment enrollment for these vulnerable groups. The aim of this study-"EQUIP" (Enhancing Quitline Utilization among In-Patients)-is to determine the effectiveness, and cost-effectiveness, of warm handoff versus fax referral for linking hospitalized smokers with tobacco quitlines. This study employs a two-arm, individually randomized design. It is set in two large Kansas hospitals that have dedicated tobacco treatment interventionists on staff. At each site, smokers who wish to remain abstinent after discharge will be randomly assigned to groups. For patients in the fax group, staff will provide standard in-hospital intervention and will fax-refer patients to the state tobacco quitline for counseling post-discharge. For patients in the warm handoff group, staff will provide brief in-hospital intervention and immediate warm handoff: staff will call the state quitline, notify them that a warm handoff inpatient from Kansas is on the line, then transfer the call to the patients' mobile or bedside hospital phone for quitline enrollment and an initial counseling session. Following the quitline session, hospital staff provides a brief check-back visit. Outcome measures will be assessed at 1, 6, and 12 months post enrollment. Costs are measured to support cost-effectiveness analyses. We hypothesize that warm handoff, compared to fax referral, will improve care transitions for tobacco treatment, enroll more participants in quitline services, and lead to higher quit rates. We also hypothesize that warm handoff will be more cost-effective from a societal perspective. If successful, this project offers a low-cost solution for more efficiently linking millions of hospitalized smokers with effective outpatient treatment-smokers that might otherwise be lost in the transition to outpatient care. Clinical Trials Registration NCT01305928.

Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol.

PubMed

Low, Lian Leng; Maulod, Adlina; Lee, Kheng Hock

2017-10-08

Poorer health outcomes and disproportionate healthcare use in socioeconomically disadvantaged patients is well established. However, there is sparse literature on effective integrated care interventions that specifically target these high-risk individuals. The Integrated Community of Care (ICoC) is a novel care model that integrates hospital-based transitional care with health and social care in the community for high-risk individuals living in socially deprived communities. This study aims to evaluate the effectiveness of the ICoC in reducing acute hospital use and investigate the implementation process and its effects on clinical outcomes using a mixed-methods participatory action research (PAR) approach. This is a single-centre prospective, controlled, observational study performed in the SingHealth Regional Health System. A total of 250 eligible patients from an urbanised low-income community in Singapore will be enrolled during their index hospitalisation. Our PAR model combines two research components: quantitative and qualitative, at different phases of the intervention. Outcomes of acute hospital use and health-related quality of life are compared with controls, at 30 days and 1 year. The qualitative study aims at developing a more context-specific social ecological model of health behaviour. This model will identify how influences within one's social environment: individual, interpersonal, organisational, community and policy factors affect people's experiences and behaviours during care transitions from hospital to home. Knowledge on the operational aspects of ICoC will enrich our evidence-based strategies to understand the impact of the ICoC. The blending of qualitative and quantitative mixed methods recognises the dynamic implementation processes as well as the complex and evolving needs of community stakeholders in shaping outcomes. Ethics approval was granted by the SingHealth Centralised Institutional Review Board (CIRB 2015/2277). The findings from this study will be disseminated by publications in peer-reviewed journals, scientific meetings and presentations to government policy-makers. NCT02678273. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol

PubMed Central

Maulod, Adlina; Lee, Kheng Hock

2017-01-01

Introduction Poorer health outcomes and disproportionate healthcare use in socioeconomically disadvantaged patients is well established. However, there is sparse literature on effective integrated care interventions that specifically target these high-risk individuals. The Integrated Community of Care (ICoC) is a novel care model that integrates hospital-based transitional care with health and social care in the community for high-risk individuals living in socially deprived communities. This study aims to evaluate the effectiveness of the ICoC in reducing acute hospital use and investigate the implementation process and its effects on clinical outcomes using a mixed-methods participatory action research (PAR) approach. Methods and analysis This is a single-centre prospective, controlled, observational study performed in the SingHealth Regional Health System. A total of 250 eligible patients from an urbanised low-income community in Singapore will be enrolled during their index hospitalisation. Our PAR model combines two research components: quantitative and qualitative, at different phases of the intervention. Outcomes of acute hospital use and health-related quality of life are compared with controls, at 30 days and 1 year. The qualitative study aims at developing a more context-specific social ecological model of health behaviour. This model will identify how influences within one’s social environment: individual, interpersonal, organisational, community and policy factors affect people’s experiences and behaviours during care transitions from hospital to home. Knowledge on the operational aspects of ICoC will enrich our evidence-based strategies to understand the impact of the ICoC. The blending of qualitative and quantitative mixed methods recognises the dynamic implementation processes as well as the complex and evolving needs of community stakeholders in shaping outcomes. Ethics and dissemination Ethics approval was granted by the SingHealth Centralised Institutional Review Board (CIRB 2015/2277). The findings from this study will be disseminated by publications in peer-reviewed journals, scientific meetings and presentations to government policy-makers. Trial registration number NCT02678273 PMID:28993391

Evolutionary transitions in parental care and live bearing in vertebrates.

PubMed Central

Reynolds, John D; Goodwin, Nicholas B; Freckleton, Robert P

2002-01-01

We provide the first review of phylogenetic transitions in parental care and live bearing for a wide variety of vertebrates. This includes new analyses of both numbers of transitions and transition probabilities. These reveal numerous transitions by shorebirds and anurans toward uniparental care by either sex. Whereas most or all of the shorebird transitions were from biparental care, nearly all of the anuran transitions have been from no care, reflecting the prevalence of each form of care in basal lineages in each group. Teleost (bony) fishes are similar to anurans in displaying numerous transitions toward uniparental contributions by each sex. Whereas cichlid fishes have often evolved from biparental care to female care, other teleosts have usually switched from no care to male care. Taxa that have evolved exclusive male care without courtship-role reversal are characterized by male territoriality and low costs of care per brood. Males may therefore benefit from care through female preference of parental ability in these species. Primates show a high frequency of transitions from female care to biparental care, reflecting the prevalence of female care in basal lineages. In the numerous taxa that display live bearing by females, including teleosts, elasmobranchs, squamate reptiles and invertebrates, we find that live bearing has always evolved from a lack of care. Although the transition counts and probabilities will undoubtedly be refined as phylogenetic information and methodologies improve, the overall biases in these taxa should help to place adaptive hypotheses for the evolution of care into a stronger setting for understanding directions of change. PMID:11958696

Parent education interventions designed to support the transition to parenthood: A realist review.

PubMed

Gilmer, Cyndi; Buchan, Judy L; Letourneau, Nicole; Bennett, Claudine T; Shanker, Stuart G; Fenwick, Anne; Smith-Chant, Brenda

2016-07-01

Public health nurses use parent education programmes to support individuals' transition to parenthood. A wide array of these programmes exists; however, the approach must be accommodated by resources available in a publicly funded system. For example, some new-parent education approaches use 1:1 home visiting (with a nurse or trained lay-home visitor) but the costs of this intensive approach can be prohibitive. Because of this limitation there is an interest in identifying effective and efficient new parent educational approaches that can realistically be provided at a universal level. Unfortunately, there is a lack of high-quality evaluation identifying programmes or educational processes that meet these criteria. To identify potentially effective new-parenting education interventions that could be implemented at a population level during the transition to parenthood period. Realist synthesis. Medline, CINAHL, ERIC, PsycINFO, Sociological Abstracts, grey literature. A realist review method generated a total of 72 papers that were used to inform the results. A three-pronged approach was used incorporating an initial search (6), a database search using applicable keywords and MeSH headings (58), and review of literature identified by advisory group (8 grey literature). An 'implementation chain' was developed to outline the overall logic and process behind parent education interventions and to guide the analysis. Seventy-two papers informed this review: 13 systematic reviews/meta-analyses, 34 intervention studies, 9 opinion papers, 8 programme reviews, and 8 grey literature reports. There was no compelling evidence to suggest that a single educational programme or delivery format was effective at a universal level. Some inherent issues were identified. For example, adult learning principles were overlooked and theories of parent-child interaction were not in evidence. No direct links between universal new-parent education programmes and child development outcomes were established. Programme reach and attrition were key challenges. Programme evaluation criteria were inconsistent, with an over-reliance on parent satisfaction or self-reported intention to change behaviour. There was evidence that effective facilitators helped increase parents' perceived satisfaction with programmes. It is unlikely that a single standardized format or programme will meet all the specific learning needs of parents. Multiple approaches that will allow people to access information or education at a time and in a format that suits them may be of value. The importance of the transition to parenthood and its impact on parent and child wellbeing warrant careful consideration of current programming and careful evaluation of future initiatives. Copyright © 2016 Elsevier Ltd. All rights reserved.

Study Protocol: The Norfolk Diabetes Prevention Study [NDPS]: a 46 month multi - centre, randomised, controlled parallel group trial of a lifestyle intervention [with or without additional support from lay lifestyle mentors with Type 2 diabetes] to prevent transition to Type 2 diabetes in high risk groups with non - diabetic hyperglycaemia, or impaired fasting glucose.

PubMed

Pascale, Melanie; Murray, Nikki; Bachmann, Max; Barton, Garry; Clark, Allan; Howe, Amanda; Greaves, Colin; Sampson, Mike

2017-01-06

This 7 year NIHR programme [2011-2018] tests the primary hypothesis that the NDPS diet and physical activity intervention will reduce the risk of transition to type 2 diabetes (T2DM) in groups at high risk of Type 2 diabetes. The NDPS programme recognizes the need to reduce intervention costs through group delivery and the use of lay mentors with T2DM, the realities of normal primary care, and the complexity of the current glycaemic categorisation of T2DM risk. NDPS identifies people at highest risk of T2DM on the databases of 135 general practices in the East of England for further screening with ab fasting plasma glucose and glycosylated haemoglobin [HbA1c]. Those with an elevated fasting plasma glucose [impaired fasting glucose or IFG] with or without an elevated HbA1c [non -diabetic hyperglycaemia; NDH] are randomised into three treatment arms: a control arm receiving no trial intervention, an arm receiving an intensive bespoke group-based diet and physical activity intervention, and an arm receiving the same intervention with enhanced support from people with T2DM trained as diabetes prevention mentors [DPM]. The primary end point is cumulative transition rates to T2DM between the two intervention groups, and between each intervention group and the control group at 46 months. Participants with screen detected T2DM are randomized into an equivalent prospective controlled trial with the same intervention and control arms with glycaemic control [HbA1c] at 46 months as the primary end point. Participants with NDH and a normal fasting plasma glucose are randomised into an equivalent prospective controlled intervention trial with follow up for 40 months. The intervention comprises six education sessions for the first 12 weeks and then up to 15 maintenance sessions until intervention end, all delivered in groups, with additional support from a DPM in one treatment arm. The NDPS programme reports in 2018 and will provide trial outcome data for a group delivered diabetes prevention intervention, supported by lay mentors with T2DM, with intervention in multiple at risk glycaemic categories, and that takes into account the realities of normal clinical practice. ISRCTN34805606 (Retrospectively registered 16.3.16).

Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS)

PubMed Central

2014-01-01

Background The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. Methods The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. Discussion This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes. PMID:24397292

Psychosocial pathways to sexually transmitted infection risk among youth transitioning out of foster care: evidence from a longitudinal cohort study.

PubMed

Ahrens, Kym R; McCarty, Cari; Simoni, Jane; Dworsky, Amy; Courtney, Mark E

2013-10-01

To test the fit of a theoretically driven conceptual model of pathways to sexually transmitted infection (STI) risk among foster youth transitioning to adulthood. The model included (1) historical abuse and foster care experiences; (2) mental health and attachment style in late adolescence; and (3) STI risk in young adulthood. We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Covariates included gender, race, and an inverse probability weight. We also performed moderation analyses comparing models constrained and unconstrained by gender. Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Square Residual of .026). Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use. There was also a borderline association with having greater than five partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 years decreased STI risk. Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models. Interventions/policies that (1) address externalizing trauma sequelae; (2) promote close, stable substitute caregiver relationships; and (3) extend care to age 21 years have the potential to decrease STI risk in this population. Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Beyond the guidelines: challenges, controversies, and unanswered questions.

PubMed

Radix, Anita; Silva, Manel

2014-06-01

Transgender and gender-nonconforming youth have unique medical and psychosocial needs that frequently go unmet. For youth who wish to have their physical appearance congruent with their gender identity, treatment guidelines are available that advocate the use of gonadotropin-releasing hormone (GnRH) analogues (puberty blockers) and cross-sex hormone regimens. Although medical transition was once considered highly controversial, there is a mounting body of evidence that providing a supportive and affirming environment, as well as appropriate medical intervention, results in improved health outcomes. Primary care pediatricians may be unaware of current guidelines and consequently the need for treatment and/or timely referrals. Transgender youth often face other hurdles to initiation of therapy, including refusal of care and harassment in medical settings, denial of coverage by insurance plans, and the high cost of puberty blockers. Because transgender youth younger than 18 years depend on their families for medical decision making, they may be unable to access necessary medical treatment when parents do not support their transition plan. Medical transition impacts many aspects of the medical system, such as insurance coverage, billing, electronic health records, and preventive health care maintenance. These issues may become more apparent with the implementation of the Affordable Care Act (ACA) and increased use of electronic records and clinical decision support. The implementation of the ACA may also present new opportunities and protections for transgender individuals. Primary pediatricians are often the first providers families and youth reach out to for advice, and they can assist families with negotiating these complex medical, legal, social, and economic challenges and optimizing access to safe and appropriate health care services. Copyright 2014, SLACK Incorporated.

Project IMPACT Pilot Report: Feasibility of Implementing a Hospital-to-Home Transition Bundle.

PubMed

Mallory, Leah A; Osorio, Snezana Nena; Prato, B Stephen; DiPace, Jennifer; Schmutter, Lisa; Soung, Paula; Rogers, Amanda; Woodall, William J; Burley, Kayla; Gage, Sandra; Cooperberg, David

2017-03-01

To improve hospital to home transitions, a 4-element pediatric patient-centered transition bundle was developed, including: a transition readiness checklist; predischarge teach-back education; timely and complete written handoff to the primary care provider; and a postdischarge phone call. The objective of this study was to demonstrate the feasibility of bundle implementation and report initial outcomes at 4 pilot sites. Outcome measures included postdischarge caregiver ability to teach-back key home management information and 30-day reuse rates. A multisite, observational time series using multiple planned sequential interventions to implement bundle components with non-technology-supported and technology-supported patients. Data were collected via electronic health record reviews and during postdischarge phone calls. Statistical process control charts were used to assess outcomes. Four pilot sites implemented the bundle between January 2014 and May 2015 for 2601 patients, of whom 1394 had postdischarge telephone encounters. Improvement was noted in the implementation of all bundle elements with the transitions readiness checklist posing the greatest feasibility challenge. Phone contact connection rates were 69%. Caregiver ability to teach-back essential home management information postdischarge improved from 18% to 82%. No improvement was noted in reuse rates, which differed dramatically between technology-supported and non-technology-supported patients. A pediatric care transition bundle was successfully tested and implemented, as demonstrated by improvement in all process measures, as well as caregiver home management skills. Important considerations for successful implementation and evaluation of the discharge bundle include the role of local context, electronic health record integration, and subgroup analysis for technology-supported patients. Copyright © 2017 by the American Academy of Pediatrics.

Implementation of an antimicrobial stewardship program targeting residents with urinary tract infections in three community long-term care facilities: a quasi-experimental study using time-series analysis.

PubMed

Doernberg, Sarah B; Dudas, Victoria; Trivedi, Kavita K

2015-01-01

Asymptomatic bacteriuria in the elderly commonly results in antibiotic administration and, in turn, contributes to antimicrobial resistance, adverse drug events, and increased costs. This is a major problem in the long-term care facility (LTCF) setting, where residents frequently transition to and from the acute-care setting, often transporting drug-resistant organisms across the continuum of care. The goal of this study was to assess the feasibility and efficacy of antimicrobial stewardship programs (ASPs) targeting urinary tract infections (UTIs) at community LTCFs. This was a quasi-experimental study targeting antibiotic prescriptions for UTI using time-series analysis with 6-month retrospective pre-intervention and 6-month intervention period at three community LTCFs. The ASP team (infectious diseases (ID) pharmacist and ID physician) performed weekly prospective audit and feedback of consecutive prescriptions for UTI. Loeb clinical consensus criteria were used to assess appropriateness of antibiotics; recommendations were communicated to the primary treating provider by the ID pharmacist. Resident outcomes were recorded at subsequent visits. Generalized estimating equations using segmented regression were used to evaluate the impact of the ASP intervention on rates of antibiotic prescribing and antibiotic resistance. One-hundred and four antibiotic prescriptions for UTI were evaluated during the intervention, and recommendations were made for change in therapy in 40 (38 %), out of which 10 (25 %) were implemented. Only eight (8 %) residents started on antibiotics for UTI met clinical criteria for antibiotic initiation. An immediate 26 % decrease in antibiotic prescriptions for UTI during the ASP was identified with a 6 % reduction continuing through the intervention period (95 % Confidence Interval ([CI)] for the difference: -8 to -3 %). Similarly, a 25 % immediate decrease in all antibiotic prescriptions was noted after introduction of the ASP with a 5 % reduction continuing throughout the intervention period (95 % CI: -8 to -2 %). No significant effect was noted on resistant organisms or Clostridium difficile. Weekly prospective audit and feedback ASP in three community LTCFs over 6 months resulted in antibiotic utilization decreases but many lost opportunities for intervention.

Using an intervention mapping approach to develop a discharge protocol for intensive care patients.

PubMed

van Mol, Margo; Nijkamp, Marjan; Markham, Christine; Ista, Erwin

2017-12-19

Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need. Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study. Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice. Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.

Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project.

PubMed

McManus, Margaret; White, Patience; Pirtle, Robin; Hancock, Catina; Ablan, Michael; Corona-Parra, Raquel

2015-01-01

This pediatric-to-adult health care transition pilot project describes the process and results of incorporating the "Six Core Elements of Health Care Transition (2.0)" into a Medicaid managed care plan with a group of 35 18-23 year olds who have chronic mental health, developmental, and complex medical conditions. The pilot project demonstrated an effective approach for customizing and delivering recommended transition services. At the start of the 18-month project, the Medicaid plan was at the basic level (1) of transition implementation of the Six Core Elements with no transition policy, member transition readiness assessment results, health care transition plans of care, updated medical summaries, transfer package for the adult-focused provider, and assurance of transfer completion and consumer feedback. At the conclusion of the pilot project, the plan scored at level 3 on each core element. The primary reason for not scoring at the highest level (4) was because the transition elements have not been incorporated into services for all enrollees within the plan. Future efforts in managed care will benefit from starting the transition process much earlier (ages 12-14), expanding the role of nurse care managers and participating pediatric and adult-focused clinicians in transition, and offering payment incentives to clinicians to implement the Six Core Elements of Health Care Transition. Copyright © 2015 Elsevier Inc. All rights reserved.

Transition Care for Children With Special Health Care Needs

PubMed Central

Davis, Alaina M.; Brown, Rebekah F.; Taylor, Julie Lounds; Epstein, Richard A.

2014-01-01

BACKGROUND: Approximately 750 000 children in the United States with special health care needs will transition from pediatric to adult care annually. Fewer than half receive adequate transition care. METHODS: We had conversations with key informants representing clinicians who provide transition care, pediatric and adult providers of services for individuals with special health care needs, policy experts, and researchers; searched online sources for information about currently available programs and resources; and conducted a literature search to identify research on the effectiveness of transition programs. RESULTS: We identified 25 studies evaluating transition care programs. Most (n = 8) were conducted in populations with diabetes, with a smaller literature (n = 5) on transplant patients. We identified an additional 12 studies on a range of conditions, with no more than 2 studies on the same condition. Common components of care included use of a transition coordinator, a special clinic for young adults in transition, and provision of educational materials. CONCLUSIONS: The issue of how to provide transition care for children with special health care needs warrants further attention. Research needs are wide ranging, including both substantive and methodologic concerns. Although there is widespread agreement on the need for adequate transition programs, there is no accepted way to measure transition success. It will be essential to establish consistent goals to build an adequate body of literature to affect practice. PMID:25287460

A randomised controlled trial of cognitive behaviour therapy versus non-directive reflective listening for young people at ultra high risk of developing psychosis: The detection and evaluation of psychological therapy (DEPTh) trial.

PubMed

Stain, Helen J; Bucci, Sandra; Baker, Amanda L; Carr, Vaughan; Emsley, Richard; Halpin, Sean; Lewin, Terry; Schall, Ulrich; Clarke, Vanessa; Crittenden, Kylie; Startup, Mike

2016-10-01

Intervention trials for young people at ultra high risk (UHR) for psychosis have shown cognitive behaviour therapy (CBT) to have promising effects on treating psychotic symptoms but have not focused on functional outcomes. We hypothesized that compared to an active control, CBT would: (i) reduce the likelihood of, and/or delay, transition to psychosis; (ii) reduce symptom severity while improving social functioning and quality of life, whether or not transition occurred. This was a single-blind randomised controlled trial for young people at UHR for psychosis comparing CBT to an active control condition, Non Directive Reflective Listening (NDRL), both in addition to standard care, with a 6month treatment phase and 12months of follow-up. Statistical analysis is based on intention-to-treat and used random effect models to estimate treatment effects common to all time-points. Fifty-seven young people (mean age=16.5years) were randomised to CBT (n=30) or NDRL (n=27). Rate of transition to psychosis was 5%; the 3 transitions occurred in the CBT condition (baseline, 2months, 5months respectively). The NDRL condition resulted in a significantly greater reduction in distress associated with psychotic symptoms compared to CBT (treatment effect=36.71, standard error=16.84, p=0.029). There were no significant treatment effects on frequency and intensity of psychotic symptoms, global, social or role functioning. Our sample was higher functioning, younger and experiencing lower levels of psychotic like experiences than other trials. The significantly better treatment effect of NDRL on distress associated with psychotic symptoms supports the recommendations for a stepped-care model of service delivery. This treatment approach would accommodate the younger UHR population and facilitate timely intervention. ANZCTR 12606000101583. Copyright © 2016 Elsevier B.V. All rights reserved.

Adapting and Pilot Testing a Parenting Intervention for Homeless Families in Transitional Housing.

PubMed

Holtrop, Kendal; Holcomb, Jamila E

2018-01-24

Intervention adaptation is a promising approach for extending the reach of evidence-based interventions to underserved families. One highly relevant population in need of services are homeless families. In particular, homeless families with children constitute more than one third of the total homeless population in the United States and face several unique challenges to parenting. The purpose of this study was to adapt and pilot test a parenting intervention for homeless families in transitional housing. An established adaptation model was used to guide this process. The systematic adaptation efforts included: (a) examining the theory of change in the original intervention, (b) identifying population differences relevant to homeless families in transitional housing, (c) adapting the content of the intervention, and (d) adapting the evaluation strategy. Next, a pilot test of the adapted intervention was conducted to examine implementation feasibility and acceptability. Feasibility data indicate an intervention spanning several weeks may be difficult to implement in the context of transitional housing. Yet, acceptability of the adapted intervention among participants was consistently high. The findings of this pilot work suggest several implications for informing continued parenting intervention research and practice with homeless families in transitional housing. © 2018 Family Process Institute.

Role adaptation of family caregivers for ventilator-dependent patients: transition from respiratory care ward to home.

PubMed

Huang, Tzu-Ting; Peng, Ji-Ming

2010-06-01

To explore the underlying theoretical framework for the role adaptation of family caregivers for ventilator-dependent patients after transferring from respiratory care ward to home. The number of ventilator-dependent patients has been increasing worldwide. Under Taiwan's National Health Insurance policy, if ventilator-dependent patients are stable, they should be transferred from an acute care hospital to a subacute unit or home. A qualitative design based on grounded theory was adopted for this study. One-on-one, in-depth interviews were conducted with a purposive sample of 15 family caregivers who were caretaking ventilator-dependent patients at their home two months after hospital discharge. Theoretical sampling was used until concepts emerging in data analysis were saturated. Analysis of audio-taped interview transcripts generated a process of role adaptation for family caregivers of a ventilator-dependent patient. The caregiver's transition to the care-giving role is a dynamic process with consequences that are impacted by level of support from the family, affective rewards from the patient, patient's health condition and a balanced life schedule for the caregiver. The results of this study can provide respiratory care professionals with skills to assess the needs of caregivers for ventilator-dependent patients and individualise interventions to caregivers' specific needs. The findings of this study contribute to nurses' understanding and promotion of role adaptation for family caregivers among ventilator-dependent patients.

Adolescent to Adult HIV Health Care Transition From the Perspective of Adult Providers in the United States.

PubMed

Tanner, Amanda E; Philbin, Morgan M; Ma, Alice; Chambers, Brittany D; Nichols, Sharon; Lee, Sonia; Fortenberry, J Dennis

2017-10-01

The HIV Care Continuum highlights the need for HIV-infected youth to be tested, linked, and maintained in lifelong care. Care engagement is important for HIV-infected youth in order for them to stay healthy, maintain a low viral load, and reduce further transmission. One point of potential interruption in the care continuum is during health care transition from adolescent- to adult-centered HIV care. HIV-related health care transition research focuses mainly on youth and on adolescent clinic providers; missing is adult clinic providers' perspectives. We examined health care transition processes through semi-structured interviews with 28 adult clinic staff across Adolescent Trials Network sites. We also collected quantitative data related to clinical characteristics and transition-specific strategies. Overall, participants described health care transition as a "warm handoff" and a collaborative effort across adolescent and adult clinics. Emergent transition themes included adult clinical care culture (e.g., patient responsibility), strategies for connecting youth to adult care (e.g., adolescent clinic staff attending youth's first appointment at adult clinic), and approaches to evaluating transition outcomes (e.g., data sharing). Participants provided transition improvement recommendations (e.g., formalized protocols). Using evidence-based research and a quality improvement framework to inform comprehensive and streamlined transition protocols can help enhance the capacity of adult clinics to collaborate with adolescent clinics to provide coordinated and uninterrupted HIV-related care and to improve continuum of care outcomes. Copyright © 2017 Society for Adolescent Health and Medicine. All rights reserved.

Specific training program improves oncologists' palliative care communication skills in a randomized controlled trial.

PubMed

Goelz, Tanja; Wuensch, Alexander; Stubenrauch, Sara; Ihorst, Gabriele; de Figueiredo, Marcelo; Bertz, Hartmut; Wirsching, Michael; Fritzsche, Kurt

2011-09-01

The aim of the study was to demonstrate that COM-ON-p, concise and individualized communication skills training (CST), improves oncologists' communication skills in consultations focusing on the transition to palliative care. Forty-one physicians were randomly assigned to a control (CG) or intervention group (IG). At t(0), all physicians held two video-recorded consultations with actor-patient pairs. Afterward, physicians in the IG participated in COM-ON-p. Five weeks after t(0), a second assessment took place (t(1)). COM-ON-p consists of an 11-hour workshop (1.5 days), pre- and postassessment (2 hours), and coaching (0.5 hours). Physicians focused on practicing individual learning goals with actor patients in small groups. To evaluate the training, blinded raters assessed communication behavior of the physicians in video-recorded actor-patient consultations using a specific checklist. Data were analyzed using a mixed model with baseline levels as covariates. Participants in the IG improved significantly more than those in the CG in all three sections of the COM-ON-Checklist: skills specific to the transition to palliative care, global communication skills, and involvement of significant others (all P < .01). Differences between the CG and IG on the global items of communication skills and involvement of significant others were also significant (P < .01). Effect sizes were medium to large, with a 0.5-point improvement on average on a five-point rating scale. Physicians can be trained to meet better core challenges during the transition to palliative care through developed concise CST. Generalization and transfer into clinical practice must be proven in additional studies.

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression

PubMed Central

Eberhart, Michael G.; Yehia, Baligh R.; Hillier, Amy; Voytek, Chelsea D.; Fiore, Danielle J.; Blank, Michael; Frank, Ian; Metzger, David S.; Brady, Kathleen A.

2015-01-01

Background Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. Methods Retrospective cohort of 1,404 persons newly diagnosed with HIV in 2008–2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention in care and residence in a hotspot associated with poor viral suppression. Results 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared to 40.4% of those residing outside hotspots (p<0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared to 75.3% of those outside hotspots (p<.0.05). Factors significantly associated with residence in a poor retention hotspots included: female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in a poor viral suppression hotspots included; female sex, higher economic deprivation, and shorter distance to pharmacies. Conclusions Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention in care and viral suppression. PMID:25867777

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression.

PubMed

Eberhart, Michael G; Yehia, Baligh R; Hillier, Amy; Voytek, Chelsea D; Fiore, Danielle J; Blank, Michael; Frank, Ian; Metzger, David S; Brady, Kathleen A

2015-05-01

Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Improving Parolees' Participation in Drug Treatment and Other Services through Strengths Case Management.

PubMed

Prendergast, Michael; Cartier, Jerome J

2008-01-01

In an effort to increase participation in community aftercare treatment for substance-abusing parolees, an intervention based on a transitional case management (TCM) model that focuses mainly on offenders' strengths has been developed and is under testing. This model consists of completion, by the inmate, of a self-assessment of strengths that informs the development of the continuing care plan, a case conference call shortly before release, and strengths case management for three months post-release to promote retention in substance abuse treatment and support the participant's access to designated services in the community. The post-release component consists of a minimum of one weekly client/case manager meeting (in person or by telephone) for 12 weeks. The intervention is intended to improve the transition process from prison to community at both the individual and systems level. Specifically, the intervention is designed to improve outcomes in parolee admission to, and retention in, community-based substance-abuse treatment, parolee access to other needed services, and recidivism rates during the first year of parole. On the systems level, the intervention is intended to improve the communication and collaboration between criminal justice agencies, community-based treatment organizations, and other social and governmental service providers. The TCM model is being tested in a multisite study through the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) research cooperative funded by the National Institute of Drug Abuse.

Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions.

PubMed

Rabin, Borsika A; McCreight, Marina; Battaglia, Catherine; Ayele, Roman; Burke, Robert E; Hess, Paul L; Frank, Joseph W; Glasgow, Russell E

2018-01-01

Many health outcomes and implementation science studies have demonstrated the importance of tailoring evidence-based care interventions to local context to improve fit. By adapting to local culture, history, resources, characteristics, and priorities, interventions are more likely to lead to improved outcomes. However, it is unclear how best to adapt evidence-based programs and promising innovations. There are few guides or examples of how to best categorize or assess health-care adaptations, and even fewer that are brief and practical for use by non-researchers. This study describes the importance and potential of assessing adaptations before, during, and after the implementation of health systems interventions. We present a promising multilevel and multimethod approach developed and being applied across four different health systems interventions. Finally, we discuss implications and opportunities for future research. The four case studies are diverse in the conditions addressed, interventions, and implementation strategies. They include two nurse coordinator-based transition of care interventions, a data and training-driven multimodal pain management project, and a cardiovascular patient-reported outcomes project, all of which are using audit and feedback. We used the same modified adaptation framework to document changes made to the interventions and implementation strategies. To create the modified framework, we started with the adaptation and modification model developed by Stirman and colleagues and expanded it by adding concepts from the RE-AIM framework. Our assessments address the intuitive domains of Who, How, When, What, and Why to classify and organize adaptations. For each case study, we discuss how the modified framework was operationalized, the multiple methods used to collect data, results to date and approaches utilized for data analysis. These methods include a real-time tracking system and structured interviews at key times during the intervention. We provide descriptive data on the types and categories of adaptations made and discuss lessons learned. The multimethod approaches demonstrate utility across diverse health systems interventions. The modified adaptations model adequately captures adaptations across the various projects and content areas. We recommend systematic documentation of adaptations in future clinical and public health research and have made our assessment materials publicly available.

Adult care providers' perspectives on the transition to adult care for emerging adults with Type 1 diabetes: a cross-sectional survey.

PubMed

Michaud, S; Dasgupta, K; Bell, L; Yale, J-F; Anjachak, N; Wafa, S; Nakhla, M

2018-03-25

To assess adult diabetes care providers' current transition practices, knowledge about transition care, and perceived barriers to implementation of best practices in transition care for emerging adults with Type 1 diabetes mellitus. We administered a 38-item web-based survey to adult diabetes care providers identified through the Québec Endocrinologist Medical Association and Diabetes Québec. Fifty-three physicians responded (35%). Fewer than half of all respondents (46%) were familiar with the American Diabetes Association's transition care position statement. Approximately one-third of respondents reported a gap of >6 months between paediatric and adult diabetes care. Most (83%) believed communication with the paediatric team was adequate; however, only 56% reported receiving a medical summary and 2% a psychosocial summary from the paediatric provider. Respondents believed that the paediatric team should improve emerging adults' preparation for transition care by developing their self-management skills and improve teaching about the differences between paediatric and adult-oriented care. Only 31% had a system for identifying emerging adults lost to follow-up in adult care. Perceived barriers included difficulty accessing psychosocial services, emerging adults' lack of motivation, and inadequate transition preparation. Most (87%) were interested in having additional resources, including a self-care management tool and a registry to track those lost to follow-up. Our findings highlight the need to better engage adult care providers into transition care practices. Despite adult physicians' interest in transition care, implementation of transition care recommendations and resources in clinical care remains limited. Enhanced efforts are needed to improve access to mental health services within the adult healthcare setting. © 2018 Diabetes UK.

Transitional care for rheumatic conditions in Europe: current clinical practice and available resources.

PubMed

Clemente, Daniel; Leon, Leticia; Foster, Helen; Carmona, Loreto; Minden, Kirsten

2017-06-09

To assess European pediatric rheumatology providers' current clinical practices and resources used in the transition from child-centered to adult-oriented care. European pediatric rheumatologists were invited to complete a 17-item anonymized e-survey assessing current transition practices, transition policy awareness, and needs in advance of the publication of EULAR/PReS recommendations on transition. The response rate was 121/276 (44%), including responses from 115 centers in 22 European Union countries. Although 32/121 (26%) responded that their centers did not offer transition services, the majority (99%) agreed that a formalized process in transitioning patients to adult care is necessary. A minority (<30%) of respondents stated that they have a written transition policy although 46% have an informal transition process. Designated staff to support transitional care were available in a minority of centers: nurse (35%), physiotherapist (15%), psychologist (15%), social worker (8%), and occupational therapist (2%). The existence of a designated team member to coordinate transition was acknowledged in many centers (64% of respondents) although just 36% use a checklist for young people as part of individualized transitional care. This survey of European pediatric rheumatology providers regarding transitional care practices demonstrates agreement that transitional care is important, and wide variation in current provision of transition services exists.

Evaluation of a complex intervention (Engager) for prisoners with common mental health problems, near to and after release: study protocol for a randomised controlled trial

PubMed Central

Lennox, Charlotte; Taylor, Rod; Anderson, Rob; Maguire, Michael; Haddad, Mark; Michie, Susan; Owens, Christabel; Durcan, Graham; Stirzaker, Alex; Henley, William; Stevenson, Caroline; Carroll, Lauren; Quinn, Cath; Brand, Sarah Louise; Harris, Tirril; Stewart, Amy; Todd, Roxanne; Rybczynska-Bunt, Sarah; Greer, Rebecca; Pearson, Mark; Shaw, Jenny; Byng, Richard

2018-01-01

Introduction The ‘Engager’ programme is a ‘through-the-gate’ intervention designed to support prisoners with common mental health problems as they transition from prison back into the community. The trial will evaluate the clinical and cost-effectiveness of the Engager intervention. Methods and analysis The study is a parallel two-group randomised controlled trial with 1:1 individual allocation to either: (a) the Engager intervention plus standard care (intervention group) or (b) standard care alone (control group) across two investigation centres (South West and North West of England). Two hundred and eighty prisoners meeting eligibility criteria will take part. Engager is a person-centred complex intervention delivered by practitioners and aimed at addressing offenders’ mental health and social care needs. It comprises one-to-one support for participants prior to release from prison and for up to 20 weeks postrelease. The primary outcome is change in psychological distress measured by the Clinical Outcomes in Routine Evaluation-Outcome Measure at 6 months postrelease. Secondary outcomes include: assessment of subjective met/unmet need, drug and alcohol use, health-related quality of life and well-being-related quality of life measured at 3, 6 and 12 months postrelease; change in objective social domains, drug and alcohol dependence, service utilisation and perceived helpfulness of services and change in psychological constructs related to desistence at 6 and 12 months postrelease; and recidivism at 12 months postrelease. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action and look for unintended consequences. An economic evaluation will estimate the cost-effectiveness. Ethics and dissemination This study has been approved by the Wales Research Ethics Committee 3 (ref: 15/WA/0314) and the National Offender Management Service (ref: 2015–283). Findings will be disseminated to commissioners, clinicians and service users via papers and presentations. Trial registration number ISRCTN11707331; Pre-results. PMID:29463586

From "Longshot" to "Fantasy": Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail.

PubMed

Weiss, Elliott Mark; Fiester, Autumn

2018-01-01

Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from "longshot" to "fantasy" is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.

Evaluation of impact of social support and care on HIV-positive and AIDS individuals' quality of life: a nonrandomised community trial.

PubMed

Li, Xing-Ming; Yuan, Xiao-Qing; Wang, Jun-Jie; Zhang, Wan-Ying; Zhou, Yang; Liu, Gu-Ning

2017-02-01

Our study was conducted to further investigate the model of social support and care for People Living with HIV/AIDS(PLHA), to explore their role in People Living with AIDS's quality of life (QOL) as reference for improving nursing policies for AIDS. Social support and care are the most important factors impacting the QOL of People Living with HIV/AIDS, but most studies conducted upon the influence of social support and QOL of People Living with HIV/AIDS are mainly based on cross-sectional design. Our study was a nonrandomised controlled community intervention study. The participants diagnosed as People Living with HIV/AIDS at Beijing You An Hospital received a comprehensive social support care from December 2013 to December 2014. To evaluate the impact of social support and care model on People Living with HIV/AIDS, our study analysed the different dimension scores of social support scale and quality of life before and after the intervention. Correlation between the net benefit value of social support and that of QOL from various dimensions were analysed. There were significant differences in the score of objective support and usage of support (all p = 0·02) for social support. Net values of objective support score and usage of support were 0·25 and 0·19, respectively, after intervention. There were significant differences in physiological function, role physical, general health, vitality, social function, mental health, health transition and total score of quality of life (all p < 0·05). The canonical correlation analysis of net values of social support and QOL indicated that the first and second canonical correlation were statistically significant, with correlation coefficients of 0·53 (p = 0·00) and 0·21 (p = 0·04). Social support and care intervention model can effectively improve perceived subjective feeling on social support and QOL condition for People Living with HIV/AIDS. And strategies to improve social support and care intervention programmes are strongly encouraged. The method is simple and cost-effective and could be a way to improve the quality of life condition for People Living with HIV/AIDS. © 2016 John Wiley & Sons Ltd.

Bridging the gap between hospital and primary care: the pharmacist home visit.

PubMed

Ensing, Hendrik T; Koster, Ellen S; Stuijt, Clementine C M; van Dooren, Ad A; Bouvy, Marcel L

2015-06-01

Bridging the gap between hospital and primary care is important as transition from one healthcare setting to another increases the risk on drug-related problems and consequent readmissions. To reduce those risks, pharmacist interventions during and after hospitalization have been frequently studied, albeit with variable effects. Therefore, in this manuscript we propose a three phase approach to structurally address post-discharge drug-related problems. First, hospitals need to transfer up-todate medication information to community pharmacists. Second, the key phase of this approach consists of adequate follow-up at the patients' home. Pharmacists need to apply their clinical and communication skills to identify and analyze drug-related problems. Finally, to prevent and solve identified drug related problems a close collaboration within the primary care setting between pharmacists and general practitioners is of utmost importance. It is expected that such an approach results in improved quality of care and improved patient safety.

Perspectives of Low Socioeconomic Status Mothers of Premature Infants

PubMed Central

Faherty, Laura J.; Wallace-Keeshen, Sara; Martin, Ashley E; Shea, Judy A.; Lorch, Scott A.

2017-01-01

BACKGROUND AND OBJECTIVES: Transitioning premature infants from the NICU to home is a high-risk period with potential for compromised care. Parental stress is high, and families of low socioeconomic status may face additional challenges. Home visiting programs have been used to help this transition, with mixed success. We sought to understand the experiences of at-risk families during this transition to inform interventions. METHODS: Mothers of infants born at <35 weeks’ gestation, meeting low socioeconomic status criteria, were interviewed by telephone 30 days after discharge to assess caregiver experiences of discharge and perceptions of home visitors (HVs). We generated salient themes by using grounded theory and the constant comparative method. Interviews were conducted until thematic saturation was achieved. RESULTS: Twenty-seven mothers completed interviews. Eighty-five percent were black, and 81% had Medicaid insurance. Concern about infants’ health and fragility was the primary theme identified, with mothers reporting substantial stress going from a highly monitored NICU to an unmonitored home. Issues with trust and informational consistency were mentioned frequently and could threaten mothers’ willingness to engage with providers. Strong family networks and determination compensated for limited economic resources, although many felt isolated. Mothers appreciated HVs’ ability to address infant health but preferred nurses over lay health workers. CONCLUSIONS: Low-income mothers experience significant anxiety about the transition from the NICU to home. Families value HVs who are trustworthy and have relevant medical knowledge about prematurity. Interventions to improve transition would benefit by incorporating parental input and facilitating trust and consistency in communication. PMID:28223372

Care Coordination and Transitions of Care.

PubMed

Choi, Youngjee

2017-11-01

Care coordination and effective transitions of care are essential for high-quality care in cancer survivors. Aspects of care that require coordination include cancer surveillance, managing the effects of cancer and its treatment, and preventive care, including screening for new cancers, with the clinician responsible for each aspect of care clearly defined. There are many barriers to transitioning and coordinating care across cancer specialists and primary care physicians; possible solutions include survivorship care plans and certain care models. Improving these areas, along with survivorship care training and education, may lead to more effective care coordination and transitions in the future. Copyright © 2017 Elsevier Inc. All rights reserved.

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

PubMed Central

2013-01-01

Background A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81–85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group. Methods Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial. Results These focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers. Conclusion Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed. Trial registration ISRCTN 53515024. PMID:23343127

Transitioning from pediatric care to adult care for adolescents with special health care needs: dentist perspectives (part 2)

PubMed Central

Bayarsaikhan, Zoljargal; Cruz, Stephanie; Neff, John; Chi, Donald L.

2015-01-01

Purpose To understand dental care transitions for adolescents with special health care needs (ASHCN) from the dentist perspective. Methods We conducted semi-structured interviews with 13 dentists (seven pediatric dentists and six general dentists) to learn about the dental transition process for ASHCN. Results Most dentists believed transitions from child-centered to adult-centered dental care were important for ASHCN. Dentists reported two main barriers to transitions: low dental reimbursements by Medicaid and a shortage of general dentists qualified or willing to treat ASHCN. Pediatric and general dentists reported playing complimentary roles in facilitating transitions for ASHCN and their families. Conclusions Dentists acknowledged the challenges that ASHCN and their families face in transitioning to adult-centered care and believed in the importance of ASHCN maintaining a dental home. Pediatric dentists and general dentists play a key role in working together to implement dental transition plans for the ASHCN and to ensure successful dental transitions. PMID:26531088

Transitioning from Pediatric to Adult Dental Care for Adolescents with Special Health Care Needs: Dentist Perspectives--Part Two.

PubMed

Bayarsaikhan, Zoljargal; Cruz, Stephanie; Neff, John; Chi, Donald L

2015-01-01

The purpose of this study was to understand dental care transitions for adolescents with special health care needs (ASHCNs) from the dentist perspective. We conducted semi-structured interviews with 13 dentists (seven pediatric dentists and six general dentists) to learn about the dental transition process for ASHCNs. Most dentists believed transitions from child-centered to adult-centered dental care were important for ASHCNs. Dentists reported two main barriers to transitions: (1) low dental reimbursements by Medicaid; and (2) a shortage of general dentists qualified or willing to treat ASHCNs. Pediatric and general dentists reported playing complimentary roles in facilitating transitions for ASHCNs and their families. Dentists acknowledged the challenges that adolescents with special health care needs and their families face in transitioning to adult-centered care and believed in the importance of ASHCNs maintaining a dental home. Pediatric dentists and general dentists play a key role in working together to implement dental transition plans for ASHCNs and to ensure successful dental transitions.

Health care providers' attitudes towards transfer and transition in young persons with long term illness- a web-based survey.

PubMed

Sparud-Lundin, Carina; Berghammer, Malin; Moons, Philip; Bratt, Ewa-Lena

2017-04-11

Transition programs in health care for young persons with special health care needs aim to maximize lifelong functioning. Exploring health care professionals' perspective may increase the possibility of successful implementation of transition programs. The aim was to survey health care professionals' attitudes towards components and barriers on transition and transfer in young people with long-term medical conditions with special health care needs. A cross-sectional web-based survey was sent by e-mail to 529 physicians and nurses in Swedish pediatric and adult outpatient clinics. Response rate was 38% (n = 201). The survey consisted of 59 questions regarding different aspects of components and barriers on transition and transfer. Descriptive statistics were computed to summarize demographic data and categorized responses. The Chi square test was used for comparison between proportions of categories. Most respondents agreed on the destinations of care for adolescents within their specialty. Age and psychosocial aspects such as maturity and family situations were considered the most important initiators for transfer. Joint meeting with the patient (82%); presence of a transition coordinator (76%) and a written individualized transfer plan (55%) were reported as important transition components. Pediatric care professionals found the absence of a transition coordinator to be more of a transition barrier than adult care professionals (p = 0.018) and also a more important transfer component (p = 0.017). Other barriers were lack of funding (45%) and limited clinical space (19%). Transition programs were more common in university hospitals than in regional hospitals (12% vs 2%, p = <0.001) as well as having a transition coordinator (12% vs 3%, p = 0.004). The findings highlight a willingness to work on new transition strategies and provide direction for improvement, taking local transition components as well as potential barriers into consideration when implementing future transition programs. Some differences in attitudes towards transitional care remain among pediatric and adult care professionals.

Systems of care for individuals with autism spectrum disorder and serious behavioral disturbance through the lifespan.

PubMed

Lubetsky, Martin J; Handen, Benjamin L; Lubetsky, Michelle; McGonigle, John J

2014-01-01

Individuals with Autism Spectrum Disorder present with unique characteristics, and the interventions designed to address associated challenging behaviors must be highly individualized to best meet their needs and those of their families. This article reviews systems of care to support the child, adolescent, or adult with Autism Spectrum Disorder and/or Intellectual Disability. The review describes mental health/behavioral health services, Intellectual Disability and other support systems, and the systems involved in a child and adolescent's life and transition to adulthood. The types of systems and services, as well as barriers, are delineated with a brief listing of Web sites and references. Copyright © 2014 Elsevier Inc. All rights reserved.

Multidimensional treatment foster care as a preventive intervention to promote resiliency among youth in the child welfare system.

PubMed

Leve, Leslie D; Fisher, Philip A; Chamberlain, Patricia

2009-12-01

Demographic trends indicate that a growing segment of families is exposed to adversity such as poverty, drug use problems, caregiver transitions, and domestic violence. Although these risk processes and the accompanying poor outcomes for children have been well studied, little is known about why some children develop resilience in the face of such adversity, particularly when it is severe enough to invoke child welfare involvement. This paper describes a program of research involving families in the child welfare system. Using a resiliency framework, evidence from 4 randomized clinical trials that included components of the Multidimensional Treatment Foster Care program is presented. Future directions and next steps are proposed.

Transition to adult care in pediatric solid-organ transplant: development of a practice guideline.

PubMed

Gold, Anna; Martin, Kathy; Breckbill, Katie; Avitzur, Yaron; Kaufman, Miriam

2015-06-01

Transition to adult-centered care is becoming an increasingly important area of practice in pediatric organ transplant. Standardized, best-practice guidelines are needed to assist transplant practitioners in providing optimal transitional care for this population of patients. To describe the development and implementation of a practice guideline for the transitional care of pediatric transplant recipients. A quality improvement project was undertaken in a pediatric multiorgan transplant program setting. Strategies employed included (1) creation of an interdisciplinary working group, (2) survey of transition-related practices and learning needs of transplant practitioners, (3) review of the literature and existing transition-related materials, and (4) creation of transition guidelines. An interdisciplinary survey of transplant practitioners at our institution identified practice strengths related to transitional care and learning needs. Review of relevant literature and other materials revealed limited but emerging research related to the transition of pediatric transplant recipients from pediatric to adult care. Existing transition tools were examined and applicable items identified. A practice guideline for use with pediatric transplant recipients transitioning to adult care was developed. Strategies to educate staff about the guideline and promote ongoing guideline use were implemented. Preparing pediatric transplant recipients and their families for transition to adult-centered care is an emerging challenge for transplant teams. These guidelines provide practitioners with a developmentally sensitive overview of important transition-related domains and strategies directed toward patients and their caregivers, who may experience the process of transition differently. Dissemination of the pediatric transplant transition guideline will make transition information more widely available to transplant practitioners.

Transitioning Adolescents and Young Adults With HIV Infection to Adult Care: Pilot Testing the "Movin' Out" Transitioning Protocol.

PubMed

Maturo, Donna; Powell, Alexis; Major-Wilson, Hannah; Sanchez, Kenia; De Santis, Joseph P; Friedman, Lawrence B

2015-01-01

Advances in care and treatment of adolescents/young adults with HIV infection have made survival into adulthood possible, requiring transition to adult care. Researchers have documented that the transition process is challenging for adolescents/young adults. To ensure successful transition, a formal transition protocol is needed. Despite existing research, little quantitative evaluation of the transition process has been conducted. The purpose of the study was to pilot test the "Movin' Out" Transitioning Protocol, a formalized protocol developed to assist transition to adult care. A retrospective medical/nursing record review was conducted with 38 clients enrolled in the "Movin' Out" Transitioning Protocol at a university-based adolescent medicine clinic providing care to adolescents/young adults with HIV infection. Almost half of the participants were able to successfully transition to adult care. Reasons for failure to transition included relocation, attrition, lost to follow-up, and transfer to another adult service. Failure to transition to adult care was not related to adherence issues, X(2) (1, N=38)=2.49, p=.288; substance use, X(2) (1, N=38)=1.71, p=.474; mental health issues, X(2) (1, N=38)=2.23, p=.322; or pregnancy/childrearing, X(2) (1, N=38)=0.00, p=.627). Despite the small sample size, the "Movin' Out" Transitioning Protocol appears to be useful in guiding the transition process of adolescents/young adults with HIV infection to adult care. More research is needed with a larger sample to fully evaluate the "Movin' Out" Transitioning Protocol. Copyright © 2015 Elsevier Inc. All rights reserved.

The transition from pediatric to adult care for youth with epilepsy: Basic biological, sociological, and psychological issues.

PubMed

Camfield, Peter; Camfield, Carol; Busiah, Kanetee; Cohen, David; Pack, Alison; Nabbout, Rima

2017-04-01

Transition from pediatric to adult health care for adolescents with epilepsy is challenging for the patient, family, and health care workers. This paper is the first of three that summarize the main findings from the 2nd Symposium on Transition in Epilepsies, held in Paris from June 14-25, 2016. In this paper we describe five basic themes that have an important effect on transition. First, there are important brain changes in adolescence that leave an imbalance between risk taking and pleasure seeking behaviors and frontal executive function compared with adults. Second, puberty is a major change during the transition age. The three most important but separate neuroendocrine axes involved in puberty are gonadarche (activation of the gonads), adrenarche (activation of adrenal androgen production), and activation of the growth hormone-insulin like growth factor. Third, sexual debut occurs during the transition years, and at an earlier age in adolescents with epilepsy than controls. Adult sexual performance is often unsatisfactory. Although AED-induced alterations in sexual hormones and temporal lobe epilepsy may play a role in hyposexuality, depression, anxiety, and other social factors appear most important. Fourth, psychological development is very important with an evolution from an early stage (ages 10-13years) with concrete thinking, to a middle stage (ages 14-17) with analytic and more abstract introspective thinking, and then to a late stage (ages 18-21) with at least the beginnings of adult reasoning. Epilepsy may derail this relatively orderly progression. Adolescents with autistic spectrum disorder may present with severe behavior problems that are sometimes related to undiagnosed epilepsy. Fifth, bone health in adolescence is critical to establish adequate mineralization for all of adult life. While AED interference with Vitamin D metabolism is important, there is evidence that the effects of AEDs on bone are more complex and involve changes in remodeling. Hence, some non-inducing AEDs may have a significant effect on bone health. All five of these themes lead to recommendations for how to approach adolescents and young adults during transition and some specific interventions to achieve maximum long-term adult independence and quality of life. Copyright © 2016 Elsevier Inc. All rights reserved.

Satisfaction and Healthcare Utilization of Transgender and Gender Non-Conforming Individuals in NYC: A Community-Based Participatory Study.

PubMed

Radix, Anita E; Lelutiu-Weinberger, Corina; Gamarel, Kristi E

2014-12-01

Transgender and gender non-conforming (TGNC) individuals face high levels of discrimination and mistreatment, including within social and medical service settings, which may lead to negative health and psychosocial sequelae. Given the many barriers to competent care, we sought to determine points of intervention by assessing the current needs, satisfaction, and health care utilization of TGNC individuals in New York City as reported by TGNC individuals. In January 2013, fifty TGNC individuals were recruited via flyers and direct referrals from healthcare professionals within community spaces and pertinent venues. We administered a brief survey and conducted four focus groups exploring participants' health care utilization and perceived barriers to care, routine care, hormone and silicone use, and recommendations for improving transgender services. Participants were 18- to 64-years-old, racially/ethnically diverse, and the majority were medically insured, underwent routine health care in the last year, and received an HIV test in their lifetime. A significant proportion reported taking hormones prescribed by a medical provider and were in the care of knowledgeable providers. Participants perceived four areas where barriers persisted: utilization of preventive services, access to transition-related procedures, access to legal assistance, and inclusion of TGNC individuals in public health education and campaigns. Structural interventions are needed, such as comprehensive provider training programs for all level staff to better serve the needs of TGNC individuals, increase service utilization and improve wellbeing, while effecting lasting institutional change. Service provision establishments should hire more TGNC staff and integrate transgender care into existing practices.

Psychologists and the Transition From Pediatrics to Adult Health Care.

PubMed

Gray, Wendy N; Monaghan, Maureen C; Gilleland Marchak, Jordan; Driscoll, Kimberly A; Hilliard, Marisa E

2015-11-01

Guidelines for optimal transition call for multidisciplinary teams, including psychologists, to address youth and young adults' multifactorial needs. This study aimed to characterize psychologists' roles in and barriers to involvement in transition from pediatric to adult health care. Psychologists were invited via professional listservs to complete an online survey about practice settings, roles in transition programming, barriers to involvement, and funding sources. Participants also responded to open-ended questions about their experiences in transition programs. One hundred participants responded to the survey. Involvement in transition was reported at multiple levels from individual patient care to institutional transition programming, and 65% reported more than one level of involvement. Direct clinical care (88%), transition-related research (50%), and/or leadership (44%) involvement were reported, with 59% reporting more than one role. Respondents often described advocating for their involvement on transition teams. Various sources of funding were reported, yet, 23% reported no funding for their work. Barriers to work in transition were common and included health care systems issues such as poor coordination among providers or lack of a clear transition plan within the clinic/institution. Psychologists assume numerous roles in the transition of adolescents from pediatric to adult health care. With training in health care transition-related issues, psychologists are ideally positioned to partner with other health professionals to develop and implement transition programs in multidisciplinary settings, provided health care system barriers can be overcome. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Improving the quality of transition and transfer of care in young adults with congenital heart disease.

PubMed

Everitt, Ian K; Gerardin, Jennifer F; Rodriguez, Fred H; Book, Wendy M

2017-05-01

The transition and transfer from pediatric to adult care is becoming increasingly important as improvements in the diagnosis and management of congenital heart disease allow patients to live longer. Transition is a complex and continuous process that requires careful planning. Inadequate transition has adverse effects on patients, their families and healthcare delivery systems. Currently, significant gaps exist in patient care as adolescents transfer to adult care and there are little data to drive the informed management of transition and transfer of care in adolescent congenital heart disease patients. Appropriate congenital heart disease care has been shown to decrease mortality in the adult population. This paper reviews the transition and transfer of care processes and outlines current congenital heart disease specific guidelines in the United States and compares these recommendations to Canadian and European guidelines. It then reviews perceived and real barriers to successful transition and identifies predictors of success during transfer to adult congenital heart disease care. Lastly, it explores how disease-specific markers of outcomes and quality indicators are being utilized to guide transition and transfer of care in other chronic childhood illnesses, and identifies existing knowledge gaps and structural impediments to improving the management of transition and transfer among congenital heart disease patients. © 2017 Wiley Periodicals, Inc.

Know Your Client and Know Your Team: A Complexity Inspired Approach to Understanding Safe Transitions in Care

PubMed Central

2013-01-01

Background. Transitions in care are one of the most important and challenging client safety issues in healthcare. This project was undertaken to gain insight into the practice setting realities for nurses and other health care providers as they manage increasingly complex care transitions across multiple settings. Methods. The Appreciative Inquiry approach was used to guide interviews with sixty-six healthcare providers from a variety of practice settings. Data was collected on participants' experience of exceptional care transitions and opportunities for improving care transitions. Results. Nurses and other healthcare providers need to know three things to ensure safe care transitions: (1) know your client; (2) know your team on both sides of the transfer; and (3) know the resources your client needs and how to get them. Three themes describe successful care transitions, including flexible structures; independence and teamwork; and client and provider focus. Conclusion. Nurses often operate at the margins of acceptable performance, and flexibility with regulation and standards is often required in complex sociotechnical work like care transitions. Priority needs to be given to creating conditions where nurses and other healthcare providers are free to creatively engage and respond in ways that will optimize safe care transitions. PMID:24349770

Next of kin's experiences of information and responsibility during their older relatives' care transitions from hospital to municipal health care.

PubMed

Rustad, Else Cathrine; Seiger Cronfalk, Berit; Furnes, Bodil; Dysvik, Elin

2017-04-01

To gain an understanding of how next of kin experience the transition of their older relatives from hospital to municipal health care. During the care transition of their older relatives, next of kin experience a period of ill-defined roles and expectations. Successful transition lays the ground for postdischarge treatment and care, in which next of kin have important roles. A descriptive, exploratory design was used to gain a greater understanding of the experiences of next of kin during their older relatives' care transitions. We conducted qualitative interviews of 13 next of kin of patients aged ≥80 years who had been discharged from the hospital to municipal care. Qualitative content analysis was used to analyse interviews. The main theme, 'Next of kin balance multiple tasks during older relatives' care transitions', emerged from two subthemes: 'Next of kin strive to fulfil informational needs during care transition' and 'Next of kin take responsibility for the older relative during care transition'. Next of kin have the challenging role of letting their older relative manage self-care during transition, when able, while being prepared to act on behalf of their relative as needed. Insufficient information and significant responsibilities contribute to unnecessary concerns and worries among next of kin. Nurses in both hospitals and municipal health care will benefit from knowing more about the experiences of next of kin; this may ensure continuity of care during transitions and diminish unnecessary worries and concerns. Clinical nurses should be sensitive to the next of kin's need for support so the next of kin can better manage their older relatives' care after homecoming. © 2016 John Wiley & Sons Ltd.

Transitioning from acute to primary health care nursing: an integrative review of the literature.

PubMed

Ashley, Christine; Halcomb, Elizabeth; Brown, Angela

2016-08-01

This paper seeks to explore the transition experiences of acute care nurses entering employment in primary health care settings. Internationally the provision of care in primary health care settings is increasing. Nurses are moving from acute care settings to meet the growing demand for a primary health care workforce. While there is significant research relating to new graduate transition experiences, little is known about the transition experience from acute care into primary health care employment. An integrative review, guided by Whittemore and Knafl's (2005) approach, was undertaken. Following a systematic literature search eight studies met the inclusion criteria. Papers which met the study criteria were identified and assessed against the inclusion and exclusion criteria. Papers were then subjected to methodological quality appraisal. Thematic analysis was undertaken to identify key themes within the data. Eight papers met the selection criteria. All described nurses transitioning to either community or home nursing settings. Three themes were identified: (1) a conceptual understanding of transition, (2) role losses and gains and (3) barriers and enablers. There is a lack of research specifically exploring the transitioning of acute care nurses to primary health care settings. To better understand this process, and to support the growth of the primary health care workforce there is an urgent need for further well-designed research. There is an increasing demand for the employment of nurses in primary health care settings. To recruit experienced nurses it is logical that many nurses will transition into primary health care from employment in the acute sector. To optimise retention and enhance the transition experience of these nurses it is important to understand the transition experience. © 2016 John Wiley & Sons Ltd.

“Just another fish in the pond”: the transitional care experience of a hip fracture patient

PubMed Central

Toscan, Justine; Manderson, Brooke; Santi, Selena M; Stolee, Paul

2013-01-01

Introduction Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care. Methods This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings. Results Four key themes were identified over the patients care trajectory: ‘Missing Crucial Coversations’—Patient and family caregivers did not feel involved or informed about decisions in care; ‘Who’s Who’—Confusion about the role of health care providers; ‘Ready or Not’—Not knowing what to expect or what is expected; and, ‘Playing by the Rules’—Health system policies and procedures hinder individualized care. Conclusion Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care. PMID:23882170

Between invisible defects and visible impact: the life experiences of adolescents and young adults with congenital heart disease.

PubMed

Chiang, Yueh-Tao; Chen, Chi-Wen; Su, Wen-Jen; Wang, Jou-Kou; Lu, Chun-Wei; Li, Yuh-Fen; Moons, Philip

2015-03-01

To describe the life experiences of adolescents and young adults with congenital heart disease. Owing to medical advances, most children with congenital heart disease are expected to survive into adulthood. The transitional development from adolescence to adult is the critical period for fostering self-care. Descriptive phenomenological study. Thirty-five patients of 15-24 years old with congenital heart disease were recruited from paediatric cardiology clinics by purposive sampling. They were individually interviewed between October 2012-February 2013 using a semi-structured interview guideline and joined adult congenital heart disease clinics at two medical centres in northern Taiwan. The data were analysed using descriptive phenomenological method developed by Giorgi. The essence of the life experience of adolescents and young adults with congenital heart disease involves a dynamic process of moving between invisible defects and coexistence with the disease. Six themes emerged: (1) invisible defects: the existence of imperfect understanding; (2) conflict: interpersonal frustrations; (3) imbalance: the loss of self-balance; (4) suffering: increasing anxiety; (5) encounters: meeting needs; and (6) coexistence: positive coping strategies. As patients with congenital heart disease transition from adolescence into adulthood, they must learn about their disease, overcome frustration and anxiety and develop self-care strategies for coexisting with congenital heart disease. Results of this study may serve as clinical care guidelines for adolescents and young adults with congenital heart disease and give a reference for developing transitional intervention strategies. © 2014 John Wiley & Sons Ltd.

Do work and family care histories predict health in older women?

PubMed

Benson, Rebecca; Glaser, Karen; Corna, Laurie M; Platts, Loretta G; Di Gessa, Giorgio; Worts, Diana; Price, Debora; McDonough, Peggy; Sacker, Amanda

2017-12-01

Social and policy changes in the last several decades have increased women's options for combining paid work with family care. We explored whether specific combinations of work and family care over the lifecourse are associated with variations in women's later life health. We used sequence analysis to group women in the English Longitudinal Study of Ageing according to their work histories and fertility. Using logistic regression, we tested for group differences in later life disability, depressive symptomology and mortality, while controlling for childhood health and socioeconomic position and a range of adult socio-economic circumstances and health behaviours. Women who transitioned from family care to either part-time work after a short break from the labour force, or to full-time work, reported lower odds of having a disability compared with the reference group of women with children who were mostly employed full-time throughout. Women who shifted from family care to part-time work after a long career break had lower odds of mortality than the reference group. Depressive symptoms were not associated with women's work and family care histories. Women's work histories are predictive of their later life disability and mortality. This relationship may be useful in targeting interventions aimed at improving later life health. Further research is necessary to explore the mechanisms linking certain work histories to poorer later life health and to design interventions for those affected. © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association.

Do work and family care histories predict health in older women?

PubMed Central

Benson, Rebecca; Glaser, Karen; Corna, Laurie M.; Platts, Loretta G.; Di Gessa, Giorgio; Worts, Diana; Price, Debora; McDonough, Peggy; Sacker, Amanda

2017-01-01

Abstract Background Social and policy changes in the last several decades have increased women’s options for combining paid work with family care. We explored whether specific combinations of work and family care over the lifecourse are associated with variations in women’s later life health. Methods We used sequence analysis to group women in the English Longitudinal Study of Ageing according to their work histories and fertility. Using logistic regression, we tested for group differences in later life disability, depressive symptomology and mortality, while controlling for childhood health and socioeconomic position and a range of adult socio-economic circumstances and health behaviours. Results Women who transitioned from family care to either part-time work after a short break from the labour force, or to full-time work, reported lower odds of having a disability compared with the reference group of women with children who were mostly employed full-time throughout. Women who shifted from family care to part-time work after a long career break had lower odds of mortality than the reference group. Depressive symptoms were not associated with women’s work and family care histories. Conclusion Women’s work histories are predictive of their later life disability and mortality. This relationship may be useful in targeting interventions aimed at improving later life health. Further research is necessary to explore the mechanisms linking certain work histories to poorer later life health and to design interventions for those affected. PMID:29036311

Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT).

PubMed

Zulman, Donna M; Ezeji-Okoye, Stephen C; Shaw, Jonathan G; Hummel, Debra L; Holloway, Katie S; Smither, Sasha F; Breland, Jessica Y; Chardos, John F; Kirsh, Susan; Kahn, James S; Asch, Steven M

2014-12-01

We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system. Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients. HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project. Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system. Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

Optimizing resource allocation for breast cancer prevention and care among Hong Kong Chinese women.

PubMed

Wong, Irene O L; Tsang, Janice W H; Cowling, Benjamin J; Leung, Gabriel M

2012-09-15

Recommendations about funding of interventions through the full spectrum of the disease often have been made in isolation. The authors of this report optimized budgetary allocations by comparing cost-effectiveness data for different preventive and management strategies throughout the disease course for breast cancer in Hong Kong (HK) Chinese women. Nesting a state-transition Markov model within a generalized cost-effectiveness analytic framework, costs and quality-adjusted life-years (QALYs) were compared to estimate average cost-effectiveness ratios for the following interventions at the population level: biennial mass mammography (ages 40-69 years or ages 40-79 years), reduced waiting time for postoperative radiotherapy (by 15% or by 25%), adjuvant endocrine therapy (either upfront aromatase inhibitor [AI] therapy or sequentially with tamoxifen followed by AI) in postmenopausal women with estrogen receptor-positive disease, targeted immunotherapy in those with tumors that over express human epidermal growth factor receptor 2, and enhanced palliative services (either at home or as an inpatient). Usual care for eligible patients in the public sector was the comparator. In descending order, the optimal allocation of additional resources for breast cancer would be the following: a 25% reduction in waiting time for postoperative radiotherapy (in US dollars: $5000 per QALY); enhanced, home-based palliative care ($7105 per QALY); adjuvant, sequential endocrine therapy ($17,963 per QALY); targeted immunotherapy ($62,092 per QALY); and mass mammography screening of women ages 40 to 69 years ($72,576 per QALY). Given the lower disease risk and different age profiles of patients in HK Chinese, among other newly emergent and emerging economies with similar transitioning epidemiologic profiles, the current findings provided direct evidence to support policy decisions that may be dissimilar to current Western practice. Copyright © 2012 American Cancer Society.

Supporting well-being in retirement through meaningful social roles: systematic review of intervention studies.

PubMed

Heaven, Ben; Brown, Laura J E; White, Martin; Errington, Linda; Mathers, John C; Moffatt, Suzanne

2013-06-01

The marked demographic change toward greater proportions of older people in developed nations poses significant challenges for health and social care. Several studies have demonstrated an association between social roles in later life and positive health and well-being outcomes. After retiring from work, people may lose roles that provide purpose and social contacts. The outcomes of interventions to promote social roles in retirement have not been systematically reviewed. We examined three research questions: (1) What kinds of intervention have been developed to promote social roles in retirement? (2) How much have they improved perceived roles? (3) Have these roles improved health or well-being? We included those studies that evaluated the provision of social roles; used a control or comparison group; targeted healthy retirement-transition adults who were living in the community; provided an abstract written in English; took place in a highly developed nation; and reported social role, health, or well-being outcomes. We searched eight electronic databases and combined the results with hand searches. Through our searches, we identified 9,062 unique publications and eleven evaluative studies of acceptable quality, which reported seven interventions that met our inclusion criteria. These interventions varied in year of inception and scope, but only two were based outside North America. The studies rarely reported the quality or meaning of roles. Only three studies used random allocation, thus limiting inferences of causality from these studies. Interventions providing explicit roles and using supportive group structures were somewhat effective in improving one or more of the following: life satisfaction, social support and activity, physical health and activity, functional health, and cognition. Social role interventions may improve health and well-being for people in retirement transition. Future research should improve the quality of intervention and assessment and look at which interventions are most effective and acceptable in facilitating social roles for diverse older populations. © 2013 Milbank Memorial Fund.

Adherence to a physical activity intervention among older adults in a post-transitional middle income country: a quantitative and qualitative analysis.

PubMed

Garmendia, M L; Dangour, A D; Albala, C; Eguiguren, P; Allen, E; Uauy, R

2013-01-01

The effectiveness of community level interventions depends to a great extent on adherence. Currently, information on factors related to adherence in older adults from developing countries is scarce. Our aim was to identify factors associated to adherence to a physical activity intervention in older adults from a post-transitional middle income country. Using a combination of quantitative and qualitative methods we studied 996 older Chilean subjects (65-67.9 years at baseline) with low to medium socioeconomic status from 10 health centers randomized to receive a physical activity intervention as part of the CENEX cluster trial (ISRCTN48153354). Using a multilevel regression model, the relationship between adherence (defined a priori as attendance at a minimum of 24 physical activity classes spread over at least 12 months) and individual, intervention-related and contextual factors was evaluated. We also conducted 40 semi-structured interviews with older adults (n=36) and instructors (n=4). Transcripts of the interviews were analyzed using content analysis to identify barriers and facilitators to adherence. Adherence to physical activity intervention was 42.6% (CI 95% 39.5 to 45.6). Depression, diabetes mellitus, percentage of impoverished households and rate of arrests for violent crimes in the neighborhood predicted less adherence (p<0.05) while being retired, participation in physical activity prior to the intervention, and green areas per habitant were positively associated with adherence (p<0.05). The qualitative interviews identified three primary barriers to adherence: current health problems, lack of time due to commitments for caring for family members, and being employed, and two primary facilitators to adherence: the health benefits attributed to the intervention and the opportunity the classes provided for social interaction with others. In order to enhance effectiveness of community exercise interventions, strategies to improve participation should be targeted to older adults from deprived areas and those with psychological and medical conditions.

Supporting Well-Being in Retirement through Meaningful Social Roles: Systematic Review of Intervention Studies

PubMed Central

Heaven, Ben; Brown, Laura Je; White, Martin; Errington, Linda; Mathers, John C; Moffatt, Suzanne

2013-01-01

Context The marked demographic change toward greater proportions of older people in developed nations poses significant challenges for health and social care. Several studies have demonstrated an association between social roles in later life and positive health and well-being outcomes. After retiring from work, people may lose roles that provide purpose and social contacts. The outcomes of interventions to promote social roles in retirement have not been systematically reviewed. Methods We examined three research questions: (1) What kinds of intervention have been developed to promote social roles in retirement? (2) How much have they improved perceived roles? (3) Have these roles improved health or well-being? We included those studies that evaluated the provision of social roles; used a control or comparison group; targeted healthy retirement-transition adults who were living in the community; provided an abstract written in English; took place in a highly developed nation; and reported social role, health, or well-being outcomes. We searched eight electronic databases and combined the results with hand searches. Findings Through our searches, we identified 9,062 unique publications and eleven evaluative studies of acceptable quality, which reported seven interventions that met our inclusion criteria. These interventions varied in year of inception and scope, but only two were based outside North America. The studies rarely reported the quality or meaning of roles. Only three studies used random allocation, thus limiting inferences of causality from these studies. Interventions providing explicit roles and using supportive group structures were somewhat effective in improving one or more of the following: life satisfaction, social support and activity, physical health and activity, functional health, and cognition. Conclusions Social role interventions may improve health and well-being for people in retirement transition. Future research should improve the quality of intervention and assessment and look at which interventions are most effective and acceptable in facilitating social roles for diverse older populations. PMID:23758511

Predicting 30- to 120-Day Readmission Risk among Medicare Fee-for-Service Patients Using Nonmedical Workers and Mobile Technology.

PubMed

Ostrovsky, Andrey; O'Connor, Lori; Marshall, Olivia; Angelo, Amanda; Barrett, Kelsy; Majeski, Emily; Handrus, Maxwell; Levy, Jeffrey

2016-01-01

Hospital readmissions are a large source of wasteful healthcare spending, and current care transition models are too expensive to be sustainable. One way to circumvent cost-prohibitive care transition programs is complement nurse-staffed care transition programs with those staffed by less expensive nonmedical workers. A major barrier to utilizing nonmedical workers is determining the appropriate time to escalate care to a clinician with a wider scope of practice. The objective of this study is to show how mobile technology can use the observations of nonmedical workers to stratify patients on the basis of their hospital readmission risk. An area agency on aging in Massachusetts implemented a quality improvement project with the aim of reducing 30-day hospital readmission rates using a modified care transition intervention supported by mobile predictive analytics technology. Proprietary readmission risk prediction algorithms were used to predict 30-, 60-, 90-, and 120-day readmission risk. The risk score derived from the nonmedical workers' observations had a significant association with 30-day readmission rate with an odds ratio (OR) of 1.12 (95 percent confidence interval [CI], 1 .09-1.15) compared to an OR of 1.25 (95 percent CI, 1.19-1.32) for the risk score using nurse observations. Risk scores using nurse interpretation of nonmedical workers' observations show that patients in the high-risk category had significantly higher readmission rates than patients in the baseline-risk and mild-risk categories at 30, 60, 90, and 120 days after discharge. Of the 1,064 elevated-risk alerts that were triaged, 1,049 (98.6 percent) involved the nurse care manager, 804 (75.6 percent) involved the patient, 768 (72.2 percent) involved the health coach, 461 (43.3 percent) involved skilled nursing, and 235 (22.1 percent) involved the outpatient physician in the coordination of care in response to the alert. The predictive nature of the 30-day readmission risk scores is influenced by both nurse and nonmedical worker input, and both are required to adequately triage the needs of the patient. Although this preliminary study is limited by a modest effect size, it demonstrates one approach to using technology to contribute to delivery model innovation that could curb wasteful healthcare spending by tapping into an existing underutilized workforce.

The Zero Suicide Model: Applying Evidence-Based Suicide Prevention Practices to Clinical Care

PubMed Central

Brodsky, Beth S.; Spruch-Feiner, Aliza; Stanley, Barbara

2018-01-01

Suicide is reaching epidemic proportions, with over 44,000 deaths by suicide in the US, and 800,000 worldwide in 2015. This, despite research and development of evidence-based interventions that target suicidal behavior directly. Suicide prevention efforts need a comprehensive approach, and research must lead to effective implementation across public and mental health systems. A 10-year systematic review of evidence-based findings in suicide prevention summarized the areas necessary for translating research into practice. These include risk assessment, means restriction, evidence-based treatments, population screening combined with chain of care, monitoring, and follow-up. In this article, we review how suicide prevention research informs implementation in clinical settings where those most at risk present for care. Evidence-based and best practices address the fluctuating nature of suicide risk, which requires ongoing risk assessment, direct intervention and monitoring. In the US, the National Action Alliance for Suicide Prevention has put forth the Zero Suicide (ZS) Model, a framework to coordinate a multilevel approach to implementing evidence-based practices. We present the Assess, Intervene and Monitor for Suicide Prevention model (AIM-SP) as a guide for implementation of ZS evidence-based and best practices in clinical settings. Ten basic steps for clinical management model will be described and illustrated through case vignette. These steps are designed to be easily incorporated into standard clinical practice to enhance suicide risk assessment, brief interventions to increase safety and teach coping strategies and to improve ongoing contact and monitoring of high-risk individuals during transitions in care and high risk periods. PMID:29527178

75 FR 67751 - Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-03

...] Medicare Program: Community-Based Care Transitions Program (CCTP) Meeting AGENCY: Centers for Medicare... guidance and ask questions about the upcoming Community-based Care Transitions Program. The meeting is open... registration information will be posted on the CMS Care Transitions Web site at http://www.cms.gov/DemoProjects...

Welfare reform: advocacy and intervention in the health care setting.

PubMed Central

Lawton, E; Leiter, K; Todd, J; Smith, L

1999-01-01

Welfare reform has drastically altered the lives of poor families in the US. In its wake, many former recipients are not receiving whatever transitional benefits and other safeguards to which they remain entitled under federal and state laws. Families are losing access to Medicaid and are not receiving the child care assistance or Food Stamps for which they continue to be eligible. Ill-served by stringent time limits and work requirements, lack of child care assistance, and lack of training and educational opportunities for the development of skills that will lead to better jobs, families need help to navigate the complexities of the new welfare system. Boston Medical Center's Department of Pediatrics has instituted a welfare screening project to educate families about their rights under welfare reform and assist them in advocating for themselves and their children. PMID:10670622

Supporting the Moral Development of Medical Students

PubMed Central

Branch, William T

2000-01-01

Philosophers who studied moral development have found that individuals normally progress rapidly in early adulthood from a conventional stage in which they base behavior on the norms and values of those around them to a more principled stage where they identify and attempt to live by personal moral values. Available data suggest that many medical students, who should be in this transition, show little change in their moral development. Possibly, this relates to perceived pressures to conform to the informal culture of the medical wards. Many students experience considerable internal dissidence as they struggle to accommodate personal values related to empathy, care, and compassion to their clinical training. Educational interventions that positively influence this process have established regular opportunities for critical reflection by the students in small groups. Other interventions include faculty development to enhance role modeling and feedback by clinical faculty. The author espouses more widespread adoption of these educational interventions. PMID:10940138

Systematic review of conservative interventions for subacute low back pain.

PubMed

Pengel, Heloise M; Maher, Chris G; Refshauge, Kathryn M

2002-12-01

To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. Systematic review of randomized controlled trials. Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise, TENS) may be effective. Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence.

Resident Dyads Providing Transition Care to Adolescents and Young Adults With Chronic Illnesses and Neurodevelopmental Disabilities

PubMed Central

Jasien, Joan; Maslow, Gary R.

2017-01-01

Background Youth with special health care needs often experience difficulty transitioning from pediatric to adult care. These difficulties may derive in part from lack of physician training in transition care and the challenges health care providers experience establishing interdisciplinary partnerships to support these patients. Objective This educational innovation sought to improve pediatrics and adult medicine residents' interdisciplinary communication and collaboration. Methods Residents from pediatrics, medicine-pediatrics, and internal medicine training programs participated in a transitions clinic for patients with chronic health conditions aged 16 to 26 years. Residents attended 1 to 4 half-day clinic sessions during 1-month ambulatory rotations. Pediatrics/adult medicine resident dyads collaboratively performed psychosocial and medical transition consultations that addressed health care navigation, self-care, and education and vocation topics. Two to 3 attending physicians supervised each clinic session (4 hours) while concurrently seeing patients. Residents completed a preclinic survey about baseline attitudes and experiences, and a postclinic survey about their transitions clinic experiences, changes in attitudes, and transition care preparedness. Results A total of 46 residents (100% of those eligible) participated in the clinic and completed the preclinic survey, and 25 (54%) completed the postclinic survey. A majority of respondents to the postclinic survey reported positive experiences. Residents in both pediatrics and internal medicine programs reported improved preparedness for providing transition care to patients with chronic health conditions and communicating effectively with colleagues in other disciplines. Conclusions A dyadic model of collaborative transition care training was positively received and yielded improvements in immediate self-assessed transition care preparedness. PMID:28439357

Resident Dyads Providing Transition Care to Adolescents and Young Adults With Chronic Illnesses and Neurodevelopmental Disabilities.

PubMed

Chung, Richard J; Jasien, Joan; Maslow, Gary R

2017-04-01

Youth with special health care needs often experience difficulty transitioning from pediatric to adult care. These difficulties may derive in part from lack of physician training in transition care and the challenges health care providers experience establishing interdisciplinary partnerships to support these patients. This educational innovation sought to improve pediatrics and adult medicine residents' interdisciplinary communication and collaboration. Residents from pediatrics, medicine-pediatrics, and internal medicine training programs participated in a transitions clinic for patients with chronic health conditions aged 16 to 26 years. Residents attended 1 to 4 half-day clinic sessions during 1-month ambulatory rotations. Pediatrics/adult medicine resident dyads collaboratively performed psychosocial and medical transition consultations that addressed health care navigation, self-care, and education and vocation topics. Two to 3 attending physicians supervised each clinic session (4 hours) while concurrently seeing patients. Residents completed a preclinic survey about baseline attitudes and experiences, and a postclinic survey about their transitions clinic experiences, changes in attitudes, and transition care preparedness. A total of 46 residents (100% of those eligible) participated in the clinic and completed the preclinic survey, and 25 (54%) completed the postclinic survey. A majority of respondents to the postclinic survey reported positive experiences. Residents in both pediatrics and internal medicine programs reported improved preparedness for providing transition care to patients with chronic health conditions and communicating effectively with colleagues in other disciplines. A dyadic model of collaborative transition care training was positively received and yielded improvements in immediate self-assessed transition care preparedness.

Mortality in perinatally HIV-infected young people in England following transition to adult care: an HIV Young Persons Network (HYPNet) audit.

PubMed

Fish, R; Judd, A; Jungmann, E; O'Leary, C; Foster, C

2014-04-01

Mortality in young people with perinatally acquired HIV infection (PHIV) following transfer to adult care has not been characterized in the UK. We conducted a multicentre audit to establish the number of deaths and associated factors. Fourteen adult clinics caring for infected young people reported deaths to 30 September 2011 on a proforma. Deaths were matched to the Collaborative HIV Paediatric Study, a clinical database of HIV-infected children in the UK/Ireland, to describe clinical characteristics in paediatric care of those who died post-transition. Eleven deaths were reported from 14 clinics which cared for 248 adults with PHIV. For the 11 deaths, the median age at transfer to adult care was 17 years (range 15-21 years), and at death was 21 years (range 17-24 years). Causes of death were suicide (two patients), advanced HIV disease (seven patients) and bronchiectasis (one patient), with one cause missing. At death, the median CD4 count was 27 cells/μL (range 0-630 cells/μL); five patients were on antiretroviral therapy (ART) but only two had a viral load < 50 HIV-1 RNA copies/mL. Nine had poor adherence when in paediatric care, continuing into adult care despite multidisciplinary support. Eight had ART resistance, although all had potentially suppressive regimens available. Nine had mental health diagnoses. Our findings highlight the complex medical and psychosocial issues faced by some adults with PHIV, with nine of the 11 deaths in our study being associated with poor adherence and advanced HIV disease. Novel adherence interventions and mental health support are required for this vulnerable cohort. © 2013 British HIV Association.

Development and deployment of a health information system in transitional countries (croatian experience).

PubMed

Stevanovic, Ranko; Pristas, Ivan; Ivicevic Uhernik, Ana; Stanic, Arsen

2005-01-01

Croatian Primary Health Care Information System pilot project, conducted between 2001 and 2003, aimed to develop and deploy a health information system based on the latest technologies which would improve the quality of primary health care and rationalise the consumption. 60 primary health care teams (physician and nurse) were equipped with PCs and connected via central server to the main national health insurer, state treasury and public health institute. Developed information system enabled rapid retrieval of documents, replacement of manual data input and a real-time insight into needed information as well as prompt interventions within the system. The project also introduced electronic smart cards for physicians and nurses, so that at each medical check-up the information system verified both the ensuree's and the physician's or nurse's status and rights.Based on the experiences from the pilot project, plan has been made for comprehensive health information system at national level which would connect primary health care teams, hospitals, laboratories, dentistries, health insurance companies, state treasury, public health institutes and electronic health records database. Its major goals are more rapid diagnostics, accuracy in prescribing therapy, standardisation of the good practice as well as better utilisation of capacities, shorter waiting times and shorter stays in hospitals, which would lead to improvement in overall health care quality and better control over the health care consumption. Estimated 5-year investment for installing such system would be 125 million EUR. However, information system could save substantially more and yield a return of investment in only two years.As information system for primary health care should be a strategic component of every health care reform and development plan, we can recommend our model, based on the results of the pilot project, to other transitional countries.

System flexibility in the rehabilitation process of mentally disabled persons in a hostel that bridges between the hospital and the community.

PubMed

Baloush-Kleinman, Vered; Schneidman, Michael

2003-01-01

Deinstitutionalization and community mental health services have become the focus of mental health care in the United States, Italy and England, and now in Israel. Tirat Carmel MHC developed an intervention model of organizational change implemented in a rehabilitation hostel. It is an interim service based on graduated transition from maintenance care to a transitional Half-way House, followed by a Transitional Living Skills Center oriented for independent community living. Of 205 rehabilitees who resided in the hostel since the beginning of the project, 138 were discharged to community residential settings: 67 patients were discharged to reinforced community hostels; 27 to sheltered housing and 23 to independent residential quarters; 7 patients were discharged to comprehensive hostels, 3 to old-age homes and 11 returned home to their families. In terms of employment, 79 were placed in sheltered employment facilities, 24 work in the open market and 3 returned to school; 22 work in therapeutic occupational settings and 10 patients discharged to comprehensive hostels and old-age homes are engaged in sheltered employment programs in those settings. The system flexibility model and the rehabilitation processes anchored in normalization supported the relocation of hospitalized psychiatric patients to community-based settings and enabled the rehabilitees to cope with readjustment to community life.

Diabetes in Vietnam.

PubMed

Khue, Nguyen Thy

2015-01-01

The prevalence for diabetes, prediabetes, and gestational diabetes in Vietnam are low relative to other parts of the world, but they are increasing at alarming rates. These changes have occurred in the setting of economic and cultural transitions. The aim of this study was to provide relevant information depicting the diabetes burden in Vietnam. Literature was reviewed using PubMed and local Vietnamese sources, including papers published in the Vietnamese language. In 2012, the prevalence of diabetes was 5.4% and prediabetes 13.7%. In 2005, the prevalence of obesity was 1.7%. There is a dual burden of over- and undernutrition observed in Vietnam. Diabetes is associated with an increased waist-to-hip ratio despite normal body mass index. Nutritional transitions occurred with increased protein, fat, and fast foods, and with decreased fresh fruits and vegetables. Tobacco use is very high in Vietnam with 66% of adult men currently smoking. Challenges include endocrinology training, health care coverage, patient education, and lack of coordination among government and specialist agencies. Diabetes is a growing problem in Vietnam and is associated with obesity, changes in dietary patterns, and other cultural transitions. More research is needed to better understand this health care problem and to devise targeted interventions. Copyright © 2015 The Author. Published by Elsevier Inc. All rights reserved.

Psychosocial outcomes in a cohort of perinatally HIV-infected adolescents in Western Jamaica.

PubMed

Evans-Gilbert, Tracy; Kasimbie, Kazie; Reid, Gail; Williams, Shelly Ann

2018-02-05

Background Psychosocial factors interact with adolescent development and affect the ability of HIV-infected adolescents to cope with and adhere to treatment. Aim To evaluate psychosocial outcomes in perinatally HIV-infected adolescents (PHIVAs) in Western Jamaica after psychosocial intervention. Methods The Bright Futures Paediatric Symptom Checklist (BF-PSC) was used for psychological screening of PHIVAs in Western Jamaica. Referred patients were evaluated using the Youth version of the Columbia Impairment Scale (CIS). Demographic, laboratory and clinical data obtained between July 2014 and June 2016 were evaluated retrospectively and outcomes were reviewed before and after psychosocial intervention. Results Sixty PHIVAs were enrolled and 36 (60%) had a positive BF-PSC score that necessitated referral. The BF-PSC correctly identified 89% of patients with impaired psychosocial assessment by CIS scores. Referred patients were less likely to adhere to treatment, to be virologically suppressed or to have a CD4+ count of >500 cells/μl, and were more likely to be in the late teenage group or to be of orphan status. After intervention, the prevalence of viral suppression increased and median viral load decreased. A difference in mean CD4+ cell count was detected before but not after intervention in teenage and orphan groups. Conclusions The BF-PSC identified at-risk PHIVAs with impaired psychosocial functioning. Increased vulnerability was noted in orphans and older teenagers. Psychosocial interventions (including family therapy) reduced psychosocial impairment and improved virological suppression. Mental health intervention should be instituted to facilitate improved clinical outcomes, autonomy of care and transition to adult care.

Young Adult Cancer Survivors' Experience with Cancer Treatment and Follow-Up Care and Perceptions of Barriers to Engaging in Recommended Care.

PubMed

Berg, Carla J; Stratton, Erin; Esiashvili, Natia; Mertens, Ann

2016-09-01

We examined correlates of low engagement in the healthcare system, experiences with survivorship care, barriers to follow-up care, and potential resources for promoting follow-up care among young adult survivors of childhood cancers. We conducted a mixed-method study involving surveys of 106 survivors of childhood cancer aged 18-34 recruited from a university-affiliated children's hospital and an NCI-designated cancer center in the Southeastern USA. Phone-based semistructured interviews were then conducted in a subset of 26. Assessments included health factors, psychosocial factors, healthcare system interaction, and interest in resources to promote engagement in healthcare. Survey participants were on average 22.14 (SD = 3.16) years old, 50.0 % female, and 77.4 % White. Overall, 46.0 % had attended survivorship clinic, 47.2 % reported receiving a treatment summary, 68.9 % had a primary care provider, and 17.0 % reported no interaction with healthcare in the past 2 years. Correlates of less than annual healthcare provider visits included being older (p = 0.003), being male (p < 0.001), lack of insurance (p = 0.002), and having had chemotherapy (p = 0.05). Participants reported varied experiences in terms of how health and treatment information was presented, from none or too little to overwhelming or anxiety-provoking amounts. Barriers to engaging in survivorship care included no/limited insurance, time, or transportation; major life changes; anxiety; and difficulty transitioning from pediatrics to adult care. Participants highlighted the need for educational and psychosocial resources, particularly technology-based resources. Multilevel interventions are needed to increase engagement in survivorship care among young adult cancer survivors. Technology-based resources addressing social support and mental well-being are intervention possibilities.

Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review.

PubMed

Luu, Ngoc-Phuong; Pitts, Samantha; Petty, Brent; Sawyer, Melinda D; Dennison-Himmelfarb, Cheryl; Boonyasai, Romsai Tony; Maruthur, Nisa M

2016-04-01

Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care. We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool. Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65%), conducted in the US (55%), and studied communication between primary care and inpatient providers (62%). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95% CI 0.92-1.26). The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.

Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods.

PubMed

Lionis, Christos; Petelos, Elena; Mechili, Enkeleint-Aggelos; Sifaki-Pistolla, Dimitra; Chatzea, Vasiliki-Eirini; Angelaki, Agapi; Rurik, Imre; Pavlic, Danica Rotar; Dowrick, Christopher; Dückers, Michel; Ajdukovic, Dean; Bakic, Helena; Jirovsky, Elena; Mayrhuber, Elisabeth Sophie; van den Muijsenbergh, Maria; Hoffmann, Kathryn

2018-02-08

The current political crisis, conflicts and riots in many Middle Eastern and African countries have led to massive migration waves towards Europe. European countries, receiving these migratory waves as first port of entry (POE) over the past few years, were confronted with several challenges as a result of the sheer volume of newly arriving refugees. This humanitarian refugee crisis represents the biggest displacement crisis of a generation. Although the refugee crisis created significant challenges for all national healthcare systems across Europe, limited attention has been given to the role of primary health care (PHC) to facilitate an integrated delivery of care by enhancing care provision to refugees upon arrival, on transit or even for longer periods. Evidence-based interventions, encompassing elements of patient-centredness, shared decision-making and compassionate care, could contribute to the assessment of refugee healthcare needs and to the development and the implementation of training programmes for rapid capacity-building for the needs of these vulnerable groups and in the context of integrated PHC care. This article reports on methods used for enhancing PHC for refugees through rapid capacity-building actions in the context of a structured European project under the auspices of the European Commission and funded under the 3rd Health Programme by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The methods include the assessment of the health needs of all the people reaching Europe during the study period, and the identification, development, and testing of educational tools. The developed tools were evaluated following implementation in selected European primary care settings.

From home to 'home': Mapping the caregiver journey in the transition from home care into residential care.

PubMed

Hainstock, Taylor; Cloutier, Denise; Penning, Margaret

2017-12-01

Family caregivers play a pivotal role in supporting the functional independence and quality of life of older relatives, often taking on a wide variety of care-related activities over the course of their caregiving journey. These activities help family members to remain in the community and age-in-place for as long as possible. However, when needs exceed family capacities to provide care, the older family member may need to transition from one care environment to another (e.g., home care to nursing home care), or one level of care to another (from less intense to more intensive services). Drawing upon qualitative interview data collected in a populous health region in British Columbia, Canada, this study explores the roles and responsibilities of family caregivers for family members making the care transition from home care to residential care. A thematic analysis of the interview transcripts resulted in the development of a conceptual framework to characterize the "Caregiver Journey" as a process that could be divided into at least three phases: 1) Precursors to transition - recognizing frailty in family members and caregivers prior to transition; 2) Preparing to transition into residential nursing home care (RC) and 3) Post-transition: Finding a new balance - where caregivers adjust and adapt to new caregiving responsibilities. Our analyses revealed that the second phase is the most complex involving a consideration of the various activities, and roles that family caregivers take on to prepare for the care transition including: information gathering, advocacy and system navigation. We conclude that there is a need for family caregivers to be better supported during care transitions; notably through ongoing and enhanced investments in strategies to support caregiver communication and education. Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

Comparative care and outcomes for acute coronary syndromes in Central and Eastern European Transitional countries: A review of the literature.

PubMed

Smith, Fraser G D; Brogan, Richard A; Alabas, Oras; Laut, Kristina G; Quinn, Tom; Bugiardini, Raffaele; Gale, Chris P

2015-12-01

The purpose of this review was to compare quality of care and outcomes following acute coronary syndrome (ACS) in Central and Eastern European Transitional (CEET) countries. This was a review of original ACS articles in CEET countries from PubMed, ISI Web of Science, Medline and Embase databases published in English from November 2003 to February 2014. Seventeen manuscripts fulfilled the search criteria. Of 19 CEET countries studied, there were no published ACS management or outcome data for four countries. In-hospital mortality for patients with acute myocardial infarction (AMI) ranged from 6.3% in the Czech Republic to 15.3% in Latvia. In-hospital mortality for ST-elevation myocardial infarction (STEMI) ranged from 3.0% in Poland to 20.7% in Romania. For STEMI, primary percutaneous coronary intervention (PCI) ranged from 1.0% to over 92.0%, fibrinolytic therapy from 0.0% to 49.6%, and no reperfusion therapy from 7.0% to 63.0%. Many CEET countries do not have published ACS care and outcomes data. Of those that do, there is evidence for substantial geographical variation in early mortality. Wide variation in emergency reperfusion strategies for STEMI suggests that acute cardiac care is likely to be modifiable and if addressed could reduce mortality from ACS in CEET countries. The collection of ACS care and outcomes data across Europe must be prioritised. © The European Society of Cardiology 2014.

Transitional Care

ERIC Educational Resources Information Center

Naylor, Mary; Keating, Stacen A.

2008-01-01

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their…

Rethinking Healthcare Transitions and Policies: Changing and Expanding Roles in Transitional Care

ERIC Educational Resources Information Center

Moreño, Patricienn K.

2014-01-01

The breakdown of care transitions between various healthcare facilities, providers, and services is a major issue in healthcare, and accounts for over US$15 billion in healthcare expenditures annually. The transition between inpatient care and home care is a very delicate period where, too often, chronically ill patients get worse and wind up back…

Transition to adult-oriented health care: perspectives of youth and adults with complex physical disabilities.

PubMed

Young, Nancy L; Barden, Wendy S; Mills, Wendy A; Burke, Tricia A; Law, Mary; Boydell, Katherine

2009-01-01

The transition to adulthood is extremely difficult for individuals with disabilities. We sought to explore the specific issue of transition to adult-oriented health care in a Canadian context. We conducted semi-structured individual interviews with 15 youth and 15 adults with cerebral palsy, spina bifida, and acquired brain injuries of childhood, and their parents (n = 30). Respondents discussed their health care services, their experience with clinical transition, and contributing factors. We analyzed the transcripts using qualitative methods. All participants identified challenges in transition, including: lack of access to health care; lack of professionals' knowledge; lack of information and uncertainty regarding the transition process. Two solutions were identified: early provision of detailed information and more extensive support throughout the clinical transition process. The challenges of clinical transition were universal. More extensive information and support is needed during transition to ensure an efficient move to appropriate adult-oriented health care.

Design and rationale for NOURISH-T: a randomized control trial targeting parents of overweight children off cancer treatment.

PubMed

Stern, Marilyn; Ewing, Lin; Davila, Esther; Thompson, Amanda L; Hale, Gregory; Mazzeo, Suzanne

2015-03-01

Approximately 40% of off-treatment pediatric cancer survivors (PCS) are overweight or obese, which increases their risk for negative long-term physical health complications. Consistent with the Institute of Medicine's (IOM) emphasis on patients transitioning from treatment to cancer survivorship and increasing long-term healthy behaviors in these survivors, we plan to conduct a pilot RCT to address the increasing overweight/obesity rates among PCS by targeting their caregivers as agents for PCS behavior change. We plan to focus on parents' behaviors, attitudes and roles in promoting healthier eating and physical activity (PA) in PCS and adapt an evidence-informed, manualized parent intervention - NOURISH - found to be effective for parents of overweight and obese children and adolescents in reducing child and adolescent BMI. We plan to adapt NOURISH for caregivers of 5-12 year old PCS (6 months-4 years off active cancer treatment). Our pilot feasibility RCT - NOURISH-T (Nourishing Our Understanding of Role modeling to Improve Support for Healthy Transitions) evaluates: 1) the preliminary efficacy of NOURISH-T for PCS, compared with an Enhanced Usual Care (EUC) control condition, and 2) factors to consider to improve future adaptations of the intervention. The project will enroll caregivers of PCS at two pediatric oncology clinics into the 6-week intervention (or EUC) with assessments occurring pre- and post-6 weeks of intervention, and at a 4-month follow-up. Copyright © 2015 Elsevier Inc. All rights reserved.

Effect of an educational intervention on attitudes toward and implementation of evidence-based practice.

PubMed

Varnell, Gayle; Haas, Barbara; Duke, Gloria; Hudson, Kathy

2008-01-01

Transitioning to an evidence-based practice (EBP) environment is a new and often overwhelming challenge for many organisations. The most effective strategies to implement EBP have yet to be determined. In this study an accelerated development EBP program, which was administered to nurses from five hospitals was evaluated. At each hospital, nurses were selected as an "EBP champion" whose role would be to help facilitate the transition within that organisation. The purpose of this study was to evaluate the effectiveness of an accelerated educational program on the attitudes toward and implementation of EBP among nurses employed in acute-care facilities. Forty-nine nurses from five acute-care facilities participated in an 8-week program to develop into EBP champions. Participants attended a 2-hour class each week conducted by four faculty members of a local university. Pre- and post-test mean scores of the EBP barriers (EBPB) and EBP implementation (EBPI) scales were compared using paired t tests to determine the effect of the accelerated development program. Respondents reported higher scores on both the beliefs and implementation scales at the end of the program. Paired t tests indicated a significant difference in means for both the EBPB (p < .01) and EBPI (p < .01). Nurses who attend an accelerated educational program have the potential to significantly improve beliefs and attitudes about EBP. Administrative support and collaboration between academia and service are essential for successful intervention.

A subacute model of geriatric care for frail older persons: the Tan Tock Seng Hospital experience.

PubMed

Chong, Mei Sian; Empensando, Esmiller F; Ding, Yew Yoong; Tan, Thai Lian

2012-08-01

The subacute care unit in Tan Tock Seng Hospital (TTSH) was set up in May 2009. We examined its impact on the transitions at the nexus between hospital and community sectors, patients' discharge destination and functional performance. We studied patients admitted during the initial 6-month period (May to October 2009). Differences in demographics, length of stay (LOS), comorbidity and severity of illness measures, functional outcomes (modified Barthel Index (MBI)) according to discharge destinations were obtained. We also studied the impact of LOS on the geriatric department and the bill size over the pre- and post-subacute implementation periods. Majority of the subacute patients' hospital stay was in subacute care. Of these patients, 44.9% were discharged home, 24.2% to a slow stream rehabilitation (SSR) setting and 29.2% to nursing homes. 16.9% consisted of a subgroup of dementia patients requiring further behavioural and functional interventions, of which 50% managed to be discharged home. Functional gains were seen during subacute stay; with greatest gains observed in the SSR group. There were no differences in overall LOS nor total bill size (DRG-adjusted) for the geriatric medicine department during the first 6 months of operating this new subacute model compared with the prior 4-month period. We propose this subacute model of geriatric care, which allows right-siting of care and improved functional outcomes. It fulfills the role easing transitions between acute hospital and community sectors. In particular, it provides specialised care to a subgroup of dementia patients with challenging behaviours and is fiscally sound from the wider hospital perspective.

A Qualitative Study of Patient and Provider Experiences during Preoperative Care Transitions

PubMed Central

MALLEY, ANN; YOUNG, GARY J.

2017-01-01

Aims To explore the issues and challenges of care transitions in the preoperative environment. Background Ineffective transitions play a role in a majority of serious medical errors. There is a paucity of research related to the preoperative arena and the multiple inherent transitions in care that occur there. Design Qualitative descriptive design was used. Methods Semi-structured interviews were conducted in a 975 bed academic medical center. Results 30 providers and 10 preoperative patients participated. Themes that arose were: (1) Need for clarity of purpose of preoperative care (2) Care coordination (3) Inter-professional boundaries of care (4) Inadequate time and resources. Conclusion Effective transitions in the preoperative environment require that providers bridge scope of practice barriers to promote good teamwork. Preoperative care that is a product of well-informed providers and patients can improve the entire perioperative care process and potentially influence post-operative patient outcomes. Relevance to Clinical Practice Nurses are well positioned to bridge the gaps within transitions of care and accordingly affect health outcomes. PMID:27706872

Transitioning adolescent and young adults with chronic disease and/or disabilities from paediatric to adult care services - an integrative review.

PubMed

Zhou, Huaqiong; Roberts, Pamela; Dhaliwal, Satvinder; Della, Phillip

2016-11-01

This paper aims to provide an updated comprehensive review of the research-based evidence related to the transitions of care process for adolescents and young adults with chronic illness/disabilities since 2010. Transitioning adolescent and young adults with chronic disease and/or disabilities to adult care services is a complex process, which requires coordination and continuity of health care. The quality of the transition process not only impacts on special health care needs of the patients, but also their psychosocial development. Inconsistent evidence was found regarding the process of transitioning adolescent and young adults. An integrative review was conducted using a five-stage process: problem identification, literature search, data evaluation, data analysis and presentation. A search was carried out using the EBSCOhost, Embase, MEDLINE, PsycINFO, and AustHealth, from 2010 to 31 October 2014. The key search terms were (adolescent or young adult) AND (chronic disease or long-term illness/conditions or disability) AND (transition to adult care or continuity of patient care or transfer or transition). A total of 5719 records were initially identified. After applying the inclusion criteria a final 61 studies were included. Six main categories derived from the data synthesis process are Timing of transition; Perceptions of the transition; Preparation for the transition; Patients' outcomes post-transition; Barriers to the transition; and Facilitating factors to the transition. A further 15 subcategories also surfaced. In the last five years, there has been improvement in health outcomes of adolescent and young adults post-transition by applying a structured multidisciplinary transition programme, especially for patients with cystic fibrosis and diabetes. However, overall patients' outcomes after being transited to adult health care services, if recorded, have remained poor both physically and psychosocially. An accurate tracking mechanism needs to be established by stakeholders as a formal channel to monitor patients' outcomes post- transition. © 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.

Update on Urological Management of Spina Bifida from Prenatal Diagnosis to Adulthood.

PubMed

Snow-Lisy, Devon C; Yerkes, Elizabeth B; Cheng, Earl Y

2015-08-01

We review the current literature regarding urological management of spina bifida from prenatal diagnosis to adulthood. We searched MEDLINE(®), EMBASE(®) and PubMed(®) for English articles published through December 2014 using search terms "spina bifida," "spinal dysraphism" and "bladder." Based on review of titles and abstracts, 437 of 1,869 articles were identified as addressing topics related to open spina bifida in pediatric patients, or long-term or quality of life outcomes in adults with spina bifida. We summarize this literature to inform clinical guidelines and create a framework for disease management. The birth prevalence of spina bifida in the United States has recently plateaued at approximately 30 per 100,000. With improved management more individuals are surviving to adulthood, with an economic impact of $319,000 during the lifetime of an individual with spina bifida. Recent advances in prenatal surgery have demonstrated that prenatal closure of spina bifida is possible. To assess safety and efficacy, the National Institutes of Health sponsored Management of Myelomeningocele Study was undertaken, in which subjects were randomized to prenatal or postnatal closure. Until the urological results of this trial are published, the impact of prenatal intervention on future bladder function remains unclear. Controversy continues regarding the optimal use and timing of urodynamic studies, and the indications for initiation of clean intermittent catheterization and anticholinergics in infants and children. Many favor expectant management, while others argue for a more proactive approach. Based on the current literature, both approaches appear to protect the child from renal injury, although delayed intervention may increase rates of bladder augmentation. The current literature regarding this topic is difficult to interpret and compare due to heterogeneity of patient populations, variable outcome measures and lack of reporting of quality of life outcomes. Surgical intervention is indicated for those at risk for renal deterioration and/or is considered for children who fail to achieve satisfactory continence with medical management. Traditionally surgery concentrates on the bladder and bladder neck, and creation of catheterizable channels. For those with a hostile bladder, enterocystoplasty remains the gold standard for bladder augmentation, although use of bowel for augmentation remains suboptimal due to secondary complications, including increased risk of infections, metabolic abnormalities, neoplastic transformation and risk of life threatening perforation. Recent advances in tissue engineering technology may provide an alternative to traditional augmentation. However, recent results from phase II trials using current techniques to augment the bladder with engineered bladder tissue are disappointing. Catheterizable channels to the bladder and ascending colon further facilitate continence measures and promote independent care. While surgical reconstruction is clearly successful in improving continence, recent outcome studies have questioned the true impact of this type of surgery on quality of life. With improved survival transitional care issues, including health related independence, sexual health needs and development of a support system, are increasingly important. Transitional care remains a significant issue for which few public health measures are being quantitatively evaluated. Despite consensus regarding early urological involvement in the care of patients with spina bifida, controversy remains regarding optimal management. Major reconstructive urological surgeries still have a major role in the management of these cases to protect the upper urinary tract and to achieve continence. However, future studies are needed to better clarify the true impact on quality of life that these interventions have on patients and their families. Transition of urological care to adulthood remains a major avenue for improvement in disease management. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Barriers and facilitators to successful transition from pediatric to adult inflammatory bowel disease care from the perspectives of providers.

PubMed

Paine, Christine W; Stollon, Natalie B; Lucas, Matthew S; Brumley, Lauren D; Poole, Erika S; Peyton, Tamara; Grant, Anne W; Jan, Sophia; Trachtenberg, Symme; Zander, Miriam; Mamula, Petar; Bonafide, Christopher P; Schwartz, Lisa A

2014-11-01

For adolescents and young adults (AYA) with inflammatory bowel disease (IBD), the transition from pediatric to adult care is often challenging and associated with gaps in care. Our study objectives were to (1) identify outcomes for evaluating transition success and (2) elicit the major barriers and facilitators of successful transition. We interviewed pediatric and adult IBD providers from across the United States with experience caring for AYAs with IBD until thematic saturation was reached after 12 interviews. We elicited the participants' backgrounds, examples of successful and unsuccessful transition of AYAs for whom they cared, and recommendations for improving transition using the Social-Ecological Model of Adolescent and Young Adult Readiness to Transition framework. We coded interview transcripts using the constant comparative method and identified major themes. Participants reported evaluating transition success and failure using health care utilization outcomes (e.g., maintaining continuity with adult providers), health outcomes (e.g., stable symptoms), and quality of life outcomes (e.g., attending school). The patients' level of developmental maturity (i.e., ownership of care) was the most prominent determinant of transition outcomes. The style of parental involvement (i.e., helicopter parent versus optimally involved parent) and the degree of support by providers (e.g., care coordination) also influenced outcomes. IBD transition success is influenced by a complex interplay of patient developmental maturity, parenting style, and provider support. Multidisciplinary IBD care teams should aim to optimize these factors for each patient to increase the likelihood of a smooth transfer to adult care.

Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and neuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional management

PubMed Central

Birnkrant, David J; Bushby, Katharine; Bann, Carla M; Apkon, Susan D; Blackwell, Angela; Brumbaugh, David; Case, Laura E; Clemens, Paula R; Hadjiyannakis, Stasia; Pandya, Shree; Street, Natalie; Tomezsko, Jean; Wagner, Kathryn R; Ward, Leanne M; Weber, David R

2018-01-01

Since the publication of the Duchenne muscular dystrophy (DMD) care considerations in 2010, multidisciplinary care of this severe, progressive neuromuscular disease has evolved. In conjunction with improved patient survival, a shift to more anticipatory diagnostic and therapeutic strategies has occurred, with a renewed focus on patient quality of life. In 2014, a steering committee of experts from a wide range of disciplines was established to update the 2010 DMD care considerations, with the goal of improving patient care. The new care considerations aim to address the needs of patients with prolonged survival, to provide guidance on advances in assessments and interventions, and to consider the implications of emerging genetic and molecular therapies for DMD. The committee identified 11 topics to be included in the update, eight of which were addressed in the original care considerations. The three new topics are primary care and emergency management, endocrine management, and transitions of care across the lifespan. In part 1 of this three-part update, we present care considerations for diagnosis of DMD and neuromuscular, rehabilitation, endocrine (growth, puberty, and adrenal insufficiency), and gastrointestinal (including nutrition and dysphagia) management. PMID:29395989

Health care services and the transition to young adulthood: challenges and opportunities.

PubMed

Park, M Jane; Adams, Sally H; Irwin, Charles E

2011-01-01

The aim of this study was to examine the potential role of the health care system in the successful transition to young adulthood for all adolescents, with emphasis on adolescents with special health care needs (ASHCN), and to evaluate the system's status in filling that role. Research and conceptual frameworks addressing successful transitions and functioning were reviewed. A framework describing a role for health care services in the transition was presented. The health care system's status in promoting healthy transitions was evaluated, including National Survey of Children with Special Health Care Needs 2005-2006 analyses of key outcomes for ASHCN. Although most national efforts to define skills needed for the transition have focused on career/vocational skills, a few frameworks integrate broader issues such as health, psychosocial development, and civic engagement. Adolescent transitional issues have generally received little attention; however, these have been articulated for ASHCN. Nevertheless, only 2 in 5 ASHCN receive transitional care, and ASHCN fare poorly on other core outcomes. ASHCN with mental health conditions fare worse on outcomes than those with physical health conditions. Our framework for healthy transitions includes the following: 1) adolescents can access a comprehensive health care system, 2) preventable problems are avoided, and 3) chronic problems are managed. The present health care system falls short of accomplishing these. Health care services can potentially play a role in facilitating a healthy transition to young adulthood; however, many gaps exist. Although the health care reform act addresses some gaps, efforts that integrate adolescents' developmental needs and address mental health issues are needed. Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Transitions: A Guide to Teens Getting Older and Changing Health Care Providers

MedlinePlus

... Transitions: A Guide to Getting Older and Changing Health Care Providers (HCP’s) Posted under Health Guides . Updated 11 ... can help me plan my transition to adult health care? Your pediatrician or other health care provider Your ...

Current practice and views of neurologists on the transition from pediatric to adult care.

PubMed

Oskoui, Maryam; Wolfson, Christina

2012-12-01

To describe the current practice and views of neurologists on transitioning patients from pediatric to adult care, a cross-sectional study of all pediatric and adult neurologists in the province of Quebec, Canada, was conducted. The response rate was 73% for pediatric and 49% for adult neurologists. Most pediatric neurologists do not have a patient transition program or policy in place. Although a transfer summary is commonly provided, critical information is often lacking. Nearly half of neurologists believed that patients experience a gap in care during the transition process, and most agreed that the transition process is often poorly coordinated, highlighting patient, family, and health care factors. Current practice does not follow existing consensus statements for transition of care with respect to timing, communication, and preparation, and many pediatric neurologists experience difficulty in finding an appropriate adult health care provider for their patients. Neurologists reported many challenges in the current transition of care process.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups.

PubMed

Farrell, Timothy W; Supiano, Katherine P; Wong, Bob; Luptak, Marilyn K; Luther, Brenda; Andersen, Troy C; Wilson, Rebecca; Wilby, Frances; Yang, Rumei; Pepper, Ginette A; Brunker, Cherie P

2018-05-01

Health professions trainees' performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = -0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

Transitioning youth with rheumatic conditions: perspectives of pediatric rheumatology providers in the United States and Canada.

PubMed

Chira, Peter; Ronis, Tova; Ardoin, Stacy; White, Patience

2014-04-01

To assess North American pediatric rheumatology providers' perspectives on practices, barriers, and opportunities concerning the transition from pediatric-centered to adult-centered care. Childhood Arthritis and Rheumatology Research Alliance (CARRA) members completed a 25-item survey assessing current transition practices, transition policy awareness, and transitional care barriers and needs. Results were compared to the American Academy of Pediatrics (AAP) 2008 survey on transitional care. Over half (158/288, 55%) of CARRA members completed the survey. Fewer than 10% are very familiar with AAP guidelines about transition care for youth with special healthcare needs. Eight percent have a formal written transition policy, but 42% use an informal approach. Patient request (75%) most frequently initiates transfer to adult care. Two major barriers to transition are fragmented adult medical care and lack of sufficient time to provide services. Compared with AAP survey participants, pediatric rheumatology providers are significantly more likely to help youth find an adult specialist (63% vs 45%) and discuss confidentiality and consent before age 18 (45% vs 33%), but are less likely to help with medical summary creation (16% vs 27%) or find a primary care provider (25% vs 47%). Outcomes ranked as "very important" in defining a successful transition are survival (76%), seeing an adult rheumatologist within 6 months of final pediatric rheumatology visit (66%), and maintaining insurance coverage (57%). This comprehensive survey of North American pediatric rheumatology providers regarding transitional care practices demonstrates deficiencies in education, resources, and a formalized process. Respondents support development of standardized rheumatology-specific transition practices.

Facilitating the transition of patients with special health care needs from pediatric to adult oral health care.

PubMed

Nowak, Arthur J; Casamassimo, Paul S; Slayton, Rebecca L

2010-11-01

Without guidelines or policies in dentistry for transitioning adolescents with special heath care needs from pediatric to adult oral health care, little is known about traditional support services. The authors surveyed pediatric dentists about their transition of adolescent patients with and without special health care needs (SHCNs) to adult care. In 2009, the authors e-mailed a pilot-tested survey modified from a survey used for U.S. pediatricians to 4,000 pediatric dentists. The survey included demographic questions and questions regarding services and barriers associated with the transition of patients to adult care. Responses were obtained from 1,686 (42.2 percent response) pediatric dentists who were mostly in group or solo private practices and were younger, in that most had completed their education in the preceding 15 years. More than one-half practiced in suburban settings, and most worked with both dental hygienists and dental assistants. Most assisted patients with SHCNs with their transitions to adult care, and the predominant barrier to transitioning to adult care was availability of general dentists and specialists who were willing to accept these new patients. Pediatric dentists' answers paralleled those of pediatricians for the most part in terms of services provided and barriers to transition. Most responding dentists helped adolescents with and without SHCNs make the transition into adult care, but the major barrier was the availability of general dentists and specialists. With an office protocol in place that includes trained staff members, transitioning patients (especially those with SHCNs) to adult care can be facilitated to provide the appropriate oral health and support services.

Multidimensional Treatment Foster Care as a Preventive Intervention to Promote Resiliency Among Youth in the Child Welfare System

PubMed Central

Leve, Leslie D.; Fisher, Philip A.; Chamberlain, Patricia

2009-01-01

Demographic trends indicate that a growing segment of families is exposed to adversity such as poverty, drug use problems, caregiver transitions, and domestic violence. Although these risk processes and the accompanying poor outcomes for children have been well-studied, little is known about why some children develop resilience in the face of such adversity, particularly when it is severe enough to invoke child welfare involvement. This paper describes a program of research involving families in the child welfare system. Using a resiliency framework, evidence from four randomized clinical trials that included components of the Multidimensional Treatment Foster Care program is presented. Future directions and next steps are proposed. PMID:19807861

Barriers and Facilitators to Engagement and Retention in Care among Transgender Women Living with Human Immunodeficiency Virus

PubMed Central

Sevelius, Jae M.; Patouhas, Enzo; Keatley, JoAnne G.; Johnson, Mallory O.

2014-01-01

Background Transgender women have 49 times the odds of human immunodeficiency virus (HIV) infection compared to other groups, yet they are disproportionately underserved by current treatment efforts. Purpose To examine culturally unique barriers and facilitators to engagement and retention in HIV care and strengthen efforts to mitigate health disparities, guided by the Models of Gender Affirmation and Health Care Empowerment. Methods Through 20 interviews and 5 focus groups (n=38), transgender women living with HIV discussed their experiences and life contexts of engagement in and adherence to HIV care and treatment. Results Our participants faced substantial challenges to adhering to HIV care and treatment, including avoidance of healthcare due to stigma and past negative experiences, prioritization of hormone therapy, and concerns about adverse interactions between antiretroviral treatment for HIV and hormone therapy. Receiving culturally competent, transgender-sensitive healthcare was a powerful facilitator of healthcare empowerment. Conclusions Recommendations are offered to inform intervention research and guide providers, emphasizing gender affirming HIV care that integrates transition-related healthcare needs. PMID:24317955

Creating and evaluating an opportunity for medication reconciliation in the adult population of South Africa to improve patient care.

PubMed

Naicker, Pranusha; Schellack, Natalie; Godman, Brian; Bronkhorst, Elmien

2018-04-16

Adverse drug events (ADEs) are a major cause of morbidity and mortality, with more than 50% of ADEs being preventable. Adverse Drug Reactions (ADRs) are typically the result of an incomplete medication history, prescribing or dispensing error, as well as over- or under-use of prescribed pharmacotherapy. Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and subsequently comparing the list against the different transitions of care. It is used to reduce medication discrepancies, and thereby ultimately decreasing ADEs. However, little is known about medicine reconciliation activities among public hospitals in South Africa. Prospective quantitative, descriptive design among Internal and Surgical wards in a leading public hospital in South Africa. 145 study participants were enrolled. Over 1300 (1329) medicines were reviewed of which there was a significant difference (p = 0.006) when comparing the medications that the patient was taking before or during hospitalisation. A total of 552 (41.53%) interventions were undertaken and the majority of patients had at least 3.96 medication discrepancies. The most common intervention upon admission was transcribing the home medication onto the hospital prescription (65.2%) followed by medication duplication (13.44%). During patient's hospital stay, interventions included patient counselling (32.5%) and stopping the previous treatment (37.5%). To ensure continuity of patient care, medication reconciliation should be implemented throughout patients' hospital stay. This involves all key professionals in hospitals.

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review.

PubMed

Jack, Helen E; Arabadjis, Sophia D; Sun, Lucy; Sullivan, Erin E; Phillips, Russell S

2017-03-01

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending. We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design. Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all). Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

[Stability of home based care arrangements for people with dementia : Development of a consensus definition of stability using expert focus groups].

PubMed

von Kutzleben, Milena; Köhler, Kerstin; Dreyer, Jan; Holle, Bernhard; Roes, Martina

2017-04-01

The majority of people with dementia in Germany live at home. These informal care arrangements, which are mostly coordinated by informal carers, are the backbone of home-based dementia care. Creating and maintaining stability is an underlying theme in informal care; however, a definition of the complex phenomenon of 'stability' in this context is still lacking. The aim was to develop a working definition of stability of home-based care arrangements for people with dementia, which can be applied in current and future research projects at the German Center for Neurodegenerative Diseases in Witten (DZNE Witten) and others. Ensuing from prior research a preliminary version of the definition was formulated. This definition was discussed in a focus group of scientific experts with expertise in dementia research and care (n = 8). After data analysis using content analysis, the definition was revised during a scientific colloquium (n = 18) and a consensus was finally reached. There were four major themes which were considered by the experts as being relevant for the definition of stability: (1) creating and maintaining stability as a continuous adaptation process, (2) a qualitative component of stability, (3) persons with dementia and informal carers as pivotal players and (4) transitions to residential care. The working definition introduced in this article reflects the authors' understanding of the phenomenon of stability of home-based care arrangements for people with dementia. In times of increasing need for evidence-based interventions it is necessary to develop elaborated definitions of complex phenomena in order to be able to systematically evaluate the efficacy of interventions on the basis of a common understanding.

A systematic review of the cost and cost-effectiveness of electronic discharge communications.

PubMed

Sevick, Laura K; Esmail, Rosmin; Tang, Karen; Lorenzetti, Diane L; Ronksley, Paul; James, Matthew; Santana, Maria; Ghali, William A; Clement, Fiona

2017-07-02

The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial.

PubMed

O'Toole, Thomas P; Johnson, Erin E; Borgia, Matthew L; Rose, Jennifer

2015-07-01

Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. Homeless Veterans not receiving primary care participated in the study. An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. We measured receipt of primary care within 4 weeks of study enrollment. Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6% were male, 43.0% were from a minority population, 12.0% were unsheltered, 25.5% were staying in a dusk-to-dawn emergency shelter, 26.1% were in transitional housing, while 27.7% were in an unstable, doubled-up arrangement. At one month, 77.3% of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7% had been seen in primary care. This was followed by the CO-only group, 50.0% of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0% and the Usual Care arm at 30.6%. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.

Synthesis: Deriving a Core Set of Recommendations to Optimize Diabetes Care on a Global Scale.

PubMed

Mechanick, Jeffrey I; Leroith, Derek

2015-01-01

Diabetes afflicts 382 million people worldwide, with increasing prevalence rates and adverse effects on health, well-being, and society in general. There are many drivers for the complex presentation of diabetes, including environmental and genetic/epigenetic factors. The aim was to synthesize a core set of recommendations from information from 14 countries that can be used to optimize diabetes care on a global scale. Information from 14 papers in this special issue of Annals of Global Health was reviewed, analyzed, and sorted to synthesize recommendations. PubMed was searched for relevant studies on diabetes and global health. Key findings are as follows: (1) Population-based transitions distinguish region-specific diabetes care; (2) biological drivers for diabetes differ among various populations and need to be clarified scientifically; (3) principal resource availability determines quality-of-care metrics; and (4) governmental involvement, independent of economic barriers, improves the contextualization of diabetes care. Core recommendations are as follows: (1) Each nation should assess region-specific epidemiology, the scientific evidence base, and population-based transitions to establish risk-stratified guidelines for diagnosis and therapeutic interventions; (2) each nation should establish a public health imperative to provide tools and funding to successfully implement these guidelines; and (3) each nation should commit to education and research to optimize recommendations for a durable effect. Systematic acquisition of information about diabetes care can be analyzed, extrapolated, and then used to provide a core set of actionable recommendations that may be further studied and implemented to improve diabetes care on a global scale. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Position of the American Dietetic Association: Providing nutrition services for people with developmental disabilities and special health care needs.

PubMed

Van Riper, Cynthia L; Wallace, Lee Shelly

2010-02-01

It is the position of the American Dietetic Association that nutrition services provided by registered dietitians (RDs) and dietetic technicians, registered (DTRs), are essential components of comprehensive care for all people with developmental disabilities and special health care needs. Nutrition services should be provided throughout life in a manner that is interdisciplinary, family-centered, community-based, and culturally competent. People with developmental disabilities and special health care needs frequently have nutrition concerns, including growth alterations (failure to thrive, obesity, or growth retardation), metabolic disorders, poor feeding skills, medication-nutrient interactions, and sometimes partial or total dependence on enteral or parenteral nutrition. Individuals with special needs are also more likely to develop comorbid conditions such as obesity or endocrine disorders that require nutrition interventions. Poor health habits, limited access to services, and long-term use of multiple medications are considered health risk factors. Health maintenance and avoidance of complications can be promoted by timely and cost-effective nutrition interventions. Public policy for individuals with special needs has evolved over time, resulting in a transition from institutional facilities and programs to community living. The expansion of public access to technology and health information on the Internet challenges RDs and DTRs to provide accurate scientific information for those with developmental disabilities and special health care needs. Nationally credentialed RDs and DTRs are best prepared to provide appropriate nutrition information for wellness and quality of life.

Barriers and facilitators to successful transition from pediatric to adult inflammatory bowel disease care from the perspectives of providers

PubMed Central

Paine, Christine Weirich; Stollon, Natalie B.; Lucas, Matthew S.; Brumley, Lauren D.; Poole, Erika S.; Peyton, Tamara; Grant, Anne W.; Jan, Sophia; Trachtenberg, Symme; Zander, Miriam; Mamula, Petar; Bonafide, Christopher P.; Schwartz, Lisa A.

2014-01-01

Background For adolescents and young adults (AYA) with inflammatory bowel disease (IBD), the transition from pediatric to adult care is often challenging and associated with gaps in care. Our study objectives were to (1) identify outcomes for evaluating transition success and (2) elicit the major barriers and facilitators of successful transition. Methods We interviewed pediatric and adult IBD providers from across the United States with experience caring for AYAs with IBD until thematic saturation was reached after 12 interviews. We elicited the participants' backgrounds, examples of successful and unsuccessful transition of AYAs for whom they cared, and recommendations for improving transition using the Social-ecological Model of Adolescent and Young Adult Readiness to Transition framework. We coded interview transcripts using the constant comparative method and identified major themes. Results Participants reported evaluating transition success and failure using healthcare utilization outcomes (e.g. maintaining continuity with adult providers), health outcomes (e.g. stable symptoms), and quality of life outcomes (e.g. attending school). The patients' level of developmental maturity (i.e. ownership of care) was the most prominent determinant of transition outcomes. The style of parental involvement (i.e. helicopter parent vs. optimally-involved parent) also influenced outcomes as well as the degree of support by providers (e.g. care coordination). Conclusion IBD transition success is influenced by a complex interplay of patient developmental maturity, parenting style, and provider support. Multidisciplinary IBD care teams should aim to optimize these factors for each patient to increase the likelihood of a smooth transfer to adult care. PMID:25137417

A Mixed Methods Investigation of Maternal Perspectives on Transition Experiences in Early Care and Education

ERIC Educational Resources Information Center

Swartz, Rebecca Anne; Speirs, Katherine Elizabeth; Encinger, Amy Johnson; McElwain, Nancy L.

2016-01-01

Research Findings: Strong relationships among children, families, and early care and education (ECE) providers are key to quality infant-toddler care. These relationships are shaped during the initial transition period to group care. We used a mixed methods approach to (a) assess maternal perspectives on the transition to group care, (b) explore…

Improving Sickle Cell Transitions of Care Through Health Information Technology.

PubMed

Frost, Jennifer R; Cherry, Rebecca K; Oyeku, Suzette O; Faro, Elissa Z; Crosby, Lori E; Britto, Maria; Tuchman, Lisa K; Horn, Ivor B; Homer, Charles J; Jain, Anjali

2016-07-01

Transitions between inpatient and outpatient care and pediatric to adult care are associated with increased mortality for sickle cell disease (SCD) patients. As accurate and timely sharing of health information is essential during transitions, a health information technology (HIT)-enabled tool holds promise to improve care transitions. From 2012 through 2014, the team conducted and analyzed data from an environmental scan, key informant interviews, and focus groups to inform the development of an HIT-enabled tool for SCD patients' use during care transitions. The scan included searches of peer-reviewed and gray literature to understand SCD patient needs, transition concerns, and best practices in mobile health applications, and searches of websites and online stores to identify existing transition tools and their features. Eleven focus groups consisted of four groups of SCD patients of varying ages (≥9 years); three groups of parents/caregivers of SCD patients; three groups of providers; and one with IT developers. In focus groups, patients and caregivers reported that the transition from home to the emergency department (ED) was the most challenging; the ED was also where transitions from pediatric to adult care usually occurred. Patients felt they were not taken seriously by unfamiliar ED providers, and their inability to convey their diagnosis, pain regimen, and detailed medical history while in significant pain hindered care. The environmental scan did not reveal an existing suitable transition tool, but patients, parents, providers, and IT experts saw the potential and appeal of creating a tool to meet ED health information needs to improve care transitions. Copyright © 2016 American Journal of Preventive Medicine. All rights reserved.

Preventing Poor Mental Health and School Dropout of Mexican American Adolescents Following the Transition to Junior High School

ERIC Educational Resources Information Center

Gonzales, Nancy A.; Dumka, Larry E.; Deardorff, Julianna; Carter, Sara Jacobs; McCray, Adam

2004-01-01

This study provided an initial test of the Bridges to High School Program, an intervention designed to prevent school disengagement and negative mental health trajectories during the transition to junior high school. The intervention included an adolescent coping skills intervention, a parenting skills intervention, and a family strengthening…

Allocation of Family Responsibility for Illness Management in Pediatric HIV

PubMed Central

Montepiedra, Grace; Nichols, Sharon; Farley, John; Garvie, Patricia A.; Kammerer, Betsy; Malee, Kathleen; Sirois, Patricia A.; Storm, Deborah

2009-01-01

Objective The purpose of the study is to describe allocation of responsibility for illness management in families of children and adolescents perinatally infected with HIV. Methods A total of 123 youth (ages 8–18) and caregivers completed family responsibility and medication adherence questionnaires as part of a substudy of Pediatric AIDS Clinical Trials Group protocol 219c. Results Approximately one-fourth of the youth reported being fully responsible for taking medications. A smaller percentage of caregivers reported full youth responsibility. Older youth and caregivers of older youth reported higher degree of youth responsibility for medication-related tasks, though age was unrelated to adherence. Caregiver report of greater responsibility for medications was associated with better adherence. Conclusions Caregivers are likely to transition responsibility for HIV care to older youth but this transition was not always successful as evidenced by poor medication adherence. Interventions supporting successful transition may improve adherence and subsequently health outcomes in pediatric HIV. PMID:18586756

It’s Time to Shine the Light on Direct-to-Consumer Advertising

PubMed Central

Mackey, Tim K.; Liang, Bryan A.

2015-01-01

Pharmaceutical marketing is undergoing a transition as the business, delivery, and consumption of health care have increasingly become part of a growing digital landscape. Changes in pharmaceutical promotion also coincide with federal “sunshine” regulations newly implemented under the Affordable Care Act that require disclosure of certain marketing and industry payments to physicians. Collectively, these trends could lead to fundamental shifts in physician-directed and direct-to-consumer advertising (DTCA) that have yet to be adequately identified or explored. In response, we advocate for greater DTCA transparency, especially in the emerging digital forms of DTCA, to complement forthcoming sunshine transparency data. This will allow more robust study and understanding of changes in overall pharmaceutical marketing trends and their impact on health care consumption and behavior. This can also lead to more targeted state and federal policy interventions leveraging existing federal transparency regulations to ensure appropriate marketing, sales, and consumption of pharmaceutical products. PMID:25583897

Managing the link and strengthening transition from child to adult mental health Care in Europe (MILESTONE): background, rationale and methodology.

PubMed

Tuomainen, H; Schulze, U; Warwick, J; Paul, M; Dieleman, G C; Franić, T; Madan, J; Maras, A; McNicholas, F; Purper-Ouakil, D; Santosh, P; Signorini, G; Street, C; Tremmery, S; Verhulst, F C; Wolke, D; Singh, S P

2018-06-04

Transition from distinct Child and Adolescent Mental Health (CAMHS) to Adult Mental Health Services (AMHS) is beset with multitude of problems affecting continuity of care for young people with mental health needs. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge globally. The overall aim of the Managing the Link and Strengthening Transition from Child to Adult Mental Health Care in Europe (MILESTONE) project (2014-19) is to improve transition from CAMHS to AMHS in diverse healthcare settings across Europe. MILESTONE focuses on current service provision in Europe, new transition-related measures, long term outcomes of young people leaving CAMHS, improving transitional care through 'managed transition', ethics of transitioning and the training of health care professionals. Data will be collected via systematic literature reviews, pan-European surveys, and focus groups with service providers, users and carers, and members of youth advocacy and mental health advocacy groups. A prospective cohort study will be conducted with a nested cluster randomised controlled trial in eight European Union (EU) countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS users, their carers, and clinicians. Improving transitional care can facilitate not only recovery but also mental health promotion and mental illness prevention for young people. MILESTONE will provide evidence of the organisational structures and processes influencing transition at the service interface across differing healthcare models in Europe and longitudinal outcomes for young people leaving CAMHS, solutions for improving transitional care in a cost-effective manner, training modules for clinicians, and commissioning and policy guidelines for service providers and policy makers. "MILESTONE study" registration: ISRCTN ISRCTN83240263 Registered 23 July 2015; ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Assessment of surgical discharge summaries and evaluation of a new quality improvement model.

PubMed

Stein, Ran; Neufeld, David; Shwartz, Ivan; Erez, Ilan; Haas, Ilana; Magen, Ada; Glassberg, Elon; Shmulevsky, Pavel; Paran, Haim

2014-11-01

Discharge summaries after hospitalization provide the most reliable description and implications of the hospitalization. A concise discharge summary is crucial for maintaining continuity of care through the transition from inpatient to ambulatory care. Discharge summaries often lack information and are imprecise. Errors and insufficient recommendations regarding changes in the medical regimen may harm the patient's health and may result in readmission. To evaluate a quality improvement model and training program for writing postoperative discharge summaries for three surgical procedures. Medical records and surgical discharge summaries were reviewed and scored. Essential points for communication between surgeons and family physicians were included in automated forms. Staff was briefed twice regarding required summary contents with an interim evaluation. Changes in quality were evaluated. Summaries from 61 cholecystectomies, 42 hernioplasties and 45 colectomies were reviewed. The average quality score of all discharge summaries increased from 72.1 to 78.3 after the first intervention (P < 0.0005) to 81.0 following the second intervention. As the discharge summary's quality improved, its length decreased significantly. Discharge summaries lack important information and are too long. Developing a model for discharge summaries and instructing surgical staff regarding their contents resulted in measurable improvement. Frequent interventions and supervision are needed to maintain the quality of the surgical discharge summary.

Moving the Journey Towards Independence: Adolescents Transitioning to Successful Diabetes Self-Management.

PubMed

Babler, Elizabeth; Strickland, Carolyn June

2015-01-01

To gain a greater understanding of adolescent's experiences living with Type 1 diabetes mellitus (T1DM) and create a theoretical paradigm. Grounded theory as described by Glaser was used. Fifteen in-depth interviews were conducted with adolescent's ages 11-15 with T1DM. Symbolic interactionism is the theoretical framework for grounded theory. Data were collected; transcribed, coded, and analyzed simultaneously using constant comparative analysis and findings were grounded in the words of participants. A theoretical model was created with the concept of "normalizing". Normalizing was defined as the ability to integrate diabetes into one's daily life to make diabetes 'part of me'. Phase four of the model, and the focus of this manuscript was "Moving the Journey towards Independence" and included: 1) taking over care, 2) experiencing conflict with parents, and 3) realizing diabetes is hard. The major task for adolescents in this phase was separating from parents to independently manage diabetes. The normalizing task for this phase was: "taking on the burden of care". Adolescents described challenges with independent care and increased parental conflict including: fearing needles, forgetting insulin, feeling embarrassed and believing that diabetes was a burden in their life. Additionally, juggling the multiple responsibilities of home, school and work along with managing a chronic illness during adolescence is challenging. Transitioning to diabetes self-management is a challenge for adolescents. This model advances understanding of the moving processes in adolescents transitioning; additionally, hypotheses are presented that may be used for developing interventions to promote success in self-management. Copyright © 2015 Elsevier Inc. All rights reserved.

Integrating palliative care across settings: A retrospective cohort study of a hospice home care programme for cancer patients.

PubMed

Tan, Woan Shin; Lee, Angel; Yang, Sze Yee; Chan, Susan; Wu, Huei Yaw; Ng, Charis Wei Ling; Heng, Bee Hoon

2016-07-01

Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31-0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54-0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62-0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40-0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62-0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68-0.88) prior to death. Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur. © The Author(s) 2016.

Psychological factors impacting transition from paediatric to adult care by childhood cancer survivors.

PubMed

Granek, Leeat; Nathan, Paul C; Rosenberg-Yunger, Zahava R S; D'Agostino, Norma; Amin, Leila; Barr, Ronald D; Greenberg, Mark L; Hodgson, David; Boydell, Katherine; Klassen, Anne F

2012-09-01

Childhood cancer survivors require life-long care focused on the specific late effects that may arise from their cancer and its treatment. In many centers, survivors are required to transition from follow-up care in a paediatric cancer center, to care provided in an adult care setting. The purpose of this study was to identify the psychological factors involved in this transition to adult care long-term follow-up clinics. Qualitative interviews were conducted with ten paediatric survivors still in paediatric care, as well as 28 adult survivors of whom 11 had transitioned successfully to adult care (attended three long-term follow-up (LTFU) appointments consecutively); ten who failed to transition (attended at least one LTFU appointment as an adult, but were inconsistent with subsequent attendance); and seven who had never transitioned (did not attend any LTFU care as an adult). Line-by-line coding was used to establish categories and themes. Constant comparison was used to examine relationships within and across codes and categories. Two overall categories and four subthemes were identified: (1) Identification with being a cancer survivor included the subthemes of 'cancer identity' and 'cancer a thing of the past' and; (2) Emotional components included the subthemes of 'fear and anxiety' and 'gratitude and gaining perspective'. The analysis revealed that the same factor could act as either a motivator or a hindrance to successful transition in different survivors (e.g., fear of recurrence of cancer might be a barrier or a facilitator depending on the survivor's life experience). Psychological factors are an important consideration when preparing cancer survivors for transition to adult long-term follow-up care. Identifying and addressing the individual psychological needs of childhood cancer survivors may improve the likelihood of their successful transition to adult care.

Texting Teens in Transition: The Use of Text Messages in Clinical Intervention Research

PubMed Central

Nicholas, David B

2014-01-01

Background The rapidly growing population of young adults living with congenital heart disease (CHD), currently challenging ill-prepared cardiac care systems, presents a novel population in which to consider the use of mHealth. This methodological study was part of a larger study that tested the effectiveness of a clinic-based nursing intervention to prepare teens for transfer from pediatric to adult cardiology care. The intervention included creation of a MyHealth Passport and subsequently SMS (short message service) text messages between the intervention nurse and study participant. Objective Our aim was to determine (1) the preference of teens with CHD to be contacted via text message following the nursing intervention, (2) the effectiveness of texting to collect data regarding the use of MyHealth Passport after participation in the intervention, (3) the nature of the texting interaction, and (4) the risks and benefits of texting. Methods Participants were recruited through the intervention study (n=24) by either choosing to receive information from the study coordinator through text message, or texting a question to the study nurses. Inclusion criteria were age 15-17 years, diagnosed with moderate or complex heart disease, and currently being followed by the Division of Cardiology at Stollery Children’s Hospital. Exclusion criteria were heart transplantation and/or less than a 6th grade reading and comprehension ability. Text message transcripts were analyzed by qualitative inductive content analysis. Results Two-thirds of teens (16/24, 67%) chose text messaging as their preferred contact, making them eligible for the study. Texting was effective in collecting information regarding the MyHealth Passport; all but one teen had their MyHealth Passport on them, and many reported carrying it with them wherever they went. All teens reported showing their MyHealth Passport to at least one person. Seven themes were identified in the texting transcripts: mixing formal and informal language, the passive teen, interaction with health care providers, texting teens in transition, texting as a mechanism to initiate other forms of communication, affirmation, and the nurse as an educator. Benefits of texting were identified as flexibility, ability to respond over time, information presented in byte-sized amounts, and information directly related to patient questions. Risks of texting were identified as the possibility that interactions may not be in-depth, distraction of teen and researcher, and invasiveness. Conclusions Text messaging was useful in collecting data regarding the use of the MyHealth Passport. Text messaging resulted in conversations with the teens that were sometimes in-depth and meaningful, especially when combined with other communication modalities. Using text messaging in a manner resulting in full conversations with the patients requires more study and may benefit from protocols and the use of solid theoretical foundations that would standardize the interaction so that more conclusions could be drawn. PMID:25379624

Texting teens in transition: the use of text messages in clinical intervention research.

PubMed

Rempel, Gwen R; Ballantyne, Ross T; Magill-Evans, Joyce; Nicholas, David B; Mackie, Andrew S

2014-11-06

The rapidly growing population of young adults living with congenital heart disease (CHD), currently challenging ill-prepared cardiac care systems, presents a novel population in which to consider the use of mHealth. This methodological study was part of a larger study that tested the effectiveness of a clinic-based nursing intervention to prepare teens for transfer from pediatric to adult cardiology care. The intervention included creation of a MyHealth Passport and subsequently SMS (short message service) text messages between the intervention nurse and study participant. Our aim was to determine (1) the preference of teens with CHD to be contacted via text message following the nursing intervention, (2) the effectiveness of texting to collect data regarding the use of MyHealth Passport after participation in the intervention, (3) the nature of the texting interaction, and (4) the risks and benefits of texting. Participants were recruited through the intervention study (n=24) by either choosing to receive information from the study coordinator through text message, or texting a question to the study nurses. Inclusion criteria were age 15-17 years, diagnosed with moderate or complex heart disease, and currently being followed by the Division of Cardiology at Stollery Children's Hospital. Exclusion criteria were heart transplantation and/or less than a 6th grade reading and comprehension ability. Text message transcripts were analyzed by qualitative inductive content analysis. Two-thirds of teens (16/24, 67%) chose text messaging as their preferred contact, making them eligible for the study. Texting was effective in collecting information regarding the MyHealth Passport; all but one teen had their MyHealth Passport on them, and many reported carrying it with them wherever they went. All teens reported showing their MyHealth Passport to at least one person. Seven themes were identified in the texting transcripts: mixing formal and informal language, the passive teen, interaction with health care providers, texting teens in transition, texting as a mechanism to initiate other forms of communication, affirmation, and the nurse as an educator. Benefits of texting were identified as flexibility, ability to respond over time, information presented in byte-sized amounts, and information directly related to patient questions. Risks of texting were identified as the possibility that interactions may not be in-depth, distraction of teen and researcher, and invasiveness. Text messaging was useful in collecting data regarding the use of the MyHealth Passport. Text messaging resulted in conversations with the teens that were sometimes in-depth and meaningful, especially when combined with other communication modalities. Using text messaging in a manner resulting in full conversations with the patients requires more study and may benefit from protocols and the use of solid theoretical foundations that would standardize the interaction so that more conclusions could be drawn.

Safety and Tolerability of Transitioning from Cangrelor to Ticagrelor in Patients Who Underwent Percutaneous Coronary Intervention.

PubMed

Badreldin, Hisham A; Carter, Danielle; Cook, Bryan M; Qamar, Arman; Vaduganathan, Muthiah; Bhatt, Deepak L

2017-08-01

The 3 phase 3 CHAMPION (Cangrelor vs Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials collectively demonstrated the safety of transitioning from cangrelor, a potent, parenteral rapidly-acting P2Y 12 inhibitor, to clopidogrel in patients who underwent percutaneous coronary intervention (PCI). However, variation in timing of therapy, site-specific binding, and drug half-lives may theoretically complicate switching to other oral P2Y 12 inhibitors. Since regulatory approval, limited data are available regarding the "real-world" safety and tolerability of transitioning to these more potent oral P2Y 12 antagonists. From November 2015 to January 2017, we evaluated the clinical profiles and efficacy and safety outcomes in cangrelor-treated patients who underwent PCI transitioned to clopidogrel (n = 42) or ticagrelor (n = 82) at a large, tertiary care center. Most patients receiving cangrelor underwent PCI with a drug-eluting stent for acute coronary syndrome via a radial approach in the background of unfractionated heparin. Stent thrombosis within 48 hours was rare and occurred in 1 patient treated with ticagrelor. Global Use of Strategies to Open Occluded Coronary Arteries-defined bleeding occurred in 20% of patients switched to ticagrelor and 29% of patients switched to clopidogrel, but none were severe or life-threatening. In conclusion, rates of stent thrombosis and severe/life-threatening bleeding were low and comparable with those identified in the CHAMPION program, despite use of more potent oral P2Y 12 inhibition. Copyright © 2017 Elsevier Inc. All rights reserved.

The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study

PubMed Central

2010-01-01

Background As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients. The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation. Methods/design The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals. Discussion The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article. Trial registration Current Controlled Trails ISRCTN58135104 PMID:20504313

The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study.

PubMed

Heijnen, Ron W H; Evers, Silvia M A A; van der Weijden, Trudy D E M; Limburg, Martien; Schols, Jos M G A

2010-05-26

As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients.The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation. The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals. The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article. Current Controlled Trails ISRCTN58135104.

Reorganization of mental health services: from institutional to community-based models of care.

PubMed

Saraceno, B; Gater, R; Rahman, A; Saeed, K; Eaton, J; Ivbijaro, G; Kidd, M; Dowrick, C; Servili, C; Funk, M K; Underhill, C

2015-09-28

Mental health services in the Eastern Mediterranean Region are predominantly centralized and institutionalized, relying on scarce specialist manpower. This creates a major treatment gap for patients with common and disabling mental disorders and places an unnecessary burden on the individual, their family and society. Six steps for reorganization of mental health services in the Region can be outlined: (1) integrate delivery of interventions for priority mental disorders into primary health care and existing priority programmes; (2) systematically strengthen the capacity of non-specialized health personnel for providing mental health care; (3) scale up community-based services (community outreach teams for defined catchment, supported residential facilities, supported employment and family support); (4) establish mental health services in general hospitals for outpatient and acute inpatient care; (5) progressively reduce the number of long-stay beds in mental hospitals through restricting new admissions; and (6) provide transitional/bridge funding over a period of time to scale up community-based services and downsize mental institutions in parallel.

Evidenced-Based Interventions for Preschool Children with Autism--Improving the Transition from Early Intervention Programs to School-Based Programs through Purposeful Implementation of Practices That Work

ERIC Educational Resources Information Center

Joseph, Tracy A.

2012-01-01

Increasing numbers of children with autism are being identified at a younger age, before the age of 3, when their intervention services are coordinated through early intervention service providers. Shortly after starting with services families are faced with their first major transition regarding intervention services when their child turns 3 and…

Transition support for new graduate and novice nurses in critical care settings: An integrative review of the literature.

PubMed

Innes, Tiana; Calleja, Pauline

2018-05-01

Transition into critical care areas for new graduate nurses may be more difficult than transitioning into other areas due to the specialised knowledge needed. It is unknown which aspects of transition programs best support new graduate nurses improve competence and confidence to transition into critical care nursing specialties. Identifying these aspects would assist to design and implement best practice transition programs for new graduates in critical care areas. Themes identified in the literature include; having a designated resource person, workplace culture, socialisation, knowledge and skill acquisition, orientation, and rotation. Allocation of a quality resource person/s, supportive workplace culture, positive socialisation experiences, knowledge and skill acquisition and structured orientation based on new graduates' learning needs all positively supported increased confidence, competence and transition into nursing practice. Rotations between areas within graduate programs can potentially have both positive and negative impacts on the transition process. Negative impacts of including a rotation component in a transition program should be carefully considered alongside perceived benefits when designing new graduate nurse transition programs. Copyright © 2018. Published by Elsevier Ltd.

Implementation of Transition in Care and Relationship Based Care to Reduce Preventable Rehospitalizations.

PubMed

Burt, Susan; Berry, Donna; Quackenbush, Patricia

2015-01-01

Home healthcare agencies are accountable for preventing rehospitalization, yet many struggle to make progress with this metric. The purpose of this article is to share how our organization turned to two frameworks, Transitions in Care and Relationship-Based Care, to prevent unnecessary rehospitalizations. Appreciative inquiry, motivational interviewing, and action plans are used by our Transitional Care Nurses to engage and motivate patients to manage chronic diseases and achieve desirable health outcomes. Implementation of a Transitional Care Program has led our organization to improve the health of our patients and to decrease rehospitalization rates.

Link to slower access to care: what is the stigma?: an Indian perspective.

PubMed

Kandwal, Rashmi; Bahl, Taru

2011-12-01

Stigma and discrimination have been "bed fellows" of HIV and AIDS in India. Perpetuated by lack of awareness, deep-rooted traditional beliefs, adherence to harmful practices, and a moralistic tag associated with a condition connected with sex (in India the method of HIV transmission being largely heterosexual in nature) and high-risk individuals such as sex workers, it made it difficult for the country to fight an epidemic that was hard to track, estimate, diagnose, and treat. Various interventions under India's National AIDS Control Program (NACP) have targeted stigma and discrimination among different groups. The program has been fairly successful in its outreach programs, bringing about a reduction in adult HIV prevalence and new infections. As the country transitions from NACP Phase III (2007-2012) to IV (2012-2017), making treatment and longevity its top priority, stigma is no longer such a terrifying word. This review discusses the social and cultural context of HIV/AIDS-related stigma in general and highlights various policies and intervention programs that have led India's campaign against HIV/AIDS-driven stigma into the testing, care, support, and treatment ambit.

HIV-infected men who have sex with men, before and after release from jail: the impact of age and race, results from a multi-site study.

PubMed

Vagenas, Panagiotis; Zelenev, Alexei; Altice, Frederick L; Di Paola, Angela; Jordan, Alison O; Teixeira, Paul A; Frew, Paula M; Spaulding, Anne C; Springer, Sandra A

2016-01-01

The US HIV/AIDS epidemic is concentrated among men who have sex with men (MSM). Black men are disproportionately affected by incarceration and Black MSM experience higher infection rates and worse HIV-related health outcomes compared to non-Black MSM. We compared HIV treatment outcomes for Black MSM to other HIV-infected men from one of the largest cohorts of HIV-infected jail detainees (N = 1270) transitioning to the community. Of the 574 HIV-infected men released, 113 (19.7%) self-identified as being MSM. Compared to other male subgroups, young Black MSM (<30 years old, N = 18) were significantly less likely: (1) before incarceration, to have insurance, access to an HIV healthcare provider, and use cocaine; (2) during incarceration, to receive a disease management intervention; and (3) in the 6 months post-release, to link to HIV care. Interventions that effectively link and retain young HIV-infected Black MSM in care in communities before incarceration and post-release from jail are urgently needed.

Cost-effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: design of a cluster-randomized controlled trial.

PubMed

van Dijk, Susan E M; Pols, Alide D; Adriaanse, Marcel C; Bosmans, Judith E; Elders, Petra J M; van Marwijk, Harm W J; van Tulder, Maurits W

2013-05-07

Co-morbid major depression is a significant problem among patients with type 2 diabetes mellitus and/or coronary heart disease and this negatively impacts quality of life. Subthreshold depression is the most important risk factor for the development of major depression. Given the highly significant association between depression and adverse health outcomes and the limited capacity for depression treatment in primary care, there is an urgent need for interventions that successfully prevent the transition from subthreshold depression into a major depressive disorder. Nurse led stepped-care is a promising way to accomplish this. The aim of this study is to evaluate the cost-effectiveness of a nurse-led indicated stepped-care program to prevent major depression among patients with type 2 diabetes mellitus and/or coronary heart disease in primary care who also have subthreshold depressive symptoms. An economic evaluation will be conducted alongside a cluster-randomized controlled trial in approximately thirty general practices in the Netherlands. Randomization takes place at the level of participating practice nurses. We aim to include 236 participants who will either receive a nurse-led indicated stepped-care program for depressive symptoms or care as usual. The stepped-care program consists of four sequential but flexible treatment steps: 1) watchful waiting, 2) guided self-help treatment, 3) problem solving treatment and 4) referral to the general practitioner. The primary clinical outcome measure is the cumulative incidence of major depressive disorder as measured with the Mini International Neuropsychiatric Interview. Secondary outcomes include severity of depressive symptoms, quality of life, anxiety and physical outcomes. Costs will be measured from a societal perspective and include health care utilization, medication and lost productivity costs. Measurements will be performed at baseline and 3, 6, 9 and 12 months. The intervention being investigated is expected to prevent new cases of depression among people with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression, with subsequent beneficial effects on quality of life, clinical outcomes and health care costs. When proven cost-effective, the program provides a viable treatment option in the Dutch primary care system. Dutch Trial Register NTR3715.

Now where was I going? The challenge of care transitions for the cognitively impaired.

PubMed

Noel, Margaret A

2012-01-01

Transitions in care settings can be disconcerting to anyone, but they can be particularly difficult for people with cognitive impairment. MemoryCare's design of integrated clinical and care management services is well suited to minimizing the preventable morbidity that can accompany transitions in health care for cognitively impaired older adults at high risk for poor outcomes.

Enablers and barriers of men with Duchenne muscular dystrophy transitioning from an adult clinic within a pediatric hospital.

PubMed

Lindsay, Sally; McAdam, Laura; Mahendiran, Tania

2017-01-01

Young men with Duchenne muscular dystrophy (DMD) live into adulthood and need specialized care. However, services for adults are fragmented. We know little about young men's experiences, their parents, and clinicians who support them as they transition to adult care. To explore the enablers and barriers of clinicians, young men, and parents as they transition from an adult DMD clinic within a pediatric hospital to an adult health facility. We conducted semi-structured, in-depth interviews with 16 participants (7 clinicians, 5 parents, 4 youth). We used an open-coding, thematic approach to analyze the data. Clinicians, youth and their parents experienced several enablers and barriers in transitioning to an adult health care center. Clinicians reported that structural factors including leadership and advocacy supported the transition. Clinicians and parents found that the availability and continuity of care both enabled and hindered the transition. Parents and youth conveyed the difficulties of adjusting to the different model of adult care and also accessing resources. All participants described how relational factors (i.e., effective communication and family involvement) enabled the transition. On an individual level, clinicians, parents and youth viewed transition readiness and other life skill supports as an enabler and a barrier to transitioning. All participants reported the difficulties of maintaining mental health for youth with DMD transitioning to adult health care. Clinicians, youth, and parents experienced several enablers and barriers in transitioning to adult health care. Further work is needed to understand the complex transition needs of youth with DMD. Copyright © 2016 Elsevier Inc. All rights reserved.

Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to Adult Care of Medically Complex Patients.

PubMed

Weeks, Matthew; Cole, Brandon; Flake, Eric; Roy, Daniel

2018-04-11

This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12-17 yr receive the necessary services to appropriately transition to adult care. Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training. Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3. The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike.

Transition from neonatal intensive care unit to special care nurseries: experiences of parents and nurses.

PubMed

Helder, Onno K; Verweij, Jos C M; van Staa, AnneLoes

2012-05-01

To explore parents' and nurses' experiences with the transition of infants from the neonatal intensive care unit to a special care nursery. Qualitative explorative study in two phases. Level IIID neonatal intensive care unit in a university hospital and special care nurseries (level II) in five community hospitals in the Netherlands. Twenty-one pairs of parents and 18 critical care nurses. Semistructured interviews were used. Thematic analysis and comparison of themes across participants were performed. Trust was a central theme for parents. Three subthemes, related to the chronological stages of transition, were identified: gaining trust; betrayal of trust; and rebuilding confidence. Trust was associated with five other themes: professional attitude; information management; coordination of transfer; different environments; and parent participation. Although nurses at an early stage repeatedly mentioned a possible transition to community hospitals, the actual announcement took many parents by surprise. Parents felt excluded during the actual transfer and most questioned its necessity. In the special care nursery, parents found it difficult to adjust to new routines and to gain trust in new caregivers, but eventually their worries dissolved. In contrast to neonatal intensive care unit nurses, special care nursery nurses quite understood the impact of transition on parents. Both parents and nurses considered present transitional arrangements to be inadequate. Nurses should provide more effective discharge planning and transitional care. A positive labeling of the transition as a first step to home discharge for the newborn seems appropriate. Parents need to be better-informed and should be involved in the planning process.

Challenges of modern day transition care in inflammatory bowel disease: From inflammatory bowel disease to biosimilars.

PubMed

Hakizimana, Ali; Ahmed, Iftikhar; Russell, Rachel; Wright, Mark; Afzal, Nadeem A

2017-07-07

In this article we discuss the challenges of delivering a high quality Transition care. A good understanding of the adolescent needs with good communication between Transition care physicians and the patient is essential for good continuity of care. Despite availability of several guidelines, one model doesn't fit all and any transition service development should be determined by the local need and available healthcare facilities.

[Prevention of medication errors in healthcare transition of patients treated with apomorphine].

PubMed

Ucha Sanmartin, M; Martín Vila, A; López Vidal, C; Caaamaño Barreiro, M; Piñeiro Corrales, G

2014-05-01

The transition of patients between different levels of care process is a particular risk in the production of medication errors. The aim of this paper is to analyze the role of the pharmacist in preventing errors transition care to ensure a safe and cross pharmacotherapy of patients.Transversal, observational and descriptive study in a University Hospital that has a pharmacy service that integrates specialized inpatient care and health centers. Transition of care a patient treated with Apormorfina was analyzed to determine the keypoints of action of the pharmacist. Demographics, disease and medication history, and care transition episodes were collected through the pharmacy program and electronics history.The pharmacist did tasks adapting, reconciliation, management and reporting of medication to the health care team to prevent medication errors in care transition of patients treated with drugs requiring special handling .In conclusion, this work represents perfectly the key role of the pharmacist as coordinator of safe and transverse pharmacotherapy of patients. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Web-Based Intervention for Transitioning Smokers From Inpatient to Outpatient Care: An RCT.

PubMed

Kathleen F, Harrington; Young-Il, Kim; Meifang, Chen; Rekha, Ramachandran; Maria, Pisu; Rajani S, Sadasivam; Thomas K, Houston; William C, Bailey

2016-10-01

Smoking-cessation follow-up care after hospitalization is known to be effective. Cost-effective and disseminable interventions adoptable by hospitals are needed. RCT. Fourteen hundred eighty-eight current smokers recruited during a tertiary care hospital stay were randomly assigned to Usual Care (UC) or Usual Care plus Web-Based Intervention (WI). Data were collected in 2011-2013 and analyzed in 2014-2015. UC provided brief bedside advice to quit, a quit plan template, and quitline contact information. WI included access to a website with asynchronous e-message communication with a tobacco counselor, use of interactive self-assessments, helpful cessation information, and access to additional web resources, as well as automated e-mail messages tailored for health concern and readiness to quit. Self-reported 30-day abstinence at 6 months was the primary outcome; a subset was verified by saliva cotinine. Six-month follow-up was completed by 83% of participants. No difference was found between study arms for self-reported abstinence rates in intent-to-treat (25.4% WI vs 26.8% UC) and complete case (31.3% WI vs 31.4% UC) analyses. Reduced smoking was reported by 45.5% (WI, n=276) and 47% (UC, n=296) of non-abstinent responders (p=0.59). Using a 10-ng/mL cotinine cut off, abstinence was verified in 52.1% of WI and 62.5% of UC (p=0.11). Significant covariates associated with abstinence at 6 months were being male, not smoking during hospitalization, being very confident in quitting, planning to quit/stay quit, smoking fewer days in the past 30 days, fewer years of smoking, and having cerebrovascular or connective tissue rheumatic disease as primary hospital diagnosis. Lack of difference between treatment arms suggests a strong effect for UC, WI was not effective, or both. Low intervention engagement may be partially responsible. Self-reported abstinence rates were relatively high in both arms, although the biochemically verified rates indicate over-reporting of abstinence. These findings suggest brief bedside counseling for all hospitalized smokers is beneficial. This study is registered at www.clinicaltrials.gov NCT01277250. Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia.

PubMed

Wenger, Neil S; Roth, Carol P; Shekelle, Paul G; Young, Roy T; Solomon, David H; Kamberg, Caren J; Chang, John T; Louie, Rachel; Higashi, Takahiro; MacLean, Catherine H; Adams, John; Min, Lillian C; Ransohoff, Kurt; Hoffing, Marc; Reuben, David B

2009-03-01

To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment. Controlled trial. Two community medical groups. Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment. Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention. Percentage of quality indicators satisfied measured using a 13-month medical record abstraction. Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35-46% vs 25%, 95% CI=20-30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care. A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.

76 FR 21372 - Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-15

...] Medicare Program; Solicitation for Proposals for the Medicare Community-Based Care Transitions Program... interested parties of an opportunity to apply to participate in the Medicare Community-based Care Transitions Program, which was authorized by section 3026 of the Affordable Care Act. DATES: Proposals will be...

77 FR 14364 - Comment Sought on Funding Pilot Program Participants Transitioning Out of the Rural Health Care...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-09

... Program Participants Transitioning Out of the Rural Health Care Pilot Program in Funding Year 2012 AGENCY..., the Wireline Competition Bureau seeks comment on whether to fund Rural Health Care Pilot Program... transition them into the permanent Rural Health Care support mechanism (RHC support mechanism). DATES...

Health Care Transition Planning among Adolescents with Autism Spectrum Disorder

ERIC Educational Resources Information Center

Walsh, Casey; Jones, Barbara; Schonwald, Alison

2017-01-01

Improving the health care transition process for youth with autism spectrum disorder (ASD) is critically important. This study was designed to examine the overall national transition core outcome among youth with ASD and each of the component measures of health care transition planning. Fewer than 10% of youth with ASD meet the national transition…

“Living With a Ball and Chain”: The Experience of Stroke for Individuals and Their Caregivers in Rural Appalachian Kentucky

PubMed Central

Danzl, Megan M.; Hunter, Elizabeth G.; Campbell, Sarah; Sylvia, Violet; Kuperstein, Janice; Maddy, Katherine; Harrison, Anne

2013-01-01

Purpose Individuals in rural Appalachian Kentucky face health disparities and are at increased risk for negative health outcomes and poor quality of life secondary to stroke. The purpose of this study is to describe the experience of stroke for survivors and their caregivers in this region. A description of their experiences is paramount to developing tailored interventions and ultimately improving health care and support. Methods An interprofessional research team used a qualitative descriptive study design and interviewed 13 individuals with stroke and 12 caregivers, representing 10 rural Appalachian Kentucky counties. The transcripts were analyzed using qualitative content analysis. Findings A descriptive summary of the participants’ experience of stroke is presented within the following structure: 1) Stroke onset, 2) Transition through the health care continuum (including acute care, inpatient rehabilitation, and community-based rehabilitation), and 3) Reintegration into life and rural communities. Conclusions The findings provide insight for rural health care providers and community leaders to begin to understand the experience of stroke in terms of stroke onset, transition through the health care continuum, return to home, and community reintegration. An understanding of these experiences may lead to discussions of how to improve service provision, facilitate reintegration, support positive health outcomes and improve quality of life for stroke survivors and their caregivers. The findings also indicate areas in need of future research including investigation of the effects of support groups, local health navigators to improve access to information and services, involvement of faith communities, proactive screening for management of mental health needs, and caregiver respite services. PMID:24088211

Value-Based Health Care Delivery, Preventive Medicine and the Medicalization of Public Health.

PubMed

Vilhelmsson, Andreas

2017-03-01

The real paradigm shift for healthcare is often stated to include a transition from accentuating health care production and instead emphasize patient value by moving to a 'value-based health care delivery'. In this transition, personalized medicine is sometimes referred to as almost a panacea in solving the current and future health challenges. In theory, the progress of precision medicine sounds uncontroversial and most welcomed with its promise of a better healthcare for all, with real benefits for the individual patient provided a tailored and optimized treatment plan suitable for his or her genetic makeup. And maybe, therefore, the assumptions underpinning personalized medicine have largely escaped questioning. The use of personalized medicine and the use of digital technologies is reshaping our health care system and how we think of health interventions and our individual responsibility. However, encouraging individuals to engage in preventive health activities possibly avoids one form of medicalization (clinical), but on the other hand, it takes up another form (preventive medicine and 'self-care') that moves medical and health concerns into every corner of everyday life. This ought to be of little value to the individual patient and public health. We ought to instead demand proof of these value ideas and the lacking research. Before this is in place critical appraisal and cynicism are requisite skills for the future. Otherwise, we are just listening to visionaries when we put our future health into their hands and let personalized solutions reach into people's everyday life regardless of patient safety and integrity.

Unifying Screening Processes Within the PROSPR Consortium: A Conceptual Model for Breast, Cervical, and Colorectal Cancer Screening

PubMed Central

Kim, Jane J.; Schapira, Marilyn M.; Tosteson, Anna N. A.; Zauber, Ann G.; Geiger, Ann M.; Kamineni, Aruna; Weaver, Donald L.; Tiro, Jasmin A.

2015-01-01

General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute–funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites. PMID:25957378

Ambulatory surgery centers and interventional techniques: a look at long-term survival.

PubMed

Manchikanti, Laxmaiah; Parr, Allan T; Singh, Vijay; Fellows, Bert

2011-01-01

With health care expenditures skyrocketing, coupled with pervasive quality deficits, pressures to provide better and more proficient care continue to shape the landscape of the U.S. health care system. Payers, both federal and private, have laid out several initiatives designed to curtail costs, including value-based reimbursement programs, cost-shifting expenses to the consumer, reducing reimbursements for physicians, steering health care to more efficient settings, and finally affordable health care reform. Consequently, one of the major aspects in the expansion of health care for improving quality and reducing the costs is surgical services. Nearly 57 million outpatient procedures are performed annually in the United States, 14 million of which occur in elderly patients. Increasing use of these minor, yet common, procedures contributes to rising health care expenditures. Once exclusive within hospitals, more and more outpatient procedures are being performed in freestanding ambulatory surgery centers (ASCs), physician offices, visits to which have increased over 300% during the past decade. Concurrent with this growing demand, the number of ASCs has more than doubled since the 1990s, with more than 5,000 facilities currently in operation nationwide. Further, total surgical center ASC payments have increased from $1.2 billion in 1999 to $3.2 billion in 2009, a 167% increase. On the same lines, growth and expenditures for hospital outpatient department (HOPD) services and office procedures also have been evident at similar levels. Recent surveys have illustrated on overall annual growth per capita in Medicare allowed ASC services of pain management of 23%, with 27% growth seen in ASCs and 16% of the growth seen in HOPD. Further, the proportion of interventional pain management which was 4% of Medicare ASC spending in 2000 has increase to 10% in 2007. Thus, interventional pain management as an evolving specialty is one of the most commonly performed procedures in ASC settings apart from HOPDs and well-equipped offices. In June 1998, the Health Care Financing Administration (HCFA), proposed an ASC rule in which at least 60% of interventional procedures were eliminated from ASCs and the remaining 40% faced substantial cuts in payments. Following the publication of this rule, based on public comments and demand, Congress intervened and delayed implementation of the rule for several years. The Centers for Medicare and Medicaid Services (CMS) published its proposed outpatient prospective system for ASCs in 2006, setting ASC payments at 62% of HOPD payments. Following multiple changes, the rule was incorporated with a 4-year transition formula which ended in 2010, with full effect taking effect in 2011 with ASCs reimbursed at 57% of HOPD payments. Thus, the landscape of interventional pain management in ambulatory surgery centers has been constantly changing with declining reimbursements, issues of fraud and abuse, and ever-increasing regulations.

Mothers' Transition Back to Work and Infants' Transition to Child Care: Does Work-Based Child Care Make a Difference?

ERIC Educational Resources Information Center

Skouteris, Helen; McCaught, Simone; Dissanayake, Cheryl

2007-01-01

The overall aim in this study was twofold: to compare the use of work-based (WB) and non-work-based (NWB) child care on the transition back to the workplace for women after a period of maternity leave, and on the transition into child care for the infants of these women. Thirty-five mothers with infants in WB centres and 44 mothers with infants in…

Transitions from hospital to community care: the role of patient-provider language concordance.

PubMed

Rayan, Nosaiba; Admi, Hanna; Shadmi, Efrat

2014-01-01

Cultural and language discordance between patients and providers constitutes a significant challenge to provision of quality healthcare. This study aims to evaluate minority patients' discharge from hospital to community care, specifically examining the relationship between patient-provider language concordance and the quality of transitional care. This was a multi-method prospective study of care transitions of 92 patients: native Hebrew, Russian or Arabic speakers, with a pre-discharge questionnaire and structured observations examining discharge preparation from a large Israeli teaching hospital. Two weeks post-discharge patients were surveyed by phone, on the transition from hospital to community care (the Care Transition Measure (CTM-15, 0-100 scale)) and on the primary-care post-discharge visit. Overall, ratings on the CTM indicated fair quality of the transition process (scores of 51.8 to 58.8). Patient-provider language concordance was present in 49% of minority patients' discharge briefings. Language concordance was associated with higher CTM scores among minority groups (64.1 in language-concordant versus 49.8 in non-language-concordant discharges, P <0.001). Other aspects significantly associated with CTM scores: extent of discharge explanations (P <0.05), quality of discharge briefing (P <0.001), and post-discharge explanations by the primary care physician (P <0.01). Language-concordant care, coupled with extensive discharge briefings and post-discharge explanations for ongoing care, are important contributors to the quality of care transitions of ethnic minority patients.

Transitions from hospital to community care: the role of patient–provider language concordance

PubMed Central

2014-01-01

Background Cultural and language discordance between patients and providers constitutes a significant challenge to provision of quality healthcare. This study aims to evaluate minority patients’ discharge from hospital to community care, specifically examining the relationship between patient–provider language concordance and the quality of transitional care. Methods This was a multi-method prospective study of care transitions of 92 patients: native Hebrew, Russian or Arabic speakers, with a pre-discharge questionnaire and structured observations examining discharge preparation from a large Israeli teaching hospital. Two weeks post-discharge patients were surveyed by phone, on the transition from hospital to community care (the Care Transition Measure (CTM-15, 0–100 scale)) and on the primary-care post-discharge visit. Results Overall, ratings on the CTM indicated fair quality of the transition process (scores of 51.8 to 58.8). Patient–provider language concordance was present in 49% of minority patients’ discharge briefings. Language concordance was associated with higher CTM scores among minority groups (64.1 in language-concordant versus 49.8 in non-language-concordant discharges, P <0.001). Other aspects significantly associated with CTM scores: extent of discharge explanations (P <0.05), quality of discharge briefing (P <0.001), and post-discharge explanations by the primary care physician (P <0.01). Conclusion Language-concordant care, coupled with extensive discharge briefings and post-discharge explanations for ongoing care, are important contributors to the quality of care transitions of ethnic minority patients. PMID:25075273

Extending residential care through telephone counseling: Initial results from the Betty Ford Center Focused Continuing Care protocol

PubMed Central

Cacciola, John S.; Camilleri, Amy C.; Carise, Deni; Rikoon, Samuel H.; McKay, James R.; McLellan, A. Thomas; Wilson, Cheryl; Schwarzlose, John T.

2009-01-01

There is increasing evidence that a chronic care model may be effective when treating substance use disorders. In 1996, the Betty Ford Center (BFC) began implementing a telephone-based continuing care intervention now called Focused Continuing Care (FCC) to assist and support patients in their transition from residential treatment to longer-term recovery in the “real world”. This article reports on patient utilization and outcomes of FCC. FCC staff placed clinically directed telephone calls to patients (N=4094) throughout the first year after discharge. During each call, a short survey was administered to gauge patient recovery and guide the session. Patients completed an average of 5.5 (40%) of 14 scheduled calls, 58% completed 5 or more calls, and 85% were participating in FCC two months post-discharge or later. There was preliminary evidence that greater participation in FCC yielded more positive outcomes and that early post-discharge behaviors predict subsequent outcomes. FCC appears to be a feasible therapeutic option. Efforts to revise FCC to enhance its clinical and administrative value are described. PMID:18539402

Self-management and Transition to Adult Health Care in Adolescents and Young Adults: A Team Process.

PubMed

Mahan, John D; Betz, Cecily L; Okumura, Megumi J; Ferris, Maria E

2017-07-01

As health care continues to evolve, the need for more effective health care transition (HCT) for all youth, but particularly children with chronic conditions and special health care needs, becomes even more important. With more than 90% of adolescents with chronic medical conditions now surviving into adulthood, suboptimal transition can lead to poorer quality of life and less successful adulthood.Through a series of clinical vignettes, the challenges of HCT are presented herein and accompanied by comments that underscore how these adolescents can best be helped to transition to successful adulthood. Several methods are presented to assess the readiness of adolescents and young adults (AYA) for transition. The process of transition can be divided into 3 stages: 1) setting the stage: initiation of HCT services and transition readiness assessment, 2) moving forward: ongoing provision of HCT services, and 3) reaching the goal: transfer of care and transition to adulthood.Several valuable suggestions for incorporating the HCT process into the health care system and improving HCT programs through a quality improvement (QI) approach are outlined. Future challenges in HCT include developing more precise assessments of transition status or transition readiness, better understanding the status and specific needs of AYA with chronic health care needs, continued program evaluation and QI efforts, and more reliance on patients and families to teach us about the challenges and methods in HCT that most effectively work for them. © American Academy of Pediatrics, 2017. All rights reserved.

The interface between child/adolescent and adult mental health services: results from a European 28-country survey.

PubMed

Signorini, Giulia; Singh, Swaran P; Marsanic, Vlatka Boricevic; Dieleman, Gwen; Dodig-Ćurković, Katarina; Franic, Tomislav; Gerritsen, Suzanne E; Griffin, James; Maras, Athanasios; McNicholas, Fiona; O'Hara, Lesley; Purper-Ouakil, Diane; Paul, Moli; Russet, Frederick; Santosh, Paramala; Schulze, Ulrike; Street, Cathy; Tremmery, Sabine; Tuomainen, Helena; Verhulst, Frank; Warwick, Jane; de Girolamo, Giovanni

2018-04-01

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

Prioritization of patient-centered comparative effectiveness research for osteoarthritis.

PubMed

Gierisch, Jennifer M; Myers, Evan R; Schmit, Kristine M; McCrory, Douglas C; Coeytaux, Remy R; Crowley, Matthew J; Chatterjee, Ranee; Kendrick, Amy S; Sanders, Gillian D

2014-06-17

Osteoarthritis is a leading cause of disability in the United States. This article describes a prioritized research agenda about osteoarthritis management developed for the Patient-Centered Outcomes Research Institute. Evidence gaps were identified by reviewing existing literature and engaging diverse stakeholders to expand and refine gaps. Stakeholders ranked evidence gaps by importance from their perspectives.Prioritized evidence gaps included the need to determine or evaluate key patient-centered outcomes; optimal duration, intensity, and frequency of nonsurgical interventions; whether the comparative effectiveness of nonsurgical interventions varies by socioeconomic factors; when and how to transition from nonsurgical to surgical interventions; effective ways to engage patients in self-management and promote long-term behavior change; standardized screening tools that improve early diagnosis; biomechanical strategies that improve symptoms; mechanisms for promoting and delivering coordinated, longitudinal care; and comparative effectiveness of nonsurgical therapies. Searches of PubMed and ClinicalTrials.gov showed many recent and ongoing studies addressing comparative effectiveness of nonsurgical interventions; relatively few of these evaluated treatments across categories (for example, drug therapy vs. weight management) or combined categories of treatment. Few studies addressed other high-priority evidence gaps.

Evaluation of a transit first-aid station providing emergency care to former Yugoslavian war victims evacuated in Ancona, Italy.

PubMed

Prospero, E; Raffo, M; Appignanesi, R; Faccenda, G; Ronveaux, O; Annino; D'Errico, M M

2000-03-01

A first-aid station was implemented in Falconara Marittima airport (Ancona, Italy). It provided medical emergency care to war victims evacuated from former Yugoslavia in transit for further treatment. A descriptive analysis of the displaced population arriving at the first-aid station was performed using three independent datasets for administrative information, of which one included medical information. The implemented resources were also evaluated. From August 1993 to March 1995, 2272 displaced persons were registered at the first-aid station, out of which 54.2% were accompanying family members. Among those needing medical intervention (45.8% of total), most frequent diagnoses were traumatisms and burns (59.8%), neoplasms (15.6%), and congenital malformations (13.2%). The medical care provided at the first-aid station was most often basic: a medical examination alone was performed on 77.0% of the patients, and a minor dressing on 17.3%. Median length of stay was 1 day. Patients were sent to 30 different countries and 8% were forwarded to the local regional hospital. Deployed logistical resources exceeded by far actual needs but a lack of psychological assistance was observed, mainly for children. The agencies involved did not coordinate data sharing and follow-up information. The medical assistance to the war victims was efficient regarding provided care and timeliness. Effectiveness of such a programme could be improved by a better coordination between partners, allowing more adequate logistics according to appropriate epidemiological information.

A phase II study in advanced cancer patients to evaluate the early transition to palliative care (the PREPArE trial): protocol study for a randomized controlled trial.

PubMed

do Carmo, Thamires Monteiro; Paiva, Bianca Sakamoto Ribeiro; de Siqueira, Milena Ruas; da Rosa, Luciana de Toledo Bernardes; de Oliveira, Cleyton Zanardo; Nascimento, Maria Salete de Angelis; Paiva, Carlos Eduardo

2015-04-12

Previous studies have demonstrated the benefit of early integration of palliative care (PC) in oncology. However, patients continue to receive late referrals to PC even in comprehensive cancer centers. Patients and health professionals may perceive PC as 'a place to die,' and this stigma is a barrier to timely referrals and to patient acceptance of treatment. The primary objective is to evaluate the feasibility of psychosocial intervention and PC in patients with advanced cancer. The patients will be submitted to a series of brief psychosocial interventions that are based on cognitive behavioral therapy, and patient acceptance and satisfaction will be assessed. In addition, the impact of these interventions on depressive symptoms will be evaluated. A randomized, open-label, phase II trial with two intervention arms and a control group will be conducted. Patients who are started on palliative chemotherapy and who meet the inclusion criteria will be enrolled. The study participants will be recruited from the outpatient oncology clinics at Barretos Cancer Hospital and will be randomized into one of the following three treatment arms: Arm A, which will include five weekly psychosocial interventions based on CBT in combination with early PC; Arm B, which will include early PC only; and Arm C, which will include standard oncologic care. The Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ-9), the Edmonton Symptom Assessment System (ESAS-br), the Family Satisfaction with End-of-Life Care (FAMCARE)-Patient scale, and the Disease Understanding Protocol will be used for data collection. The patients will answer these questionnaires at baseline and 45, 90, 120 and 180 days after randomization. Despite evidence of the positive impact of early PC, it is often provided to patients only at later stages. The inadequate awareness and stigmatization of PC as a place to die are barriers that complicate the early referral. Patients with advanced cancer may benefit from a psychosocial and educational strategy that adequately prepares them for initial PC appointments after an early referral to PC. We anticipate that benefits of psychological intervention shall be synergistic to secondary emotional benefits from the early integration of PC. This trial was registered on 6 May 2014 with ClinicalTrials.gov (identifier: NCT02133274).

The Changing Nature of Guilt in Family Caregivers: Living Through Care Transitions of Parents at the End of Life.

PubMed

Martz, Kim; Morse, Janice M

2017-06-01

Older adults cared for at home by family members at the end of life are at risk for care transitions to residential and institutional care settings. These transitions are emotionally distressing and fraught with suffering for both families and the older adult. A theoretical model titled "The Changing Nature of Guilt in Family Caregivers: Living Through Care Transitions of Parents at the End of Life" was developed using the method of grounded theory. When a dying parent cannot remain at home to die, family members experience guilt throughout the transition process. Findings indicated that guilt surrounding transfers escalated during the initial stages of the transfer but was mitigated by achieving what family members deemed as a "good" death when relatives were receiving hospice care. The findings of this interpretative approach provide new insights into family-focused perspectives in care transfers of the dying.

Transitional Child Care: State Experiences and Emerging Policies under the Family Support Act.

ERIC Educational Resources Information Center

Ebb, Nancy; And Others

This guide is designed to provide information about transitional child care (TCC) program policies and operations and to offer recommendations to policymakers and advocates. Transitional child care is a new federal child care program that every state must implement by April 1, 1990. Established by the Family Support Act (FSA) of 1988, TCC is…

Communication with young people in paediatric and adult endocrine consultations: an intervention development and feasibility study.

PubMed

Downing, J; Gleeson, H; Clayton, P E; Davis, J R E; Dimitri, P; Wales, J; Young, B; Callery, P

2017-06-15

Communication is complex in endocrine care, particularly during transition from paediatric to adult services. The aims of this study were to examine the feasibility of interventions to support young people to interact with clinicians. Development and evaluation of a complex intervention in 2 phases: Pre-intervention observational study; Intervention feasibility study. Purposive sample of recordings of 62 consultations with 58 young people aged 11-25 years with long-term endocrine conditions in two paediatric and two adult endocrine clinics. Proportion of time talked during consultations, number and direction of questions asked; Paediatric Consultation Assessment Tool (PCAT); OPTION shared decision making tool; Medical Information Satisfaction Scale (MISS- 21). Young people were invited to use one or more of: a prompt sheet to help them influence consultation agendas and raise questions; a summary sheet to record key information; and the www.explain.me.uk website. Nearly two thirds of young people (63%) chose to use at least one communication intervention. Higher ratings for two PCAT items (95% CI 0.0 to 1.1 and 0.1 to 1.7) suggest interventions can support consultation skills. A higher proportion of accompanying persons (83%) than young people (64%) directed questions to clinicians. The proportion of young people asking questions was higher (84%) in the intervention phase than in the observation phase (71%). Interventions were acceptable and feasible. The Intervention phase was associated with YP asking more questions, which implies that the availability of interventions could promote interactivity.

Using logic models to enhance the methodological quality of primary health-care interventions: guidance from an intervention to promote nutrition care by general practitioners and practice nurses.

PubMed

Ball, Lauren; Ball, Dianne; Leveritt, Michael; Ray, Sumantra; Collins, Clare; Patterson, Elizabeth; Ambrosini, Gina; Lee, Patricia; Chaboyer, Wendy

2017-04-01

The methodological designs underpinning many primary health-care interventions are not rigorous. Logic models can be used to support intervention planning, implementation and evaluation in the primary health-care setting. Logic models provide a systematic and visual way of facilitating shared understanding of the rationale for the intervention, the planned activities, expected outcomes, evaluation strategy and required resources. This article provides guidance for primary health-care practitioners and researchers on the use of logic models for enhancing methodological rigour of interventions. The article outlines the recommended steps in developing a logic model using the 'NutriCare' intervention as an example. The 'NutriCare' intervention is based in the Australian primary health-care setting and promotes nutrition care by general practitioners and practice nurses. The recommended approach involves canvassing the views of all stakeholders who have valuable and informed opinions about the planned project. The following four targeted, iterative steps are recommended: (1) confirm situation, intervention aim and target population; (2) document expected outcomes and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components. Over a period of 2 months, three primary health-care researchers and one health-services consultant led the collaborative development of the 'NutriCare' logic model. Primary health-care practitioners and researchers are encouraged to develop a logic model when planning interventions to maximise the methodological rigour of studies, confirm that data required to answer the question are captured and ensure that the intervention meets the project goals.

Process of Transition for Congenital Heart Patients: Preventing Loss to Follow-up.

PubMed

Habibi, Hajar; Emmanuel, Yaso; Chung, Natali

The aim of this article is to provide an overview of our nurse-led transition clinic provided to congenital heart disease patients moving from pediatric into adult care setting. Nurse-led transition clinic was analyzed at various stages of young adult care from an early stage of 12 to 14 years to entering adult setting at 16 years or older. Overview of current transition service for young adults being transferred from pediatric into adult services highlights the integral role of clinical nurse specialist as a coordinator of care. The result of the service overview indicates that nurse-led transition service enables patients to build on their knowledge. This is achieved by providing them time and the opportunities to develop an understanding of their condition and the attitudes required to engage with the adult care setting as indicated in the psychology questionnaire from transition day. A nurse-led transition clinic enhances long-term care of patients by supporting the young adults and their family/carer through the transition and transfer of the care to promote the young adult's understanding of their condition and to prevent any lost to follow-up.

The effects of menopausal health training for spouses on women's quality of life during menopause transitional period.

PubMed

Bahri, Narjes; Yoshany, Nooshin; Morowatisharifabad, Mohammad Ali; Noghabi, Ali Delshad; Sajjadi, Moosa

2016-02-01

Spouses' support during menopausal transition has an important role for improving the quality of life in postmenopausal women. Since the first step in providing support is having adequate knowledge, this study aimed to investigate the effects of an educational program on menopause health for spouses on women's quality of life during the menopausal transition. This clinical trial was conducted in Yazd, Iran. A hundred healthy women aged 45 to 60 years were recruited by random sampling. The spouses in the intervention group (n = 50) attended three training sessions about the management and health of menopausal transition. The spouses in the control group (n = 50) did not receive any intervention. Knowledge and performance about menopausal health were assessed in all spouses before and 3 months after intervention. All women were assessed by the Menopause Rating Scale, and the Menopause Quality of Life questionnaire before and 3 months after educational intervention. Analyses were carried out using SPSS 16 software. The level of significance was set at P less than 0.05. The knowledge and performance of spouses in the intervention group were significantly higher 3 months after intervention (P < 0.0001). The quality of life in women in the intervention group was higher 3 months after intervention (P < 0.0001). The mean scores of psychological and physical domains were significantly lower in the intervention group (P = 0.002 and P = 0.001, respectively). The training of menopausal health for spouses improves the quality of life in women during menopausal transition. We suggest integrating such educational programs in menopausal management programs.

Asthma Academy: Developing educational technology to improve Asthma medication adherence and intervention efficiency.

PubMed

Nair, Aiswaria S; DeMuth, Karen; Chih-Wen Cheng; Wang, May D

2017-07-01

Asthma is a leading chronic disorder among children and adolescents. Although some children outgrow asthma while transitioning into adulthood, there are others who continue to suffer from life-threatening asthmatic exacerbations. Teenagers tend to have certain misconceptions about their asthmatic condition and treatment which are rarely recognized or addressed in regular clinical consultations. After reviewing the literature in this field, we have identified that improving patient knowledge can be effective in augmenting engagement, and considerably improving their clinical outcomes. It is necessary to develop an effective educational intervention that can help Asthma patients change their perception about self-efficacy and ultimately reduce the total health care costs incurred. Hence, a sound transfer of knowledge during the transition from childcare to adult care is highly recommended. On these very lines, Georgia Institute of Technology designed an interactive educational application called Asthma Academy in conjunction with Children's Healthcare of Atlanta. This website resides in the public cloud and uses a novel animation video-based curriculum to deliver essential healthcare education to asthmatic adolescents in an interactive manner. What distinguishes it from similar initiatives is the use of a cost-effective technique to simulate caregiver-patient interactions and the ability to cater to a wide range of socio-economic statuses and educational levels. A group-based study with twenty asthma adolescents was conducted to evaluate the user acceptance and performance of Asthma Academy supplemented by regular check-ups over a period of eight to ten weeks. Observations recorded post the study clearly indicate higher levels of engagement and the systematic dissemination of information offered by Asthma Academy.

Transition of pediatric to adult care in inflammatory bowel disease: Is it as easy as 1, 2, 3?

PubMed

Afzali, Anita; Wahbeh, Ghassan

2017-05-28

Inflammatory bowel disease (IBD) is a heterogeneous group of chronic diseases with a rising prevalence in the pediatric population, and up to 25% of IBD patients are diagnosed before 18 years of age. Adolescents with IBD tend to have more severe and extensive disease and eventually require graduation from pediatric care toadult services. The transition of patients from pediatric to adult gastroenterologists requires careful preparation and coordination, with involvement of all key players to ensure proper collaboration of care and avoid interruption in care. This can be challenging and associated with gaps in delivery of care. The pediatric and adult health paradigms have inherent differences between health care models, as well as health care priorities in IBD. The readiness of the young adult also influences this transition of care, with often times other overlaps in life events, such as school, financial independence and moving away from home. These patients are therefore at higher risk for poorer clinical disease outcomes. The aim of this paper is to review concepts pertinent to transition of care of young adults with IBD to adult care, and provides resources appropriate for an IBD pediatric to adult transition of care model.

Economic analysis of an internet-based depression prevention intervention.

PubMed

Ruby, Alexander; Marko-Holguin, Monika; Fogel, Joshua; Van Voorhees, Benjamin W

2013-09-01

The transition through adolescence places adolescents at increased risk of depression, yet care-seeking in this population is low, and treatment is often ineffective. In response, we developed an Internet-based depression prevention intervention (CATCH-IT) targeting at-risk adolescents. We explore CATCH-IT program costs, especially safety costs, in the context of an Accountable Care Organization as well as the perceived value of the Internet program. Total and per-patient costs of development were calculated using an assumed cohort of a 5,000-patient Accountable Care Organization. Total and per-patient costs of implementation were calculated from grant data and the Medicare Resource-Based Relative Value Scale (RBRVS) and were compared to the willingness-to-pay for CATCH-IT and to the cost of current treatment options. The cost effectiveness of the safety protocol was assessed using the number of safety calls placed and the percentage of patients receiving at least one safety call. The willingness-to-pay for CATCH-IT, a measure of its perceived value, was assessed using post-study questionnaires and was compared to the development cost for a break-even point. We found the total cost of developing the intervention to be USD 138,683.03. Of the total, 54% was devoted to content development with per patient cost of USD 27.74. The total cost of implementation was found to be USD 49,592.25, with per patient cost of USD 597.50. Safety costs accounted for 35% of the total cost of implementation. For comparison, the cost of a 15-session group cognitive behavioral therapy (CBT) intervention aimed at at-risk adolescents was USD 1,632 per patient. Safety calls were successfully placed to 96.4% of the study participants. The cost per call was USD 40.51 with a cost per participant of USD 197.99. The willingness-to-pay for the Internet portion of CATCH-IT had a median of USD 40. The break-even point to offset the cost of development was 3,468 individuals. Developing Internet-based interventions like CATCH-IT appears economically viable in the context of an Accountable Care Organization. Furthermore, while the cost of implementing an effective safety protocol is proportionally high for this intervention, CATCH-IT is still significantly cheaper to implement than current treatment options. Limitations of this research included diminished participation in follow-up surveys assessing willingness-to-pay. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE AND HEALTH POLICIES: This research emphasizes that preventive interventions have the potential to be cheaper to implement than treatment protocols, even before taking into account lost productivity due to illness. Research such as this business application analysis of the CATCH-IT program highlights the importance of supporting preventive medical interventions as the healthcare system already does for treatment interventions. This research is the first to analyze the economic costs of an Internet-based intervention. Further research into the costs and outcomes of such interventions is certainly warranted before they are widely adopted. Furthermore, more research regarding the safety of Internet-based programs will likely need to be conducted before they are broadly accepted.

Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative.

PubMed

Rantz, Marilyn J; Popejoy, Lori; Vogelsmeier, Amy; Galambos, Colleen; Alexander, Greg; Flesner, Marcia; Crecelius, Charles; Ge, Bin; Petroski, Gregory

2017-11-01

The goals of the Missouri Quality Initiative (MOQI) for long-stay nursing home residents were to reduce the frequency of avoidable hospital admissions and readmissions, improve resident health outcomes, improve the process of transitioning between inpatient hospitals and nursing facilities, and reduce overall healthcare spending without restricting access to care or choice of providers. The MOQI was one of 7 program sites in the United States, with specific interventions unique to each site tested for the Centers for Medicaid and Medicare Services (CMS) Innovations Center. A prospective, single group intervention design, the MOQI included an advanced practice registered nurse (APRN) embedded full-time within each nursing home (NH) to influence resident care outcomes. Data were collected continuously for more than 3 years from an average of 1750 long-stay Medicare, Medicaid, and private pay residents living each day in 16 participating nursing homes in urban, metro, and rural communities within 80 miles of a major Midwestern city in Missouri. Performance feedback reports were provided to each facility summarizing their all-cause hospitalizations and potentially avoidable hospitalizations as well as a support team of social work, health information technology, and INTERACT/Quality Improvement Coaches. The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents. As the population of older people explodes in upcoming decades, it is critical to find good solutions to deal with increasing costs of health care. APRNs, working with multidisciplinary support teams, are a good solution to improving care and reducing costs if all nursing home residents have access to APRNs nationwide. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Current Status and Issues Regarding Transitional Health Care for Adults and Young Adults with Special Health Care Needs in Japan.

PubMed

Ariyasu, Hiroyuki; Akamizu, Takashi

2018-05-15

With the progress of medical care in recent years, the prognosis of intractable diseases of childhood onset has markedly improved. Young adults with special health care needs require continuous medical support throughout their lifetimes. To provide them with optimal health care services, a smooth transition from the pediatric medical system to the adult one is essential. However, in Japan many adult health providers are not sufficiently prepared to care for these patients, due both to limited opportunities to gain up-to-date medical knowledge on transitional health care and a lack of familiarity with the medical treatment of childhood-onset chronic diseases. In this review, we discuss current issues in transitional health care in Japan from an internist's viewpoint.

Handoffs: Transitions of Care for Children in the Emergency Department.

PubMed

2016-11-01

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included. Copyright © 2016 by the American Academy of Pediatrics.

Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in Health Care

PubMed Central

Fisher, Thomas L.; Burnet, Deborah L.; Huang, Elbert S.; Chin, Marshall H.; Cagney, Kathleen A.

2008-01-01

The authors reviewed interventions using cultural leverage to narrow racial disparities in health care. Thirty-eight interventions of three types were identified: interventions that modified the health behaviors of individual patients of color, that increased the access of communities of color to the existing health care system, and that modified the health care system to better serve patients of color and their communities. Individual-level interventions typically tapped community members’ expertise to shape programs. Access interventions largely involved screening programs, incorporating patient navigators and lay educators. Health care interventions focused on the roles of nurses, counselors, and community health workers to deliver culturally tailored health information. These interventions increased patients’ knowledge for self-care, decreased barriers to access, and improved providers’ cultural competence. The delivery of processes of care or intermediate health outcomes was significantly improved in 23 interventions. Interventions using cultural leverage show tremendous promise in reducing health disparities, but more research is needed to understand their health effects in combination with other interventions. PMID:17881628

Using Qualitative Methods to Evaluate a Family Behavioral Intervention for Type 1 Diabetes

PubMed Central

Herbert, Linda Jones; Sweenie, Rachel; Kelly, Katherine Patterson; Holmes, Clarissa; Streisand, Randi

2013-01-01

Introduction The objectives of this study were to qualitatively evaluate a dyadic adolescent-parent type 1 diabetes (T1D) program developed to prevent deterioration in diabetes care among adolescents with T1D and provide recommendations for program refinement. Method Thirteen adolescent-parent dyads who participated in the larger RCT, the TeamWork Project, were interviewed regarding their perceptions of their participation in the program and current T1D challenges. Interviews were transcribed and coded to establish broad themes. Results Adolescents and parents thought the TeamWork Project sessions were helpful and taught them new information. Five themes catalog findings from the qualitative interviews: TeamWork content, TeamWork structure, transition of responsibility, current and future challenges, and future intervention considerations. Discussion Addressing T1D challenges as a parent-adolescent dyad via a behavioral clinic program is helpful to families during adolescence. Findings highlight the utility of qualitative evaluation to tailor interventions for the unique challenges related to pediatric chronic illness. PMID:24269281

Adapting The Joint Commission's Seven Foundations of Safe and Effective Transitions of Care to Home

PubMed Central

Labson, Margherita C.

2015-01-01

The purpose of this article is to describe The Joint Commission's 7 foundations of safe and effective transitions of care to home: (a) leadership support; (b) multidisciplinary collaboration; (c) early identification of patients/clients at risk; (d) transitional planning; (e) medication management; (f) patient and family action/engagement; and (g) transfer of information. These foundations were identified by The Joint Commission after a review of published research; focus groups with healthcare professionals involved in transitions of care; and visits to diverse healthcare organizations. The author, who is the executive director of The Joint Commission's Home Care Accreditation Program, illustrates how healthcare organizations are adapting the 7 foundations of safe and effective transitions of care to home. PMID:25742092

Lifestyle interventions targeting body weight changes during the menopause transition: a systematic review.

PubMed

Jull, Janet; Stacey, Dawn; Beach, Sarah; Dumas, Alex; Strychar, Irene; Ufholz, Lee-Anne; Prince, Stephanie; Abdulnour, Joseph; Prud'homme, Denis

2014-01-01

To determine the effectiveness of exercise and/or nutrition interventions and to address body weight changes during the menopause transition. A systematic review of the literature was conducted using electronic databases, grey literature, and hand searching. Two independent researchers screened for studies using experimental designs to evaluate the impact of exercise and/or nutrition interventions on body weight and/or central weight gain performed during the menopausal transition. Studies were quality appraised using Cochrane risk of bias. Included studies were analyzed descriptively. Of 3,564 unique citations screened, 3 studies were eligible (2 randomized controlled trials, and 1 pre/post study). Study quality ranged from low to high risk of bias. One randomized controlled trial with lower risk of bias concluded that participation in an exercise program combined with dietary interventions might mitigate body adiposity increases, which is normally observed during the menopause transition. The other two studies with higher risk of bias suggested that exercise might attenuate weight loss or weight gain and change abdominal adiposity patterns. High quality studies evaluating the effectiveness of interventions targeting body weight changes in women during their menopause transition are needed. Evidence from one higher quality study indicates an effective multifaceted intervention for women to minimize changes in body adiposity.

Lifestyle Interventions Targeting Body Weight Changes during the Menopause Transition: A Systematic Review

PubMed Central

Jull, Janet; Stacey, Dawn; Beach, Sarah; Dumas, Alex; Strychar, Irene; Ufholz, Lee-Anne; Prince, Stephanie; Abdulnour, Joseph; Prud'homme, Denis

2014-01-01

Objective. To determine the effectiveness of exercise and/or nutrition interventions and to address body weight changes during the menopause transition. Methods. A systematic review of the literature was conducted using electronic databases, grey literature, and hand searching. Two independent researchers screened for studies using experimental designs to evaluate the impact of exercise and/or nutrition interventions on body weight and/or central weight gain performed during the menopausal transition. Studies were quality appraised using Cochrane risk of bias. Included studies were analyzed descriptively. Results. Of 3,564 unique citations screened, 3 studies were eligible (2 randomized controlled trials, and 1 pre/post study). Study quality ranged from low to high risk of bias. One randomized controlled trial with lower risk of bias concluded that participation in an exercise program combined with dietary interventions might mitigate body adiposity increases, which is normally observed during the menopause transition. The other two studies with higher risk of bias suggested that exercise might attenuate weight loss or weight gain and change abdominal adiposity patterns. Conclusions. High quality studies evaluating the effectiveness of interventions targeting body weight changes in women during their menopause transition are needed. Evidence from one higher quality study indicates an effective multifaceted intervention for women to minimize changes in body adiposity. PMID:24971172

Supporting Heart Failure Patient Transitions From Acute to Community Care With Home Telemonitoring Technology: A Protocol for a Provincial Randomized Controlled Trial (TEC4Home)

PubMed Central

2016-01-01

Background Seniors with chronic diseases such as heart failure have complex care needs. They are vulnerable to their condition deteriorating and, without timely intervention, may require multiple emergency department visits and/or repeated hospitalizations. Upon discharge, the transition from the emergency department to home can be a vulnerable time for recovering patients with disruptions in the continuity of care. Remote monitoring of heart failure patients using home telemonitoring, coupled with clear communication protocols between health care professionals, can be effective in increasing the safety and quality of care for seniors with heart failure discharged from the emergency department. Objective The aim of the Telehealth for Emergency-Community Continuity of Care Connectivity via Home Telemonitoring (TEC4Home) study is to generate evidence through a programmatic evaluation and a clinical trial to determine how home telemonitoring may improve care and increase patient safety during the transition of care and determine how it is best implemented to support patients with heart failure within this context. Methods This 4-year project consists of 3 studies to comprehensively evaluate the outcomes and effectiveness of TEC4Home. Study 1 is a feasibility study with 90 patients recruited from 2 emergency department sites to test implementation and evaluation procedures. Findings from the feasibility study will be used to refine protocols for the larger trial. Study 2 is a cluster randomized controlled trial that will include 30 emergency department sites and 900 patients across British Columbia. The primary outcome of the randomized controlled trial will be emergency department revisits and hospital readmission rates. Secondary outcomes include health care resource utilization/costs, communication between members of the care team, and patient quality of life. Study 3 will run concurrently to study 2 and test the effectiveness of predictive analytic software to detect patient deterioration sooner. Results It is hypothesized that TEC4Home will be a cost-effective strategy to decrease 90-day emergency department revisits and hospital admission rates and improve comfort and quality of life for seniors with heart failure. The results from this project will also help establish an innovation pathway for rapid and rigorous introduction of innovation into the health system. Conclusions While there is some evidence about the effectiveness of home telemonitoring for some patients and conditions, the TEC4Home project will be one of the first protocols that implements and evaluates the technology for patients with heart failure as they transition from the emergency department to home care. The results from this research are expected to inform the full scale and spread of the home monitoring approach throughout British Columbia and Canada and to other chronic diseases. ClinicalTrial ClinicalTrials.gov NCT02821065; https://clinicaltrials.gov/ct2/show/NCT02821065 (Archived by WebCite at http://www.webcitation.org/6ml2iwKax) PMID:27977002

Cost-effectiveness of a Population-based Lifestyle Intervention to Promote Healthy Weight and Physical Activity in Non-attenders of Cardiac Rehabilitation.

PubMed

Cheng, Qinglu; Church, Jody; Haas, Marion; Goodall, Stephen; Sangster, Janice; Furber, Susan

2016-03-01

To evaluate the long-term cost-effectiveness of two home-based cardiac rehabilitation (CR) interventions (Healthy Weight (HW) and Physical Activity (PA)) for patients with cardiovascular disease (CVD), who had been referred to cardiac rehabilitation (CR) but had not attended. The interventions consisted of pedometer-based telephone coaching sessions on weight, nutrition and physical activity (HW group) or physical activity only (PA group) and were compared to a control group who received information brochures about physical activity. A cost-effectiveness analysis was conducted using data from two randomised controlled trials. One trial compared HW to PA (PANACHE study), and the second compared PA to usual care. A Markov model was developed which used one risk factor, body mass index (BMI) to determine the CVD risk level and mortality. Patient-level data from the trials were used to determine the transitions to CVD states and healthcare related costs. The model was run for separate cohorts of males and females. Univariate and probabilistic sensitivity analysis were conducted to test the robustness of the results. Given a willingness-to-pay threshold of $50,000/QALY, in the long run, both the HW and PA interventions are cost-effective compared with usual care. While the HW intervention is more effective, it also costs more than both the PA intervention and the control group due to higher intervention costs. However, the HW intervention is still cost-effective relative to the PA intervention for both men and women. Sensitivity analysis suggests that the results are robust. The results of this paper provide evidence of the long-term cost-effectiveness of home-based CR interventions for patients who are referred to CR but do not attend. Both the HW and PA interventions can be recommended as cost-effective home-based CR programs, especially for people lacking access to hospital services or who are unable to participate in traditional CR programs. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Factors Influencing Transition to Shisheh (Methamphetamine) among Young People Who Use Drugs in Tehran: A Qualitative Study.

PubMed

Noroozi, Alireza; Malekinejad, Mohsen; Rahimi-Movaghar, Afarin

2018-01-29

Iran has experienced an emerging epidemic of methamphetamine use during recent years which has added to existing non-injecting and injecting opioid use in the country. This study explored factors influencing the initiation into or transition to methamphetamine use among young people who use drugs (PWUD). We conducted 42 semi-structured, in-depth interviews with young PWUD (n = 35) and health care workers (HCWs) (n = 7) between July and October 2011 in Tehran, Iran. The PWUD were purposefully recruited from different tiers of drug services and lived in geographically diverse areas of Tehran. The HCWs were substance use experts and/or service providers of treatment and harm reduction facilities. All interviews were recorded, transcribed, and coded using OpenCode 3.6 software. The predominant factors for initiation into or transition to methamphetamine use were individual domain factors. The peer domain factors were the second most frequently stated perceived factor category for transition to methamphetamine use. Other perceived factors affecting transition to stimulant use included both family and community domains. Drug prevention programs should consider targeting certain settings, including workplaces and sports clubs, for preventative interventions. Existing opioid treatment and harm reduction services should be adjusted in response to the methamphetamine use epidemic.

We Never Thought This Would Happen: Transitioning Care of Adolescents with Perinatally-Acquired HIV Infection from Pediatrics to Internal Medicine

PubMed Central

Vijayan, Tara; Benin, Andrea L.; Wagner, Krystn; Romano, Sostena; Andiman, Warren A.

2009-01-01

Purpose Transitioning the medical care of children with perinatally-acquired HIV from pediatric care to internal medicine practices has become increasingly important as newer therapies prolong survival. The study aims to describe challenges to caring for these adolescents and the potential barriers to transitioning them to internal medicine-based care. Methods Qualitative study in which data were gathered from open-ended interviews conducted from November 2005-April 2006 with 18 adolescents with HIV, 15 of their principal guardians, and 9 pediatric health care providers from the Yale Pediatric AIDS Care Program, New Haven, Connecticut. Results Issues of stigma played a prominent role in both the challenges to care and barriers to transitioning care. Challenges to care were: (1) poor adherence to medication regimens; (2) adolescent sexuality; and (3) disorganized social environments. Potential barriers to transitioning care were: (1) families’ negative perceptions of and experiences with stigma of HIV disease--which undermined the desire to meet new providers; (2) perceived and actual lack of autonomy-- pediatric providers feared that staff in adult clinics would demand a level of independence that adolescents did not have; and (3) difficulty letting-go of relationships-- adolescents, guardians, and providers described a familial relationship and expressed anxiety about terminating their relationships. Conclusion Understanding these challenges and barriers can inform both pediatric and adult HIV care providers and enable them to create successful transition programs, with the goal of improving retention and follow-up to care. PMID:20024697

Organization of surveillance in GI practice.

PubMed

Senore, Carlo; Bellisario, Cristina; Hassan, Cesare

2016-12-01

Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches. We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas. Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations. Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance. Copyright © 2016 Elsevier Ltd. All rights reserved.

The Radiologist Is in, but Was it Worth the Wait? Radiology Resident Note Quality in an Outpatient Interventional Radiology Clinic.

PubMed

Abboud, Salim E; Soriano, Stephanie; Abboud, Rayan; Patel, Indravadan; Davidson, Jon; Azar, Nami R; Nakamoto, Dean A

Preprocedural evaluation of patients in an interventional radiology (IR) clinic is a complex synthesis of physical examination and imaging findings, and as IR transitions to an independent clinical specialty, such evaluations will become an increasingly critical component of a successful IR practice and quality patient care. Prior research suggests that preprocedural evaluations increased patient's perceived quality of care and may improve procedural technical success rates. Appropriate documentation of a preprocedural evaluation in the medical record is also paramount for an interventional radiologist to add value and function as an effective member of a larger IR service and multidisciplinary health care team. The purpose of this study is to examine the quality of radiology resident notes for patients seen in an outpatient IR clinic at a single academic medical center before and after the adoption of clinic note template with reminders to include platelet count, international normalized ratio, glomerular filtration rate, and plan for periprocedural coagulation status. Before adoption of the template, platelet count, international normalized ratio, glomerular filtration rate and an appropriate plan for periprocedural coagulation status were documented in 72%, 82%, 42%, and 33% of patients, respectively. After adoption of the template, appropriate documentation of platelet count, international normalized ratio, and glomerular filtration rate increased to 96%, and appropriate plan for periprocedural coagulation status was documented in 83% of patients. Patient evaluation and clinical documentation skills may not be adequately practiced during radiology residency, and tools such as templates may help increase documentation quality by radiology residents. Copyright © 2017 Elsevier Inc. All rights reserved.

Examining the Role of Primary Care Physicians and Challenges Faced When Their Patients Transition to Home Hospice Care.

PubMed

Shalev, Ariel; Phongtankuel, Veerawat; Lampa, Katherine; Reid, M C; Eiss, Brian M; Bhatia, Sonica; Adelman, Ronald D

2018-04-01

The transition into home hospice care is often a critical time in a patient's medical care. Studies have shown patients and caregivers desire continuity with their physicians at the end of life (EoL). However, it is unclear what roles primary care physicians (PCPs) play and what challenges they face caring for patients transitioning into home hospice care. To understand PCPs' experiences, challenges, and preferences when their patients transition to home hospice care. Nineteen semi-structured phone interviews with PCPs were conducted. Study data were analyzed using standard qualitative methods. Participants included PCPs from 3 academic group practices in New York City. Measured: Physician recordings were transcribed and analyzed using content analysis. Most PCPs noted that there was a discrepancy between their actual role and ideal role when their patients transitioned to home hospice care. Primary care physicians expressed a desire to maintain continuity, provide psychosocial support, and collaborate actively with the hospice team. Better establishment of roles, more frequent communication with the hospice team, and use of technology to communicate with patients were mentioned as possible ways to help PCPs achieve their ideal role caring for their patients receiving home hospice care. Primary care physicians expressed varying degrees of involvement during a patient's transition to home hospice care, but many desired to be more involved in their patient's care. As with patients, physicians desire to maintain continuity with their patients at the EoL and solutions to improve communication between PCPs, hospice providers, and patients need to be explored.

42 CFR 460.52 - Transitional care during termination.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Sanctions, Enforcement Actions, and Termination § 460.52 Transitional care...

42 CFR 460.52 - Transitional care during termination.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) Sanctions, Enforcement Actions, and Termination § 460.52 Transitional care...