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"Care transitions"

Ping Zhu, Xianglin L Du, Jay-Jiguang Zhu, Yoshua Esquenazi
OBJECTIVEThe present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment.METHODSBased on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1-G4): < 5.0, 5.0-14.9, 15.0-24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15...
February 15, 2019: Journal of Neurosurgery
Gertrude van den Brink, Martha A C van Gaalen, Lissy de Ridder, C Janneke van der Woude, Johanna C Escher
BACKGROUND: Transition programs are designed to prepare adolescent Inflammatory Bowel Disease (IBD) patients for transfer to adult care. It is still unclear which outcome parameters define "successful transition". Therefore, this study aimed to identify outcomes important for success of transition in IBD. METHODS: A multinational Delphi study in patients, IBD-nurses and paediatric and adult gastroenterologists was conducted. In Stage 1, panellists commented on an outcome list...
February 14, 2019: Journal of Crohn's & Colitis
Edward C Portillo, Andrew Wilcox, Ellina Seckel, Amanda Margolis, Jean Montgomery, Prakash Balasubramanian, Geri Abshire, Jim Lewis, Christopher Hildebrand, Sameer Mathur, Alan Bridges, Sujani Kakumanu
A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from hospital to home.
November 2018: Federal Practitioner: for the Health Care Professionals of the VA, DoD, and PHS
Devy Zisman, Aaida Samad, Stacy P Ardoin, Peter Chira, Patience White, Idit Lavi, Emily von Scheven, Erica F Lawson, Melinda Hing, Elizabeth D Mellins
OBJECTIVE: To assess the attitudes and common practices of adult rheumatologists in the United States regarding health care transition (HCT) for young adults with rheumatic diseases. METHODS: An anonymous online survey was sent to U.S. adult rheumatologist members of the American College of Rheumatology to collect demographic data and information on attitudes and common practices regarding the transition process. RESULTS: Of 4,064 contacted rheumatologists, 203 (5%) completed the survey...
February 11, 2019: Arthritis Care & Research
Rayzel Shulman, Roger Chafe, Astrid Guttmann
OBJECTIVES: Individuals living with diabetes often experience gaps in care, poor experiences and acute complications when they transfer from pediatric to adult care. We aimed to describe the structure of diabetes transition care in Ontario and to explore perceptions of barriers to optimal outcomes. METHODS: We conducted a cross-sectional descriptive study of 35 centres in the Pediatric Diabetes Network in Ontario between April and June 2017. We collected survey data about the number of individuals with all diabetes types transferring to adult care, transition practices and providers' perceptions of facilitators of and barriers to optimal transition...
November 15, 2018: Canadian Journal of Diabetes
Kelly C Rogers, Daniel W Neu, Melanie C Jaeger, Rahman Shah, Shannon W Finks
A poorly understood significant drug-drug interaction compounded by ineffective communication among providers at times of care transition most likely contributed to multiple thromboembolic events in an 81-year-old patient. Increased awareness of drug interactions with direct oral anticoagulants (DOACs), as well as improved communication among inpatient and outpatient providers at the time of discharge is essential in maximizing efficacy and safety outcomes in patients requiring chronic anticoagulation. When rifampin is coadministered with apixaban, a reduction in apixaban exposure results in decreased efficacy and increased risk for thromboembolic events...
February 2019: Southern Medical Journal
Helle Vendel Petersen, Signe Foged, Vibeke Nørholm
AIMS AND OBJECTIVES: To explore how the hospital and home care nurses talk about and experience cross-sectoral collaboration related to the transitional care of frail older patients. BACKGROUND: Effective communication and collaboration between nurses involved in care transition are crucial for a safe patient handover. Organizational systems to support cross-sectoral collaboration have been developed but do not always promote the intended dialogue and precise and useful exchange of information...
January 31, 2019: Journal of Clinical Nursing
Alok Kapoor, Valentina Landyn, Joann Wagner, Pamela Burgwinkle, Wei Huang, Joel Gore, Frederick A Spencer, Robert Goldberg, David D McManus, Chad Darling, Edwin Boudreaux, Bruce Barton, Kathleen M Mazor
OBJECTIVE: The aim of the study was to assess the feasibility, satisfaction, and effectiveness of a care transition intervention with pharmacist home visit and subsequent anticoagulation expert consultation for patients with new episode of venous thromboembolism within a not-for-profit health care network. METHODS: We randomized patients to the intervention or control. During the home visit, a clinical pharmacist assessed medication management proficiency, asked open-ended questions to discuss knowledge gaps, and distributed illustrated medication instructions...
January 29, 2019: Journal of Patient Safety
Meredith MacKenzie Greenle, Karen B Hirschman, Ken Coburn, Sherry Marcantonio, Alexandra L Hanlon, Mary Naylor, Elizabeth Mauer, Connie Ulrich
Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when health-care utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used...
January 29, 2019: American Journal of Hospice & Palliative Care
Christopher N Osuafor, Syazwani N M Sahimi, Sree Enduluri, Frances McCarthy
BACKGROUND AND AIMS: Elderly rehabilitation programs provide a period of rehabilitation to optimize a safe home discharge after acute hospitalization of older adults. Often, these patients may have their rehabilitation interrupted when they become unwell and subsequently require transfer back to an acute hospital setting. We will look at the incidence and outcome of this interruption. This paper aimed to determine the incidence of interrupted post-acute geriatric rehabilitation requiring acute hospital transfer and to analyze the outcome of the transfers...
January 25, 2019: Irish Journal of Medical Science
Dawn Wiest, Qiang Yang, Carter Wilson, Natasha Dravid
Importance: Previous research suggests the important role of timely primary care follow-up in reducing hospital readmissions, although effectiveness varies by program design and patients' readmission risk level. Objective: To evaluate the outcomes of the 7-Day Pledge program to reduce readmissions by increasing access to timely primary care appointments after hospitalization. Design, Setting, and Participants: Retrospective cohort study of hospital readmissions among Medicaid patients 18 years or older hospitalized from January 1, 2014, to April 30, 2016, in Camden, New Jersey...
January 4, 2019: JAMA network open
Benjamin Schneider, Frances E Biagioli, Ryan Palmer, Peggy O'Neill, Sean C Robinson, Rebecca E Cantone
BACKGROUND AND OBJECTIVES: Competency-based medical education (CBME) has been incorporated into graduate medical education accreditation and is being introduced in undergraduate medical education. Family medicine (FM) faculty at one institution developed a CBME FM clerkship to intentionally maintain the integrity of FM specialty-specific teaching during their institutional CBME curricular revision. METHODS: From the five FM domains (Access to Care, Continuity of Care, Comprehensive Care, Coordination of Care, and Contextual Care), 10 competencies and 23 FM educational activities (EAs) were defined...
January 24, 2019: Family Medicine
Chantal Backman, Sharon Johnston, Nelly D Oelke, Katharina Kovacs Burns, Linda Hughes, Wendy Gifford, Jeanie Lacroix, Alan J Forster
BACKGROUND: Research has shown that adverse events during care transitions from hospital to home can have a significant impact on patients' outcomes, leading to readmission, delayed healing or even death. Gaps exist in the ways of monitoring care during transition periods and there is a need to help organizations better implement and monitor safe person-and family-centered care. Value statements are a way to obtain narratives in lay terms about how well care, treatment and support is organized to meet the needs and preferences of patients/families...
2019: PloS One
Dori A Cross, Jeffrey S McCullough, Julia Adler-Milstein
OBJECTIVES: To characterize the drivers of the use of electronic health information exchange (HIE) by skilled nursing facilities (SNFs) to access patient hospital data during care transitions. STUDY DESIGN: Explanatory, sequential mixed-methods study. Quantitative data from an audit log captured HIE use by 3 SNFs to retrieve hospitalization information for the 5487 patients discharged to their care between June 2014 and March 2017, along with patient demographic data...
January 1, 2019: American Journal of Managed Care
Chase D A Kooyman, Matthew J Witry
BACKGROUND: The impact of multidisciplinary interventions to support patients moving from hospital to home have generally demonstrated a benefit. However, the role of community pharmacists is still being defined. OBJECTIVES: To review, with the use of the Coleman Care Transitions Intervention (CTI) pillars, the interventions performed by community and ambulatory-care pharmacists for patients undergoing care transitions. DATA SOURCES: The following databases were searched for manuscripts published from 1997 to 2017: Pubmed, Cochrane Database, Cinahl, and Embase...
January 16, 2019: Journal of the American Pharmacists Association: JAPhA
Devon C Freudenberger, Erin A Baker, Matthew P Siljander, Rachel S Rohde
Introduction: Differences in female and male patient perception of care and satisfaction following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) were assessed via Hospital Consumer Assessment of Healthcare Providers and Systems survey, demographic, and clinical data. Methods: After institutional review board approval, a retrospective review of the Hospital Consumer Assessment of Healthcare Providers and Systems survey responses at a private, academic, level-I trauma center was performed from January 2011 to December 2013...
November 2018: Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews
Alyssa Milano, Holly Stankewicz, Jill Stoltzfus, Philip Salen
Introduction: Transitions of patient care during physicians' change of shift introduce the potential for critical information to be missed or distorted, resulting in possible morbidity. The Joint Commission, the Accreditation Council for Graduate Medical Education, and the Society of Hospital Medicine jointly encourage a structured format for patient care sign-out. This study's objective was to examine the impact of a standardized checklist on the quality of emergency medicine (EM) resident physicians' patient-care transition at shift change...
January 2019: Western Journal of Emergency Medicine
Janet Prvu Bettger, Sara B Jones, Anna M Kucharska-Newton, Janet K Freburger, Sylvia W Coleman, Laurie H Mettam, Mysha E Sissine, Sabina B Gesell, Cheryl D Bushnell, Pamela W Duncan, Wayne D Rosamond
OBJECTIVE: This study (1) describes transitional care for stroke patients discharged home from hospitals, (2) compares hospitals' standards of transitional care with core transitional care management (TCM) components recognized by Medicare, and (3) examines the association of policy and hospital specialty designations with TCM implementation. METHODS: Hospitals participating in the Comprehensive Post-Acute Stroke Services (COMPASS) Study provided data on their hospital, stroke patient population, and standards of transitional care...
January 11, 2019: Neurology
Marisol Samartín-Ucha, Guadalupe Piñeiro-Corrales
OBJECTIVE: Describe the phases of implementation, scaling and integration of a  pharmacy teleconsultation model in electronic history, to coordinate the care  transition of patients. METHOD: Descriptive and retrospective study in a health area of 500,000 inhabitants (3 years). In the first phase, a working group was created,  a communication platform was designed and a continuity program was piloted between a hospital pharmacist and the 13 primary care pharmacists...
January 1, 2019: Farmacia Hospitalaria
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