A Call to Bridge Across Silos during Care Transitions

Sheikh, Fatima; Gathecha, Evelyn; Bellantoni, Michele; Christmas, Colleen; Lafreniere, Justin P.; Arbaje, Alicia I.

doi:10.1016/j.jcjq.2017.10.006

Cited by 17 publications

(17 citation statements)

References 29 publications

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“…Multiple studies suggest that hospital-to-home care transitions for this population are fragmented and poorly coordinated, resulting in increased hospital readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden [23][24][25][26][27][28][29][30][31]. Studies in Canada, the USA, and elsewhere have attributed these adverse outcomes to factors such as lack of patient knowledge about available community-based services resulting in suboptimal or delayed utilization of these services [31,32], conflicting plans of care and instructions from different providers [31,[33][34][35][36], medication errors [29-31, 37, 38], lack of timely follow-up with specialists and family physicians after hospital discharge [30,31,39], limited engagement of older adults and caregivers in care decisions [29,40] and preparation for self-care [30,37,38,[41][42][43], lack of support for family caregivers, poor communication and collaboration among providers within and across settings [29,30,44], lack of timely and adequate home-based support after hospital discharge [29,30], untreated or under-treated depressive symptoms [29,[45][46][47], inadequate community mental health supports [29], and having other unaddressed social and psychological needs during previous hospitalization…”

Section: Plos Onementioning

confidence: 99%

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

et al. 2021

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Objective To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms. Design and setting Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control). Participants 127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms. Intervention This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months. Outcome measures The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling. Results Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group. Conclusions Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended. Trial registration clinicaltrials.gov Identifier: NCT03157999.

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Section: Plos Onementioning

confidence: 99%

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

et al. 2021

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“…1 A transition in care is a vulnerable period for patients as pertinent information needs to be communicated from one healthcare setting to another. 1,2 Patients can suffer negative outcomes if the transitional care is suboptimal. 2,3 The patients who are most often harmed by bad transitions are older, frail, complex individuals, especially those who lack sufficient agency.…”

Section: Introductionmentioning

confidence: 99%

“…1,2 Patients can suffer negative outcomes if the transitional care is suboptimal. 2,3 The patients who are most often harmed by bad transitions are older, frail, complex individuals, especially those who lack sufficient agency. Key factors contributing to poor care transition include gaps in communication, 4 lack of formal training of clinicians in care transitions, breakdown of cross-site communication and collaboration, lack of knowledge of patient wishes, abilities, and goals of care (GOC), and medication reconciliation breakdown.…”

Section: Introductionmentioning

confidence: 99%

“…The medical staff caring of older adults are inadequately trained in care transitions 3 and get infrequent formal education in transitional care. 2,12 As geriatric population is growing, it is important to have interprofessional and educational training on care transitions integrated into the medical education. Coronavirus disease 19 pandemic has added to the existing challenges in transitional care as hospitals attempt to discharge patients early to prepare for COVID-19 surges making it more prudent to improve care transitions for older adults as they transition across different health systems.…”

Section: Introductionmentioning

confidence: 99%

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Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention

Sheikh

Gathecha

Arbaje

et al. 2021

Journal of Medical Education and Curricular Development

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Problem: Suboptimal care transitions can lead to re-hospitalizations. Intervention: We developed a 2-week “Transitions of Care Curriculum” to train first-year internal medicine residents to improve their knowledge and skills to deliver optimal transitional care. Our objective was to use reflective writing essays to evaluate the impact of the curriculum on the residents. Methods: The rotation included: Transition of Care Teaching modules, Transition Audit, Transitional Care Site Visits, and Transition of Care Conference. Residents performed the above elements of care transitions during the curriculum and wrote reflective essays about their experiences. These essays were analyzed to assess for the overall impact of the curriculum on the residents. Qualitative analysis of reflective essays was used to evaluate the impact of the curriculum. Of the 20 residents who completed the rotation, 18 reflective essays were available for qualitative analysis. Results: Five major themes identified in the reflective essays for improvement were: discharge planning, patient-centered care, continuity of care, goals of care discussions, and patient safety. The most discussed theme was continuity of care, with following subthemes: fragmentation of the healthcare system, disjointed care to the patients, patient specific factors contributing to lack of continuity of care, lack of primary care provider role as a coordinator of care, and challenges during discharge process. Residents also identified system-based gaps and suggested solutions to overcome these gaps. Conclusions: This experiential learning and use of reflective writing enhanced the residents’ self-identified awareness of gaps in care transitions and prompted them to generate ideas for systems improvement and personal actions to improve their practice during care transitions.

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“…These adverse outcomes have been attributed to factors such as lack of patient knowledge about available community-based services resulting in suboptimal or delayed utilization of these services [ 6 ], conflicting plans and instructions from different providers [ 7 – 10 ], medication errors [ 11 , 12 ], lack of support for self-management of their complex chronic conditions [ 11 , 12 ], lack of support for family caregivers, lack of communication and connections between older adults and health care providers, and untreated or under-treated depressive symptoms [ 13 – 15 ]. Factors related to social and structural determinants of health can further worsen the challenge of managing hospital to home transitions for older adults with MCC and depressive symptoms [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

et al. 2020

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Background: Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-tohome. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities. Methods: Participants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety,

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A Call to Bridge Across Silos during Care Transitions

Cited by 17 publications

References 29 publications

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

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

Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial

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