Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities

Kitzman, Patrick H.; Hudson, Keisha; Sylvia, Violet; Feltner, Frances J.; Lovins, Johnnie

doi:10.1007/s10900-016-0289-0

Cited by 43 publications

(43 citation statements)

References 31 publications

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“…The forms to have access and the offering of services in the PEBA interstate region is still characterized by an unorganized and uncoordinated care, showing organizational weaknesses in health regionalized networks linked to the Country and, theoretically, in a construction phase in the region studied. This research confirms findings of previous studies the very own regionalization process, which marks the low of coordination and planning actions, especially from the APS, [26][27][28] as well as other more recent studies that test the fragility of the articulation between the levels of care in regional networks, a recognized fact by managers themselves in another health region in São Paulo State. 29 It should be noted that the presence of the University Hospital in the region is a critical component for the patients' care who were affected by AVE. With all the obstacles in care present in the therapeutic itineraries analyzed in this study, the University Hospital of Traumas has allowed the access of the interviewed healthcare users who arrive at the emergency department, through formal or informal ways, from the two macro-regions that link the interstate health region.…”

Section: Discussionsupporting

confidence: 90%

Therapeutic itineraries for patients with cerebrovascular accident: fragmentation of care in a regionalized health network

Fausto

Campos

Almeida

et al. 2017

Rev. Bras. Saude Mater. Infant.

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Section: Discussionsupporting

confidence: 90%

Therapeutic itineraries for patients with cerebrovascular accident: fragmentation of care in a regionalized health network

Fausto

Campos

Almeida

et al. 2017

Rev. Bras. Saude Mater. Infant.

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“…(31)(32)(33) Another strategy to contain costs and facilitate patient referral and follow-up would be the employment of patient navigators, who have been proven to reduce unnecessary emergency department visits and readmissions in other settings. (34,35) Our findings support those of previous studies that demonstrated the importance of hospital-level characteristics to outcomes among patients with cirrhosis. (7,8) Mellinger et al found that patients admitted to rural hospitals had a 27% higher odds of in-hospital mortality than patients admitted to urban hospitals after accounting for patient-level factors.…”

Section: Discussionsupporting

confidence: 90%

“…Subspecialty care through dispersed networks have shown telemedicine and spoke‐and‐hub referral systems to be highly cost‐effective in other disease settings . Another strategy to contain costs and facilitate patient referral and follow‐up would be the employment of patient navigators, who have been proven to reduce unnecessary emergency department visits and readmissions in other settings …”

Section: Discussionmentioning

confidence: 99%

Rural‐Urban Differences in In‐Hospital Mortality Among Admissions for End‐Stage Liver Disease in the United States

et al. 2019

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Access to quality hospital care is a persistent problem for rural patients. Little is known about disparities between rural and urban populations regarding in‐hospital outcomes for end‐stage liver disease (ESLD) patients. We aimed to determine whether rural ESLD patients experienced higher in‐hospital mortality than urban patients and whether disparities were attributable to the rurality of the patient or the center. This was a retrospective study of patient admissions in the National Inpatient Sample, a population‐based sample of hospitals in the United States. Admissions were included if they were from adult patients who had an ESLD‐related admission defined by codes from the International Classification of Diseases, Ninth Revision, between January 2012 and December 2014. The primary exposures of interest were patient‐level rurality and hospital‐level rurality. The main outcome was in‐hospital mortality. We stratified our analysis by disease severity score. After accounting for patient‐ and hospital‐level covariates, ESLD admissions to rural hospitals in every category of disease severity had significantly higher odds of in‐hospital mortality than patient admissions to urban hospitals. Those with moderate or major risk of dying had more than twice the odds of in‐hospital mortality (odds ratio [OR] for moderate risk, 2.41; 95% confidence interval [CI], 1.62‐3.59; OR for major risk, 2.49; 95% CI, 1.97‐3.14). There was no association between patient‐level rurality and mortality in the adjusted models. In conclusion, ESLD patients admitted to rural hospitals had increased odds of in‐hospital mortality compared with those admitted to urban hospitals, and the differences were not attributable to patient‐level rurality. Our results suggest that interventions to improve outcomes in this population should focus on the level of the health system.

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“…5 They place patients at extra risk for adverse events and poor health outcomes. 10,11 The occurrence of complications (eg, delirium) or functional loss, of which some may be avoidable and some may be not, can also contribute to the risk for hospital readmissions. It has been reported that persons with dementia were 28% more likely to be readmitted within 30 days of hospital discharge 8 and twice likely to be readmitted within 12 months of hospital discharge.…”

Section: Introductionmentioning

confidence: 99%

“…These factors include premature or poorly planned discharge of the index admission, lack or unavailability of postdischarge care services such like home health care, and the frailty and vulnerability of these individuals. 10,11 The occurrence of complications (eg, delirium) or functional loss, of which some may be avoidable and some may be not, can also contribute to the risk for hospital readmissions. 12 While hospital readmissions in persons with dementia is increasingly recognized as a critical issue, this phenomenon is poorly understood.…”

mentioning

confidence: 99%

Hospital readmission in persons with dementia: A systematic review

Bao

Dull

et al. 2019

Int J Geriat Psychiatry

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Objective Hospital readmission in persons with dementia is becoming a critical safety and cost issue. The purpose of this review is to systematically assess published evidence on hospital readmissions in persons with dementia, including rate, clinical reasons, risk factors, and prevention programs. Methods A systematic review of relevant literature was conducted. Literature were searched in PubMed, CINAHL, PsycINFO, and Embase as well as hand searching. Quality of reviewed studies were assessed independently by reviewers using quality assessment checklists. Results Nineteen studies met the inclusion criteria and were reviewed. In persons with dementia, all‐cause 30‐day readmission rate was most frequently reported and ranged from 7% to 35%. Compared with those without dementia, persons with dementia had significantly higher rate of readmission. Reported risk factors of readmission varied across studies from patient sociodemographic and clinical status, history of health care utilization, to family caregivers. Reasons for readmission were rarely documented. Programs of home‐based individualized care and interdisciplinary team care were used for preventing readmissions. Findings from some of the studies were limited by small sample sizes, single data source, and other methodologic flaws. Conclusions Persons with dementia are at high risk for hospital readmission, but many of the readmissions are potentially preventable. Multiple strategies such like identifying high‐risk individuals and the clinical reasons for index admission and readmission and implementing home‐based individualized care by interdisciplinary team can reduce preventable hospital readmissions. Future studies should use multiple national data sources and advanced methodology to identify risk factors and clinical reasons of hospital readmissions.

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Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities

Cited by 43 publications

References 31 publications

Therapeutic itineraries for patients with cerebrovascular accident: fragmentation of care in a regionalized health network

Therapeutic itineraries for patients with cerebrovascular accident: fragmentation of care in a regionalized health network

Rural‐Urban Differences in In‐Hospital Mortality Among Admissions for End‐Stage Liver Disease in the United States

Hospital readmission in persons with dementia: A systematic review

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