Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too

Li, Jing; Clouser, Jessica Miller; Brock, Jane E.; Davis, Terry C.; Jack, Brian; Levine, Carol; Mays, Glen P.; Mittman, Brian; Nguyen, Huong Q.; Sorra, Joann; Stromberg, Arnold J.; Du, Gaixin; Dai, Chen; Adu, Akosua; Vundi, Nikita; Williams, Mark

doi:10.1016/j.jcjq.2021.09.012

Cited by 13 publications

(13 citation statements)

References 61 publications

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“…Readmission is a highly confounded outcome, and results should be interpreted with caution. In a large prospective national study, several thousand patients were assigned to receive a variety of interventions related to TOC, which reduced readmissions . This finding was driven by hospital-based TOC interventions that included but were not limited to medication reconciliation, identification of high-risk patients, and promotion of trust in the hospital.…”

Section: Discussionmentioning

confidence: 99%

Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

et al. 2022

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IMPORTANCEAlthough prescribers face numerous patient-centered challenges during transitions of care (TOC) at hospital discharge, prolonged duration of antimicrobial therapy for common infections remains problematic, and resources are needed for antimicrobial stewardship throughout this period.OBJECTIVE To evaluate a pharmacist-driven intervention designed to improve selection and duration of oral antimicrobial therapy prescribed at hospital discharge for common infections. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a nonrandomized stepped-wedge design with 3 study phases from September 1, 2018, to August 31, 2019. Seventeen distinct medicine, surgery, and specialty units from a health system in Southeast Michigan participated, including 1 academic tertiary hospital and 4 community hospitals. Hospitalized adults who had urinary, respiratory, skin and/or soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge were included in the analysis. Data were analyzed from

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Section: Discussionmentioning

confidence: 99%

Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

et al. 2022

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“…Project ACHIEVE was a PCORI‐funded study with the goal of understanding what patients and family caregivers want from TC, 26 and which TC strategies implemented by hospitals are associated with improved patient outcomes 24,27,28 . As one part of Project ACHIEVE, we conducted hospital site visits to observe the implementation of transitional care strategies, one of which was the implementation of IDRs.…”

Section: Introductionmentioning

confidence: 99%

“…Project ACHIEVE was a PCORI-funded study with the goal of understanding what patients and family caregivers want from TC, 26 and which TC strategies implemented by hospitals are associated with improved patient outcomes. 24,27,28 As one part of Project ACHIEVE, we conducted hospital site visits to observe the implementation of transitional care strategies, one of which was the implementation of IDRs. The purpose of this observational study was to document the heterogeneity of hospitals' IDRs and to assess what characteristics were associated with IDR functions of effective communication and completeness of content covered.…”

Section: Introductionmentioning

confidence: 99%

Implementation and function of interdisciplinary rounds: An observational multisite hospital study from project ACHIEVE

Vundi

Clouser

Adu

et al. 2023

Journal of Hospital Medicine

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Background: Interdisciplinary rounds (IDR) are increasingly employed by hospitals; however, there is no formal definition, structure, or framework.Objective: The purpose of this observational study was to document the heterogeneity of IDRs and assess the different characteristics associated with IDR functions.Designs, Settings, and Participants: Observation of IDR occurred at 27 hospitals that were purposively selected to ensure a mix of the following criteria: geographic region, provider type, for-profit status, population (e.g., urban, rural), and teaching status.Hospitals identified general medical floors covered by hospitalists for IDR observations. Intervention:The study team conducted hospital site visits to observe the implementation of IDR. A checklist was developed to record IDR structure and processes, content, and outcomes. Data from two content expert observers were reconciled, and a consensus was attained. Main Outcome and Measures:The study measures include two IDR functions: topics discussed during IDR (changes in medical treatment, responsibilities and shared understanding of goals and expectations, anticipation of discharge date and needs, anticipating follow-up care and service needs), and effective communication.Results: Hospitals varied significantly in IDR implementation. 51.9% included the "core" team (i.e., a physician, nurse, pharmacist, and case manager/social worker), though all included a case manager or social worker. Most (81.5%) occurred before noon. Content chiefly focused on medical care (74.1 to 92.6%) with patient responsibilities and preferences being less frequently discussed (25.9 to 40.7%). Bivariate analyses revealed that afternoon rounds were more likely to include dischargeȐrelated topics, such as patient/caregiver preferences (100% vs. 27.3%, p = .003) and follow-up needs (100% vs. 36.4%, p = .010).When IDR occurred at bedside, financial resources were more often assessed (100% vs. 34.8%, p = .015) and patient's ability to obtain medication was more often anticipated (75% vs. 21.7%, p = .031).

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“…A subsequent survey of nearly 8000 patients going through the hospital discharge process identified the importance of trust. 18 Box 1 Achieving healthcare that delivers what matters most to patients in care transitions 17 What matters most to patients and carers (family caregivers) when transitioning from hospital to home 1. To feel prepared and capable; they want: 2.…”

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confidence: 99%

Embracing carers: when will adult hospitals fully adopt the same practices as children’s hospitals?

Williams

2023

BMJ Qual Saf

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Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too

Cited by 13 publications

References 61 publications

Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge

Implementation and function of interdisciplinary rounds: An observational multisite hospital study from project ACHIEVE

Embracing carers: when will adult hospitals fully adopt the same practices as children’s hospitals?

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