Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution

Ursan, Iulia D.; Krishnan, Jerry A.; Pickard, A. Simon; Calhoun, Elizabeth A.; DiDomenico, Robert J.; Prieto-Centurion, Valentin; Sullivan, Jamie; Valentino, Lauren; Williams, Mark; Joo, Min J.

doi:10.1353/hpu.2016.0026

Cited by 13 publications

(11 citation statements)

References 21 publications

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“…This survey describes variation in elements of patient navigation programs nationally but does not evaluate the impact of those differences on patient outcomes. These outcomes range greatly given the breadth of PN interventions; recent studies provide a set of patient navigator tasks for cancer care [28] colorectal cancer screening [51] medical home services for HIV-positive homeless patients [52] transitional care post discharge [53]. A systematic review and meta-analysis of care coordination demonstrated positive results across cancer continuum outcomes [28].…”

Section: Discussionmentioning

confidence: 99%

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

Valverde

Calhoun

Espàrza

et al. 2018

Translational Behavioral Medicine

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Patient navigators (PNs) coordinate medical services and connect patients with resources to improve outcomes, satisfaction, and reduce costs. Little national information is available to inform workforce development. We analyzed 819 responses from an online PN survey conducted in 2009-2010. Study variables were mapped to the five Consolidated Framework for Implementation Research (CFIR) constructs to explore program variations by type of PN. Five logistic regression models compared each PN type to all others while adjusting for covariates. Thirty-five percent of respondents were nurse navigators, 28% lay navigators, 20% social work (SW)/counselor navigators, 7% allied health navigators, and 10% were "other" types of PNs. Most were non-Hispanic White (71%), female (94%), and at least college educated (70%). The primary differences were observed among: the core intervention tasks; position structure; work setting; health conditions navigated; navigator race/ethnicity; personal cancer experiences; navigation training; and patient populations served. Lay PNs had fewer odds of identifying as Hispanic, work in rural settings and assist underserved populations compared to others. Nurse navigators showed greater odds of clinical responsibilities, work in hospital or government settings and fewer odds of navigating minority populations compared to others. SW/counselor navigators also had additional duties, provided greater assistance to Medicare patient populations, and less odds of navigating underserved populations than others. In summary, our survey indicates that the type of PN utilized is an indicator of other substantial differences in program implementation. CFIR provides a robust method to compare differences and should incorporate care coordination outcomes in future PN research.

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Section: Discussionmentioning

confidence: 99%

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

Valverde

Calhoun

Espàrza

et al. 2018

Translational Behavioral Medicine

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“…The role of patient navigators. Studies are also being conducted to evaluate innovative and patient-centered interventions, such as patient navigators (43,61). The PCORI (Patient-Centered Outcomes Research Institute)-funded PArTNER (Patient Navigator to Reduce Readmissions) study is a pragmatic trial testing the role of community health workers serving as patient navigators to reduce anxiety and improve social support (coprimary outcomes); the study examines readmissions as a secondary outcome.…”

Section: Case Presentationsmentioning

confidence: 99%

Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report

Press¹,

Au²,

Bourbeau³

et al. 2019

Annals ATS

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Chronic obstructive pulmonary disease (COPD) is the third leading cause of hospital readmissions in the United States. The quality of care delivered to patients with COPD is known to be lacking across the care continuum, and may contribute to high rates of readmission. As part of the response to these issues, the Centers for Medicare and Medicaid instituted a penalty for 30-day readmissions as part of their Hospital Readmission Reduction Program in October 2014. At the time the penalty was instated, there was little published evidence on effective hospital-based programs to reduce readmissions after acute exacerbations of COPD. Even now, several years later, few published programs exist, and we continue to lack consistent approaches that lead to improved readmission rates. In addition, there was concern that the penalty would widen health disparities. Despite the dearth of published evidence to reduce readmissions beyond available COPD guidelines, many hospitals across the United States began to develop and implement programs, based on little evidence, due to the financial penalty. We, therefore, assembled a diverse group of clinicians, researchers, payers, and program leaders from across the country to present and discuss approaches that had the greatest potential for success. We drew on expertise from ongoing readmission reduction programs, implementation methodologies, and stakeholder perspectives to develop this Workshop Report on current best practices and models for addressing COPD hospital readmissions.

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“…All abstracts were reviewed for exclusion criteria, and studies were removed for the exclusion reasons noted earlier. A total of 12 articles were included in the qualitative metasynthesis, as outlined in the PRISMA chart in Figure 1 (Bakas, Austin, Okonkwo, Lewis, & Chadwick, 2002; Blair, Volpe, & Aggarwal, 2014; Coleman & Roman, 2015; Dossa et al, 2012; Foust et al, 2012; Kangovi et al, 2014; Linton, Ing, Vento, & Nakagawa, 2015; MacLeod, 2011; Naylor, Stephens, Bowles, & Bixby, 2005; Ursan et al, 2016; Werner, Tong, Borkenhagen, & Holden, 2018; White et al, 2015).…”

Section: Resultsmentioning

confidence: 99%

Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis

et al. 2019

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Caregivers of patients often provide key support for patients after hospitalization. This qualitative metasynthesis describes caregiver perspectives about care coordination for patients discharged from the hospital. A literature search of Ovid Medline and CINAHL completed on May 23, 2018, identified 1,546 studies. Twelve articles were included in the final metasynthesis. Caregiver perspectives about care coordination were compiled into overall themes. A subanalysis of studies in which patients were discharged with home health services was completed. Five main themes emerged related to caregiver perspectives on care coordination after hospitalization: (a) Suboptimal access to clinicians after discharge, (b) Feeling disregarded by clinicians, (c) Need for information and training at discharge, (d) Overwhelming responsibilities to manage appointments and medications, and (e) Need for emotional support. Findings from this metasynthesis suggest the need for clinicians to engage with caregivers to provide support, training, and communication after hospital discharge.

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Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution

Cited by 13 publications

References 21 publications

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report

Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis

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