Engaging patients and families in communication across transitions of care: An integrative review

Bucknall, Tracey; Hutchinson, Alison; Botti, Mari; McTier, Lauren; Rawson, Helen; Hitch, Danielle; Hewitt, Nicky; Digby, Robin; Fossum, Mariann; McMurray, Anne; Marshall, Andrea P.; Gillespie, Brigid M.; Chaboyer, Wendy

doi:10.1016/j.pec.2020.01.017

Cited by 24 publications

(26 citation statements)

References 62 publications

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“…However, for successful transitional care patients and families should be partners in decision-making and care. 35 In Middle Eastern countries, including Iran, Family is the first and main source of support in the care of chronic patients. Family members are committed to tradition, and there is a strong emotional relationship between them, and they have a commitment to each other.…”

Section: Discussionmentioning

confidence: 99%

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

Nasrabadi

Dehkordi

Taleghani

2021

Home Health Care Management & Practice

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Transitional care is a designed plan to ensure the continuity of care received by patients as they transfer between different locations or levels of care. The aim of this paper is to explore nurses’ experiences of transitional care in multiple chronic conditions. A qualitative method with a conventional content analysis approach was utilized. The study was conducted at university hospitals in 2 big cities (Isfahan and Tehran) of Iran. This study is performed from November 2018 to December 2019 using deep, semi-structured, and face-to-face interviews which are focused on nurses’ experiences of transitional care. Data collection continued until saturation was reached. Finally, 15 nurses take part in this study. Data collection and data analysis were conducted concurrently. Data were analyzed using Graneheim and Lundman’s techniques. Two main themes providing a descriptive summary of the major elements of transitional care identified: “threat to patient safety” and “Care breakdown”. Findings showed an exclusive image of unsafe transitional care which was done unplanned without appropriate delegating care to family and threat patient safety. There is still a gap in the transition from hospital to home. Nursing managers can address this issue by creating a culture of teamwork, training competent nurses by continuum education, and more supervision of nursing care. Policymakers can ensure continuity of care by developing policies and programs about transitional care.

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Section: Discussionmentioning

confidence: 99%

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

Nasrabadi

Dehkordi

Taleghani

2021

Home Health Care Management & Practice

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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%

“…While this intervention did not specifically focus on transitional care, 60% of the older adult study participants reported one or more hospital admissions in the last six months, thus serving as a strong foundation for the hospital-to-home transitional care intervention tested in this trial. The intervention also included most of the key elements recommended in best practice guidelines for transitional care [31,40,[65][66][67][68]. The results of our feasibility study of the effectiveness of this intervention showed that the intervention was feasible to implement, and resulted in a statistically significant reduction in depressive symptoms, significant improvements in mental and physical functioning, and a statistically significant reduction in the use of hospitalization, ambulance service utilization and emergency room visits [50].…”

Section: Plos Onementioning

confidence: 99%

“…The intervention was developed using the Medical Research Council Framework for developing complex interventions, which highlights the importance of theoretical and empirical evidence [75]. The intervention was based on Bandura's Social Cognitive Theory [76], where the aim is to build self-efficacy to improve self-management of health conditions and associated risk factors [76], and on research evidence [31,40,[66][67][68][77][78][79][80][81][82], More importantly, the intervention incorporated input from a range of stakeholders, including patients, providers, and decision-makers from local and provincial health authorities. The stakeholders worked as a team to identify gaps in the delivery of hospital-to-home transitional care which, in turn, informed the core components of the intervention and how they were delivered and tailored in the study settings.…”

Section: Interventionmentioning

confidence: 99%

“…The CAST intervention was designed to improve both the quality and experience of hospital-to-home transitions. It was based on a patient-centred model and encapsulates strategies included in effective care transitions interventions [31,40,[66][67][68], and PLOS ONE recommended in best practice guidelines for system navigation [77], management of depressive symptoms [31,78,79], and prevention and management of multimorbidity [80][81][82].…”

Section: Interventionmentioning

confidence: 99%

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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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Home care

Duke

2024

Reference Module in Biomedical Sciences

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Engaging patients and families in communication across transitions of care: An integrative review

Cited by 24 publications

References 62 publications

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions

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

Home care

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