Improving continuity of care of patients with respiratory disease at hospital discharge

Abstract

Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease.In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely.Educational aimsTo understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.

Clinical Efficacy and Psychological Impact of Omaha-Based Continuing Care for Prostate Cancer Patients

“…Radical prostatectomy is the most effective and commonly used treatment for prostate cancer, but patients usually have serious psychological problems after surgery, and the body is traumatized, and the patient's postoperative immune status is poor [12][13][14][15]. Patients still need professional health guidance after they are discharged.…”

Are We Missing the Opportunity to Disseminate GOLD Recommendations Through AECOPD Discharge Letters?

“…In general, the inaccuracy seen in AECOPD discharge notes and the lack of information continuity required in the transition of care result in worse patient outcomes, including a high re-admission rate. 45 In this regard, various improvement measures have been proposed. For example, Epstein et al designed and successfully implemented a decision support tool to automatically generate discharge recommendations based on GOLD guidelines.…”

Multi-disciplinary community respiratory team management of patients with chronic respiratory illness during the COVID-19 pandemic

“…Respiratory conditions are a key contributor to acute admissions, accounting for 850,000 pre-pandemic emergency hospital visits per year, with a yearly cost to the NHS of £9.9 billion 35 . Continuity of care is also important in this often multimorbid group, with integrated respiratory services providing holistic care for patients between the primary and secondary care interface shown to improve patient outcomes 36 , 37 . The National Institute for Health and Care Excellence (NICE) recommends multidisciplinary hospital-at-home schemes for managing selected patients with exacerbations of COPD 38 and this study has shown that the NHS GGC CRRT was able to effectively provide this service resulting in a reduction in emergency department attendances for COPD across the Trust, low rates of admission and death amongst CRRT patients, and no nosocomial COVID-19 infections.…”