Improving the Quality of Transitional Care for Persons with Complex Care Needs

Coleman, Eric A.; Boult, Chad

doi:10.1046/j.1532-5415.2003.51186.x

Cited by 679 publications

(556 citation statements)

References 9 publications

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“…It is important to consider how populations who receive transitions of care interventions within hospitals implementing these programs (3) CMS Publicly reported definition. The readmission measures count readmission as a "yes/no" outcome regardless of the number of times the patient was readmitted during the 30-Day post-discharge time period.…”

Section: Discussionmentioning

confidence: 99%

“…This is seen especially in the elderly and the chronically ill, for whom decreased capacity for self-care and difficulties with navigating the health system lead to significant challenges [3]. Studies have consistently identified mistakes in several areas, including medication reconciliation [4,5], communication between hospital-based and primary care [6,7], and coordination of follow-up visits [3,8].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Transition Coach Program Implementation Associated with Thirty-Day Readmission Rates in a Community Hospital Setting

Moore¹,

Gerke²,

Bourgoine³

et al. 2016

Arch Community Med Public Health

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Transition Coach Program Implementation Associated with Thirty-Day Readmission Rates in a Community Hospital Setting

Moore¹,

Gerke²,

Bourgoine³

et al. 2016

Arch Community Med Public Health

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“…For some, the slower pace of change can make it harder to recognize their palliative status, thereby restricting access to specialized, end-oflife services when needed (Covinsky et al, 2003). Research also indicates that persons with dementia experience more care transitions than others (Coleman & Boult, 2003) and have a higher risk of adverse events such as medication errors, hospitalizations, stress and anxiety, and other problems than those without the disease (Manderson et al, 2012). Although most individuals with dementia are cared for at home, the progression of the disease often leads to higher levels of care (McCabe, You, & Tatangelo, 2016), with increased likelihood of institutionalization over time (Eska et al, 2013).…”

Section: Introductionmentioning

confidence: 99%

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

Cloutier¹,

Penning

2016

GERONT

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Purpose of the Study: Janus, the two-faced, Roman god of beginnings and transitions, is used as a metaphor to explore our personal narratives and our quantitative research on the experiences of older women with dementia in long-term care (LTC). Two research questions are addressed: (a) How do our quantitative data map onto our mothers' experiences? (b) What lessons do our mothers' experiences offer for the care of older women with dementia? Design and Methods: Informed by a life-course perspective, we triangulate administrative data on 3,717 women with dementia receiving LTC in British Columbia, Canada, with personal narratives-the stories of our mothers who made the transition from home care into residential (nursing home) care. Results: Our quantitative data reveal that the home care to residential care transition is the most common LTC trajectory for women with dementia who are most likely to be widowed and living alone in suburban areas. On entry into residential care, they exhibit greater frailty in terms of activities of daily living, cognition, aggression, and incontinence. Our personal narrative data on our mothers reveals that the relatively straightforward pathways through LTC for women with dementia, are often considerably more complex in a real-world context. Attention is drawn to the public and private services, hospitalization patterns, and substantial communication gaps experienced by our moms and families. Implications: A life-course perspective, and qualitative and quantitative data facilitate understanding the care journeyshealth and service trajectories of older women with dementia. Writing over a decade ago about their mother's experience of nursing home care after a serious stroke, Kane and West (2005) argued that society appears uninterested in making the necessary commitment to care for frail older adults in creative, compassionate, and appropriate ways aligned with goals of quality of care and quality of life. In this special issue called, Aging-It's Personal, we explore this concern by triangulating data from our funded research program with our personal narratives describing our mothers' experiences as clients of the long-term care (LTC) system.As social gerontologists, we have spent much of our careers studying health service provision for vulnerable older adults. As adult children, we have recent personal and family-centered experience related to our mothers' care journeys as women who began their service trajectory in home care and continued on to become clients of residential (nursing home) care until their deaths. In thisThe Gerontologist cite as : Gerontologist, 2017, Vol. 57, No. 1, 68-81 doi:10.1093 Advance Access publication November 16, 2016 article, we employ the metaphor of Janus, the two-faced Roman god of beginnings and transitions, to explore how our personal and professional worlds have intertwined, affecting us indelibly as family members, sparking our research questions, and giving us a greater appreciation for the ways that care is navigated. We consider ...

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“…[1][2][3][4][5][6][7][8][9] Adverse events, defined as poor outcomes due to medical care, occur in one in five medical patients in the first month following discharge. 5,6 A significant proportion of adverse events have important clinical consequences, including death, and at least half of them are preventable or ameliorable.…”

Section: Introductionmentioning

confidence: 99%

“…Several studies suggest a simple telephone intervention may improve identification of these early symptoms and in turn reduce the risk of them progressing. 2,3,8,10 Although this intervention is promising, resource limitations impede uptake.…”

Section: Introductionmentioning

confidence: 99%

Identifying Patients with Post-discharge Care Problems Using an Interactive Voice Response System

et al. 2009

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INTRODUCTION:Adverse events (AEs) are poor outcomes caused by medical care. They occur in 20% of medical patients following hospital discharge. We designed an interactive voice response system (IVRS) with the intent of identifying patients who might be experiencing an AE following discharge or were at risk of developing one. OBJECTIVES:We determined the proportion of postdischarge patients requiring an intervention after identifying potential problems using the IVRS, the relationship between IVRS responses and AE occurrence, and patients' opinions of the IVRS call. METHODS:We studied patients discharged from the general medical service of an academic hospital. The IVRS called patients 2 days post-discharge and asked three questions to determine the need for nurse follow-up. We contacted patients 30 days later to elicit AE status and perceptions of the IVRS. RESULTS:Our cohort consisted of 270 elderly patients [median 64 years (IQR 50-76)] with multiple comorbidities. Responses to the IVRS identified 57 patients (21%, 95% CI 17%-27%) for follow-up. When contacted by a nurse, 25 patients (9%, 95% CI 6%-13%) actually required an intervention. At 30-day follow-up, AEs occurred in 33 patients (12%, 95% CI 8%-17%). Only three AEs (9%) were identified by the IVRS; the remainder occurred before or after the IVRS call. Patients remembering the IVRS call found it easy to use (97%), and a minority would prefer a person to call (8%).CONCLUSION: An IVRS-based method of monitoring was acceptable to patients and identified a significant proportion requiring changes in management. However, the method identified only a minority of AEs. To have a significant improvement in care, this method will need to be combined with other interventions.KEY WORDS: interactive voice response system; adverse events; hospital discharge.

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Improving the Quality of Transitional Care for Persons with Complex Care Needs

Cited by 679 publications

References 9 publications

Transition Coach Program Implementation Associated with Thirty-Day Readmission Rates in a Community Hospital Setting

Transition Coach Program Implementation Associated with Thirty-Day Readmission Rates in a Community Hospital Setting

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

Identifying Patients with Post-discharge Care Problems Using an Interactive Voice Response System

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