Patient-Centered Approaches to Transitional Care Research and Implementation

Parry, Carla; Johnston-Fleece, Michelle; Johnson, Maurice; Shifreen, Aaron; Clauser, Steven B.

doi:10.1097/mlr.0000000000001593

Cited by 15 publications

(23 citation statements)

References 41 publications

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“…Generally, there is a gap in patient‐centered outcomes measured in work on transitional care even outside of the ED setting, as it is a relatively new development 27 . We also recognize that the use of patient‐centered outcome measures in the acute and ED setting is difficult, as a previous review highlighted challenges to their use such as the heterogeneity of the ED population and the time constraints of providing ED care that can pose challenges to communication 28 .…”

Section: Discussionmentioning

confidence: 99%

“…28 Examples of patient-centered metrics for future use may be drawn from the care transition literature outside the ED setting, including transitions from inpatient hospital settings, rehabilitation facilities, and long-term care. 27 One current example is the adaptation of the Three-Item Care Transitions Measure, which was originally developed as a patient-reported measure of patient preparedness for discharge from the inpatient setting. 29 Early results in the ED demonstrated an association with more traditional acute care utilization metrics such as 14-day ED revisits and medication adherence.…”

Section: Discussionmentioning

confidence: 99%

“…23,24 Although there are few examples of its use in the ED setting, 25,26 Generally, there is a gap in patient-centered outcomes measured in work on transitional care even outside of the ED setting, as it is a relatively new development. 27 We also recognize that the use of patient-centered outcome measures in the acute and ED setting is difficult, as a previous review highlighted challenges to their use such as the heterogeneity of the ED population and the time constraints of providing ED care that can pose challenges to communication. 28 Examples of patient-centered metrics for future use may be drawn from the care transition literature outside the ED setting, including transitions from inpatient hospital settings, rehabilitation facilities, and long-term care.…”

Section: Discussionmentioning

confidence: 99%

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Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

Seidenfeld

Ramos

Bruening

et al. 2023

Academic Emergency Medicine

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Objectives: Care transition interventions (CTIs) are used to improve outcomes after an emergency department (ED) visit. A recent randomized controlled trial of a Veterans Health Administration (VHA) CTI titled Discharge Information and Support for Patients receiving Outpatient care in the ED (DISPO ED) demonstrated no difference in repeat ED visits. However, changes in health care utilization are not the only measures of a CTI worth evaluation, and there is interest in using patient-centered outcomes to assess CTIs as well. To inform future CTI design and outcome measure selection, the study aims were to understand how patients experienced the CTI and what elements they valued.Methods: This was a qualitative study of participants randomized to the intervention arm of the DISPO ED trial using semistructured interviews. The interview guide included questions about clinical health and other issues addressed by the study nurse, the most and least helpful aspects of the intervention, and impacts of the intervention on their perceptions of self-management. Interviews were analyzed using directed content analysis.Results: Our sample comprised 24 participants, with average age of 61 years, 58% male, and 50% Black or African American. We identified six major themes related to (1) experiences during the intervention and (2) elements they valued. Patients reported clinical health coaching recommendations covering a wide range of topics as well as care coordination actions such as appointment scheduling. Valuable elements

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

Seidenfeld

Ramos

Bruening

et al. 2023

Academic Emergency Medicine

View full text Add to dashboard Cite

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“…The careful consideration of study design that reflects the needs of cancer patients is one important step that was noted. For example, including stakeholder-driven outcomes and comparators that are clinically justified and appropriate for the care setting and population is a way to better meet patient needs and preferences in the research setting [41,42]. Understanding the unique perspectives of cancer patients and survivors who experience oncologic complications and designing future research studies that accurately reflect their needs are critical.…”

Section: Designing and Conducting Oncologic Emergency Researchmentioning

confidence: 99%

Cancer-related emergency and urgent care: expanding the research agenda

et al. 2022

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Purpose of review Cancer-related emergency department (ED) visits often result in higher hospital admission rates than non-cancer visits. It has been estimated many of these costly hospital admissions can be prevented, yet urgent care clinics and EDs lack cancer-specific care resources to support the needs of this complex population. Implementing effective approaches across different care settings and populations to minimize ED and urgent care visits improves oncologic complication management, and coordinating follow-up care will be particularly important as the population of cancer patients and survivors continues to increase. The National Cancer Institute (NCI) and the Office of Emergency Care (OECR) convened a workshop in December 2021, “Cancer-related Emergency and Urgent Care: Prevention, Management, and Care Coordination” to highlight progress, knowledge gaps, and research opportunities. This report describes the current landscape of cancer-related urgent and emergency care and includes research recommendations from workshop participants to decrease the risk of oncologic complications, improve their management, and enhance coordination of care. Recent findings Since 2014, NCI and OECR have collaborated to support research in cancer-related emergency care. Workshop participants recommended a number of promising research opportunities, as well as key considerations for designing and conducting research in this area. Opportunities included better characterizing unscheduled care services, identifying those at higher risk for such care, developing care delivery models to minimize unplanned events and enhance their care, recognizing cancer prevention and screening opportunities in the ED, improving management of specific cancer-related presentations, and conducting goals of care conversations. Summary Significant progress has been made over the past 7 years with the creation of the Comprehensive Oncologic Emergency Research Network, broad involvement of the emergency medicine and oncology communities, establishing a proof-of-concept observational study, and NCI and OECR’s efforts to support this area of research. However, critical gaps remain.

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“…Person-centered care involves using outcomes in clinical studies that are important to people living with HF, such as health-related quality of life, symptoms, functional status, decision-making, and process measures, such as patient self-efficacy measures and post-discharge follow-up metrics [ 29 ]. Such outcomes are commonly reported in transitional-care studies that integrally involve patients in the research process [ 30 ]. Nonetheless, a significant challenge to implementing person-centered care in patients with long-term illness includes relegation of the patient narrative to a subsidiary role in favor of objective biological markers [ 27 ].…”

Section: Introductionmentioning

confidence: 99%

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post–hospital discharge period

Butler

Petrie

Bains³

et al. 2023

Res Involv Engagem

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Background People living with heart failure (HF) are particularly vulnerable after hospital discharge. An alliance between patient authors, clinicians, industry, and co-developers of HF programs can represent an effective way to address the unique concerns and obstacles people living with HF face during this period. The aim of this narrative review article is to discuss challenges and opportunities of this approach, with the goal of improving participation and clinical outcomes of people living with HF. Methods This article was co-authored by people living with HF, heart transplant recipients, patient advocacy representatives, cardiologists with expertise in HF care, and industry representatives specializing in patient engagement and cardiovascular medicine, and reviews opportunities and challenges for people living with HF in the post–hospital discharge period to be more integrally involved in their care. A literature search was conducted, and the authors collaborated through two virtual roundtables and via email to develop the content for this review article. Results Numerous transitional-care programs exist to ease the transition from the hospital to the home and to provide needed education and support for people living with HF, to avoid rehospitalizations and other adverse outcomes. However, many programs have limitations and do not integrally involve patients in the design and co-development of the intervention. There are thus opportunities for improvement. This can enable patients to better care for themselves with less of the worry and fear that typically accompany the transition from the hospital. We discuss the importance of including people living with HF in the development of such programs and offer suggestions for strategies that can help achieve these goals. An underlying theme of the literature reviewed is that education and engagement of people living with HF after hospitalization are critical. However, while clinical trial evidence on existing approaches to transitions in HF care indicates numerous benefits, such approaches also have limitations. Conclusion Numerous challenges continue to affect people living with HF in the post–hospital discharge period. Strategies that involve patients are needed, and should be encouraged, to optimally address these challenges.

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Patient-Centered Approaches to Transitional Care Research and Implementation

Cited by 15 publications

References 41 publications

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

Cancer-related emergency and urgent care: expanding the research agenda

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post–hospital discharge period

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