Reducing Preventable Hospitalizations With Two Models of Transitional Care

Morrison, J.; Palumbo, Mary Val; Rambur, Betty

doi:10.1111/jnu.12210

Cited by 37 publications

(35 citation statements)

References 26 publications

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“…Promoting mental and emotional status of patients is necessary and essential for changing their behavior. In this regard, nurses' collaboration with social organizations of counterpart groups, families, and friends (2,22,24).…”

Section: Educating and Promoting Self-managementmentioning

confidence: 99%

Transitional care model: managing the experience of hospital at home

Rezapour-Nasrabad

2018

Electron J Gen Med

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Introduction: Design and use of effective strategies to improve care and achieve better results for patients with chronic diseases, reduce the frequency and cost of hospitalization is necessary for these patients. Transitional care model is a new model that have been effective in meeting the needs of these patients. The aim of this mini review study is investigating and describing the various aspects of transitional care model, benefits and core components. Design: The present investigation is a mini review study that conducted with library reading for data collecting. Methods: Scientific database (ISI, Pubmed, Scopus, Sciencedirect) were reviewed for articles related to the transitional care model literature. A total of 80 articles were obtained. Following applying the inclusion criteria (published between 2000 and 2017 in English language among peer-review journals), 5 articles were retained. These articles propose core components of the transitional care model and its benefits. Results: Transitional care model has some benefits, 8 main elements and 7 core components including:

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Section: Educating and Promoting Self-managementmentioning

confidence: 99%

Transitional care model: managing the experience of hospital at home

Rezapour-Nasrabad

2018

Electron J Gen Med

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“…Although one would expect that these moves would be beneficial for the care recipient and their family, they are increasingly being viewed as problematic. Low-quality transitions due to medication errors and other mistakes or mishaps have been identified as common (Gozalo et al, 2011;Larkin, Dierckx de Casterle, & Schotsmans, 2007;Morrison, Palumbo, & Rambur, 2016). Moving from one care setting to another has also been cited for disrupting care teams, with a loss of informed and trusting relationships (Aaltonen et al, 2014;Abarshi et al, 2010;Lawson, Burge, Critchley, & McIntyre, 2006;Lawson, Burge, Mcintyre, Field, & Maxwell, 2008).…”

mentioning

confidence: 99%

Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in O ntario

Wilson

Birch

2017

Health Soc Care Community

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Moving from one care setting to another is common as death nears. Many concerns exist over these end-of-life (EOL) care setting transitions, including low-quality moves as mistakes and other mishaps can occur. Delayed or denied moves are also problematic, such as a move out of hospital for dying inpatients who want to spend their last hours or days at home. The aim of the study was to identify current issues or problems with care setting transitions during the last year of life as well as potential or actual solutions for these problems. A grounded theory analysis approach was used based on interviews with 38 key informants who represent a wide range of healthcare providers, healthcare managers, government representatives, lawyers, healthcare recipients and their family/friends across Ontario in 2016. Three interrelated themes were revealed: (a) communication complexities, (b) care planning and coordination gaps and (c) health system reform needs. Six solutions were highlighted, with these designed to prevent care setting transition issues and monitor care setting transitions for continued improvements.

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“…However, multidisciplinary nurse-directed transitional care programs have been successful in reducing hospitalization, and ED visits. 11,12 For example, a Clinical Nurse Specialist (CNS) directed transitional care program with a chronic disease self-management focus significantly reduced ED utilization. 12 This multi-faceted transitional program included making the initial visit in the hospital and conducting a follow-up home visit within 24–48 hours post discharge.…”

Section: Introduction and Review Of Literaturementioning

confidence: 99%

“…11,12 For example, a Clinical Nurse Specialist (CNS) directed transitional care program with a chronic disease self-management focus significantly reduced ED utilization. 12 This multi-faceted transitional program included making the initial visit in the hospital and conducting a follow-up home visit within 24–48 hours post discharge. During the first visit in the hospital, the CNS completed a comprehensive physical assessment, reviewed medication, and assessed patient risk factors and the presence of social support.…”

Section: Introduction and Review Of Literaturementioning

confidence: 99%

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ED Utilization and Self-Reported Symptoms in Community-Dwelling Older Adults

Dermody¹,

Sawyer²,

Kennedy³

et al. 2017

Journal of Emergency Nursing

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Background The rise in emergency department (ED) utilization among older adults is a nursing concern, because emergency nurses are uniquely positioned to positively impact the care of older adults. Symptoms have been associated with ED utilization, however, it remains unclear if symptoms are the primary reason for ED utilization. Purpose Describe the self-reported symptoms of community-dwelling older adults prior to accessing the emergency department. Examine the differences in self-reported symptoms among those who utilized the emergency department, and those who did not. Procedures A prospective longitudinal design was used. The sample included 403 community-dwelling older adults 75 years and older. Baseline in-home interviews were conducted followed by monthly telephone interviews over 15 months. Main Findings Commonly reported symptoms at baseline included pain, feeling tired, and having shortness of breath. In univariate analysis, pain, shortness of breath, fair/poor well-being, and feeling tired were significantly correlated with ED utilization. In multivariable models, problems with balance, and fair/poor well-being were significantly associated with ED utilization. Conclusions Several symptoms were common among this cohort of older adults. However, there were no significant differences in the types of symptoms reported by older adults who utilized the emergency department compared to those who did not use the emergency department. Based on these findings, symptoms among community-dwelling older adults may not be the primary reason for ED utilization.

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Reducing Preventable Hospitalizations With Two Models of Transitional Care

Abstract: Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.

Cited by 37 publications

References 26 publications

Transitional care model: managing the experience of hospital at home

Transitional care model: managing the experience of hospital at home

Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in O ntario

ED Utilization and Self-Reported Symptoms in Community-Dwelling Older Adults

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