Successes and Challenges in Patient Care Transition Programming: One Hospital’s Journey

Abstract

The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions. Data are emerging from the additional Care Transition Measures and benchmarks have been developed. This article briefly describes the context of care transition. We describe the journey of Indiana University Health North Hospital to overcome patient care transition obstacles, ultimately achieving designation as a top performer. We will discuss our efforts to personalize patient outcomes and transition through activation and improve transitions for vulnerable populations, specifically in the bariatric and orthopedic patient populations. The article concludes with discussion of overcoming obstacles and future directions with continued focus on collaboration and improvement.

Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions

“…First, it can be used as a risk stratification tool in transitional care planning and coordination. The identification of patients at risk, coordination of care, and the timeliness of follow-ups have been identified as critical factors for successful transitional care 45, . 46 Another study suggested that a datadriven approach for scheduling post-discharge interventions leads to a significant reduction in readmission rate by 44.7%, compared to regular visit-based home care.…”

Vivências relatadas por profissionais de saúde na transição do cuidado de pessoas indígenas

“…O termo "transição do cuidado" tem sido comumente utilizado na literatura internacional e nacional (Rayan-Gharra et Research, Society and Development, v. 11, n. 11, e194111133467, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i11.33467 4 al, 2018), (Brasil, 2017), (Choi, 2017), (Gallagher et al, 2017), (Kamermayer et al, 2017), (Delboccio et al, 2015), (Borges, & Santos-Junior, 2014), (Centeno, & Kahveci, 2014) e (Rodrigues et al, 2013), sendo que abrange não meramente a "des" hospitalização ou alta hospitalar, mas o deslocamento do paciente entre os distintos serviços de saúde ou até mesmo em diferentes unidades de um mesmo local. Durante a transição do cuidado, são demandadas ações específicas para a garantia da continuidade do cuidado (Coleman, & Boult, 2003).…”