Transitional care interventions: Relevance for nursing in the community

Coffey, Alice; Mulcahy, Helen; Savage, Eileen; Fitzgerald, Sarah; Bradley, Colin; Benefield, Lazelle E.; Leahy‐Warren, Patricia

doi:10.1111/phn.12324

Cited by 39 publications

(34 citation statements)

References 27 publications

(154 reference statements)

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“…Previous research on patient involvement in transitional care has revealed that older patients experience a lack of participation during transitions [8][9][10][11]. Transitional care is also characterized by the challenges of coordinating care across organizational and disciplinary boundaries, managing conflicting goals of care, which may be stressful for health care providers (HCPs) [12][13][14]. Dyrstad et al [8] found that the focus on efficiency and time constraints affected patient involvement negatively, and practices were often task-oriented instead of patientoriented.…”

Section: Introductionmentioning

confidence: 99%

What matters when asking, “what matters to you?” — perceptions and experiences of health care providers on involving older people in transitional care

Olsen

Bergland

Bye

et al. 2020

BMC Health Serv Res

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Background: Transitional care for older chronically ill people is an important area for healthcare quality improvement. A central goal is to involve older people more in transitional care and make care more patient-centered. Recently, asking, "What matters to you?" (WMTY) has become a popular way of approaching the implementation of patientcentered care. The aim of this study was to explore health care providers' perceptions and experiences regarding the question of WMTY in the context of improving transitional care for older, chronically ill persons. Methods: The data comprise semi-structured individual interviews with 20 health care providers (HCPs) who took part in a Norwegian quality improvement collaborative, three key informant interviews, and observations of meetings in the quality improvement collaborative. We used a thematic analysis approach. Results: Three interrelated themes emerged from the analysis: WMTY is a complex process that needs to be framed competently; framing WMTY as a functional approach; and framing WMTY as a relational approach. There was a tension between the functional and the relational approach. This tension seemed to be based in different understandings of the purpose of asking the WMTY question and the responsibility that comes with asking it. Conclusions: WMTY may appear as a simple question, but using it in everyday practice is a complex process, which requires professional competence. When seen in terms of a patient-centered goal process, the challenge of competently eliciting older people's personal goals and transferring these goals into professional action becomes evident. An important factor seems to be how HCPs regard the limits of their responsibility in relation to giving care within the larger frame of the patient's life project. Factors in the organizational and political context also seem to influence substantially how HCPs approach older patients with the WMTY question.

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Section: Introductionmentioning

confidence: 99%

What matters when asking, “what matters to you?” — perceptions and experiences of health care providers on involving older people in transitional care

Olsen

Bergland

Bye

et al. 2020

BMC Health Serv Res

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“…In this study, quality of life of all patients who had received transitional care was higher than patients who had experienced other forms of care. In fact, it can be said that the transitional care model is a set of services and treatments that is complementary to primary care (1,17,18). This care model aims to ensure continuity of care and prevention of negative outcomes of patients at risk during the transition from hospital to home and it is among medical staff and caregivers.…”

Section: Literature Review In Transitional Care Modelmentioning

confidence: 99%

“…Transitional care is provided by expert nurses as complementary and supportive care in the patient's home and after discharge from the hospital. In this model, providing patient care is done through coordination between professional and skilled nurse with the patient and his family, doctors and other health care team members (2,4,16,17).…”

Section: Literature Review In Transitional Care Modelmentioning

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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“…This integration should operate within a primary care system, and through effective communications between specialist and primary care providers, to guarantee better transitions of care for patients with chronic disease. The latter has significant positive effects in reducing hospital readmissions and mortality 41–43 ( table 1G ).…”

Section: Methodsmentioning

confidence: 99%

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

Buja

Toffanin²,

Claus

et al. 2018

BMJ Open

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ObjectivesOur goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.SettingPrimary care.ParticipantsChronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.InterventionsWe conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.ResultsAll primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.ConclusionsA framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

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Transitional care interventions: Relevance for nursing in the community

Abstract: Effective transitional care requires excellent communication between acute and primary care providers. This has implications for integration and organization of care across settings and nursing competence.

Cited by 39 publications

References 27 publications

What matters when asking, “what matters to you?” — perceptions and experiences of health care providers on involving older people in transitional care

What matters when asking, “what matters to you?” — perceptions and experiences of health care providers on involving older people in transitional care

Transitional care model: managing the experience of hospital at home

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

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