Project description:BackgroundOlder cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients' participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients.MethodsA generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed.ResultsThree themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants' recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention.ConclusionOur results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients' needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.
Project description:IntroductionFrail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit.MethodsThis study is part of the European TRANS-SENIOR project. PubMed, CINAHL and Embase were searched for studies in English, German and Dutch that describe a TCM for frail older patients including both pre- and post-discharge components.ResultsSeventeen studies, covering 15 TCMs were included. All TCMs describe a person-centred, tailored, pro-active and continuous transitional care service. Components like a small sized care team, intensive follow-up, shared decision making and informal caregiver involvement are likely to be associated with reduced hospital readmission and ED visits. Twenty-seven transitional care outcomes were reported: 19 service outcomes, six patient outcomes and two provider outcomes.ConclusionHeterogeneity in content and outcomes complicates between-study comparison, yet several components were identified that improved care outcomes. Patient and provider outcomes should be included in future research.
Project description:Background and objectivesOur aim was to create a "storyline" that provides empirical explanation of stakeholders' perspectives underlying the use of patient- and family-reported outcome and experience measures to inform continuity across transitions in care for frail older adults and their family caregivers living at home.Research design and methodsWe conducted a meta-narrative synthesis to explore stakeholder perspectives pertaining to use of patient-reported outcome and experience measures (PROMs and PREMs) across micro (patients, family caregivers, and healthcare providers), meso (organizational managers/executives/programs), and macro (decision-/policy-makers) levels in healthcare. Systematic searches identified 9,942 citations of which 40 were included based on full-text screening.ResultsPROMs and PREMS (54 PROMs; 4 PREMs; 1 with PROM and PREM elements; 6 unspecified PROMs) were rarely used to inform continuity across transitions of care and were typically used independently, rarely together (n = 3). Two overarching traditions motivated stakeholders' use. The first significant motivation by diverse stakeholders to use PROMs and PREMs was the desire to restore/support independence and care at home, predominantly at a micro-level. The second motivation to using PROMs and PREMs was to evaluate health services, including cost-effectiveness of programs and hospital discharge (planning); this focus was rarely at a macro-level and more often split between micro- and meso-levels of healthcare.Discussion and implicationsThe motivations underlying stakeholders' use of these tools were distinct, yet synergistic between the goals of person/family-centered care and healthcare system-level goals aimed at efficient use of health services. There is a missed opportunity here for PROMs and PREMs to be used together to inform continuity across transitions of care.
Project description: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 patient-centered 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.
Project description:BackgroundPatients are at risk for harm when treated simultaneously by healthcare providers from different healthcare organisations. To assess current practice and improvements of transitional patient safety, valid measurement tools are needed.Aim and methodsTo identify and appraise all measurement tools and outcomes that measure aspects of transitional patient safety, PubMed, Cinahl, Embase and Psychinfo were systematically searched. Two researchers performed the title and abstract and full-text selection. First, publications about validation of measurement tools were appraised for quality following COSMIN criteria. Second, we inventoried all measurement tools and outcome measures found in our search that assessed current transitional patient safety or the effect of interventions targeting transitional patient safety.ResultsThe initial search yielded 8288 studies, of which 18 assessed validity of measurement tools of different aspects of transitional safety, and 191 assessed current transitional patient safety or effect of interventions. In the validated measurement tools, the overall quality of content and structural validity was acceptable; other COSMIN criteria, such as reliability, measurement error and responsiveness, were mostly poor or not reported. In our outcome inventory, the most frequently used validated outcome measure was the Care Transition Measure (n = 9). The most frequently used non-validated outcome measures were: medication discrepancies (n = 98), hospital readmissions (n = 55), adverse events (n = 34), emergency department visits (n = 33), (mental or physical) health status (n = 28), quality and timeliness of discharge summary, and patient satisfaction (n = 23).ConclusionsAlthough no validated measures exist that assess all aspects of transitional patient safety, we found validated measurement tools on specific aspects. Reporting of validity of transitional measurement tools was incomplete. Numerous outcome measures with unknown measurement properties are used in current studies on safety of care transitions, which makes interpretation or comparison of their results uncertain.
Project description:This study aimed to investigate the feasibility, acceptability, and clinical outcome measures of BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), a culturally tailored traumatic brain injury (TBI) transitional care intervention, among diverse younger adult patients with TBI (age 18-64) and their caregivers. Trained clinical interventionists addressed patient/family needs; established goals; coordinated post-hospital care and resources; and provided patient/family training on self- and family-management coping skills. Fifteen dyads enrolled (N = 31, 15 patients, 16 caregivers). All completed baseline data; 74.2% (n = 23; 10 patients, 13 caregivers) completed 8-week data; 83.8% (n = 26; 13 each) completed 16-week data. Approximately 38% (n = 12, 3 patients, 9 caregivers) completed acceptability data, showing positive experiences (mean = 9.25, range 0-10; SD = 2.01). Overall and mental quality of life (QOL) scores did not differ over time but physical QOL scores did improve over time (baseline: 30.3, 8 weeks: 46.5, 16 weeks: 61.6; p = 0.0056), which was considered to be a suitable outcome measure for a future trial. BETTER is a promising intervention with implications to improve TBI care standards. Research is needed to determine efficacy in a randomized trial.
Project description:BackgroundA growing number of older adults use in-home Medicaid Waiver Home and Community Based services (HCBS) to facilitate aging-in-place. A primary service of this program is Home Care Aide assistance with activities of daily living and homemaker needs. Despite the known benefits of exercise, exercise programs are currently not offered to clients in the Medicaid Waiver system. Thus, the purpose of this paper is to describe a six-month Home Care Aide-led resistance exercise intervention protocol for frail older adults receiving Medicaid waiver services.Methods/designA randomized controlled trial will be used. We will enroll 126 Home Care Aide-client dyads for a 6-month exercise intervention. The intervention will consist of training phases to promote muscle strength, power, and endurance. We will use an intention to treat principle using mixed effects models for the quantitative outcomes. To analyze qualitative outcomes, we will use conventional content analysis to examine themes from participant program evaluations.DiscussionAs greater numbers of adults age in place with frailty and employ Home Care Aides to help manage functional limitations, interventions embedded within usual care services play a critical role in bringing exercise into the home setting. The research described in this protocol will provide important knowledge about the impact of a Home Care Aide-led exercise intervention in reducing frailty in older adults.Clinical trials registrationClinicalTrials.gov Identifier: NCT02942992.
Project description:ObjectivesTo identify and synthesise available evidence on the impact of transitional care interventions with both predischarge and postdischarge elements on readmission rates in older medical patients.DesignA systematic review.MethodInclusion criteria were: medical patients ≥65 years or mean age in study population of ≥75 years; interventions were transitional care interventions between hospital and home with both predischarge and postdischarge components; outcome was hospital readmissions. Studies were excluded if they: included other patient groups than medical patients, included patients with only one diagnosis or patients with only psychiatric disorders. PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from January 2008 to August 2019. Study selection at title level was undertaken by one author; the remaining selection process, data extraction and methodological quality assessment were undertaken by two authors independently. A narrative synthesis was performed, and effect sizes were estimated.ResultWe identified 1951 records and included 11 studies: five randomised trials, four non-randomised controlled trials and two pre-post cohort studies. The 11 studies represent 15 different interventions and 29 outcome results measuring readmission rates within 7-182 days after discharge. Twenty-two of the 29 outcome results showed a drop in readmission rates in the intervention groups compared with the control groups. The most significant impact was seen when interventions were of high intensity, lasted at least 1 month and targeted patients at risk. The methodological quality of the included studies was generally poor.ConclusionTransitional care interventions reduce readmission rates among older medical patients although the impact varies at different times of outcome assessment. High-quality studies examining the impact of interventions are needed, preferably complimented by a process evaluation to refine and improve future interventions.Prospero registration numberCRD42019121795.
Project description:BackgroundThe growth of frail older patients with extensive care needs in homecare creates a need for competence development. Improvement programmes are essential to fill this knowledge gap. However, the outcomes of such programmes remain unknown. Therefore, the aim of this study is to describe the outcomes of a competence improvement programme for the systematic observation of frail older patients in homecare.MethodsThis study applied a qualitative mixed-method design. Data were collected in two homecare districts using participant observation, focus group interviews, and individual interviews.ResultsThe analysis revealed five concepts characterising the outcomes of the competence improvement programme: 1) frequency of vital sign measurements, 2) situational awareness, 3) expectations and coping level, 4) activities for sustained improvement, and 5) organisational issues affecting CIP focus. Substantial differences were revealed across the two homecare districts in how homecare professionals enacted new knowledge and routines resulting from the competence improvement programme. The differences were related to the frequency of vital sign measurements, coping levels, and situational awareness, in which successful outcomes were shaped by implementation issues and contextual setting. This involved whether routines and planned activities were set to follow up the improvement programme, or whether organisational issues such as leadership focus, resources, and workforce stability supported the programme.ConclusionsThis study documents the differences entailed in creating sustainable outcomes of an improvement programme for homecare professionals' competence in recognising and responding to deteriorating frail older patients. Depending on the implementation process and the homecare context, professionals enact the activities of the improvement programme differently.