BackgroundLittle is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.MethodsThis was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.ResultsA total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9–2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31–53%]. Qualitative analyses identified eight themes related to focus (central point – e.g., problem list), structure (organization, – e.g., note-taking style), and purpose (intention – e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.ConclusionsImportant gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-1941-0) contains supplementary material, which is available to authorized users.

Background Certain kinds of housing instability, such as foreclosure and homelessness, have been associated with poorer physical and mental health. The Connect 2 Care (C2C) program targets medically complex individuals who are unstably housed, primarily aimed at reducing acute care utilization and connecting clients to appropriate community-based care. However, because housing status is a fundamental determinant of health, the team also assists clients in finding permanent housing. As the C2C program aims to improve the health of its clients, we hope that this intervention positively impacts the housing stability of clients. Objective To determine whether the C2C program is effective in reducing factors of housing instability, such as the frequency of housing moves made, and time spent in unstable housing (such as shelters or sleeping outside). Methods C2C clients were asked to participate in 6- and 12- month follow-up surveys with a member of the research team. During both surveys, participants were prompted to describe their housing history using the Residential Time-Line Follow-Back (rTLFB) inventory. Starting at six months prior to their intake into C2C, participants created a twelve- to eighteen-month timeline that detailed their residential locations and number of housing transitions. Location descriptions provided by clients were categorized as stable, temporary, institutional, or literal homelessness. The number of housing transitions and the proportion of time spent in each housing category were then calculated for each individual. Changes in proportion of time spent over three unique time periods were evaluated using Wilcoxon’s paired rank test with Holm’s multiplicity correction. Results Since September 2018, housing data was collected from 100 unique clients. In comparing the six months preceding C2C intake with the six-to-twelve months after C2C intake, significant reductions in the amount of time spent in literal homelessness (p < 0.001) and reductions in the number of housing changes (p = 0.014) were observed. Discussion Housing stability for C2C clients improved after enrolment in the program. This study was potentially limited by incomplete sampling of the C2C population. Based on our findings, further research should be conducted in evaluating the relationship between increases in housing stability and increases of health status. Acknowledgements The C2C research team thanks Alberta Innovates and the Canadian Institute of Health Research for their financial support. The authors have no conflict of interests to state.

RÉSUMÉLe présent article vise à évaluer les problèmes de santé des Calgariens de plus de 50 ans en situation d’itinérance chronique, à identifier les manques en matière de services pour cette population et à cerner les prédicteurs de l’itinérance chronique, tels que les traumatismes durant l’enfance, qui pourraient être atténués par des modifications touchant les politiques ou la prestation de services. Des personnes en situation d’itinérance, dont trois cents provenaient de refuges d’urgence, ont été recrutées à Calgary (Canada) à hiver 2016. Les logiciels Excel et SPSS ont été utilisés pour l’analyse des statistiques descriptives des participants qui ont été séparés en deux groupes, soit les répondants de 50 ans et plus (n = 142) et ceux de moins de 50 ans (n = 158). Plus de la moitié des participants étaient en situation d’itinérance continue depuis plus de dix ans. Les personnes plus âgées ont fait état de problèmes de santé complexes et d’obstacles importants pour l’accès aux soins de santé, associés notamment à leurs problèmes financiers, aux listes d’attente et au fait de ne pas recevoir d’aide malgré leurs demandes. Les répondants plus âgés ont rapporté des taux de traumatismes durant l’enfance inférieurs à ceux des répondants plus jeunes, bien que la moyenne de ces taux soit 2,5 fois supérieure à celle de la population générale. La reconnaissance des effets croisés et cumulatifs de l’itinérance de long terme et de l’âge pourrait guider la modification des politiques visant à réduire les cloisonnements entre les services publics. Étant donné que les personnes âgées en situation d’itinérance sont plus à risque de mourir prématurément, elles devraient être priorisées par les programmes d’aide au logement. Des interventions adaptées au contexte culturel et tenant compte des traumatismes seraient nécessaires pour répondre aux besoins à la fois variés et complexes de ce groupe vulnérable.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination.Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness.Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

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