An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission

Nall, Ryan; Herndon, Brandon B.; Mramba, Lazarus K.; Vogel-Anderson, Katherine; Hagen, Melanie

doi:10.1016/j.amjmed.2019.10.040

Cited by 19 publications

(11 citation statements)

References 11 publications

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“…Hospital readmissions are a worldwide, major health-care burden, with a negative impact on patient health, public health, and healthcare systems' associated national financial burden. Previous publications describe the heavy toll of hospital (non-surgical) re-admissions while the same researchers and others attempted various strategies for either predicting the risk for readmission and proactively reducing it (albeit with conflicting results) [5][6][7][8][9][10].…”

Section: The Need For Internal Medicine Personalization Hospital Lenmentioning

confidence: 99%

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predicts Length of Hospital Stay and Re-Admission: A Prospective Study of 980 Patients

Anani

Goldhaber

Brom

et al. 2020

JCM

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Background: Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized in internal medicine departments could help better prognosticate patients in the realm of internal medicine. Methods: During a 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood alanine-amino transferase (ALT) activity, and mid-arm muscle circumference (MAMC) measurements. Results: We recruited 980 consecutive patients upon hospital admission (median age 72 years (IQR 65–79); 56.8% males). According to the FRAIL questionnaire, 106 (10.8%) patients were robust, 368 (37.5%) pre-frail, and 506 (51.7%) were frail. The median ALT value was 19IU/L (IQR 14–28). The median MAMC value was 27.8 (IQR 25.7–30.2). Patients with low ALT activity level (<17IU/L) were frailer according to their FRAIL score (3 (IQR 2–4) vs. 2 (IQR 1–3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30 days readmission in the whole cohort was 17.4%. Frail patients, according to the FRAIL score (FS), had a higher risk for 30 days readmission (for FS > 2, HR = 1.99; 95CI = 1.29–3.08; p = 0.002). Frail patients, according to low ALT activity, also had a significantly higher risk for 30 days readmission (HR = 2.22; 95CI = 1.26–3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥4 days (for FS > 2, HR = 1.87; 95CI = 1.39–2.52; p < 0.001). Frail patients, according to low ALT activity, were also at higher risk for LOS ≥4 days (HR = 1.87; 95CI = 1.39–2.52; p < 0.001). MAMC values were not correlated with patients’ LOS or risk for re-admission. Conclusion: Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.

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Section: The Need For Internal Medicine Personalization Hospital Lenmentioning

confidence: 99%

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predicts Length of Hospital Stay and Re-Admission: A Prospective Study of 980 Patients

Anani

Goldhaber

Brom

et al. 2020

JCM

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“…This service development has been undertaken and joined by interdisciplinary-led and nurse-led/nurse-directed TOC models. 27,28 Given the need for safe, quality TOC, nurse educators will need to develop curriculum content including the use of simulation and other innovative modalities that address the TOC essential competencies described in this paper. These will position nurses to skillfully lead in healthcare delivery that focuses on improving outcomes, preventing harm, and ensuring patient safety specifically for the populations who at high risk for adverse events when transferring within or between healthcare services.…”

Section: Educational Applicationmentioning

confidence: 99%

Nurse competencies for transitions of care: Implications for education and practice

et al. 2020

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Although there are a number of transitions of care initiatives that address specific needs as patients move across healthcare settings, adverse events still occur during handoffs. Transitions of care create periods of vulnerability for populations with complex needs that include communication gaps, medication changes, and poorly coordinated treatment plans, often without involving patients and their families. This paper outlines what nurses need to know to provide for safe transitions of care across the healthcare continuum. The theoretical basis for transitions of care at the macro level, examples of nurse-led models for transitions of care, and key activities and implications for nursing education and practice are described. A holistic framework for effective transitions of care across healthcare settings can guide nursing educators in the development of specific nursing competencies for transitions of care.

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“…Hospital readmissions are a worldwide, major health-care burden, with negative impact on patients' health, public health and healthcare systems' associated national nancial burden. Previous publications describe the heavy toll of hospital (non-surgical) re-admissions while the same researchers and others attempted various strategies for either predicting the risk for readmission and proactively reducing it (albeit with con icting results) (5)(6)(7)(8)(9)(10).…”

Section: Introductionmentioning

confidence: 99%

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predict Worse Short-term Clinical Outcomes. 1-Year, Prospective Study of 980 patients.

Anani¹,

Goldhaber²,

Brom³

et al. 2020

Preprint

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Background. Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized to internal medicine departments could help better prognostication of patients in the realm of internal medicine. Methods. During 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood Alanine-amino transferase (ALT) activity and Mid-Arm Muscle Circumference (MAMC) measurements. Results. We recruited Nine-hundred and eighty consecutive patients upon hospital admission (median age 72 years (IQR 65-79); 56.8% males). According to the FRAIL questionnaire 106 (10.8%) patients were robust, 368 (37.5%) pre-frail and 506 (51.7%) were frail. The Median ALT value was 19IU/L (IQR 14-28). The median MAMC value was 27.8 (IQR 25.7-30.2). Patients with low ALT activity level (< 17IU/L) were more frail according to their FRAIL score (3 (IQR 2-4) vs. 2 (IQR 1-3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30-days readmission in the whole cohort was 17.4%. Frail patients according to the FRAIL score (FS) had a higher risk for 30-days readmission (for FS > 2, HR = 1.99; 95CI = 1.29-3.08; p = 0.002). Frail patients according to low ALT activity also had a significantly higher risk for 30-days readmission (HR = 2.22; 95CI = 1.26-3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥ 10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥ 4 days (for FS > 2, HR = 1.87; 95CI = 1.39-2.52; p < 0.001). Frail patients according to low ALT activity were also at higher risk for LOS ≥ 4 days (HR = 1.87; 95CI = 1.39-2.52; p < 0.001). MAMC values were not correlated with patients' LOS or risk for re-admission. Conclusion. Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.

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An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission

Cited by 19 publications

References 11 publications

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predicts Length of Hospital Stay and Re-Admission: A Prospective Study of 980 Patients

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predicts Length of Hospital Stay and Re-Admission: A Prospective Study of 980 Patients

Nurse competencies for transitions of care: Implications for education and practice

Frailty and Sarcopenia Assessment upon Hospital Admission to Internal Medicine Predict Worse Short-term Clinical Outcomes. 1-Year, Prospective Study of 980 patients.

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