Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care

Austin, Elizabeth; Neukirch, Jen; Ong, Thuan D.; Simpson, Louise; Berger, Gabrielle N.; Keller, Carolyn; Flum, David R.; Giusti, Elaine; Azen, Jennifer; Davidson, Giana H.

doi:10.1007/s11606-020-06140-2

Cited by 6 publications

(7 citation statements)

References 36 publications

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“…For adults with complex conditions (ie, multiple physical, mental, social, cultural, and/or spiritual needs) transitions across the healthcare system are common. 1 - 4 Transitions between HCPs and care settings are often fragmented, which limits patients’ access to services and hinders the quality and effectiveness of care. 5 - 7 Fragmentation of the healthcare system has been recognized as problematic worldwide.…”

Section: Introductionmentioning

confidence: 99%

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature

Kokorelias

Shiers-Hanley

Rios

et al. 2021

Health�Serv�Insights

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Patient navigation is a model of care that aims to improve access to care by reducing the complexity of navigating health, education, and social services across the continuum of care and care settings. Little is known about the processes that facilitate or impede the implementation of patient navigation programs (PNPs). We conducted a scoping review to identify and summarize the current state of knowledge regarding the implementation and outcomes of existing implemented PNPs. We employed a 6-stage scoping review framework to identify and review eligible articles. Sixty-articles met the inclusion criteria (58 peer-reviewed and 2 grey literature). The Consolidated Framework for Implementation Research served as the theoretical framework during analysis to help extract factors relevant to implementation of navigator programs. Results of the scoping review are reported thematically. Influences on implementation were identified: (a) planning to ensure alignment with organizational need (b) funding (c) multidisciplinary engagement (d) establishing workflow (e) mechanisms for communication (f) stakeholders to encourage buy-in (g) appropriate caseload (h) in kind resources. PNPs improve the experiences of patients and families. The findings of this scoping review provides implementation considerations of PNPs across global care settings. Strategies for overcoming pragmatic and logistical issues must be developed for optimal implementation.

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Section: Introductionmentioning

confidence: 99%

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature

Kokorelias

Shiers-Hanley

Rios

et al. 2021

Health�Serv�Insights

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“…Austin et al [ 49 ] corroborate the importance of iterative, internally driven intervention, monitoring, and wide dissemination during the implementation process as was applied in the Free State and will be reported in another paper. In the current study monitoring or evaluation was conducted using Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool [ 4 ].…”

Section: Discussionmentioning

confidence: 82%

“…Previous studies to find ways to improve health outcomes through a consultative and iterative process involving users identified barriers such as weak and unorganised referral patterns and inadequate human resources as crucial [ 44 , 49 ]. The development of the ‘Better Health Outcomes through Mentoring and Assessment’ (BHOMA) intervention in Zambia was intended to specifically address such challenges [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

“…Within and between these levels, transitions in the form of READ and RED [ 40 ] were intended to be managed efficiently and effectively in an integrated manner to mitigate morbidity and mortality. Austin et al [ 49 ] acknowledged that the movement of a patient from the home or community setting into the health system during admissions into a healthcare facility or hospital and vice versa, constitutes transitions to avoid the effects of care-risk factors that can lead to morbidities, excess stays and even re-admissions if those transitions are ineffective and inefficient. In the Free State, the READ and RED transitions were conceptualised and applied to improve referral up and down the referral hierarchy.…”

Section: Discussionmentioning

confidence: 99%

“…The effectiveness and efficiency of these transitions were based on the strength of the referral system which the HSGA intervention model sought to integrate and improve. Austin et al [ 49 ] pointed out that both the system and patient factors exert influence on the transitions and the capacity to address complex barriers to safe admission and discharge procedures and workflows. The development of approaches like the HSGA intervention model to address and improve complex transitions effectively and efficiently require continued testing and assessment of their effectiveness in view of the complexity of the transitions.…”

Section: Discussionmentioning

confidence: 99%

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Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Malakoane

Heunis

Chikobvu

et al. 2022

BMC Health Serv Res

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Background Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components. Methods This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation. Results The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them. Conclusion The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

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Design, Development, and Evaluation of an Automated Solution for Electronic Information Exchange Between Acute and Long-term Postacute Care Facilities: Design Science Research

Gottumukkala¹

2023

JMIR Form Res

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Background Information exchange is essential for transitioning high-quality care between care settings. Inadequate or delayed information exchange can result in medication errors, missed test results, considerable delays in care, and even readmissions. Unfortunately, long-term and postacute care facilities often lag behind other health care facilities in adopting health information technologies, increasing difficulty in facilitating care transitions through electronic information exchange. The research gap is most evident when considering the implications of the inability to electronically transfer patients’ health records between these facilities. Objective This study aimed to design and evaluate an open standards–based interoperability solution that facilitates seamless bidirectional information exchange between acute care and long-term and postacute care facilities using 2 vendor electronic health record (EHR) systems. Methods Using the design science research methodology, we designed an interoperability solution that improves the bidirectional information exchange between acute care and long-term care (LTC) facilities using different EHR systems. Different approaches were applied in the study with a focus on the relevance cycle, including eliciting detailed requirements from stakeholders in the health system who understand the complex data formats, constraints, and workflows associated with transferring patient records between 2 different EHR systems. We performed literature reviews and sought experts in the health care industry from different organizations with a focus on the rigor cycle to identify the components relevant to the interoperability solution. The design cycle focused on iterating between the core activities of implementing and evaluating the proposed artifact. The artifact was evaluated at a health care organization with a combined footprint of acute and postacute care operations using 2 different EHR systems. Results The resulting interoperability solution offered integrations with source systems and was proven to facilitate bidirectional information exchange for patients transferring between an acute care facility using an Epic EHR system and an LTC facility using a PointClickCare EHR system. This solution serves as a proof of concept for bidirectional data exchange between Epic and PointClickCare for medications, yet the solution is designed to expand to additional data elements such as allergies, problem lists, and diagnoses. Conclusions Historically, the interoperability topic has centered on hospital-to-hospital data exchange, making it more challenging to evaluate the efficacy of data exchange between other care settings. In acute and LTC settings, there are differences in patients’ needs and delivery of care workflows that are distinctly unique. In addition, the health care system’s components that offer long-term and acute care in the United States have evolved independently and separately. This study demonstrates that the interoperability solution improves the information exchange between acute and LTC facilities by simplifying data transfer, eliminating manual processes, and reducing data discrepancies using a design science research methodology.

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Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care

Cited by 6 publications

References 36 publications

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Design, Development, and Evaluation of an Automated Solution for Electronic Information Exchange Between Acute and Long-term Postacute Care Facilities: Design Science Research

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