Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial

Altfeld, Susan; Shier, Gayle; Rooney, Madeleine; Johnson, Tricia J.; Golden, Robyn; Karavolos, Kelly; Avery, Elizabeth; Nandi, Vijay; Perry, A.J.

doi:10.1093/geront/gns109

Cited by 113 publications

(190 citation statements)

References 20 publications

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“…In interventions that focused on unmet psychosocial patient needs, master's-prepared social workers coordinated post-hospital care and performed discharge planning. 17,20 …”

Section: Role Of the Person Directing Interventionsmentioning

confidence: 99%

“…25,[37][38][39] In some programs, follow-up calls were intended to ensure or improve continuity of care transitions after hospitalization, to improve medication adherence, to increase adherence for follow-up appointments with primary care providers, 40 and to reduce rehospitalization. 18,41 In many programs, the first call was to be made within 48 to 72 hours, 17,20,28,34,42 as per national organization guidelines, 1 or based on performance metric recommendations. 43,44 A common feature was to make regular follow-up calls for up to 30 days after discharge.…”

Section: Telephone Follow-upmentioning

confidence: 99%

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Transitions of Care in Heart Failure

Albert¹,

Barnason²,

Deswal³

et al. 2015

Circ: Heart Failure

218

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In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

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“…In interventions that focused on unmet psychosocial patient needs, master's-prepared social workers coordinated post-hospital care and performed discharge planning. 17,20 …”

Section: Role Of the Person Directing Interventionsmentioning

confidence: 99%

Section: Telephone Follow-upmentioning

confidence: 99%

Transitions of Care in Heart Failure

Albert¹,

Barnason²,

Deswal³

et al. 2015

Circ: Heart Failure

218

View full text Add to dashboard Cite

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“…Through this practice, re-hospitalizations have been reduced, caregivers were enabled to understand discharge plans and drug indications given to the patients, participation in post-discharge doctor visits were ensured, and a reduction in the stress on patients and caregivers was achieved. (39). "Care Transitions Program" is a project created for the purpose that a health personnel monitors and manages drug treatment, understands the signs and symptoms requiring medical intervention, and makes visits at home or via telephone.…”

Section: What Can Be Done?mentioning

confidence: 99%

Preventable Hospitalizations in Older Adults: A Dream or Reality?

Naharci¹

2017

Istanbul Med J

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An 84-year-old male patient applied to a primary care clinic with the complaint of left hip pain. The patient was diagnosed with myalgia and was given nonsteroidal anti-inflammatory drug (NSAID) (dexketoprofen) and muscle relaxant (feniramidol). After 1 week, the patient was brought to the emergency service due to anorexia and nausea by his relatives. He had been continuously using escitalopram 10 mg and rivastigmine patch 10 cm 2 for depression and dementia comorbidities. According to the laboratory investigations, it was seen that serum creatinine was 2.53 mg/dL (1.07 mg/dL 3 months ago), urea was 89 mg/dL (30 mg/dL 3 months ago), and potassium was 6.02 mg/dL (3.79 mg/dL 3 months ago). The patient was hospitalized with the diagnosis of acute renal failure and dehydration. Sample Case-2A 78-year-old female patient applied to the emergency care unit with the complaints of fever, cough, and respiratory disorder. It was found out that the patient had chronic obstructive pulmonary disease (COPD) and hypertension in her history. In physical examination, O 2 saturation was found to be 86%, arterial blood pressure was 95/55 mmHg, respiratory rate was 32/min, and there was a decrease in the respiratory sounds in the right lower lung zone. After the posteroanterior chest X-ray showed an infiltration zone on the right, the patient was hospitalized with the diagnosis of pneumonia and intravenous antibiotic therapy was started. On the second day of hospitalization, the patient had a complaint about chest pain. Clinical, laboratory, and electrocardiography (ECG) examinations were performed at the first evaluation. Following these examinations, cardiac catheterization was decided to be applied. A few days after cardiac catheterization, delirium developed in the patient with the symptoms of sudden loss of consciousness, attention disorder, and hyperactivity. The patient fell off the bed on the eighth day of hospitalization when she was in the delirium state and an intertrochanteric fracture developed in the right hip. The patient was transferred to the orthopedic clinic. After the preparation for surgery, a partial hip prosthesis replacement was performed in the patient. The Key Points• "Potentially preventable hospitalizations" are unnecessary hospitalizations despite the possibility of outpatient treatment.• Frail and old people with multiple chronic conditions are under high risk for hospitalization.• These hospitalizations put a heavy burden on the country's economy.• Heart failure, COPD, pneumonia, urinary infections, and dehydration are the most common causes.• To prevent these hospitalizations, interdisciplinary team work, discharge planning, support for drug use, and residential care are needed.Preventable Hospitalizations in Older Adults: A Dream or Reality?Preventable hospitalization is defined as hospitalization of patients in healthy conditions with the possibility of treatment by outpatient care. Preventable hospitalizations are seen commonly in patients aged 65 years or older. Congestive heart failure and chroni...

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“…One evidence-based model addresses the needs of SHHC populations by having hospital social workers partner with SHHC agencies to coordinate post-discharge care. 33 Further research is needed in the area of improving care transitions for recipients of SHHC services.…”

Section: Identifying Factors That Make Transitions More Complexmentioning

confidence: 99%

Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs

et al. 2014

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With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.

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Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial

Cited by 113 publications

References 20 publications

Transitions of Care in Heart Failure

Transitions of Care in Heart Failure

Preventable Hospitalizations in Older Adults: A Dream or Reality?

Regardless of Age: Incorporating Principles from Geriatric Medicine to Improve Care Transitions for Patients with Complex Needs

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