Impact of a Novel Post-Discharge Transitions of Care Clinic on Hospital Readmissions

Baldino, Michael; Bonaguro, Anne Marie; Burgwardt, Sean; Lombardi, Andrea; Cristancho, Cagney; Mann, Chitsimran; Wright, Brad; Jackson, Christopher; Seth, Ankur

doi:10.1016/j.jnma.2020.07.018

Cited by 11 publications

(29 citation statements)

References 26 publications

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“…Nurses as team coordinators have an important role in maintaining communication with patients and families, as well as follow-up by telephone and home visits to see patient progress as a form of readmission prevention. Several articles mention that TC is led by another health worker who is called a community care worker (Kitzman et al, 2017), general practitioner (GP) (Eichner et al, 2021), and doctor (Baldino et al, 2021;Nkemdirim Okere et al, 2020).…”

Section: Transitional Care Coordinatormentioning

confidence: 99%

“…Nearly 20% of people with stroke experience recurrence, with ischemic stroke being the most frequent type (Misbach & Ali, 2001). Three times as many acute stroke patients end up in the hospital than non-stroke patients (Baldino et al, 2021). Up to 20% of adults experience readmissions to the hospital within 30 days of receiving a medical ward release; this is a significant indicator of the quality of treatment received (Lau et al, 2016).…”

Section: Introductionmentioning

confidence: 99%

“…These elements combine to create a "post-discharge syndrome" that momentarily raises a patient's susceptibility to unfavorable incidents. The capacity of the transitional caring (TC) team to lessen this susceptibility is correlated with the probability of developing post-discharge syndrome (Baldino et al, 2021). The inability of families to care for patients, poor communication between patients, families, and service providers, non-adherence to medicine taking, missing control regimens, and difficulty accessing home care are all factors that lead to repeated readmissions (Prusaczyk et al, 2019;Puhr & Thompson, 2015).…”

Section: Introductionmentioning

confidence: 99%

“…Transitional care is expected to improve communication between health workers, patients, and their families during the transition from hospital to home (Geng et al, 2019;Puhr & Thompson, 2015). Some literature shows the effectiveness of TC in reducing the readmission (Baldino et al, 2021;Ballard et al, 2018;Condon et al, 2016;Lin et al, 2021), improving the patient outcome (Markle-Reid et al, 2020;Reeves et al, 2019;Santana et al, 2017), and increasing the service satisfaction (Duncan et al, 2020;Eichner et al, 2021). The review was conducted to see outcomes that focused on the management of health services in general, not on patient outcomes because the indications that had to be measured were numerous and complex.…”

Section: Introductionmentioning

confidence: 99%

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Can Transitional Care Decrease Readmission in Stroke Patients?

Septianingrum

Nurjanah

Nursalam

2022

nhjk

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Background: One strategy to reduce the hospital readmission rate of stroke patients is to implement transitional care. Objective: The aim of this study was to identify the application of transitional care to the hospital readmission rate of stroke patients. Design: Design of this literature review was A Systematic review. Data Sources: We searched English articles in PubMed, CINAHL, SAGE, and Science Direct databases from January 2016 to September 28, 2021. Participants in the study were adults (17 years old or older) who had transitioned from hospital to home care. The included publications were mined for information on study features and research findings. Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was followed when conducting this review. The study question and search method were developed with the aid of the PICO framework, which provides descriptions of participants, interventions, comparisons, and results. Results: Eight articles were reviewed regarding the outcomes of implementing transitional care on readmission rates and satisfaction in stroke patients. All reviewed articles showed decreased readmission rates and increased patient satisfaction. There were some differences in the transitional care process, team coordinator, duration of transition care follow-up, and service satisfaction. Conclusion: Our findings show that the application of transitional care has a positive impact on decreasing readmission rates before 30 days and increasing patient satisfaction with nursing care. Transitional care policies need to be considered to reduce readmission rates in an effort to improve the quality of hospital services.

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Section: Transitional Care Coordinatormentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Can Transitional Care Decrease Readmission in Stroke Patients?

Septianingrum

Nurjanah

Nursalam

2022

nhjk

View full text Add to dashboard Cite

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“…The days and weeks following a hospitalisation are a period of vul- between the inpatient and post-acute care teams (Baldino et al, 2020). This communication should not only focus on securing an appointment, but also ensure the outpatient provider is completely informed about the hospitalisation and any social or clinical issues that may complicate the patient's care (Jackson et al, 2013), including access to medical equipment and barriers to filling prescriptions (Mansukhani et al, 2015).…”

Section: Con Clus Ionsmentioning

confidence: 99%

Access to post‐acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study

Brom

Anusiewicz

Udoeyo³

et al. 2021

Journal of Clinical Nursing

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Aims and objectives:We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation.Background: Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use posthospitalisation for individuals insured by Medicaid. Design:We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study.Methods: Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit.Results: Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01). Conclusions:Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid.

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Evaluation of a transitions clinic to bridge emergency department and primary care

Zhang

Spiegel

Bundy

et al. 2023

Journal of Hospital Medicine

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Background: Suboptimal transitions from the emergency department (ED) to ambulatory settings contribute to poor clinical outcomes and unnecessary nonurgent ED utilization. Care transition clinics (CTCs) are a potential solution by providing ED follow-up and facilitating the bridge to longer-term primary care. Objective: The objective was to evaluate the implementation of an ED transitions clinic on 30-day ED revisits and hospital readmissions. Designs: Retrospective cross-sectional study. Settings and Participants: This study included adults 18 years and older discharged from the ED and reeferred to the CTC. Main Outcome and Measures: Appointment attendance, follow-up time, and frequencies of care type provided were computed to assess clinic utilization.Rates of 30-day ED revisit and hospital admission were compared between completed and missed appointments using logistic regression.Results: Between March 2021 and March 2022, 373 patients were referred to the CTC totaling 405 appointments. Half (53%) of appointments were completed with a median follow-up time of 4 days (IQR = [2,7]). The most common care types provided were wound care (44%) and clinical problem management (33%), with wound care appointments more likely to be completed compared with clinical appointments (OR = 1.7, CI = [1.1, 2.8], p = .03). Patients who completed their CTC appointment were 50% less likely to return to the ED in 30 days compared with those who did not complete their appointment (OR = 0.51, CI = [0.27, 0.98], p < .05). No effect was seen for CTC appointment completion on hospital readmission. Transition clinics are a viable method to provide timely access to follow-up for patients discharged from the ED and may help reduce excess ED use for ambulatory care needs.

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Impact of a Novel Post-Discharge Transitions of Care Clinic on Hospital Readmissions

Cited by 11 publications

References 26 publications

Can Transitional Care Decrease Readmission in Stroke Patients?

Can Transitional Care Decrease Readmission in Stroke Patients?

Access to post‐acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study

Evaluation of a transitions clinic to bridge emergency department and primary care

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