Measuring Processes of Integrated Care for Hospital to Home Transitions

Brown, Cara; Menec, Verena

doi:10.5334/ijic.5552

Cited by 4 publications

(2 citation statements)

References 30 publications

(90 reference statements)

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“…As for future studies, it will be necessary to consider the characteristics and discharge support systems applied by good HSHR hospitals so that poor HSHR hospitals can benefit from improving the home-transition rate [ 33 , 34 ]. To improve the quality of hospital care, it is important for hospitals to check the quality of their care management, including discharge management.…”

Section: Discussionmentioning

confidence: 99%

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

et al. 2022

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Discharge to home is considered appropriate as a treatment goal for diseases that often leave disabilities such as cerebral infarction. Previous studies showed differences in risk-adjusted in-hospital mortality and readmission rates; however, studies assessing the rate of hospital-to-home transition are limited. We developed and calculated the hospital standardized home-transition ratio (HSHR) using Japanese administrative claims data from 2016–2020 to measure the quality of in-hospital care for cerebral infarction. Overall, 24,529 inpatients at 35 hospitals were included. All variables used in the analyses were associated with transition to another hospital or facility for inpatients, and evaluation of the HSHR model showed good predictive ability with c-statistics (area under curve, 0.73 standard deviation; 95% confidence interval, 0.72–0.73). All HSHRs of each consecutive year were significantly correlated. HSHRs for cerebral infarction can be calculated using Japanese administrative claims data. It was found that there is a need for support for low HSHR hospitals because hospitals with high/low HSHR were likely to produce the same results in the following year. HSHRs can be used as a new quality indicator of in-hospital care and may contribute to assessing and improving the quality of care.

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Section: Discussionmentioning

confidence: 99%

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

et al. 2022

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“…Such activities may be effective in yielding positive changes in certain groups, but, in the real world, a model with a more person-directed approach to engaging individuals in decision-making is needed. In contrast to the geriatric model, several integrated care approaches at the community setting have been proposed, but they have only targeted a single chronic disease (e.g., stroke), outcomes (e.g., quality of care, costs), or process (communication, team building) [ 10 – 12 ].…”

Section: Introduction {6a}mentioning

confidence: 99%

Evaluation of a community-based integrated care model (CIE) for frail older people in rural Foshan, China: study protocol for a stepped-wedge cluster randomized controlled trial {1}

Xie

Wen

Deng

et al. 2023

Trials

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Background While community-based eldercare has proven to be effective in qualitative studies, there is limited evidence on the effectiveness of this geriatric care model in rural communities where caring for older people is traditionally the responsibility of family members, but a formal long-term care was recently introduced in China. CIE is a rural community-embedded intervention using multidisciplinary team, to provide evidenced-based integrated care services for frail older people including social care services and allied primary healthcare and community-based rehabilitation services. Methods CIE is a prospective stepped-wedge cluster randomized trial conducted at 5 community eldercare centers in rural China. The multifaceted CIE intervention, guided by chronic care model and integrated care model, consists of five components: comprehensive geriatric assessment, individualized care planning, community-based rehabilitation, interdisciplinary case management, and care coordination. The intervention is rolled out in a staggered manner in these clusters of centers at an interval of 1 month. The primary outcomes include functional status, quality of life, and social support. Process evaluation will also be conducted. Generalized linear mixed model is employed for binary outcomes. Discussion This study is expected to provide important new evidence on clinical effectiveness and implementation process of an integrated care model for frail older people. The CIE model is also unique as the first registered trial implementing a community-based eldercare model using multidisciplinary team to promote individualized social care services integrated with primary healthcare and community-based rehabilitation services for frail older people in rural China, where formal long-term care was recently introduced. Trial registration {2a} China Clinical Trials Register (http://www.chictr.org.cn/historyversionpub.aspx?regno=ChiCTR2200060326). May 28th, 2022.

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Characteristics and Trajectory of Older Adults Supported by a Patient Navigator Program in a Hospital Setting: A Cohort Observational Study

Liu,

Kokorelias,

Knoepfli

et al. 2024

Can. J. Aging

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To improve transitions in care, a new patient navigation (PN) program was introduced to support older adults with complex care needs transition from hospital to home. The patient navigator is a community social worker embedded in the hospital’s care teams. A cohort observational design was used to conduct the study by analysing the patient navigator’s clinical notes and hospital’s administrative data to describe the characteristics of patients, scope of the patient navigator’s activities, and patient outcomes. Ninety patients were assigned to the patient navigator’s caseload (November 2019–November 2021) in which the average age was 78.9 (range 55–95). The most frequent PN intervention types were referrals to community services (66%, n = 59) and discharge planning (61%, n = 55). The patient navigator supported 66% patients (n = 59) in returning home and provided follow-up care for 74 days (average). This study provides important insights into the patient navigator’s role to guide decision makers in implementing PN programs for older adults in a hospital setting.

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Measuring Processes of Integrated Care for Hospital to Home Transitions

Cited by 4 publications

References 30 publications

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

Evaluation of a community-based integrated care model (CIE) for frail older people in rural Foshan, China: study protocol for a stepped-wedge cluster randomized controlled trial {1}

Characteristics and Trajectory of Older Adults Supported by a Patient Navigator Program in a Hospital Setting: A Cohort Observational Study

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