The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

Heim, Noor; Rolden, Herbert J. A.; Fenema, Esther M. van; Weverling-Rijnsburger, Annelies W. E.; Tuijl, Jolien P.; Jue, Peter; Oleksik, Anna M.; Craen, Anton J. M. de; Mooijaart, Simon P.; Blauw, Gerard J.; Westendorp, Rudi G. J.; Mast, Roos C. van der; Everdinck, Irma E C van

doi:10.1093/ageing/afw098

Cited by 18 publications

(21 citation statements)

References 12 publications

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“…Some partners worked closely with PhD students, allowing the exchange of data and discussions concerning the progress of research. This aspect is expected to be important and valuable for the project ( 35 ). The process of stakeholder selection was not systematic, but no major gaps were identified.…”

Section: Discussionmentioning

confidence: 99%

A One Health Evaluation of the University of Copenhagen Research Centre for Control of Antibiotic Resistance

et al. 2018

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We applied the evaluation framework developed by the EU COST Action “Network of Evaluation of One Health” (NEOH) to assess the operations, supporting infrastructures and outcomes of a research consortium “University of Copenhagen Research Centre for Control of Antibiotic Resistance” (UC-CARE). This 4-year research project was a One Health (OH) initiative with participants from 14 departments over four faculties as well as stakeholders from industry and health authorities aiming to produce new knowledge to reduce the development of antimicrobial resistance (AMR). This was a case study focusing on assessing beneficial and counter-productive characteristics that could affect the OH outcomes. The study was also used to provide feedback to NEOH about the evaluation framework. The framework and evaluation tools are described in the introduction paper of this special journal issue. Data for the evaluation were extracted from the funding research proposal, the mid-term UC-CARE project evaluation report and supplemented with opinions elicited from project participants and stakeholders. Here, we describe the underlying system, theory of change behind the initiative and adapted questions from the NEOH tools that we used for semi-open interviews with consortium members throughout the evaluation process. An online survey was used to obtain information from stakeholders. The NEOH evaluation tools were then used for the qualitative and quantitative evaluation of the OH characteristics of UC-CARE. Senior UC-CARE researchers were interested and willing to be interviewed. Young scientists were more difficult to engage in interviews, and only 25% of stakeholders answered the online survey. Interviewees mentioned that the main benefit of UC-CARE was an increased awareness and general understanding of AMR issues. All interviewees stated that the adopted OH approach was relevant given the complexity of AMR. However, some questioned the applicability, and identified potentially counter-productive issues mainly related to the information sharing, collaboration and working methods across the consortium. A more integrated project organization, more stakeholder involvement and time for the project, flexibility in planning and a dedicated OH coordinator were suggested to allow for more knowledge exchange, potentially leading to a higher societal impact.

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Section: Discussionmentioning

confidence: 99%

A One Health Evaluation of the University of Copenhagen Research Centre for Control of Antibiotic Resistance

et al. 2018

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“…Nesse enfoque, ao pensar na estruturação de Programas de Transição de Cuidados, voltados para idosos hospitalizados, observou-se concordância entre os autores (Hinch et al, 2021;Poelzl et al, 2021;Gilbert et al, 2021;Crannage et al, 2020;Neu et al, 2020;Baecker et al, 2020;Vearing et al, 2019;Wu et al, 2019;Warren et al, 2019;Huckfeldt et al, 2019;Murphy et al, 2019;Finlayson et al, 2018;Ballard et al, 2018;Robertson et al, 2018;Hanan et al, 2018;Iseler et al, 2018;Low et al, 2017;Takahashi et al, 2016;Heim et al, 2016;Wong et al, 2016;Morrison et al, 2016;Lovelace et al, 2016;Zhou et al, 2015;Low et al, 2015;Mae et al, 2014;Wee et al, 2014;Cheng et al, 2014;Logue et al, 2013;Kind et al, 2012;Shu et al, 2011;Stauffer et al, 2011;Ornstein et al, 2011;Daley et al, 2010) acerca do impacto positivo desses programas, principalmente no que tange à redução das taxas de reinternação hospitalar em até 30 dias (Hinch & Staffileno, 2021;Gilbert et al, 2021;Crannage et al, 2020;Wu et al, 2019;Warren et al, 2019;Huckfeldt et al, 2019;Low et al, 2017;…”

Section: Discussionunclassified

“…No que se refere às taxas de readmissão hospitalar, é concordância entre os autores que, em média, 20% dos pacientes idosos que receberam alta hospitalar para domicílio experimentaram algum tipo de evento adverso evitável, sobre sua condição de saúde, que acarretou o processo de readmissão hospitalar. Dentre os quais, dois terços desses eventos estão relacionados ao manejo incorreto da terapêutica medicamentosa prescrita para uso em domicílio (Heim et al, 2016).…”

Section: Discussionunclassified

Ações em saúde propostas em programas de transição do cuidado para idosos: revisão integrativa

Petrocini

Tomazela

Amaral

et al. 2022

RSD

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Este estudo visa analisar as evidências científicas acerca das ações em saúde propostas em Programas de Transição de Cuidados para idosos. O recorte escolhido para este estudo foi o de uma revisão integrativa. A estratégia de busca ocorreu no portal da Biblioteca Virtual de Saúde – que incorpora a LILACS, BDENF e IBECS; além da MEDLINE, SCOPUS, Embase e Web of Science, com descritores controlados e descritores não controlados (palavras-chave) que foram utilizados para a localização dos artigos. As buscas ocorreram no mês de janeiro de 2021. A amostra de artigos eleitos desta revisão integrativa foi composta por 37 artigos, sendo os anos de 2015 (n = 4), 2016 (n = 5), 2018 (n = 5), 2019 (n = 6) e 2020 (n = 5) os de maior número de publicações. Quanto às bases de dados, não foram encontrados artigos passíveis de serem eleitos no portal da BVS, que engloba a LILACS, IBECS e BDENF, em detrimento das outras bases em que se elegeu os artigos desta revisão, sendo elas: Scopus (n = 12), Embase (n = 5), Web Of Science (n = 13), e Medline (n = 7). Programas de Transição de Cuidados para idosos impactam diretamente na melhora da adesão à medicação, melhor estilo de vida saudável e melhores indicadores clínicos, bem como menores taxas de eventos adversos e readmissão hospitalares, por meio de ações em saúde como: educação do paciente e cuidador, ainda em ambiente hospitalar; acompanhamento telefônico e domiciliar após alta; supervisão e gestão de medicações e criação de planos terapêuticos individuais que visem a reabilitação nutricional, física e cognitiva.

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“…Although we were able to examine many of the common indicators reported in the literature, 36,44 we were unable to examine other meaningful health system outcomes, such as the total cost of care. 44,45 Future work will focus on examining the program from a costeffectiveness perspective. Other important indicators for future research include nursing home entry, type and levels of home care services used post-discharge, functional decline and reason for hospital readmission.…”

Section: Discussionmentioning

confidence: 99%

A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care

Robert

Sun

Sinden

et al. 2021

Journal of the American Medical Directors Association

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Objectives: In Canada, alternate-level-of-care (ALC) beds in hospitals may be used when patients who do not require the intensity of services provided in an acute care setting are waiting to be discharged to a more appropriate care setting. However, when there is a lack of care options for patients waiting to be discharged, it contributes to prolonged hospital stays and bottlenecks in the health care system manifested as "hallway medicine." We examined the effectiveness of a function-focused transitional care program, the Sub-Acute care for Frail Elderly (SAFE) Unit, in reducing the length of stay (LOS) in hospital, as well as post-discharge acute care use and continuity of care. Design: Case-control study. Setting and Participants: A 450-bed nursing home located in Ontario, Canada, where the SAFE Unit is based. The study population included frail, older patients aged 60 years and older who received care in the SAFE Unit between March 1, 2018, and February 28, 2019 (n ¼ 153) to controls comprising of other hospitalized patients (n ¼ 1773). Methods: We linked facility-level to provincial health administrative databases on hospital admissions and emergency department (ED) visits, and the Ontario Health Insurance Plan claims database for physician billings to investigated the LOS during the index hospitalization, 30-day odds of post-discharge ED visits, hospital readmission, and follow-up with family physicians. Results: SAFE patients had a median hospital LOS of 13 days [interquartile range (IQR): 8e19 days], with 75% having fewer than 1 day in an ALC bed. In comparison, the median LOS in the control group was 15 days (IQR: 10e24 days), with one-third of those days spent in an ALC bed (median: 5 days, IQR: 3 e10 days). SAFE patients were more likely (64.1%) to be discharged home than control patients (46.3%). Both groups experienced similar 30-day odds of ED visits, hospital readmission and follow-up with a family physician. Conclusions and Implications: Frail older individuals in the SAFE Unit experienced shorter hospital stays, were less likely to be discharged to settings other than home and had similar 30-day acute care outcomes as control patients post-discharge.

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The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

Cited by 18 publications

References 12 publications

A One Health Evaluation of the University of Copenhagen Research Centre for Control of Antibiotic Resistance

A One Health Evaluation of the University of Copenhagen Research Centre for Control of Antibiotic Resistance

Ações em saúde propostas em programas de transição do cuidado para idosos: revisão integrativa

A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care

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