The Interdisciplinary Team and Improving Transitions of Care

Treiger, Teresa M.; Lattimer, Cheri

doi:10.1891/0198-8794.31.189

Cited by 7 publications

(8 citation statements)

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“…In the literature, multiple studies evidenced that when inconsistencies exist in information sharing, it creates service fragmentations within the provider setting which affects smooth patient-centered care transitions. 10…”

Section: Disconnect Communicationsmentioning

confidence: 99%

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Smith

Treschuk

2018

Home Health Care Management & Practice

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Transitional care incorporates actions to ensure the coordination and continuity of care between provider settings (ie, hospitals, nursing homes, home health care, patients' home, and physician offices) occurs to meet the patient's goals relative to their disease management. The evolution of transitional care over the past decade has facilitated the emergence of several transitional care models. However, there is a dearth of understanding related to the collaboration between nurse transition coaches and home care nurses when implementing transitional care model activities to achieve desired patient outcomes in the home health care setting. This case study describes the enactment of a specific transitional care model's conceptual framework to derive an in-depth understanding of the collaborations between nurse transition coaches and home health nurses in the unique context of home health care. The case is a specific patient-centered Care Transitions Intervention (CTI) model with 4 embedded subunits: (1) the experiences and actions of the nurse transitions coach, (2) the experiences and actions of the home health nurse, (3) document and artifacts review, and (4) the experiences and observations of key leadership stakeholders involved in transitional care activities in one home health care organization located in Michigan.

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Section: Disconnect Communicationsmentioning

confidence: 99%

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Smith

Treschuk

2018

Home Health Care Management & Practice

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“…Older adults and their unpaid caregivers are required to navigate within and between various types of services to sustain their health, yet they often experience challenges in doing so (Coleman, Parry, Chalmers, & Min, 2006). It is often during transitions between types of health services that key issues can arise including poor communication; inappropriate placement in long-term care facilities; care that is delayed, unnecessary, not evidence based, potentially unsafe, fragmented and poorly coordinated; mental health issues; transportation issues; and additional burden placed on unpaid caregivers (Cummings et al, 2012;Reid et al, 2013;Robison, Shugrue, Porter, Fortinsky, & Curry, 2012;Schoen et al, 2011;Treiger & Lattimer, 2011;Walker, Johns, & Halliday, 2015;Wanklyn, 1996). These obstacles undermine the benefits of Canada's health system, reduce the likelihood for older adults to access appropriate services when necessary, and can ultimately lead to increased burden of care and health-care costs (Park, Branch, Bulat, Vyas, & Roever, 2013;Watkins, Hall, & Kring, 2012).…”

Section: Background and Purposementioning

confidence: 99%

Insights Into Roles for Health-Care Professionals in Meeting the Needs of Older Adults and Unpaid Caregivers During Health-Care Transitions

et al. 2016

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We provided insights from older adults, their unpaid caregivers, and health-care professionals into specific roles for professionals within the health system to better meet the needs of community-dwelling older adults and their unpaid caregivers experiencing transitions between health services. We used a qualitative approach to collect data within one Canadian province from older adults and unpaid caregivers of older adults who participated in focus groups ( n = 98) and professionals working in the health system who participated in an online survey ( n = 52). Questions included experiences with health service transitions, strengths, challenges, and suggestions to improve transitions. Thematic analysis resulted in identifying seven specific roles for professionals in supporting health-care transitions: information and education, planning for future health needs, supporting the acceptance of necessary care, facilitating access to the right services at the right time, facilitating communication between services, facilitating the discharge planning process and advocacy for older adults and unpaid caregivers. Our results based on evidence from older adults, unpaid caregivers, and health-care professionals will inform future research and further development of the instrumental and relational roles for professionals supporting older adults and their caregivers experiencing health-care transitions.

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“…4,5 It is often during these transitions that issues arise including delayed, unnecessary, and poorly coordinated care; poor communication; exacerbated mental health challenges; worsening health outcomes; additional family and friend caregiver burden; and inappropriate placement in long-term care facilities. [6][7][8] Transitional care refers to a wide range of time-limited services designed to ensure the coordination and continuity of care for patients as they move between different locations, healthcare providers, or different levels of care within the same location. 9,10 The majority of transitional care programs are initiated while patients, predominately older adults, are hospitalized and awaiting discharge, 11 although some identify patients from primary care practices or other health and social service organizations.…”

Section: Introductionmentioning

confidence: 99%

An exploration of Canadian transitional care programs for older adults

Weeks

Barber

MacDougall

et al. 2020

Healthc Manage Forum

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Transitional care programs are effective for improving patient outcomes upon discharge from acute care services and reducing the burden of healthcare costs; however, little is known about the types of transitional care programs for older adults across Canada. This exploratory study gathered an in-depth understanding of Canadian transitional care programs and described how each program functions to support older adults and family/friend caregivers. Nine key informants were interviewed about the development of transitional care programs within four Canadian provincial regions including Atlantic, Central, Prairie, and West Coast. Key facilitators and barriers influencing the development and long-term success of transitional care programs included program scope, program structure, continuity of care, funding, and health system infrastructure. Future research is required to identify how a broad range of transitional care programs operate and to disseminate knowledge with health leaders and decision-makers to ensure transitional care programs are embedded as essential health system services.

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The Interdisciplinary Team and Improving Transitions of Care

Cited by 7 publications

References 0 publications

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Insights Into Roles for Health-Care Professionals in Meeting the Needs of Older Adults and Unpaid Caregivers During Health-Care Transitions

An exploration of Canadian transitional care programs for older adults

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