Transitions of Elders Between Long-Term Care and Hospitals

Abstract

Elderly long-term care recipients who require acute hospitalizations must navigate a fragmented system with poor "handoffs," often resulting in negative outcomes. This article makes the case that reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders. Immediate action targeting diffusion of evidence-based care is recommended to decrease avoidable rehospitalizations and achieve cost savings. Policy changes are needed to address barriers to high-quality transitional care, including deficits in health professionals' and caregivers' knowledge and resources, regulatory obstacles, and inadequate financial incentives and clinical information systems.

An Analysis Of The Work System Framework For Examining Information Exchange In A Healthcare Setting

“…Organizational infrastructure and strategies also influence the performance of health information exchange (Kodner & Spreeuwenberg, 2002;Naylor et al, 2009;World Health Organization, 2013).…”

“…Participants should adhere to environmental aspects such as internal routines, culture, and policies of information management and health information exchange in their organization (Georgiou et al, 2013;Naylor et al, 2009). Organizational infrastructure and strategies also influence the performance of health information exchange (Kodner & Spreeuwenberg, 2002;Naylor et al, 2009;World Health Organization, 2013).…”

“…Several studies have explored barriers that influence the process of information exchange (Coleman, 2003;Olsen, Østnor, Enmarker, & Hellzén, 2013;Riesenberg et al, 2010), the quality of nurse documentation and information management across healthcare organizations (Hellesø, Lorensen, & Sorensen, 2004;Hellesø, Sorensen, & Lorensen, 2005;Jefferies, Johnson, & Griffiths, 2010), and how to improve information exchange between healthcare providers (Hustey & Palmer, 2010;LaMantia, Scheunemann, Viera, BusbyWhitehead, & Hanson, 2010;Riesenberg et al, 2010). However, we need more research to assess the effectiveness and outcome of patient handover by focusing on systems' factors and human performance measurement (Naylor, Kurtzman, & Pauly, 2009;Riesenberg et al, 2010;Sobolewski, 2011).…”

Heart Failure Patients in Skilled Nursing Facilities

“…Including family caregivers in interventions conducted with patients in SNFs has the potential to improve clinical outcomes and to allow caregivers to assist with transitioning patients to home or other postacute care settings and to be engaged in making decisions about the interventions their family members require. 13 Dolansky and colleagues 14 focused on physical health by evaluating the cardiac rehabilitation services used by 80 older adults (mean age, 78.8 years) discharged to 2 SNFs after a cardiac event (mean length of SNF stay, 14 days). Most (78%) patients were eligible for cardiac rehabilitation, but in a review of nursing notes, 312 physical therapy session notes, and 308 occupational therapy session notes, there was limited documentation that patients received cardiac rehabilitation interventions (eg, 4 patients used NuStep over a 7-day period, 12 used arm ergometry, and 1 received cardiac risk reduction education).…”

Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients

“…[1][2][3][4][5][6][7] These admissions often lead to frequent cycling in and out of the hospital, with approximately 20% of all Medicare beneficiaries being rehospitalized within 30 days of discharge. 8 Rehospitalizations in this patient population are associated with a diminished quality of life, and are often incongruent with the wishes of terminally ill patients, leading to a misalignment of patient expectation and care delivery.…”