Translating research into practice: transitional care for older adults

Naylor, Mary D.; Feldman, Penny Hollander; Keating, Stacen A.; Koren, Mary Jane; Kurtzman, Ellen T.; Maccoy, Maureen C.; Krakauer, Randall S.

doi:10.1111/j.1365-2753.2009.01308.x

Cited by 108 publications

(92 citation statements)

References 16 publications

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“…Thus, hospitals could prioritize integrated behavioral health and health care planning when formulating hospital and aftercare plans for patients with these comorbidities [20]. Evidence-based transitional care models that encompass time-limited interventions aimed at promoting continuity of care could be incorporated into the care of persons with a comorbid SMI diagnosis from the start of the hospital admission, regardless of medical comorbidity [24,25]. Unfortunately, most of the research examining these interventions has specifically excluded persons with psychiatric comorbidity, and thus there is little reliable information on the feasibility, associated costs and effectiveness of these programs for this population [26].…”

Section: Conclusion and Implications For Future Researchmentioning

confidence: 99%

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Hanrahan

Bressi

Marcus

et al. 2016

General Hospital Psychiatry

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Section: Conclusion and Implications For Future Researchmentioning

confidence: 99%

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Hanrahan

Bressi

Marcus

et al. 2016

General Hospital Psychiatry

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“…4 Several transitional care models using advanced practice (AP) nurses and specific tools to enhance communication (e.g., care records and patient education materials) have achieved improved care outcomes. 5,6 More recently, AP physiotherapists have improved care transitions through their involvement in follow-up clinics for patients after total joint arthroplasty. 7 The act of transferring information at the time of patient transition is known as the handoff.…”

mentioning

confidence: 99%

Hip-Fracture Care in Rural Southwestern Ontario: An Ethnographic Study of Patient Transitions and Physiotherapy Handoffs

Johnson¹,

Forbes

Egan

et al. 2013

Physiotherapy Canada

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Purpose: To examine information exchange by physiotherapists during care handoffs of patients with hip fracture in a rural health care setting. Methods: This qualitative ethnographic study used observation and interviews of 11 networks of patients with hip fracture (n ¼ 11), family caregivers (n ¼ 8), and health care providers (n ¼ 24). Patients were followed from acute care through each subsequent care setting. Data were supplemented by health care records and policy documents. Results: Findings revealed that handoffs were less successful when information transfer was untimely or incomplete. Family caregivers experienced challenges in obtaining information required to facilitate the handoff, especially when direct contact with physiotherapists was not possible as a result of distance or other factors. Physiotherapists had to navigate multiple data sources to retrieve important information, and managed information gaps in various ways. Information flow was often unidirectional and suggested no further clinical accountability for the discharging physiotherapist. Conclusions: Providing information in a structured and timely fashion facilitated physiotherapy handoffs. Inadequate handoffs compromised continuity of care, delayed progress in rehabilitation, and resulted in families' missing information of vital importance to their caregiving role. A multi-directional exchange of information is needed between patients, families, and health care providers across care settings.Key Words: continuity of patient care; hip fractures; qualitative research; rural health services. RÉ SUMÉObjectif : Examiner l'é change d'information assuré par les physiothé rapeutes au cours des transferts du soin de patients qui ont subi une fracture de la hanche en contexte de soins de santé ruraux. Mé thodes : Cette é tude ethnographique qualitative reposait sur l'observation et des entrevues de 11 ré seaux de patients ayant subi une fracture de la hanche (n ¼ 11), d'aidants naturels (n ¼ 8) et de fournisseurs de soins de santé (n ¼ 24). Les patients ont é té suivis du service de soins actifs jusqu'à chaque contexte de soins subsé quent. Les dossiers de santé et des documents straté giques ont complé té les donné es. Ré sultats : Les constatations ont ré vé lé que les transferts é taient moins ré ussis lorsque le transfert de l'information é tait en retard ou incomplet. Les aidants naturels ont eu de la difficulté à obtenir l'information né cessaire pour faciliter le transfert, surtout lorsque la distance ou d'autres facteurs empê chaient de communiquer directement avec les physiothé rapeutes. Les physiothé rapeutes ont dû consulter de multiples sources de donné es pour extraire des renseignements importants et ont gé ré le manque d'information de diverses fac¸ons. L'information a souvent circulé de fac¸on unidirectionnelle, ce qui indique qu'un physiothé rapeute qui donne son congé au patient n'a plus d'autre obligation clinique. Conclusions : L'information fournie d'une fac¸on structuré e et à temps a facilité les transferts en phys...

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“…The studies that have examined stakeholders who oppose change focus on the identification of these stakeholders as resistors and their participation is viewed as a barrier to change. (Bearman & Stevens, 2014;Naylor et al, 2009;Saint et al, 2009). …”

Section: Discussionmentioning

confidence: 99%

Stakeholder Participation in System Change: A New Conceptual Model

O’Rourke

Higuchi

Hogg

2016

Worldviews Ev Based Nurs

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Translating research into practice: transitional care for older adults

Abstract: The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with "real world" management.

Cited by 108 publications

References 16 publications

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

Hip-Fracture Care in Rural Southwestern Ontario: An Ethnographic Study of Patient Transitions and Physiotherapy Handoffs

Stakeholder Participation in System Change: A New Conceptual Model

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