Understanding Patient, Provider, and System Factors Related to Medicaid Readmissions

Transition to home study

“…However, as shown in Figure G1, there were some discharge teams that had higher and lower Teamwork SMM quality (Aim 1A); and mean Teamwork SMM scores differed between inpatient unit types (Aim 1C). These findings are supported by previous qualitative studies that have suggested that teams may vary in their level of agreement on aspects of teamwork such as communication, understanding of roles, and agreement on which team members are responsible different tasks (Coleman et al, 2013;Fuji et al, 2013;Goldman et al, 2015;Greysen et al, 2012;Hesselink 2013;Jiang et al, 2016;Waring et al, 2016).…”

“…These include (a) patient education, (b) medication reconciliation, and (c) structured discharge communication (e.g., following up with lab results or communication with primary care provider). Although these three components have been identified as important for patient safety, research indicates that these are frequently missing, incomplete, or ineffectively delivered in practice (AHRQ, 2012;Hesselink et al, 2013;Jiang et al, 2016).…”

“…The rationale given by healthcare providers for essential discharge components not occurring in current practice includes role confusion; competing priorities; and the lack of standardized processes, time, and accountability (Coleman et al, 2013;Fuji et al, 2013;Goldman et al, 2015;Greysen et al, 2012;Hesselink 2013;Jiang et al, 2016;Waring et al, 2016). The tasks required to prepare patients for discharge cross professional boundaries, which creates a situation of role ambiguity and diffuse individual responsibility for completing tasks (Greysen et al, 2012;Waring et al, 2016;Waring et al, 2015).…”

“…This highlights the complexity of studying interprofessional teams and supports the need to examine the discharge process from a team perspective. Although additional investigation is needed to determine if teams with low levels of convergence are at high risk for providing lower quality patient care, findings from qualitative research suggests that discharge teams that lack a shared understanding among the team members limits their ability to provide effective care (Coleman et al, 2013;Fuji et al, 2013;Goldman et al, 2015;Greysen et al, 2012;Hesselink 2013;Jiang et al, 2016;Waring et al, 2016).…”

“…Although the majority of discharge teams reported that their patients were ready for hospital discharge, the variation in Taskwork SMM Convergence scores indicates that some discharge teams had lower levels of agreement on how ready the patient was to go home (see Figure G4). Findings from qualitative studies suggest that when providers do not see eye to eye on a patient's situation (e.g., care plan, patients coping ability, expected home support) there is a inadequate communication among team members and the patient is at risk for poor post-hospitalization outcomes (Greysen et al, 2012;Hesselink 2013;Jiang et al, 2016;Waring et al, 2016). This is the first study to measure Taskwork SMMs and Taskwork SMMs Convergence for RNs, MDs, and DCs, and provides early support for assessing patient readiness for hospital discharge from a team perspective.…”