The Importance Of Transitional Care In Achieving Health Reform

School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Health Affairs (Impact Factor: 4.97). 04/2011; 30(4):746-54. DOI: 10.1377/hlthaff.2011.0041
Source: PubMed


Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

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Available from: Karen Hirschman, Jul 28, 2014
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    • "Once patients have returned home, community health workers provide care coordination and patient navigation to promote greater access to care and integration of complex services required by many health conditions . These kinds of services are designed to ensure the safe and timely movement of patients from the hospital to their homes (Bray-Hall, 2012), while preventing avoidable readmissions and helping to ensure that positive health outcomes can be sustained (Naylor et al., 2011). Use of community health workers in this manner recognizes that low-socioeconomic status patients have lower access to postdischarge primary care (Asplin et al., 2005; Misky et al., 2010), receive poorer care while in the hospital (Rathore et al., 2006), and have higher risks of all-cause hospital readmission and death (Baker et al., 2002; Foraker et al., 2011). "
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    ABSTRACT: The focus of community health workers on health disparities in vulnerable communities means that they address issues of poverty, while many recipients of psychiatric rehabilitation services live at or below the poverty line. Their focus on improving health in low-income populations of color is in line with some of our field's biggest challenges at this point in history, including poverty, cultural competence, and health comorbidities. By allying with community health workers we have the opportunity to extend our reach into new neighborhoods as well as to better serve our current clientele. By reaching out to local community health worker programs, conducting cross-training, and exploring new funding opportunities presented by health care reform, we may be able to enrich the multidisciplinary, collaborative ethos that makes psychiatric rehabilitation so relevant and effective. (PsycINFO Database Record
    Psychiatric Rehabilitation Journal 09/2015; 38(3):207-209. DOI:10.1037/prj0000164 · 0.75 Impact Factor
    • "Problems with discharge preparation, discharge care processes , problems occurring after discharge home and subsequent unplanned use of health services are well documented, particularly for the older population (Mistiaen et al. 2007). Efforts to reduce readmission rates in the US have focused on improvements in systems of care for improving discharge transitional care coordination (Naylor et al. 2011). Initiatives to improve the process of discharge and models of discharge planning have been introduced in many countries including the USA, the UK, Australia and Ireland (Coffey 2006). "
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    ABSTRACT: To develop and psychometrically test Readiness for Hospital Discharge Scale for older people and to reduce the scale to a more practical short form. The Readiness for Hospital Discharge Scale is the only available and validated scale measuring patients' perceived readiness just prior to discharge. Secondary analysis of hospital studies data from three countries. Data were collected between 2008-2012. The study sample comprised 998 medical-surgical older patients. Factor analysis was undertaken to identify the factor structure of the Readiness for Hospital Discharge Scale. Group comparisons for construct validity and predictive validity for readmission were also conducted. The Readiness for Hospital Discharge Scale original four factor solution does not appear to be consistent with the observed data of older people in the three countries. Confirmatory factor analysis revealed that a 17-item scale with three factors produced the best model fit. Nine items, three from each factor, loaded consistently on their respective factors in each country sample. Confirmatory factor analysis of this short form model indicated that the model adequately fit the data. Patients who lived alone, were older, or who indicated 'not ready' for discharge had lower Readiness for Hospital Discharge Scale for Older People scores, which were also associated with readmission risk. The revised three factor structure of the Readiness for Hospital Discharge Scale for Older People in long and short forms more adequately assesses core components of discharge readiness in the older adult population than the original adult form. © 2015 John Wiley & Sons Ltd.
    Journal of Advanced Nursing 07/2015; DOI:10.1111/jan.12731 · 1.74 Impact Factor
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    • "Transitional care has been defined as ''a broad range of time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another'' (Naylor et al., 2011, p. 747). Transitional services may include: developing an individualised needs-based comprehensive discharge plan, connecting patients and outpatient providers, providing educational and behavioural interventions, managing symptoms and providing direct patient care, monitoring patients and caregivers regularly through home visits and/or telephone contact, providing counselling and self-care instruction, and reviewing and managing medications (Naylor et al., 2011). Hospitals are experiencing increasing pressure from payers to reduce the length of stay. "
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    ABSTRACT: Objectives To determine the cost-effectiveness of nurse practitioners delivering transitional care. Design Systematic review of randomised controlled trials. Data sources Ten electronic databases, bibliographies, hand-searches, study authors, and websites. Review methods We included randomised controlled trials that compared formally trained nurse practitioners to usual care and measured health system outcomes. Two reviewers independently screened articles and assessed study quality using the Cochrane Risk of Bias and the Quality of Health Economic Studies tools. We pooled data for similar outcomes and applied the Grading of Recommendations Assessment, Development and Evaluation tool to rate the quality of evidence for each outcome. Results Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p < 0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5 to 24.5, p < 0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n = 766, pooled relative risk (RR): 0.69, 95%CI: 0.34 to 1.43, I2 = 0%) and any re-hospitalisation up to 180 days (n = 800, pooled RR: 0.87, 95%CI: 0.69 to 1.09, I2 = 32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32 to 0.94, p = 0.03) and 180 days (RR: 0.62, 95%CI: 0.40 to 0.95, p = 0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p < 0.05). Conclusions Given the low quality evidence, weak economic analyses, small sample sizes, and small number of nurse practitioners evaluated in each study, evidence of the cost-effectiveness of nurse practitioner-transitional care is inconclusive and further research is needed.
    International journal of nursing studies 01/2015; 52(1):436. DOI:10.1016/j.ijnurstu.2014.07.011 · 2.90 Impact Factor
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