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Identifying Challenges Associated With the Care Transition Workflow From Hospital to Skilled Home Health Care: Perspectives of Home Health Care Agency Providers

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Abstract and Figures

Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions-information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.
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Home Health Care Services Quarterly, 34:185–203, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0162-1424 print/1545-0856 online
DOI: 10.1080/01621424.2015.1092908
Identifying Challenges Associated With the
Care Transition Workflow From Hospital to
Skilled Home Health Care: Perspectives of
Home Health Care Agency Providers
Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore,
Maryland, USA
Department of Industrial and Systems Engineering, University of Wisconsin–Madison,
Madison, Wisconsin, USA
Johns Hopkins Home Care Group, Baltimore, Maryland, USA
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins
University; Department of Community and Public Health, Johns Hopkins School of Nursing;
and Department of Health Policy and Management, Johns Hopkins Bloomberg School of
Public Health, Baltimore, Maryland, USA
Armstrong Institute for Patient Safety and Quality, and the Department of Anesthesiology and
Critical Care, Johns Hopkins University; and Department of Health Policy and Management,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Armstrong Institute for Patient Safety and Quality, and the Division of Geriatric Medicine and
Gerontology, Department of Medicine, Johns Hopkins University; and Department of Clinical
Investigation, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Older adults discharged from the hospital to skilled home health
care (SHHC) are at high risk for experiencing suboptimal tran-
sitions. Using the human factors approach of shadowing and
contextual inquiry, we studied the workflow for transitioning
Address correspondence to Alicia I. Arbaje, MD, MPH, Division of Geriatric Medicine
and Gerontology, Department of Medicine, Johns Hopkins University, 5200 Eastern Avenue,
Center Tower, 7th Floor, Baltimore, MD 21224, USA. E-mail:
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186 M. Nasarwanji et al.
older adults from the hospital to SHHC. We created a represen-
tative diagram of the hospital to SHHC transition workflow, we
examined potential workflow variations, we categorized workflow
challenges, and we identified artifacts developed to manage varia-
tions and challenges. We identified three overarching challenges
to optimal care transitions—information access, coordination,
and communication/teamwork. Future investigations could test
whether redesigning the transition from hospital to SHHC, based
on our findings, improves workflow and care quality.
KEYWORDS care transitions, communication, frail elderly, home
health care, human factors engineering, qualitative research,
Problems during care transitions of older adults are common, costly, and
sometimes lead to adverse events (Arbaje et al., 2014; Coleman & Boult,
2003; Coleman, Smith, Raha, & Min, 2005). After over two decades of
research focused on reducing such problems, unfavorable outcomes persist.
Readmissions rates remain high, and older adults are often dissatisfied with
the quality of their care (Coleman, Min, Chomiak, & Kramer, 2004; Jencks,
Williams, & Coleman, 2009; Sato, Shaffer, Arbaje, & Zuckerman, 2011). Older
adults who require skilled home health care (SHHC) services following hos-
pital discharge are among those at highest risk of experiencing suboptimal
outcomes during care transitions (Murtaugh & Litke, 2002; Rosati & Huang,
2007; Wolff, Meadow, Weiss, Boyd, & Leff, 2008). SHHC are services pro-
vided by health care professionals (e.g., nurses, physical therapists) in a
residential environment. Hospital readmission rates from the SHHC setting
are approximately 25%, with most occurring within 2–4 weeks after hospi-
tal discharge (Anderson, Hanson, DeVilder, & Helms, 1996; Ashton et al.,
1999). Although interventions exist to improve care transitions from hospital
to home (Arbaje et al., 2010; Boult et al., 2011; Coleman, Parry, Chalmers, &
Min, 2006; Jack et al., 2009; Naylor et al., 1999), given that re-hospitalization
rates from SHHC settings remain high (Madigan et al., 2012; Rosati & Huang,
2007), interventions that account for the complexity of the hospital to SHHC
transitions are still needed.
Due to challenges associated with addressing the complex workflows expe-
rienced by SHHC providers, the need for a systems approach to improving
transitions has been identified (National Research Council Committee on the
Role of Human Factors in Home Health Care, 2011; Madigan & Anderson,
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Care Transition Workflow 187
1999). The use of a human factors and ergonomics (HFE) work systems
approach can facilitate the identification and mitigation of challenges related
to the complex transition workflow. HFE is a scientific discipline that studies
the interactions between humans and elements of their work system (e.g., a
hospital unit, an SHHC agency, an older adult’s home) to optimize overall
performance and reduce harm (Carayon, 2012; Carayon et al., 2014; Gurses,
Ozok, & Pronovost, 2011). The work system comprises of elements—such
as the people performing the work, the tasks they are performing, and the
tools they use to perform tasks within that context—that interact to perform
processes that produce outcomes (Carayon & Wood, 2010; Carayon et al.,
2006, 2014; Holden et al., 2013). Within the structure of a work system,
there are workflows, which are “the flow of people, equipment, information,
and tasks, in different places, and at different levels, at different time scales
... that are used or required to support the goals of the work domain”
(Carayon, 2012, p. 509). Challenges within the workflow are mechanisms
that impede the execution of the desired workflow. To better understand the
hospital to SHHC transition and its workflow challenges, we: (a) developed
a representative diagram of the coordinator transition workflow; (b) identi-
fied variations to the workflow; (c) categorized challenges to the workflow;
and (d) described the artifacts or aides created to manage variations and
We used a HFE approach consisting of two methods: shadowing and con-
textual inquiry. Shadowing is a qualitative ethnographic method that makes
use of observation to collect detailed information about the tasks performed
within a workflow (McDonald, 2005). Contextual inquiry involves the col-
lection of detailed information about the tasks performed by asking probing
questions to clarify or gain an in-depth understanding of the tasks (Beyer &
Holtzblatt, 1997). We unobtrusively shadowed SHHC coordinators as they
performed all tasks in transitioning older adults from the hospital to an
SHHC. When shadowing, we asked probing questions as necessary to aug-
ment our observations. The Systems Engineering Initiative for Patient Safety
(SEIPS) guided our data collection during both shadowing and contextual
inquiry. SEIPS is an HFE work system model with five elements: (a) peo-
ple—e.g., nurses, older adults, caregivers, physicians, as well as teams of
providers and how they coordinate information and communicate with those
involved; (b) tasks that people perform; (c) tools and technology available
and needed to complete the tasks; (d) organizational factors shaping the
work, such as staffing and policies; and (e) factors related to the physi-
cal environment in which workflows are performed (Carayon et al., 2006;
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188 M. Nasarwanji et al.
Holden et al., 2013). These elements interact to constitute processes that
produce outcomes (Carayon et al., 2006; Holden et al., 2013). Based on
both the SEIPS model and our workflow conceptualization, two researchers
(MN, AA) developed a semi-structured guide for the contextual inquiry. The
guide included questions on the sequence of tasks; how, where, and by
whom tasks were performed; variations in the tasks, tools, and technolo-
gies used to perform tasks; and strategies used to overcome observed or
voiced challenges to task completion. We shadowed and performed contex-
tual inquiry in 4-hour intervals on different days and at different times, for a
total of 24 hours. During this time period, we observed hospital-based multi-
disciplinary rounds, older adult bedside visits, and office work involving
development and transmittal of referrals to the SHHC agency. We collected
data over 4 months in 2013.
Participants and Institutional Review Board Approval
We used purposive and network sampling (Crabtree & Miller, 1999) to iden-
tify health care professionals with substantial experience in transitioning
older adults from the hospital to the SHHC. Participants were from nine
medical and surgical units, and an SHHC agency affiliated with a large urban
academic hospital network. We did not place restrictions on the type of hos-
pital unit or cause of hospitalization when identifying the SHHC coordinators
to participate in the study. We enrolled 15 coordinators who fulfilled different
roles within the transition workflow, and who were responsible for initiating,
executing, and coordinating an older adult’s transition. Table 1 lists the spe-
cific roles and responsibilities of these coordinators and the other providers
identified to be involved in the the transition work system. This study was
approved by The Johns Hopkins School of Medicine’s Institutional Review
Data Collection and Analysis
We observed the transition from the time an older adult was identified as
needing an SHHC (occurring primarily in the hospital setting, 24–72 hours
prior or close to the time of discharge) to when the SHHC referral was com-
pleted and sent to an SHHC agency, but before the older adult was seen
for the initial SHHC start-of-care visit (occurring up to 72 hours after hos-
pital discharge). Although the transition continued beyond this parameter
with an initial home visit, the transition typically occurred in two parts: (a)
workflow prior to hospital discharge and (b) workflow after hospital dis-
charge. We focused on the workflow prior to hospital discharge, as it was
responsible for ensuring completeness and accuracy of information about
the transition, and identifying and securing the appropriate services.
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TABLE 1 Roles Involved in Initiating, Executing, and Coordinating the Transition of an Older Adult From the Hospital to an SHHC
Role Location Description of role (related to the hospital to SHHC transition)
SHHC coordinatoraHospitalbInitiates and executes the hospital to SHHC transition.
SHHC coordinator assistantaHospitalbProvides support to the SHHC coordinator, verifies insurance, finds
appropriate SHHC agency.
Physician Hospital Orders SHHC services, completes documentation certifying need for
SHHC, and determines older adult’s care plan.
Nurse practitioner/physician assistant Hospital Assists physician with documentation, and educates patient and
caregiver regarding care plan prior to discharge.
Hospital nurse Hospital Educates patient and caregiver regarding care plan prior to discharge.
Case manager Hospital Manages planning of care for multiple patients in a ward, oversees
multidisciplinary rounds, identifies need for postdischarge services,
and works with SHHC coordinator to identify patients in need of
Social worker; physical therapist;
occupational therapist; dietician
Hospital Identifies postdischarge needs and recommends appropriate services.
Insurance verification specialistaSHHC agency Ensures that SHHC agency can accept patient’s insurance and
reconciles discrepancies in insurance information.
Intake nurseaSHHC agency Ensures that SHHC agency has the required resources and can provide
the care recommended by the hospital.
ScheduleraSHHC agency Informs SHHC nurses of new cases, and manages schedules for all
SHHC nurses.
Older adult and informal caregiver Hospital, home Individual being transitioned; and able and willing individual who is
responsible for care for the older adult once at home.
aThese participants were shadowed and the focus of contextual inquiries for this study.
bThough these participants were located in the hospital, they were employed by the SHHC agency.
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190 M. Nasarwanji et al.
Using the notes and transcripts from our contextual inquiries, two HFE
experts (MN, AG) generated a list of chronological tasks. Each task was
annotated with the tools and technologies used to complete the task, and
the different people involved in the task. Tasks were then grouped into
independent “action groups” or sets of tasks that had to be completed dur-
ing the transition. Two HFE experts (MN, NW) and two geriatricians (AA, BL)
used the list to create a diagram depicting the workflow for a typical transi-
tion. SHHC subject matter experts, including SHHC administrators and SHHC
coordinators, reviewed the workflow diagram for accuracy and complete-
ness. To assess face and content validities, accuracy, and completeness of
the initial diagram, we presented it to SHHC nurse administrators during two
individual interview sessions, and made changes based on their feedback.
We then evaluated the diagram in two focus groups with SHHC coordina-
tors. We presented a final version of the diagram to two SHHC administrators
(DH, KC) and one SHHC coordinator for validation.
Due to the complexity of the work system, we anticipated that the workflow
diagram might not capture all of the nuances of the transition. Hence, to
provide a more comprehensive understanding of the transition, we identified
variations in the workflow by comparing the diagram to notes and transcripts
from the contextual inquiry. We defined a variation as any data representing
a change in the typical workflow as depicted in the diagram. Variations were
not necessarily negative and did not necessarily represent challenges, but
they were crucial to document and provided a comprehensive understanding
of how the transition is executed in real world situations.
During our shadowing and contextual inquiries, we also identified the
challenges coordinators encountered in completing the workflow. We cat-
egorized their challenges by the five elements of the SEIPS model. Then,
through group consensus, a group of HFE experts (AG, MN, NW), geriatri-
cians (AA, BL), and SHHC administrators (DH, KC) narrowed the challenges
into categories by similar content.
We documented artifacts or aides created by coordinators to manage the
variations and challenges encountered in the workflow. Artifacts are “those
artificial devices that maintain, display, or operate upon information to serve
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Care Transition Workflow 191
a representational function and that affect human cognitive performance”
(Carroll, 1991, p. 17). Artifacts often serve as memory aides, reference lists
or a means to communicate information.
Representative Diagram of Coordinator Transition Workflow
We identified 15 major tasks in the transition workflow diagram (Figure 1).
We categorized these tasks into five action groups: (a) identifying hospi-
talized older adults in need of SHHC services; (b) informing older adults
of SHHC options; (c) finding the appropriate SHHC agency; (d) gathering
and synthesize information to complete referral; and (e) informing SHHC of
The two major mechanisms coordinators used to identify older adults in need
of SHHC services were to: (a) attend daily multidisciplinary rounds to gain
FIGURE 1 Hospital-to-SHHC transition workflow diagram prior to discharge, showing action
groups (column headers) and tasks (rows) that must be completed by specific roles (listed
under bullet points) using tools and technology (in parentheses) to reach the goal of that
action group.
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192 M. Nasarwanji et al.
information about older adults potentially in need of SHHC services; and
(b) maintain close contact with the hospital case manager responsible for
discharge planning. Once a potential referral was identified, the coordinator
assessed the older adult’s care needs and insurance eligibility.
The coordinator first established whether the older adult would accept SHHC
services. Once accepted, coordinators determined whether the older adult
had received SHHC services before or if a particular SHHC agency was pre-
ferred. The coordinator then determined if there was an able and willing
caregiver. Combined, these tasks required multiple phone calls, conversa-
tions with older adults and informal caregivers, and simultaneous tracking of
any changes in the older adult’s discharge status or care plan.
The coordinator was also responsible for finding an appropriate SHHC
agency to staff the referral based on the needs and preferences of the older
adult, SHHC agency staffing abilities, and insurance eligibility. Coordinators
had to contact insurance companies and SHHC agencies to identify the
appropriate SHHC agency with the capability to provide for the older adult,
based on the discharge date.
As part of the transition process, the coordinator gathered and synthesized
the information needed to complete the referral, which included patient
history, demographic information, and the types of SHHC services needed.
It is important to note that this sequence of tasks was completed iteratively,
as care plans changed prior to discharge. For example, coordinators might
begin a referral for one SHHC service such as home oxygen, only to be
informed later that the older adult also needed physical therapy. Similarly,
the coordinator might not have had all of the information needed to complete
the referral. Thus, the coordinator sometimes needed to revise or amend a
referral prior to hospital discharge.
Upon completion of the SHHC referral, the coordinator sent the completed
referral to the SHHC agency. The SHHC agency verified insurance eligibility
and determined staffing needs prior to admitting the older adult to SHHC.
If the older adult was admitted to the SHHC agency, a health record was
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Care Transition Workflow 193
generated. This sequence of tasks was also iterative. Sometimes insurance
issues arose once the referral was sent to the agency, and the coordinator
was contacted to change the referral or find a new agency. For example,
coordinators may have initiated a referral with one SHHC agency based
on documented, but outdated, insurance information. A new insurer may
have been documented in one record system, but not in another. Often, this
change in information would require a change in SHHC agency. Another
example might be if the older adult’s discharge was delayed due to a change
in their clinical condition. In that case, the coordinator contacted the SHHC
agency and either sent an addendum or completed a new referral.
Each action group and related tasks required the coordinator to com-
municate or coordinate with other providers from the hospital care team
or the SHHC agency. Further, the coordinator used multiple tools and
technologies—both from the SHHC agency and the hospital—to arrange the
transition. Coordinators reported that the most common mode of communi-
cation was the telephone. In addition, coordinators used fax machines, email,
and pagers to communicate with other hospital providers and SHHC agen-
cies. Information was typically obtained from the hospital electronic medical
record or from in-person conversations with case managers or physicians.
Identification of Variations to the Workflow
As expected in the complex work system of the hospital, there were varia-
tions to and significant flexibility in the typical transition workflow presented
in Figure 1. Depending on each unique transition situation, tasks were added,
removed, or occurred in a different order. For example, coordinators typically
waited to receive physician orders before completing a referral. But when
physicians were not immediately available to verify orders and certify the
need for SHHC, coordinators would modify their workflow by partially com-
pleting the referrals and adding in physician orders at a later date. Sometimes,
the workflow was temporarily suspended, as in cases when the coordinator
visited the older adult to provide information, but found the room changed
or the older adult at therapy or a test. Changes in the older adult’s clinical
status often modified their SHHC needs in terms of treatment or the SHHC
start-of-care date. Often the referral needed to be redone, revised, or have
an addendum attached; and these changes then needed to be communicated
to the SHHC agency.
Categorization of Challenges to Successful Execution of the Workflow
Each action group within the workflow—both the typical workflow and the
variations—with its multiple tasks, coordinators, and tools, was susceptible to
challenges associated with its completion. Across the workflow, we identified
three main categories of challenges, as shown in Table 2.
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194 M. Nasarwanji et al.
TABLE 2 Challenges Identified as Part of the Hospital/SHHC Transition Workflow
Challenges Description
Information access
Information extraction Information needed by coordinators was located in multiple
record systems (electronic and paper) or needed to be
extracted from multiple fields in the EHR or lengthy notes.
Coordinators had difficulty identifying an older adult
needing SHHC due to vaguely defined conditions for
determining need.
Access to complete
Coordinators experienced referrals, discharge plans,
discharge summaries, medication lists, and related materials
with missing or incomplete information.
Uncertainty in care
Change(s) in the older adult’s condition typically warranted
amendments to the referral or a new discharge plan.
Management of
Coordinators had no systematic or specified method to track
and manage multiple SHHC referrals simultaneously.
Coordinators experienced delayed delivery of durable
medical equipment or other supplies or incorrect items
delivered, and other difficulties in procuring or
coordinating equipment.
Difficulty accessing
Coordinators had difficulty communicating with physicians
supervising the SHHC plan due to lack of access to a direct
phone line or pager, lack of timely response from the
physician, and difficulty securing required orders and other
documents such as face-to-face certifications, etc.
breakdown between
hospital providers
and SHHC
An older adult’s situation may have changed and/or care
plans changed and documented by hospital providers, but
the information was not communicated to the coordinator.
Challenges with care
team members of
different roles
Coordinator had to consider other factors such as home
setting, family, social support, etc., when deciding on level
of care.
Lack of a clear
discharge plan
Coordinators received care plans outlined in the SHHC orders
and/or discharge instructions from hospital providers, but
the plans were not clear enough to execute and required
additional clarification.
Information access challenges identified within the workflow included chal-
lenges with information extraction, and receiving incomplete and/or missing
information. Information extraction was a challenge both when identifying
older adults who needed SHHC and when creating the referral. Coordinators
referred to themselves as “transition police,” intimating that they were con-
stantly trying to find information to ensure appropriate referrals. Garnering
information from multiple sources including electronic health records (EHR)
and charts was also a challenge. Coordinators explained that each physi-
cian put the information needed to complete SHHC referrals in different
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Care Transition Workflow 195
places. In addition, information in the EHR was often incomplete or incor-
rect, as the EHR had not been updated and specific details were often part
of lengthy physician notes. Thus, compiling all of the information to com-
plete a referral could take days and sometimes up to a week, leading to a
backlog of referrals. One coordinator described this scenario explaining, “I
have all my new referrals, but then I have a pile of [pending] referrals to
follow up on.” Information extraction also posed a challenge when the plan
of care or discharge status of an older adult changed. Coordinators were not
typically informed of changes and had to monitor multiple record systems
for any changes in the plan of care. Finally, coordinators often had access
to incomplete or outdated information to complete the referral, leading to
more information extraction challenges.
Information and services had to be coordinated across health care set-
tings, but this coordination was constantly in flux, especially if there was
a change in the clinical state of the patient. This uncertainty in care plans
required SHHC coordinators to iteratively repeat tasks within the workflow.
In addition, there was no standardized or systematic way to manage multiple
referrals, and there were no tools to help support this task. Further, changes
to equipment procurement procedures made the coordination of equipment
one of the most frequently cited challenges. Equipment procurement chal-
lenges led to discharge delays, which then led to delays in admitting older
adults to SHHC.
Coordinators often cited a lack of a clear discharge plan, mainly due to
ineffective teamwork and communication as a factor leading to redundant
actions to complete a referral. Without enough information to execute the
transition, the coordinators had to find physicians to clarify information.
Coordinators regularly experienced difficulty accessing physicians due to
lack of access to a direct phone line or pager, or lack of timely response. For
example, coordinators often reported “hounding” physicians to ensure SHHC
orders were signed. One coordinator explained that, “sometimes you are
chasing down five doctors to get the information you need for one referral.”
They also experienced communication breakdowns between other hospi-
tal providers and coordinators. Coordinators felt like “detectives,” because
instead of having information communicated to them, they felt they had to
find information on their own. Coordinators were frustrated with the feeling
that they were “the last in the loop” and felt that one of their greatest chal-
lenges was waiting for information from the hospital provider team (i.e.,
physicians, hospital nurses, case managers). Attempting to identify older
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196 M. Nasarwanji et al.
adults for SHHC sometimes lead to challenges with care team members in
different roles due to contradictory opinions about the older adult’s needs
and SHHC eligibility criteria. Coordinators attributed these differences to the
hospital care team not fully understanding SHHC eligibility and services, and
to the need to have clarification about each provider’s role in the transi-
tion. This challenge often led to increased time and effort when referring a
patient who might not be appropriate for the SHHC, and took away time
from referring patients who were more appropriate for SHHC.
Description of Artifacts Created by Coordinators
The artifacts we identified were most often created by coordinators to man-
age both variations in and challenges to the workflow. Table 3 provides a
summary of the artifacts identified and their purpose in facilitating transitions.
TABLE 3 Description of Artifacts Created to Support Transition Workflow
Artifact Description and purpose
Transition workflow
challenge overcome by
creating artifact
Sticky note hand-offs Coordinators created their own
strategies for informing the next
coordinator on duty about
potential and pending SHHC
Information access,
File of extra forms Coordinators carried a file of extra
forms such as the SHHC orders
document to increase chances of
obtaining documentation from
Personal reference
Each coordinator created their own
reference guide of insurance
contacts, SHHC agency
information, and physician pager
and personal cell phone
Information extraction,
SHHC “Bible” One group of coordinators created
a reference guide of
difficult-to-find contact
information for use in the office.
Information extraction,
Printed list of potential
Coordinators printed a list of
current patients and used this list
to track pending and potential
patients by notating and highlight
the list.
Information extraction,
Layout of work
Coordinators organized their
workspace by stacking SHHC
referrals spatially to represent
pending, past, and potential
Information access
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Care Transition Workflow 197
Paper artifacts (records, notes, instructions,andannotations made) played
a major role in completing the SHHC referral. Coordinators printed lists of
older adults who would be discussed during multidisciplinary rounds, and
took notes on the lists about next actions, follow-up, and questions they had
for any potential SHHC referrals. They used these documents to track older
adults as they moved toward discharge and to assist in completing the SHHC
referral. Artifacts were also created to communicate between coordinators
and other providers. For example, coordinators referred to sticky notes and
printed e-mails as “hand-offs,” and attached them to the SHHC “bible”—a
compiled book of all insurance and SHHC agency information—when they
needed to pass information to another coordinator. Others reported creating
their own reference guides for hard-to-find information or relied on more
senior members of the team for help with challenging tasks. One coordina-
tor explained, “We all have our own manuals that we have created to help
us [perform transitions].” To overcome difficulties accessing physicians and
obtaining necessary documentation, the coordinators traveled with printed
copies of their commonly used forms, such as SHHC orders and face-to-face
forms, to have physicians complete if the opportunity arose. Coordinators
also developed their own systems to manage multiple and partially com-
pleted referrals. Some used their desk space to spatially organize referrals
into stacks of completed, in progress, incomplete, revised, and potential
Currently, transition interventions focus on the older adult transitioning from
the hospital to home (Coleman et al., 2006; Jack et al., 2009; Naylor et al.,
1999). These interventions are primarily at the patient level (Boling, 2006,
2009; Kripalani et al., 2007) and do not specifically account for challenges
associated with clinical workflow during complex transitions. To help bridge
this gap, some have called for a systems approach to improving transitions
(Arbaje et al., 2014; Madigan & Anderson, 1999). In our study, we used an
innovative HFE work systems approach and gained a rich, detailed under-
standing of the work performed by coordinators who are responsible for
initiating, executing, and coordinating the transition of older adults from the
hospital to SHHC. We identified complex nonstandardized transition work-
flows, as coordinators developed their own strategies to manage limitations
in the current work system. By analyzing the workflow, variations in the
workflow, and artifacts used by the coordinators, we identified novel chal-
lenges that begin prior to hospital discharge and continued throughout the
transition. Our findings have important implications for re-engineering the
work system to guide the improvement of transitions.
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198 M. Nasarwanji et al.
Having access to information that was accurate, up to date, and con-
cisely presented was critical to coordinators during the transition. Adequate
information sharing between the coordinators, and seamless information
flow to and from other providers were equally important. Artifacts created by
coordinators helped cope with limitations in the workflow, since tools and
technologies were inadequate to support the information needs of coordina-
tors. Some of the information management challenges could be remediated
by health information technologies (HIT). These HIT solutions would need to
focus on improving information access, electronic information sharing, seam-
less information transmission, compatibility between electronic information
systems, and a streamlined user interface design.
Recent research has shown that designing interventions based on an
HFE workflow analysis has improved performance in health care (Arthur
et al., 2012; Fernandez-Gutierrez et al., 2015; Möckel, Searle, Hüttner, &
Vollert, 2015; Tacker, Topardo, Mahaffey, & Perrotta, 2014). Transition inter-
ventions and HIT systems in hospitals are often designed and implemented
without accounting for the needs of the clinicians or having undergone an
adequate analysis of workflows, both of which lead to unintended con-
sequences. There is a need to design the next generation of transition
interventions and HIT solutions to support coordinator workflow, and to
assist in the execution of multiple and simultaneous transitions. Adopting
a human system integration, or user-centered design approach, may help
overcome some of the challenges identified with the current systems.
A lack of situation awareness within the transition workflow leads to
a myriad of coordination challenges, especially when care plans are in flux.
Situation awareness is an HFE construct that refers to the level of comprehen-
sion and coherent representation of the current system state (Endsley, 1995a,
1995b). Tools to increase situation awareness could take the form of shared
office space, interoperable data documentation systems, and automatic notifi-
cations of changes to the clinical status or care plan. Implementing solutions
such as HIT platforms that support shared situation awareness across the
provider team would support coordinator workflow by improving real-time
knowledge of changes to care plans and SHHC needs that impact the older
adult’s transition. Coordinators wanted open lines of communication with
other hospital providers to foster information sharing. Other health care
teams have improved this by bringing providers together using specific com-
munication tools to openly discuss the needs of each group, thus improving
the shared mental model—i.e., a shared understanding among team mem-
bers of the role of other team members and what each needs to do their
work. These open discussions can improve team cohesiveness by bring-
ing awareness to common goals. In addition, communication challenges
had an overall negative impact on the functioning of teams. Our findings
suggest a culture change is needed, as well as clarifying roles and increas-
ing accountability of members of the transition team. This culture change
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Care Transition Workflow 199
could address some of the communication/teamwork challenges we found.
Others have shown that both ambiguity in accountability and incongruence
between ideal and routine roles are important factors leading to subopti-
mal care transitions (Schoenborn, Arbaje, Eubank, Maynor, & Carrese, 2013).
Historically, the culture of health care in general has used the medical model
as a framework for service delivery, which has notable limitations for improv-
ing transitional care (Rooney & Arbaje, 2012–2013). The medical model for
diagnosing and treating illness focuses on treating dysfunction caused by
biological aspects of specific diseases and conditions. The main limitation of
using this approach alone to guide service delivery is the absence of recog-
nition of other factors affecting health care utilization—such as the patient,
caregiver, health care provider, work system, community, and regional
There are important implications of our work in the context of the
Affordable Care Act (ACA), which encourages the creation of accountable-
care organizations (ACOs) and partnerships with community-based organi-
zations to execute smooth transitions and deliver quality care after hospital
discharge. The Department of Health and Human Services announced that
by 2018, 90% of fee-for-service Medicare payments would be tied to qual-
ity or value of care (Burwell, 2015; Gurwitz et al., 2003). The alternative
payment models needed to support ACOs will further incentivize health
care organizations to develop seamless coordination during transitions, since
organizations will now be financially at risk if patients experience problems
during the transition or after discharge. The findings of our work can help
guide health care organizations in their efforts to design more seamless care
transitions for older adults.
Three limitations of this study should be considered. First, it was conducted
with coordinators affiliated with one SHHC agency and might not represent
the experiences of coordinators and SHHC providers elsewhere; although,
the themes identified would likely resonate with similar stakeholders in other
settings. Second, the study did not include the perspectives of other partic-
ipants in the transitions—such as older adults, family caregivers, hospital
nurses, or rehabilitation therapists. Although these perspectives are impor-
tant, we chose to examine the views of health care professionals responsible
for initiating and executing older adults’ transitions and those who were
likely to be directly affected by workflow challenges, as these views were
not sufficiently represented in the literature and can complement the views
of other stakeholders. Third, the study focuses on transition quality itself and
not on clinical outcomes or health care utilization that might result from the
quality of the transition—e.g., re-hospitalizations.
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200 M. Nasarwanji et al.
The purpose of this research was to understand hospital-to-SHHC transi-
tion workflow, identify common variations in the workflow, identify artifacts
used during care transitions, and categorize challenges associated with the
transition workflow. Our findings suggest the need for improved informa-
tion access, coordination, and communication/teamwork solutions during
an older adult’s transition from the hospital to SHHC. Coordinators need the
ability to create a referral using information from the entire health care team
and a way to seamlessly transition information across health care settings.
Applying an HFE work systems approach to evaluate transition challenges
provided insights that aid our understanding of transitions and have impor-
tant implications for improving transitions. Our findings have implications
for ways to engineer the work system to improve transitions. Improved HIT
and culture change are two recommendations to help combat some of the
challenges with the current transition workflow. Future investigations could
test whether work system redesign could improve coordinators’ workflow
and quality of care provided during transitions.
We acknowledge Deborah Statom for her support in organizing the rele-
vant literature and the Johns Hopkins Home Care Group and their staff
for their continued support of this research. An abstract of this work was
presented as a poster at the Academy Health annual research conference in
2013, Baltimore, MD. We thank Ryan Fongemie, Medical Illustrator, Center for
Teaching and Learning, Johns Hopkins Bloomberg School of Public Health,
for her assistance with preparing Figure 1.
Mr. Nasarwanji was supported by funding from the National Patient Safety
Foundation. Dr. Arbaje is a former Robert Wood Johnson Foundation
Harold Amos Medical Faculty Development Program Scholar, supported by
Grant Number 63518; a former National Patient Safety Foundation Research
Scholar; and a former Johns Hopkins Clinical Research Scholar, supported
by Grant Number KL2TR001077. Dr. Arbaje has received funding from the
Secunda Family Foundation, the John A. Hartford Foundation, and the Johns
Hopkins University School of Nursing Center for Innovative Care in Aging.
She currently receives funding from the Agency for Healthcare Research
and Quality (Grant Number 1K08HS022916). The funders had no role in
any of the following activities: design and conduct of the study; collection,
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Care Transition Workflow 201
management, analysis, and interpretation of the data; and preparation,
review, or approval of the manuscript.
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... Overtime, to address identified issues with hospital care, CMS has adjusted HVBP performance domains, metrics, and reimbursement calculations, and implemented the Hospital Readmissions Reduction Program (CMS, 2021a,b). Yet, despite these efforts, problems of inadequate physician and patient communications and rushed hospital discharges regardless of patient readiness persist, and risks in transitions to home-based postacute care remain high (Lawrence et al., 2020;Nasarwanji et al., 2015;Qian et al., 2011). ...
... Rushed hospital discharges can strain postacute care by discharging patients too early, referring patients not meeting admission eligibility or otherwise unsuitable, and initiating transfers with incomplete or inconsistent information (Finkel & Worsowicz, 2017;Lawrence et al., 2020). These problems could delay the starts of home care services, affect care timeliness, and increase the risks of complications and hospital readmission (Nasarwanji et al., 2015). Nevertheless, associations between hospital discharges, transitions to home-based care, and hospital readmissions have not been adequately documented in the literature. ...
... These limitations could delay administrative processes and create service delivery logjams, referral backlogs, duplicated data collection, and communication gaps between frontline staff, management, and support teams. These issues could impede coordination in care transitions; continuity of care; service quality; and client safety and satisfaction (Georgiou et al., 2013;Nasarwanji et al., 2015;Sockolow et al., 2021). Barriers in data-sharing also challenge cross-sector and cross-organizational collaborations for common population health goals. ...
Demands for home-based care have surged alongside population aging, preferences for aging in place, policy-driven reforms incentivizing lower hospital utilization, and public concerns around COVID-19 transmissions in institutional care settings. However, at both macro and micro levels, sociopolitical and infrastructural contexts are not aligned with the operational needs of home healthcare organizations, presenting obstacles to home healthcare equity. We integrate the social-ecological model and organizational theory to highlight contextual forces shaping the delivery of home-based care services between 2010 and 2020. Placing home-based healthcare organizations at the center of observation, we discuss patterns and trends of service delivery as systematic organizational behaviors reflecting the organizations’ adaptations and responses to their surrounding forces. In this light, we consider the implications of provision and access to home care services for health equity, discuss topics that are understudied, and provide recommendations for home-based healthcare organizations to advance home healthcare equity. The paper represents a synthesis of recent literature and our research and industry experiences.
... This theme consists of studies where teamwork is used to care for specific patient groups including geriatric home care (Larsen et al., 2017;Nasarwanji et al., 2015), paediatric home care (Castor et al., 2017), oncology home care (Dhollander et al., 2019) and dementia home care (Karlsson et al., 2015). Castor et al. (2017) describe the importance of teamwork when caring for sick children at home. ...
... Larsen et al. (2017) state that professionals in community home care teams need to interact closely, flexibly and collaborate interdependently across organisational boarders to care for multimorbid elderly patients at home. When transferring older patients from hospitals to home health care, Nasarwanji et al. (2015) find that care coordinators play an important role since they assemble collective information from teams and transfer it across healthcare boundaries. This theme highlights the importance of teamwork, often multidisciplinary, when caring for patient groups that suffer from complex multimorbidity. ...
... This theme includes studies that describe how teamwork is used to target specific tasks or problems like medication management (Fløystad et al., 2018; home care (Bjornsdottir, 2018), integrated home care nursing and social service (Gudnadottir et al., 2019), patient centred medical home (PCMH) care (Hoff & Scott, 2017), pain assessment (Karlsson et al., 2015) or patient care transition (Nasarwanji et al., 2015). Both Sweden (Berggren et al., 2017;Castor et al., 2017;Josefsson & Peltonen, 2015;Karlsson et al., 2015;Klarare et al., 2019;Klarare et al., 2020;Larsen et al., 2017;Lindblad et al., 2018) 8 ...
Full-text available
Due to an increased number of complex multi‐ and long‐term ill patients, healthcare and nursing provided in patients' homes are expected to grow. Teamwork is important in order to provide effective and safe care. As care becomes more complex, the need for teamwork in home care nursing increases. However, the literature on teamwork in the patients' home environment is limited. The aim of this study is to describe the scope of the current literature on teamwork in home care nursing and outline needs for future research. Seven electronic databases were systematically searched and 798 articles were identified and screened. Seventy articles remained and were assessed for eligibility by two of the authors. Eight themes were identified among the 32 articles that met the inclusion criteria. Studies concerned with teamwork regarding isolated tasks/problems and specific teamwork characteristics were most common. Methods were predominantly qualitative. Multiple method approaches and ethnographic field studies were rare. Descriptions of the context were often lacking. The terms ‘team’ and ‘teamwork’ were inconsistently used and not always defined. However, it is apparent that teamwork is important and home care nurses play a crucial role in the team, acting as the link between professionals, the patient and their families. Future studies need to pay more attention to the context and be more explicit about how the terms team and teamwork are defined and used. More research is also needed regarding necessary team skills, effects of teamwork on the work environment and technology‐mediated teamwork.
... Others have noted the need to bring hospital-based and home-based staff together to understand information needs and to redesign information-sharing tools between hospital-based and home-based staff. 7,27,28 We suggest that this information redesign should also occur in home infusion therapy. ...
Full-text available
Objectives Access to patient information may affect how home-infusion surveillance staff identify central-line–associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards. Design Qualitative study using semistructured interviews. Setting and participants The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion. Results Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers. Conclusions Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.
... Collaboration among caregivers is critical to ensure safety and quality care in someone's home, especially when living with complex medical conditions and health service needs [13,[22][23][24][25]. Mobile apps are a promising solution to support caregiver collaboration in the home, where computer use has become ubiquitous as a technology to enhance communication and information sharing. ...
Full-text available
Background: Providing care in home environments is complex, and often the pressure is on caregivers to document information and ensure care continuity. Digital information management and communication technologies may support care coordination among caregivers. However, they have yet to be adopted in this context, partly because of issues with supporting long-term disease progression and caregiver anxiety. Voice assistant (VA) technology is a promising method for interfacing with digital health information that may aid in multiple aspects of being a caregiver, thereby influencing adoption. Understanding the expectations for VAs to support caregivers is fundamental to inform the practical development of this technology. Objective: This study explored caregivers’ perspectives on using VA technology to support caregiving and inform the design of future digital technologies in complex home care. Methods: This study was part of a larger study of caregivers across North America on the design of digital health technologies to support health communication and information management in complex home care. Caregivers included parents, guardians, and hired caregivers such as personal support workers and home care nurses. Video interviews were conducted with caregivers to capture their mental models on the potential application of VAs in complex home care and were theoretically analyzed using the technology acceptance model. Interviews were followed up with Likert-scale questions exploring perspectives on other VA applications beyond participants’ initial perceptions. Results: Data were collected from 22 caregivers, and 3 themes were identified: caregivers’ perceived usefulness of VAs in supporting documentation, care coordination, and person-centered care; caregivers’ perceived ease of use in navigating information efficiently (they also had usability concerns with this interaction method); and caregivers’ concerns, excitement, expected costs, and previous experience with VAs that influenced their attitudes toward use. From the Likert-scale questions, most participants (21/22, 95%) agreed that VAs should support prompted information recording and retrieval, and all participants (22/22, 100%) agreed that they should provide reminders. They also agreed that VAs should support them in an emergency (18/22, 82%)—but only for calling emergency services—and guide caregivers through tasks (21/22, 95%). However, participants were less agreeable on VAs expressing a personality (14/22, 64%)—concerned they would manipulate caregivers’ perceptions—and listening ambiently to remind caregivers about their documentation (16/22, 73%). They were much less agreeable about VAs providing unprompted assistance on caregiving tasks (9/22, 41%). Conclusions: The interviews and Likert-scale results point toward the potential for VAs to support family caregivers and hired caregivers by easing their information management and health communication at home. However, beyond information interaction, the potential impact of VA personality traits on caregivers’ perceptions of the care situation and the passive collection of audio data to improve user experience through context-specific interactions are critical design considerations that should be further examined.
... As the transition process of discharging the patient from admittance to home relies on neatly coordinated organizational work, it simultaneously comprises information handover, Hybrid cognition in medical discharges 251 teamwork and interprofessional collaboration between units that each are highly specialized in their own domain and physically positioned in different places and working within different macro-structures. Structural and processual organizational factors challenging the discharge process have already been identified (Davidson et al., 2017) and described through, for instance a human factors and ergonomics work systems approach (Nasarwanji et al., 2015). While this work has identified improvement opportunities in organizational workflow and quality care, we argue that there is a need to address the various socio-technical components which organize a successful discharge from the perspective of cognitive ecosystems (Hutchins, 2014). ...
Purpose The purpose of this study is to gain insight into the interaction-sensitive skills medical practitioners enact as they manage multiple organizational factors in the context of discharging patients. Design/methodology/approach For that purpose, we carried out a cognitive ethnographic study in a Danish hospital, where we video-recorded three pre-ward round meetings, five discharge conversations and conducted seven semi-structured interviews. Fieldnotes and interview transcripts were analyzed using the method Cognitive Task Analysis, and video-recordings were analyzed via the interactivity-based approach Cognitive Event Analysis. Findings Our findings show that practitioners coordinate multi-scalar resources (e.g. verbal patterns and cognitive artifacts) in order to discharge patients in a safe and integrated way, which we propose amounts to the social and intercorporeal ability to align simultaneously emerging factors, like organizational procedures in the hospital, artifacts in use, sociocultural resources and the individual medical expertise of the practitioner in the emerging social interaction with the patient. In pursing this claim, we investigate the linguistic and cognitive processes emerging in a single case study of a nurse who discharges a patient. We propose that the interaction-sensitive skill which enables the nurse to solve the task of discharging the patient can be characterized via hybrid cognition. Originality/value Thus, the value of the article is dual: On the one hand, it empirically contributes with knowledge of the complex organizational structures that constrains micro-level medical interactions in discharges, and on the other, the article contributes theoretically with a hybrid cognitive framework that allows organizational researchers to understand and assess complex cognitive and linguistic processes that goes into the social micro-coordination in complex organizational-medical task.
Background The hospital-to-home transition remains a high-risk care interval for older adults. Skilled home health (HH) agencies are uniquely positioned to address care-transitions-associated patient safety threats. We previously developed the Hospital-to-Home-Health Transition Quality (H3TQ) Index to identify safety issues after hospital discharge. Our objective is to evaluate a participatory ergonomics process engaging stakeholders to develop strategies to implement the H3TQ into HH agency workflow to improve transition-associated safety issues in real-time. Methods Stakeholders participated in three, two-hour Intervention Refinement Team (IRT) meetings with a focus on: (1) identifying facilitators and barriers to collect H3TQ data in real-time, (2) integration of H3TQ into workflows, and (3) sharing H3TQ safety threat information to improve care transition safety outcomes. We used the human factors engineering-informed Systems Ambiguity Framework to guide the structure of IRT meetings and qualitative data analysis to evaluate the IRT process itself. Results Stakeholders (N = 9) represented patients, family caregivers, and HH staff. Stakeholders identified three key strategies for H3TQ implementation: (1) mechanism and timing of H3TQ data collection using multiple platforms; (2) data sharing conditions for safety reporting across the health system; and (3) identification of targeted care transitions outcomes for improvement. Participants highly rated IRT meetings regarding meeting usefulness, comfort, and degree of input into the discussion. Conclusions The IRT participatory ergonomics process was successful. Stakeholders identified strategies to facilitate implementation of the H3TQ implementation to improve the hospital-to-HH. IRTs have potential application to other health system issues related to the care of people with complex needs.
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Purpose: The objective of this study was to understand how caregivers manage and communicate health information for older adults who require complex home care, informing the design of new technologies to support patient safety in the home. Methods: The research involved semi-structured interviews with 15 caregivers, including family and hired caregivers, in Ontario, Canada. An inductive analysis was used to develop themes. Results: The findings described how participants were Updating the Caregiver Team to share health information in the home. Participants were also Learning to Improve Care & Decision-Making. However, sometimes participants experienced Conflicts within Caregiver Teams using current technologies, which may not fully meet their information management and communication needs. Conclusion: This research highlights the difficulties of caring for older adults in complex home care situations and the challenges that family and hired caregivers face when managing health information and communication. Currently, paper-based technologies are used, but there is a growing interest in digital tools that can efficiently gather and transform health information to better support decision-making. Collaborative digital systems involving family caregivers as important care team members could improve information sharing and reduce conflicts. However, implementing new technologies in this context can be difficult, and successful adoption may require systems that improve the overall caregiving experience in complex environments. This study recommends integrating caregivers as collaborators and implementing two-way communication in digital systems to enhance caregiver satisfaction. Future research should delve deeper into these complexities and prioritize designing effective tools for this crucial caregiving domain.
Background: Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions. Objective: To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks. Methods: Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists). Results: The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%). Conclusions: The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.
Background: Older adults see multiple outpatient providers and increasingly use home health care (HHC) services. Previous studies attempting to draw inferences about the association between HHC use and patient outcomes have been mixed. Whether HHC is associated with care coordination and how both influence outcomes are unknown. In addition, prior studies have not taken the patient perspective into account. We examined the association between receiving HHC and self-reported gaps in care coordination and separately, preventable adverse outcomes. Methods: The analysis for this cross-sectional study was conducted between October 2021 and June 2022, using data on 4296 Medicare beneficiaries from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who completed a survey on care coordination from 2017 to 2018. The associations between the receipt of HHC and two outcomes (a gap in care coordination, and separately, a preventable adverse event) were examined with Poisson models with robust standard errors. Potential confounders were accounted for through propensity score-based inverse probability weighting. Results: Among 4296 participants, 430 (10%) received HHC and they were older and had more comorbidities and ambulatory visits than those without HHC. HHC was not associated with differences in self-reported gaps in care coordination (33.3% HHC vs. 32.5% no-HHC, p = 0.70). HHC recipients reported more preventable drug-drug interactions (9.1% vs. 4.0%, p < 0.001) but not more preventable ED visits or hospital admissions. In IPW-adjusted models, HHC was not associated with gaps in care coordination (p = 0.60) but was associated with double the risk of a preventable adverse outcome (aRR 2.06; CI: 1.37, 3.10, p < 0.001). Conclusions: HHC recipients were significantly more likely (than those without HHC) to report a potentially preventable adverse event (particularly a drug-drug interaction), suggesting an opportunity to improve patient safety by leveraging the observations of older adults receiving HHC.
The increasing volume of our aging population is dramatically affecting the need for home care services. The discharge process from hospital to home can be fraught with communication challenges if critical information is not provided. The transition process can threaten patient safety and incur adverse patient health outcomes. However, little is known about how the communication occurs between hospital and home health providers. Therefore, this integrative literature review was conducted to (1) describe the discharge communication that is occurring for older patients between hospital and home healthcare providers and (2) summarize the limitations of current discharge communication. A systematic search was conducted using CINAHL, PubMed, Web of Science, and PsycINFO databases. Findings were categorized to address each aim. Seven studies were included for full reviews. Healthcare providers used a variety of communication methods, including: written information, phone calls, or in-person meetings to exchange the discharge information of older patients. Limitations in communications included excessive and incomplete discharge documents, lack of provider’s contact information, lack of trust in each other, and lack of bidirectional communications. The quality of discharge communications can improve by utilizing mediators and implementing standardized discharge documentation requirements. Overall, there was a lack of literature that described the methods and limitations of discharge communication for older patients between hospital and home care services. Further studies can be conducted to generate more evidence. Healthcare providers may improve the quality of discharge communication by addressing the suggested areas.
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A methodological framework is introduced to assess and compare a conventional fluoroscopy protocol for peripheral angioplasty with a new magnetic resonant imaging (MRI)-guided protocol. Different scenarios were considered during interventions on a perfused arterial phantom with regard to time-based and cognitive task analysis, user experience and ergonomics. Three clinicians with different expertise performed a total of 43 simulated common iliac angioplasties (9 fluoroscopic, 34 MRI-guided) in two blocks of sessions. Six different configurations for MRI guidance were tested in the first block. Four of them were evaluated in the second block and compared to the fluoroscopy protocol. Relevant stages' durations were collected, and interventions were audio-visually recorded from different perspectives. A cued retrospective protocol analysis (CRPA) was undertaken, including personal interviews. In addition, ergonomic constraints in the MRI suite were evaluated. Significant differences were found when comparing the performance between MRI configurations versus fluoroscopy. Two configurations [with times of 8.56 (0.64) and 9.48 (1.13) min] led to reduce procedure time for MRI guidance, comparable to fluoroscopy [8.49 (0.75) min]. The CRPA pointed out the main influential factors for clinical procedure performance. The ergonomic analysis quantified musculoskeletal risks for interventional radiologists when utilising MRI. Several alternatives were suggested to prevent potential low-back injuries. This work presents a step towards the implementation of efficient operational protocols for MRI-guided procedures based on an integral and multidisciplinary framework, applicable to the assessment of current vascular protocols. The use of first-user perspective raises the possibility of establishing new forms of clinical training and education.
Our healthcare system emphasizes brief episodes of treatment for acute medical conditions, followed by poorly coordinated care delivery. Care transitions are a particularly vulnerable time for older adults and those with complex needs. Developing new models to improve care coordination across settings is an opportunity to reduce re-hospitalizations and other objectives tied to patient safety and improving care quality during transitions. This article explores the challenges to changing our current culture during transitions, presents new frameworks for culture change, and provides examples of transitional care interventions that are evolving the culture into one that encourages collaboration, problem-solving, and accountability to improve patient outcomes.
Context Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting.Objective To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting.Design, Setting, and Patients Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors.Main Outcome Measures Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable.Results There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events.Conclusions Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.
Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA's new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment . . .
Objective: To quantify the benefits of automating specimen extraction in terms of specimen-preparation times and labor usage. Methods: We used workflow modeling and time-motion studies to compare manual and automated solid-phase extraction methods to prepare specimens for a mass spectrometry-based vitamin D assay. We processed 20 batches, that included 5 to 90 specimens each, with both methods in parallel and randomly over a 4-week period. Technologist discomfort/fatigue was subjectively measured. Results: Batch preparation time, per-specimen processing time, and labor requirements were significantly lower for all batch sizes on the Tecan Freedom EVO 150 robotic liquid-handling system (EVO). Technologist fatigue was significant when batch sizes reached 60 specimens. Cycle times were more uniform on the EVO. Automation provided as many as 85 minutes of useable technologist idle time for the 90-specimen batch. Conclusions: Automated specimen preparation should be considered when batch sizes reach 35 to 40 specimens per day.
Objectives: Over the past few years, the number of patients attending emergency services has increased steadily. As a result, emergency departments (EDs) worldwide face frequent crowding, with the risk of reduced treatment quality and impaired patient outcome, patient and staff dissatisfaction and inefficient use of ED resources. A qualitative process analysis and process modelling was used as a method to detect critical process steps in the ED with respect to time and efficiency. Methods: The analysis was carried out by independent external process experts. Over a period of 1 week, the complete treatment process of 25 patients was recorded. The monitoring of overall activities, decision points, causalities and interfaces was based on the treatment of 100 additional patients and on interviews with nurses and physicians. The project was closed with the identification of the three most critical process steps and modelling of the standard emergency care process in an event-process chain (EPC). Results: The most time-crucial steps detected by the analysis were the process of developing a tentative diagnosis, including consultation and advice seeking by inexperienced physicians, the interface to imaging diagnostics and the search of hospital beds for inpatients. The results were visualized by standardized modelling of an event-process chain (EPC). Conclusion: The process analysis helped to identify inefficient process steps in the ED. Modelling with EPC is a useful tool to visualize and to understand the complexity of the emergency medical care and to identify key performance indicators for effective quality management.