The TC program, designed to decrease preventable readmissions and support patients who have chronic illnesses including HF, at BUMCP has had a low referral rate. This low referral rate results in the program being unable to make an impact to decrease readmission rates in the HF population and increase quality of life among this patient population. The purpose of this project was to identify current barriers to referral and develop interventions directed at the identified barriers. An online survey was sent to a hospitalist group employed at BUMCP. Results revealed perceived barriers include decreased accessibility, limited number of accepted patient diagnoses, and lack of involvement in launch of TC. Recommended interventions include increased accessibility through 24 hours day, seven days week availability, abolishment of current accepted patient diagnoses, and implementation of Lewin's Change Theory to increase buy-in from physicians.

In an effort to reduce hospital 30-day readmissions a Transitional Care Coach Program (TCCP) was developed in 2014 at a Southwest Urban Medical Center. The CDC Framework for Program Evaluation (2012) applies insight and experience gained from past program experience to effect change in practice and improve patient outcomes. The evaluation seeks to determine TCCP utilization, to assess its impact on 30-day readmission rates for high-risk patients, to inform stakeholders of a viable follow-up program, and to determine evidence-based interventions for program improvement. This TCCP program evaluation describes characteristics of patients who participated in the program, assesses whether interventions were delivered as intended, and determines if interventions reduced hospital 30-day readmission rates compared to readmission rates prior to program implementation. Descriptive statistics are used to describe the patient population, health status, and program utilization. For the diagnoses of acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), and pneumonia (PNA), Chi-square test analyses were performed to compare 30-day readmission rates of the TCCP participants and readmission rates for this medical center for the time period prior to program implementation. The primary finding of this program evaluation is an overall numerical decrease in hospital readmission rate by 3% compared to the baseline data. Although the change (a decrease) was in the desired direction, the degree of change was not statistically significant based on pooled data. A statistically significant decrease was observed only for the AMI diagnosis. However, as any decrease in readmissions decreases the financial burden to both the organization and the patient, the TCCP appears to have had a positive impact. It is recommended that a renewed TCCP be conducted to allow for (1) an increased timespan for data collection, (2) an increased number of medical categories assessed to allow for more non-parametric statistical analysis (e.g. adding categories of Total Joint Replacement and Sepsis diagnoses), (3) tracking of number of days to readmittance to allow for improvement to be measured and analyzed beyond a single dichotomous category. Evidence-based recommendations have been made to continue and improve interventions that further reduce hospital readmissions.

Background: Frequent ED users are generally over the age of 65 years, Medicare beneficiaries, sicker and have more health issues than non-frequent users. Elderly patients suffer a 20% mortality rate upon admission and a 30% decrease in activities of daily living (ADL) after discharge. Transitional care programs (TCP) decrease ED visits and readmission rates, improves ADLs, and increases event-free survival. Purpose: To evaluate the need of an ED TCP in the ED. Aims are to assess ED providers’, nurses’ and managers’ perceptions of elderly frequent ED users’ discharge needs, resources, and potential role of a TCP. Methods: Conducted within one community based ED in Tucson, Arizona. Survey content determined by a review of the literature focused upon elderly transitional care. Recruitment of nurses, providers, and managers following verbal consent. Inclusion criteria: willingness to participate in a 10-minute survey and work two shifts a month minimum within the ED. The survey is comprised of 19 questions focused on patient needs, current resources and the role of a TCP. Surveys were followed by a 5-minute post-survey session to review questions regarding content. Questions structured using a Likert scale format and categorical answers. Data analyzed using descriptive statistics. A needs assessment (NA) executive summary was presented to the ED staff and management. Results: One hundred providers, nurses, and managers completed the survey of which 79% were female, 73% registered nurses, 14% physicians, and 10% advanced practice providers. The majority of respondents believed elderly patients are discharged unsafely, additional resources were needed, more time was spend caring for elderly patients, and TCPs were a viable supportive option. “What is a transitional care team (TCT)?” was the most asked question during question and answer session. Implications: This NA revealed providers’, nurses’, and managers’ perceptions of elderly frequent ED user needs and the role of a TCP. Concerns identified are consistent with the literature. This NA provided information about ED staff perceptions of elderly frequent users and addressed transitional care while laying the groundwork for the potential future implementation of a TCP initiated in the ED.

Transitional care represents a critical juncture in the continuing care of patients with chronic conditions, particularly for adolescent patients. It also represents a significant point of failure in that process for adolescents, with many patients experiencing difficulties during the transition between adolescent and adult medicine that lead to negative long-term impact on health and wellbeing. This thesis aims at addressing adolescent transitional care processes and its obstacles through a broad medical humanities inquiry in a multidisciplinary dialogue between philosophy, social sciences, and medicine. The social, anthropological, and medical concepts of adolescence and autonomy were derived from a literature review and used to identify and philosophically analyze obstacles to adolescent transitional care. Studies were used to illuminate those obstacles. For a first person-perspective analysis, an autoethnography was developed to provide patient testimony, towards improving the reflection on transitional care. This analysis tested the alignment of the author’s experiences in interacting with a healthcare transition as part of the patient population with those recorded in the literature. This study has found barriers and facilitators concerning autonomy and communication at many levels and among many parties involved in the transition, such as patients, caregivers, healthcare providers, and healthcare systems operations, particularly regarding insurance management. This study recommends a focused coordination of primary care and/or transitional care specialists with the participation of adolescent patients’ voices and testimony to develop and manage challenges to autonomy in transitional care.

Heart failure (HF) is a chronic condition affecting older adults. It is estimated over 5.8 million Americans are currently diagnosed with HF, with an anticipated increase to seven million by 2030. HF patients are faced not only with the physical symptoms, but also with emotional tolls, and socioeconomic burdens related to HF. Low income and rural facilities, which lack financial resources, are at greater risk for closure if there are concerns of loss of reimbursement. Hospitals are now challenged to prevent readmissions and to avoid penalties associated with HF admission within the 30-day window. Incorporating various interventions have shown improvements in readmission rates. Nurse practitioners and registered nurses can serve as patient educators regarding topics such as diagnoses, procedures, disease monitoring, medications, and medication side effects. In most hospitals, RNs at patients' bedside are at the forefront of providing HF patients discharge instructions and education, which should include symptom recognition and management. The aim of this project inquiry was to assess the knowledge of HF education and perceived barriers to providing HF education by nurses and nurse practitioners, such that improved transition of care for patients in the rural health setting can occur.

Background: Heart failure (HF) is a complex, costly and debilitating chronic health condition. Symptom recognition and self-care are crucial components of heart failure management; however, many HF patients struggle to perform these behaviors and skills at a proficient level. A transitional care program in the Southwest provides services to heart failure patients. A primary program aim is to help facilitate enhanced symptom recognition and self-care among heart failure patients. This project focuses on the assessment of the impact of such a transitional care program on HF patients' ability to perform symptom recognition and self-care. Methods: Demographic questionnaires were distributed to collect socioeconomic data and clinical characteristics of participants. A pre and post SCHFI survey was completed by participants, and analysis of data performed using a paired t-test. Results: The 15 participants were primarily Hispanic, elderly, and male. The majority of participants reported an annual income less than $10,000, lived in close proximity to the transitional care clinic, reported living with family and/or friends, and had at least one additional comorbidity. There was improvement in self-care maintenance scores following the initial transitional care encounter; however, participants did not achieve self-care adequacy in this domain. Participants also did not achieve self-care adequacy in self-management. Self-confidence scores improved to reach adequacy following the initial transitional care encounter; however, results were not statistically significant. Conclusion: With the complexities of HF self-management, it is not alarming that these patients have continued to struggle with symptom recognition and self-care. Recommendations are made for future research and interventions.

The hypothesis of this study is: Transitional care patients reinforced for displaying a particular affective verbal habit (either positive or negative) opposite their original affective verbal habit (either negative or positive) will increase their tendency to display the reinforced affective verbal habit.

Thesis advisor: Ellen K. Mahoney / Purpose: The purpose of this qualitative descriptive study was to investigate the experiences of post stroke survivors (PSSs) during transition from hospital discharge home during the first four weeks. Background: PSSs describe the transition from hospital to home as an important time in recovery and stress various physical and cognitive concerns early within the recovery period. Research to date fails to adequately reflect PSSs' experiences early after discharge home. This gap in research limits the ability to create interventions for PSSs during this critical time period. Methods/analysis: Semi-structured telephone interviews were conducted with 31 participants, recruited from a large metropolitan hospital in the northeastern United States. The use of in-vivo codes lead to the development of themes that described PSSs' experiences during the four week transitional period. Credibility and transferability of findings were strengthened through memoing, field notes, reflexivity of analysis, member checking, and peer review throughout the analysis process by qualitative experts. Results: The five major themes were: (a) the shock of a stroke interrupting a normal day, (b) transition to an unfamiliar home, (c) experiencing a life riddled with uncertainty, (d) a journey to a new sense of self, and (e) adjusting to a new sense of self. Throughout their journey all PSSs had to cope with uncertainty and adjust to a new sense of self. PSSs that experienced less uncertainty were able to return to their prior daily routine, knew how to prevent another stroke, had a helpful support system, and had frequent follow-up and communication with health care professionals. Conclusion: All PSSs are at risk for complications regardless of stroke severity. To address PSSs complex needs, nurses can provide care beyond symptom management by fostering a dynamic intentional relationship to support recovery. The framework resulting from this study can provide the platform for advanced neuroscience nurses to engage with PSSs to improve their recovery and adjustment to a new sense of self as they transition from hospital to home. / Thesis (PhD) — Boston College, 2014. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Philosophy.

Recovering from a cardiac surgery procedure and the transition to home can be an overwhelming experience for patients and caregivers. A tertiary care hospital's cardiothoracic surgery department suspended a nurse-practitioner-coordinated transitional care program in the 1st quarter of 2016. Following this decision, the readmission rate increased from its previous rate of 15.6% in quarter 1 to 20% in quarter 3. The purpose of this scholarly project was to develop a clinical practice guideline (CPG) that can bridge the gap in the transitional care process. The transitional care model informed the design of the project. A draft guideline was distributed to 5 stakeholders from the inpatient cardiac surgery care team for initial review. After initial review and revisions an edited version was then distributed to 5 additional stakeholders. Those stakeholders provided an assessment utilizing the AGREE II tool to assess the 6 domains of scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application and editorial independence, and overall quality. Four domains indicated a high level of agreement (96%-100%) and 2 domains indicated a response of < 76% for domains related to rigor and organizational resources. The overall guideline assessment of the quality of the CPG received a score of 96%, with a recommendation to adopt the guideline. Advanced practice nurses will utilize this guideline to provide a systematic process in bridging gaps in care for the transition of the cardiac surgery patient population from hospital to home. Social change will be promoted through improved patient management by using evidence-based transitional care, decreased readmissions, and improved health outcomes for the cardiac surgical population.

<p>Background: Each year, 2 million older Americans complete three to four week courses of post-acute care in nursing homes and return home; however, scant research describes services to protect older adults during their transitions from nursing homes to home. In hospital-based studies, transitional care interventions were associated with improved health outcomes for older adults, but these interventions added new staff positions, which are likely cost-prohibitive in nursing homes. Further, no prior study explored transitional care provided for vulnerable, post-acute care patients in nursing homes. Thus, this dissertation was designed to develop new understandings about transitional care provided by existing staff members in nursing homes. The study has two specific aims: (a) describe transitional care and outcomes for older adults who obtain post-acute care in nursing homes from the day of admission through discharge; (b) explore the influence of interactions, among selected older adult patients and their group of nursing home caregivers, on their ability to accomplish transitional care processes.</p><p>Method: Using data from a literature review and theoretical models, including Donabedian's Model of Healthcare Quality and Anderson's Local Interaction Model, a conceptual model of transitional care for post-acute care patients in nursing homes was constructed. The conceptual model was then used to guide exploration of the research aims with a longitudinal, multiple case study of transitional care in a nursing home. The unit of analysis was the patient care-team, defined as individual post-acute care patients, family caregivers, and 6 to 8 professional staff in each team (e.g., rehabilitation therapists, physicians, nurses and social workers). Three patient care-team members were purposively sampled for study. Moreover, longitudinal data were collected using repeated interviews and observations with patients, family caregivers, and staff; document and daily chart reviews; and surveys of patient preparedness for discharge. Manifest content analysis and thematic analysis (qualitative methods) were used to conduct within- and across-case analyses of trajectories of transitional care and to identify strengths, gaps and inconsistencies in care. </p><p>Results: Findings related to the first research aim include a description of transitional care in the study nursing home. Serious gaps and inconsistencies in transitional care exposed older, post-acute care patients to risks for complications in their transitions from the study nursing home to home: (a) systemic supports were not available to support nursing home staff who provided transitional care; further, nursing home staff and leadership were unaware that they provided transitional care; (b) care processes were not in place to prepare older adults and their caregivers to continue care at home; (c) care-team interactions often excluded family members; and (d) post-acute care patients left the nursing home without resources needed to support safe transitions in care, including transitional care plans, education to appropriately respond to acute changes in health, written materials to guide care at home, referrals for medical follow-up after discharge, and transfers of clinical information to primary care physicians. </p><p>Findings related to the second research aim include a description of local interaction strategies and the effectiveness of transitional care processes. When professional staff more consistently used local interaction strategies, specified in the model, care-team members exhibited greater capacity for connections, information exchange, and cognitive diversity. Further, when care-team interactions were of high quality and sufficient frequency, there were multiple indications of more effective transitional care, such as patient engagement in care, inclusion of patient priorities in care plans, and problem solving which included family members and diverse members of the patient care-team. Thus, local interaction strategies were essential staff behaviors needed to adapt care processes to the specific transitional care needs of individual patients.</p><p>Because transitional care is a grossly under-developed care process in nursing homes, these findings will likely have immediate implications for practice and research. Findings will provide nursing home administrators and staff with resources to develop and evaluate care in nursing homes; further, the findings will help to create targets for protocol and care process development to strengthen existing practice and address deficiencies. Findings will provide researchers with resources for studying transitional care in diverse samples of nursing homes, which should facilitate development of testable hypotheses for needed intervention studies. In addition, the local interaction strategies findings in the study may generalize to other settings of care, where interdependent staff work is required to establish connections, information networks, and to coordinate care among multiple staff members.</p> / Dissertation