No description available.

Background: Family caregivers represent a critical component in the management of the health of older adults. The inclusion of family caregivers during transitions occurring between hospital and community settings has been previously considered. However, the experience of family caregivers during transitions occurring within the same setting remains unclear. The purpose of this study was to describe the experiences of family caregivers during transitions occurring within an acute care setting. Method: A qualitative description study was conducted. Semi-structured interviews were conducted with 10 family caregivers. Interviews were audio-recorded and occurred in person or over the telephone. Analysis included coding of interview data and the development of overarching themes. Findings: In this study, family caregivers reported the following themes. These themes included: "a lack of central brain during hospitalization," "muddling through transitions alone" and "wariness towards the care delivery system. The environmental influence of the hospital setting influenced family caregivers' view of the care provided by healthcare professionals and the transitions occurring between different units. Furthermore, half of the family caregiver participants (n=5) identified as having a background in healthcare. Healthcare professionals as family caregivers (HCP-FCs) reported unique experiences from other non-healthcare family caregivers. Interviews and field notes from HCP-FC participants were analyzed separately following the same procedures as the larger study. Three themes emerged including, "seeking inclusion," "insider perspectives," and "role struggle." Conclusion: Experiences of HCP-FCs and family caregivers during hospitalization of older adults have the potential to influence perceptions regarding transitional events occurring within acute care settings. Additionally, family caregivers' and HCP-FCs' perceptions of care coordination among healthcare professionals had the potential to negatively influence perceptions of transitions occurring within the acute care setting.

The rising cost of health care and changes in healthcare delivery have prompted a need to improve continuity from the hospital to home. This scholarly project was initiated to assess the impact on patient outcomes related to initiation of a nurse practitioner-led transitional care program (TCP). Using the Diffusion of Innovations and Health Belief Models, the purpose of this study was to identify the impact of a TCP on improving the health of patients with congestive heart failure (CHF), diabetes mellitus Type II (DM II), and chronic obstructive pulmonary disorder (COPD). The impact of the TCP was evaluated by a review of patient satisfaction results, reduction in patient readmission rate, and emergency room consults. Two years of data from a community-based health care program were collated from a sample of 819 individuals with chronic disease between 65- and 85-years-old who had a 30-day hospital readmission after a nurse practitioner home visit and a 30- day readmission for an exacerbation of their CHF, DM II, or COPD. The secondary data were analyzed, using SPSS, to determine changes in rates of readmission. Descriptive statistics were used to represent and compare changes in rates. After implementation of the nurse practitioner home visit program, the 30-day readmission demonstrated an 81.07% reduction and the 30-day readmission for exacerbation of COPD, CHF, and DM II was reduced by 36.77%. The project findings contribute to social change by identifying how a reduction in the frequency of hospitalizations could contribute to decreased health care expenses and improved health outcomes. Home care and chronic health care organizations, as well as advanced-practice nurses working in home care settings, may use the results of the study to establish effective community interventions that reduce health care costs.

Healthcare costs have risen from 13.8% in 2000 to 17.9% in 2009 (Gordon, Leiman, Deland, & Pardes, 2014). Poor transitional care has been identified as a cause of the high healthcare costs (Naylor et al., 2013; Obama, 2013). In 2009, the Department of Veterans Health Administration (VHA) implemented a national reform of outpatient care to create Patient-Aligned Care Teams (PACTs) with a goal to improve transitional care and reintegration into outpatient care through registered nurse case managers conducting discharge telephone follow-up calls. However, discharge telephone follow-up calls have not been explored within the VHA. This study explored the relationships among discharge telephone follow-up calls, selected Veteran characteristics including the length of index hospital stay, and 30-day all cause hospital readmissions between fiscal years 2011 and 2013. Hospital readmissions were explored in parallel time periods to the timing of the discharge telephone follow-up calls. Study data were collected retrospectively from VHA inpatient and outpatient records. Descriptive statistics, measures of central tendency, bivariate statistics, and logistic regression were used to analyze the data. The study found 124,069 Veterans were discharged from the VHA from 2011 to 2013. Of those discharges, 15,954 (12.86%) were readmitted to the hospital within 30 days and 35.06% of the readmissions occurred within the first seven days after discharge. Discharge telephone follow-up calls increased from 312 in 2011 to 26,549 in 2013. Increasing Veteran age, number of comorbidities, length of index hospital stay, and being identified as frequently hospitalized in the previous year were significantly related to hospital readmissions at each of the hospital readmission time frames (within two days, between three and seven days, and between eight and thirty days after hospital discharge). This study identified a relationship between discharge telephone follow-up calls and the parallel hospital readmission time period. However, only discharge telephone follow-up calls within two days were found to decrease the likelihood of hospital readmissions and only hospital readmissions within two days after discharge (OR=0.595). The relationships between discharge telephone follow-up calls and hospital readmissions potentially explains previously mixed results and suggests two potential explanations. One, discharge telephone follow-up calls have a limited relationship to hospital readmissions and a short duration of protective effects preventing hospital readmissions. The second explanation is self-selection bias confounds the relationship between discharge telephone follow-up calls and hospital readmissions. Both explanations suggest future research and clinical practice should focus on exploring bundled transitional care interventions as a method to reduce hospital readmissions.

Adolescent survivors of childhood cancer are a growing population with unique needs as they face a combination of challenges associated with normal development and returning to life after treatment completion (Wakefield et al., 2010). One specific need identified in the research literature includes the effective delivery of transitional care and planning (Hewitt, Greenfield, & Stovall, 2005). It has been suggested that the provision of transition care and planning can help facilitate the shift from one phase of care to another and promote positive transition experiences (National Cancer Institute, 2008). The shift from off-treatment to post-treatment and school reintegration have been identified in the literature as significant transitions for adolescent survivors of childhood cancer (Cabat & Shafer, 2002; MacLean, Foley, Ruccione, & Sklar, 1996). However, limited research has been conducted to explore these transitions from the perspectives of adolescent survivors of childhood cancer. An exploratory, qualitative study was conducted with eight adolescent survivors of childhood cancer between the ages of 14 and 17. A multiple case study research design was used to explore adolescent cancer survivors' perceptions of these transition processes, challenges associated with these transitions, and their beliefs about what supports/services were or would be beneficial during these transitions. Data collected for analysis included questionnaires, transcribed interviews and follow-up meetings, direct observation, documents, and parent feedback. These data were analyzed using a combination of a template organizing style, immersion/crystallization (I/C) approach, and multiple case study strategies (Borkan, 1999; Crabtree & Miller, 1999, Stake, 2005; Yin, 2008). Results indicated that adolescents perceived that change was occurring on some level during the shift from off-treatment to post-treatment and school reintegration but did not necessarily define this time as a "transition." They defined these times in personalized terms that reflected more subtle changes in their lives. The focus was placed on returning to a sense of "normalcy" and capitalizing on opportunities to regain some control over one's life. The improvement and/or absence of treatment residuals along with re-engagement in activities and roles served as signs, or indicators, that life was returning back to "normal" and provided feedback to the adolescent on their transition progress. Conversely, the presence of these signs continued to impact their lives as they restricted participation in desired activities and served as reminders that the effects of cancer and treatment extended beyond treatment completion. In addition to the presence of treatment residuals, fear of relapse also was a concern associated with the transition from off to post-treatment. However, adolescents tended not to let this be the focus of their lives. School reintegration challenges included disruption of school life and routines as well as academic and social concerns. Academic challenges included falling behind/catching up with work, maintaining motivation to do work, and readjusting to school demands and routines. Social challenges included answering peer questions, adjusting to peer awkwardness/discomfort, and managing peer reactions to their physical side effects. These challenges were not perceived by adolescents as sources of significant distress and, often times, they adapted and employed coping strategies to address these concerns in the school setting. Adolescents also varied in their perceived need for transitional care and support during these transitions. Support received during the shift from off-treatment to post-treatment included advice from health care team members as well as relationships with peer cancer survivors across school, community, hospital, and camp settings. They received a variety of academic and social support during school reintegration. Teachers, family members, and peers provided academic support across home, hospital, and school settings. Teachers were a particularly important source of academic assistance. Accommodations and modifications also were provided to these adolescents at school. Peers, teachers, and other school staff provided social support. Based on the findings of the study, suggestions for future research and practical implications are offered.

Happy Hearts Automatic Referral (HHAR) was a program that referred heart failure (HF) patients to Transitional Care (TC) at Banner Health. The purpose of the human subject’s research was to examine the use of the Minnesota Living with Heart Failure® questionnaire (MLHFQ) as a survey instrument to identify moderate quality of life (QOL) in patients living with HF. The most common referral to TC prior to the project was patients with poor QOL. The project explored the influence of earlier referrals to improve QOL for participants living with HF. The MLHFQ was chosen because it is a valid and reliable instrument specific to QOL. The HF population was chosen because the most commonly referred patients to interventions such as TC are those that pose the smallest risk for readmission, have the highest risk of readmission, or have the potential to demonstrate the most significant increase in QOL. By offering TC to patients with moderate QOL, an opportunity existed to reduce advancement into a population that is characteristic of high-risk readmissions. The project identified potential participants, then administered the MLHFQ, and scored it. When scores were between 26 and 45, participants were considered qualified participants for this project. Ideally, the patient would have been enrolled in TC for 30 days and the project would have administered another MLHFQ at completion of 30 days of TC to evaluate a change in QOL; however, due to the short-term nature of this project the TC content and follow-up administration of the MLHFQ was not evaluated. Also, while this project was taking place the TC team at Banner Health was not accepting new patients. A human subject’s research approach was applied and examined the responses to the MLHFQ from a small sample of five moderate QOL participants and described the expected responses for improved QOL if a second MLHFQ was to be administered following TC. Specifically items 1, 7, 8, 14, and 19 were examined to discuss how TC interventions might have improved scores on these items. The project concluded by describing how future cycles should be completed for further research.

No description available.

abstract: Traditional healthcare narratives have set the stage for the care of the population with Severe Mental Illness (P-SMI). Thus far, two prevailing health strategies anchor services for mental illnesses, acute psychiatric care, and mental health, psychosocial rehabilitation. Between these, care transitions mediate PSMI’s needs and their movements from the hospital to the community and home. However, as individuals with Severe Mental Illness (i-SMI’s) leave the hospital, time is short with little opportunity to make known authentic narratives born out of self-evidence. After transitional care, maintenance treatment re-centers these individuals back into a playbook with operatives of pathology and disability and inconsistencies with the narratives on recovery and rehabilitation. This project sought to hear i-SMI’s stories and propose how their experience can be used to create a new “counter” story of transition that empowers these individuals through a better understanding of their “space”: conceptualized here, as all that surrounds them and is dynamic and responsive to their interactions and needs. Underpinning this inquiry is a post-modernist conversation that converges on the critical perspectives in the theory of architecture, philosophy of mind, cognitive science, and the aesthetic practice of psychiatric nursing in the context of transitional care. A qualitative paradigm of narrative repair guides an ethical appraisal, “deprivation of opportunity,” and “infiltrated consciousness,” regarding relational power dynamics that are at work in healthcare master narratives. Narrative findings of this study reveal that identity and agency come together in a personal space of safety born out of a core sense of self, belonging, and control. Space emerges within the self-narrative as physical sensibilities in the constructs of agency and safety, and as with emotional responses, metaphor and meaning can repair personal transitions. The counterstory derived from the narrative findings reveals: Equitable relational dynamics attune social space, the physical environment, and meaning, as a response to the dismissiveness and overcontrolling health professional power. Thus, the journey toward narrative repair from the perspective of i-SMI’s uncovers a deeper counternarrative, Ecosystem of Space: the manifestation of a personal architecture for healing, making a systematic organic-space-experience for the core sense of self to transition and flourish. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2020

Heart failure (HF) affects 6 million Americans, has an expected increasing prevalence in the next 20 years, and has a 5-year mortality rate of 50%. It represents the number one reason for hospitalization in patients older than 65 years. Recent legislation has increased the accountability of care of patients with HF, specifically readmission rates for HF in less than 30 days. This increased focus on HF readmission rates has led many health care organizations to reassess transition-of-care issues (i.e., from home to hospital, from hospital to home) and possible interventions to positively impact these readmission rates. During this process, home health care providers play an integral role and should be aware of possible issues to ensure optimum care for patients.

Heart failure (HF) patients are among the populations with the highest rates of hospital readmission within 30 days of discharge. Because of the 2010 Health Care Reform legislation, healthcare organizations are subject to financial penalty when a patient population exhibits excess readmissions. A significant reason for readmission of HF patients is a gap in the transition of care from hospital to home. The purpose of this doctoral project was to develop a practice guideline of best practices for transitioning HF patients from hospital to home. The transitional care model and care transitions intervention provided the theoretical underpinnings for developing this project. The research question explored whether a transition-of-care guideline would reduce hospital readmission for the HF population. The methodology used to develop the clinical practice guideline was derived from a synthesis of scholarly literature and evidence-based transitional care quality initiatives. Seven interdisciplinary experts involved in HF transition of care used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the development of the practice guideline. The scores of 6 AGREE II domains were summed and scaled to obtain a percentage of the maximum possible score for each domain. Scores showed that the clinical practice guideline was rigorous, high quality, effective in improving transition of care, and has the potential to reduce HF readmission. Positive social changes resulting from this practice guideline include an improvement in patient outcomes, a reduction in readmission rates, and a reduction in the associated financial burden to the hospital.