Background/Objectives: Gaps in care due to the movement of patients between health settings and/or practitioners, known as transitions of care (TOC), may contribute to second stroke or TIA events. The elements that impact TOC in the stroke/TIA population have not been fully elucidated. The purpose of this study is to identify key elements of a Doctor of Nursing Practice-led TOC model that could be used to develop and evaluate a TOC program for the stroke/TIA population. Design: A descriptive study was performed to 1) identify elements that may affect transitions of care using a stroke database and post-discharge phone surveys and 2) based on information from Aim 1, propose a DNP-led TOC model specific to the stroke/TIA. Setting: An urban primary stroke center in the southwest United States. Participants: All patients in the GWTG®-stroke database from May 1 - December 31st, 2012 and patients who consented at discharge from the stroke unit following a stroke or TIA. Measurements: Patient demographics including: length of stay (LOS), age, race, ethnicity, comorbidities, insurance, discharge status, thirty-day readmission rate, and follow up survey. Results: Patient data (n=276) from GWTG®-stroke database was obtained. Average LOS was 7.81 +/- 11.15 days. The majority of patients were greater than age 65 (59%); 53% relied on Medicare support; those age 50-59 (21%) were most likely to be uninsured (47%). Fifty-one percent were discharged directly home, 48% of those were referred to outpatient rehab services. Two-thirds received rehabilitation services during hospitalization. Eight patients experienced a subsequent hospital readmission; two of those had a repeat stroke event. Although patients reported understanding their discharge instructions, their perception of ongoing care was poor. Conclusion: Key elements of a TOC model specific to the stroke and TIA patient population could include: patient surveillance, comprehensive care planning, follow-up, stroke education and point of contact. Advanced practice nurses have been successful in leading such programs, and a DNP-led model providing continuity of care would support the transition of an effective model into clinical practice.

INTRODUCTION: While transitions of care (TOC) programs are known to decrease readmissions for heart failure (HF), significant policy and resource challenges inhibit the implementation of hospital based TOC programs, thus novel models of TOC are urgently needed. The purpose of this study is to evaluate the need and readiness of a private practice based TOC program led by DNP-prepared nurse practitioners. METHODS: In this descriptive study, cardiology providers from a private practice in the Southwest (N=14) participated in a survey on HF TOC. The practice’s electronic medical records (EMR) database was queried for patient demographic data along with other HF measures (N=3175). RESULTS: There were 1,827 females (57.5%) and 1,348 males (42.5%) with the mean age being 75.1 years +/-11.1. The 70-79 year age bracket represented 41.0% of all HF patients. The most common ICD-10 code for HF was [I50.32] Chronic Diastolic Congestive Heart Failure (N=986), which translates into 31.0% of the total HF population. Almost 30% of the providers (N=4) acknowledge that they never document their HF readmissions in the practice’s EMR. Nearly 65% percent of respondents “strongly agree,” that HF patients discharged from the hospital require a specific plan of care, while 86% of providers (N=12) either “somewhat agree” to “strongly agree” in the need for a TOC program for HF patients within their cardiology practice. Over 71% (N=10) of the providers “strongly agree” with a DNP-led TOC program for HF. CONCLUSION: This study provides encouraging results for the future implementation of a cutting edge private cardiology practice based TOC program for HF in Tucson, AZ. The study results clearly indicate the need and readiness for the Tucson-based private practice TOC program for HF. The DNP prepared nurse practitioner is thoroughly prepared to take the lead in designing, implementing and evaluating such a program and this unique role was supported by the practice. Importantly, the results of this study may provide the foundation for future studies examining the effects of private practice based TOC programs for HF.

Objectives: Transitions of care (ToC) for a high-risk neonatal population, and in some cases inappropriate and early discharge, can have important implications for community and broader population health. As it is a key indicator of the efficiency of the system of health services, the ease of ToC has been a priority for improving care outcomes across all settings in our nation’s healthcare system. Research shows that inappropriate discharges can lead to negative outcomes for patients and their families, health professionals, and the health system. Collaboration amongst the health care professionals, the community, and the patient’s family is needed for an efficient transition. This research examined how interprofessional collaboration (IPC) can act as a catalyst for efficient and effective ToC from a high-risk neonatal unit to care back in the community. Approach: Twelve infants were observed from their admission on the Neonatal Intensive Care Unit (NICU) until their discharge home. The 12 consisted of four patients discharged directly home, four to another unit within the same hospital, and four to another institution. Stage one involved a document analysis of documents related to ToC policy on the NICU. Stage two involved observation. Stage three involved interviews with healthcare professionals (HCPs) in the hospital and community (n=30) and family members (n=12). Stage four consisted of deliberative workshops with the hospital management and research participants to share the results and obtain their feedback. Results: Including parents early in the ToC planning process helps parents feel they’re a part of the interprofessional care team, in-charge of their infant’s care and thus better equipped mentally to handle their infant’s ToC. Knowing early on their infant’s discharge plan allows parents the opportunity to ask questions regarding caring for the infant at home or to meet the new healthcare team at the new site (hospital/floor) prior to the transfer. Mechanisms need to be in place to ensure that communication regarding ToC is consistent and clear to and between all HCPs whether in the hospital (e.g. bedside nurse) or in the community (e.g. family doctor). Having a clear understanding of what information should be transferred during a ToC will prevent unnecessary tests and misunderstandings. Increasing HCPs’ knowledge of available community resources will aide in transitioning infants to community care and thus freeing bed space and decreasing unnecessary costs at the hospital (i.e. A feeding and growing baby can be weighed by family doctor or Rapid Response Nurse and not necessarily the neonatologist). A consistent ToC policy across all NICUs would also be beneficial to ensuring a smoother ToC of infants. Conclusion: It is believed that communication and education in an interprofessional context is critical for more efficient and effective ToC of neonates.

Transition of care refers to the movement of patients between health care settings; it occurs each time patients move between providers within the same setting or between settings based on the patient's acute or chronic health care needs. Care transition includes the efficient and accurate exchange of information needed to provide high-quality continuity of care. A rural community hospital in in the northeastern region of the United States has a skilled nursing facility and an acute care hospital on one campus. This project focused on the development of a clinical practice guideline (CPG) for the hospital to improve communication during transitions of care. The Iowa model of evidence-based practice informed the development of the guideline. A project team developed the CPG. Five multidisciplinary experts reviewed the CPG using the appraisal of guidelines for research and evaluation (AGREE II) evaluative tool. Results for the 6 domains of the AGREE II tool showed experts' agreement greater than 90% with the guideline as developed. The creation of a CPG to improve communication during care transition could benefit nurses with improved clinical decision making and patients with improved outcomes. The CPG could impact social change by supporting the application of the principles of evidence-based nursing practice, which could result in improved care and patient outcomes.

Improving medication management at transitions of care is a national and international priority. People with dementia, who transition between hospitals and care homes, can be at an increased risk of adverse events, harm and costly re-hospitalisation. There is limited research which examines factors which may influence the quality and continuity of medication management in this context, particularly in the UK. This research uses a systems approach to explore the factors which may influence the quality and continuity of medication management when people, with dementia, move between the care home and hospital setting. This multi method, multi-phase study included interviews with hospital staff, care home staff, residents with dementia and relatives and examination of policies and documents used to support medication management at transition. Overall, policy recommendations and implementation strategies to support medication management at transition were limited. Residents, staff and relatives emphasised the importance of administration routines and preferences, but there were no strategies to support the communication of this information. Procedures, tools and training to support care homes based medication reconciliation was also limited. Residents and relatives were rarely involved in medication management due to limited resources and decision making. This sustained, rather than challenged, the power imbalance between residents and staff. Better defined roles and integrated processes which take account of the needs of this transition may help residents, relatives and care home staff to feel valued and empowered to provide information which supports person-centred medication management and boost resilience by helping to identify medication errors or adverse events. / Alzheimer’s Society

A mixed methods approach was used for this study. The setting was a low-income, subsidized housing apartment building for community-dwelling older and younger disabled adults identified as a health care hot spot due to high rates of ambulance use. The study purpose was to identify reasons for ED use and problems during transition from ED to home, predictors of zip code 23220 (health care hot spot) in emergent and non-emergent ED visits, and predictors of total ED costs in community-dwelling older adults living in a health care hot spot. Semi-structured interviews with residents who used the ED, an existing database from an interprofessional care coordination and wellness program for residents, and community-dwelling older adults’ electronic medical record and billing data from 2010-2013 ED visits from an academic medical center were used. The Gelberg-Andersen Behavioral Model for Vulnerable Populations was utilized. A total of 14 interviews were conducted. Themes related to ED use included: high use of ambulance services, timely use of the ED or attempt at self-care, and lack of communication with a health care provider prior to ED visit. Themes related to care transitions were: delay in medication receipt after discharge, lack of a current medication list and personal health record, PCP follow-up instruction, and education on warning signs of a worsening condition. The interprofessional program’s care coordination activities were education, disease monitoring, referral for PCP visit, and discrepancy reconciliation. A total of 7,805 ED visits were included, of which 3,871 were non-emergent and 1,179 were emergent. Common primary ED visit diagnoses were chest pain and abdominal pain. White race, a Charlson Comorbidity Index score of 3, and a total disease count of 10 or more were significant predictors of zip code 23220 in non-emergent ED visits. White race was a significant predictor of zip code 23220 in emergent ED visits. Significant predictors of total ED costs were white or other race, arrival by ambulance, emergent visit type, and year of visit. Pain was a common reason for ED use. Care transition problems related to medication management and follow-up care indicate an area for targeted interventions after ED discharge.

This project focused on developing a more complete picture of the event that most often occurs when an older adult’s health care needs can no longer be met in the community setting; the transition from home into a new long-term care (LTC) environment (i.e., assisted living [AL] or residential care [RC]). Informed by a life course perspective (Elder, 1998; Marshall, 2009) and by the health service utilization framework (Andersen, 1995; Andersen & Newman, 1973), this thesis explores the relationship between service users and their social and service contexts in the Fraser Health (FH) region of British Columbia. Employing a multi-method research design, two studies, one quantitative and one qualitative, were conducted. The goal of the quantitative study was to draw attention to individual, social, and structural factors (e.g., age, gender, marital status, presence of/relationship to primary caregiver, and health variables) that influence the transition from home and community care (HC) services to either AL or RC among older LTC clients (age 65+; N=3233) in three geographic areas (urban, suburban, and rural). Findings revealed that marital status, income, functional disability, and cognitive performance influenced type of transition for both rural and urban clients. However, gender, medical frailty (i.e., CHESS score), number of chronic conditions, and total hospitalizations emerged as significant among clients in suburban areas. The goal of the qualitative study was to draw attention to the role of family caregivers in the care transition context. Employing thematic analysis, this study drew on a sample of 15 semi-structured interviews with family caregivers who had helped a family member transition from home into a new care environment in FH. Out of this work, a conceptual framework was developed inductively to illustrate three key phases that seemed important in their care journey: ‘Precursors leading to transition’, ‘Preparing to transition into new care environment’, and ‘Post-transition: Finding a new balance Three overarching themes, labelled with direct quotes (in vivo), were also developed to capture how family caregivers made sense of their roles and responsibilities: “I’m just her daughter” / “I’m just his wife”, “Just go with the flow”, and “There wasn’t a door I didn’t try to open”. Overall, the findings from both studies draw attention to the importance of generating a better understanding of the local service and social contexts. Implications for social policy are addressed and highlight the need to continue to invest in efforts aimed at supporting older adults to remain in the community as long as possible, including ensuring appropriate forms of care are available and adequate resources for family caregivers are offered. / Graduate

As the population ages, policymakers struggle to cope with the increasing demands for home care and institutional long-term care. This thesis project focuses on factors associated with the transition from home to institutional care for people with dementia. Using health administrative data at a population level, we construct a multivariable model that estimates the time between home care initiation after dementia diagnosis and placement in a long-term care home. From the model, we identify protective factors that allow people with dementia to remain at home for longer, with a particular emphasis on the health workforce and the contribution of formal and informal caregivers to delaying the transition from home to institutional care. Together, these results inform policymakers in capacity planning and in determining where investments should be targeted to maintain people with dementia at home, along with the associated health workforce implications.

During transitions of care, great opportunity exists for miscommunication, poor care coordination, adverse events, medication errors and unnecessary healthcare utilization costing billions of dollars annually. An Interprofessional Transitions of Care (IPTC) clinic was developed utilizing a Family Medicine team that included physicians, nurses, a clinical social worker, and a clinical pharmacist. The purpose of this study was to determine if utilization of an IPTC clinic prevented hospital readmission, and to identify factors that predict most benefit from an interprofessional approach to transitions of care. A retrospective chart review of 1,001 patients was completed. A treatment group (TG) of 501 patients were offered IPTC clinic appointments following hospital discharge. A control group (CG) of 500 patients were hospitalized and received traditional follow-up prior to development of the IPTC clinic. Traditional follow-up typically consisted of an automated appointment reminder and a physician office visit. Outcomes assessed included 30-day hospital readmission of TG versus CG, and whether patient characteristics predisposed specific patient groups to attend IPTC appointments or benefit more from IPTC participation. Compared with CG, patients who completed an IPTC appointment were 48% less likely to be readmitted to the hospital within 30 days. Patients with congestive heart failure and cellulitis particularly benefited from IPTC. Telephone contact within two business days of discharge was the greatest predictor of patients attending an IPTC appointment. These results demonstrate that an interprofessional approach to transitions in care effectively addresses this high risk for error and high cost time in the continuum of care.

Yes / Multiple changes are made to older patients' medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post-discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life. To explore the experiences of older patients and their family carers as they enacted post-discharge medicines management. Semi-structured interviews took place in participants' homes, approximately two weeks after hospital discharge. Data analysis used the Framework method. Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty-seven participants aged 75 plus who lived with long-term conditions and polypharmacy, and nine family carers, were interviewed. Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health-care professionals about medicines changes often lacked detail, which disrupted some participants' knowledge and medicines management capabilities. Participants used multiple strategies to support post-discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied. Participants experienced gaps in their post-discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines-related care during the hospital-to-home transition. / This work was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). This independent research is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0317-20010).