This paper examines three important and interrelated concepts pertinent to the provision of high quality health care namely care transitions, integration and leadership. The population focus is seniors over the age of sixty-five living within the geographical boundary who access care and services across the continuum. The examination illustrates some of the current challenges, opportunities, barriers and gaps identified in the literature and to draw out pertinent evidence to support future practices. Nurse leaders are well positioned to make a significant contribution to patient-centered care and integration by drawing together the strands of the management of care systems, cross-boundary working and thinking and the effective allocation of resources. / Graduate / 5069

Poorly executed transitions between health care settings can lead to poor outcomes and greater use of health care resources for older adults. Older adults with complex needs often receive care from many health care providers in multiple care settings, and face greater risk of experiencing fragmented care. System navigation roles have been suggested as an innovative strategy to address these challenges, yet there is a lack of consensus on the desired characteristics and effectiveness of the role. The goal of this research is to develop a framework for a system navigation role to enhance coordination of formal and community-based services to older persons with chronic disease through health care transitions. This research gathered information from multiple perspectives and a variety of data sources, including a systematic literature review, focus group interviews and in-depth interviews with a variety of health care consumers and providers. A critical analysis of collected data, using a frame derived from content analysis, sought to understand how older adults navigate the health care system, and subsequently to explore the potential of a “system navigator” role to facilitate successful transitions across care settings. Finally, following a grounded theory approach, a model was empirically derived to reflect what role system navigators may have on the experience of older adults navigating the health care system in Waterloo Wellington. This research study aimed to describe optimal care coordination practices across the continuum of care for complex, high-risk individuals, such as those with chronic disease or hip fracture. Ultimately, this study may lead to improved patient care coordination, safety and satisfaction during transitions and in accessing community services, which may assist patients to achieve a higher quality of life.

Poorly executed transitions between health care settings can lead to poor outcomes and greater use of health care resources for older adults. Older adults with complex needs often receive care from many health care providers in multiple care settings, and face greater risk of experiencing fragmented care. System navigation roles have been suggested as an innovative strategy to address these challenges, yet there is a lack of consensus on the desired characteristics and effectiveness of the role. The goal of this research is to develop a framework for a system navigation role to enhance coordination of formal and community-based services to older persons with chronic disease through health care transitions. This research gathered information from multiple perspectives and a variety of data sources, including a systematic literature review, focus group interviews and in-depth interviews with a variety of health care consumers and providers. A critical analysis of collected data, using a frame derived from content analysis, sought to understand how older adults navigate the health care system, and subsequently to explore the potential of a “system navigator” role to facilitate successful transitions across care settings. Finally, following a grounded theory approach, a model was empirically derived to reflect what role system navigators may have on the experience of older adults navigating the health care system in Waterloo Wellington. This research study aimed to describe optimal care coordination practices across the continuum of care for complex, high-risk individuals, such as those with chronic disease or hip fracture. Ultimately, this study may lead to improved patient care coordination, safety and satisfaction during transitions and in accessing community services, which may assist patients to achieve a higher quality of life.

BACKGROUND:The Affordable Care Act of 2010 proposed maximum penalty equal to 1% of regular Medicare reimbursements which prompted change in how hospitals regard 30-day readmissions. While several hospital to home transitional care models demonstrated a reduction in readmissions and cost savings, programs adapted to population needs and existing resources was essential.METHODS:Focusing on process and outcomes evaluation, a retrospective analysis of a modified community based care transitions program was conducted.RESULTS:In addition to high levels of patient satisfaction with the care transitions program, participants' confidence with self care was significantly improved. Further, the program evaluation demonstrated a 73% reduction in readmissions and an actual Medicare cost savings during the 9-month study period of $214,192, excluding the cost to administer the program.CONCLUSIONS:While there are several transitional care programs in existence, a customized approach is desirable and often required as the most cost effective way to manage care transitions and employ evidence based policy making. This study established some of the pitfalls when implementing a community-based transitional care program and demonstrated encouraging outcomes.

Background: Care transitions are a common and frequently adverse aspect of health care, resulting in a high-risk period for both care quality and patient safety (Coleman, 2003; Forster et al., 2003; Picker Institute 1999; van Walraven et al., 2004; Cook et al., 2000). Patients who have complex care needs and undergo treatment from multiple care settings may be at a greater risk for poor care transitions (Coleman et al., 2004). Using quantitative performance measurement scales is one method that can assess the quality of care transitions, and identify areas for improvement. The psychometric properties of the primary performance measurement scale, the Care Transitions Measure (CTM), have not been rigorously assessed, particularly within a higher risk, medically complex population such as older adults with musculoskeletal (MSK) disorders. Furthermore, despite the negative health implications that can result from poor transitions and the commonality of care transitions among persons with complex care needs, there is a significant dearth of research on this crucial aspect of health care. Methods: This research examines the ability of the CTM to adequately assess the quality of care transitions among a complex population of older MSK rehabilitation patients and explores care transitions from the perspective of the patient and the health care provider. Information was gathered through telephone administration of the CTM to MSK patients after they transitioned from inpatient rehabilitation units to home, and through a series of qualitative key informant interviews with a range of health care professionals in care settings relevant to the care continuum of older MSK patients. Inter-rater reliability, a type of reliability that has never been tested with the CTM, and construct validity were assessed and qualitative analyses were used to examine qualitative information obtained through the CTM administration to patients and through the interviews with health care providers. Results: The CTM demonstrated excellent inter-rater reliability for the overall score (intraclass correlation coefficient = 0.77; p=0.03) despite only fair agreement between each item. Internal consistency of the CTM was high (Cronbach’s alpha = 0.94). The construct validity of the CTM was supported; however qualitative data from the patient and health care provider perspectives suggest additional items should be considered for inclusion. Qualitative information from patients also suggests the need for revisions to the wording of some items and the response options. Health care provider interviews suggest that issues surrounding transitional care are similar regardless of the care setting involved. Conclusions: Although the CTM proved to be reliable, qualitative data suggests that the addition of items should be considered to improve the content validity of the CTM, which would in turn improve its construct validity as well. Recommendations for scale improvement are made, as are recommendations for an alternative scale to assess care transition quality from a health care provider perspective. The results of this study support efforts to improve the outcomes of care transitions, care planning, and the overall quality of life for older rehabilitation patients.

Background: Care transitions are a common and frequently adverse aspect of health care, resulting in a high-risk period for both care quality and patient safety (Coleman, 2003; Forster et al., 2003; Picker Institute 1999; van Walraven et al., 2004; Cook et al., 2000). Patients who have complex care needs and undergo treatment from multiple care settings may be at a greater risk for poor care transitions (Coleman et al., 2004). Using quantitative performance measurement scales is one method that can assess the quality of care transitions, and identify areas for improvement. The psychometric properties of the primary performance measurement scale, the Care Transitions Measure (CTM), have not been rigorously assessed, particularly within a higher risk, medically complex population such as older adults with musculoskeletal (MSK) disorders. Furthermore, despite the negative health implications that can result from poor transitions and the commonality of care transitions among persons with complex care needs, there is a significant dearth of research on this crucial aspect of health care. Methods: This research examines the ability of the CTM to adequately assess the quality of care transitions among a complex population of older MSK rehabilitation patients and explores care transitions from the perspective of the patient and the health care provider. Information was gathered through telephone administration of the CTM to MSK patients after they transitioned from inpatient rehabilitation units to home, and through a series of qualitative key informant interviews with a range of health care professionals in care settings relevant to the care continuum of older MSK patients. Inter-rater reliability, a type of reliability that has never been tested with the CTM, and construct validity were assessed and qualitative analyses were used to examine qualitative information obtained through the CTM administration to patients and through the interviews with health care providers. Results: The CTM demonstrated excellent inter-rater reliability for the overall score (intraclass correlation coefficient = 0.77; p=0.03) despite only fair agreement between each item. Internal consistency of the CTM was high (Cronbach’s alpha = 0.94). The construct validity of the CTM was supported; however qualitative data from the patient and health care provider perspectives suggest additional items should be considered for inclusion. Qualitative information from patients also suggests the need for revisions to the wording of some items and the response options. Health care provider interviews suggest that issues surrounding transitional care are similar regardless of the care setting involved. Conclusions: Although the CTM proved to be reliable, qualitative data suggests that the addition of items should be considered to improve the content validity of the CTM, which would in turn improve its construct validity as well. Recommendations for scale improvement are made, as are recommendations for an alternative scale to assess care transition quality from a health care provider perspective. The results of this study support efforts to improve the outcomes of care transitions, care planning, and the overall quality of life for older rehabilitation patients.

No / Avoidable harm associated with medicines is widespread – particularly at care transitions – and unintended discrepancies in patients’ medicines after discharge from hospital affect more than half of all patients. Patients with heart failure are frequent service users (including readmission to hospital), and susceptible to deficiencies in medicines management. Heart failure is responsible for approximately 5% of medical admissions and the readmission rate within 3 months of discharge may be as high as 50%.[1] The Improving Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) study is an NIHR-funded programme of research in patients with heart failure. The first work package, described here, aimed to map and evaluate current medicines management pathways across care transitions, describing the core characteristics of best practice and effective systems at each stage. Mixed-methods research collecting data centred on patients’ journey out of hospital and back home exploring current practice relating on heart failure. NHS REC approval was obtained (16/NS/0018). Following a process of informed consent, data were collected from patients (n=16) in four health economies in England using semi-structured interviews conducted shortly after their discharge from hospital and again after two and six weeks and included video recording. Non-participant observation was conducted on cardiology wards in the four areas to understand predominant systems employed by the hospitals to deliver information to patients and to primary care. Interviews with staff in hospitals and primary care explored policy, practice and systems across the transition. Data were analysed using integrative ‘parallel mixed’ analysis. Several themes emerged that described the resilience of the system that manages patients’ medicines across the whole pathway. Spatial dimensions – including local working conditions – impacted on staff who managed transfers. Process efficiencies and effectiveness, including the degree of staff training and policy awareness, both enhanced and hindered communication with patients and health care professionals (HCPs) in primary care. The system did not allow staff to assess the impact of the management of medicines at discharge across the transition into primary care. Patients themselves were found to have different levels of knowledge and confidence in their medicines once back at home and, where their pathway included this, to value the care co-ordination functions of heart failure nurses. Primary care staff operated varying systems for managing discharge communication and implementing recommendations and some reported positive outcomes from integration of practice pharmacists into the system. To our knowledge this is the first UK study of medicines management along the patient’s journey from hospital into primary care for patients with heart failure. A whole pathway analysis has enabled a detailed understanding of resilience in each part of the healthcare system. These findings will be used in the co-design of an intervention to improve medicines management in the next phase of the research.

Medication reconciliation is a systematic and comprehensive review of medication regimens during care transitions aiming to prevent adverse drug events. Poorly executed transitions negatively impact patient welfare and cause financial burden. Medication-related problems (MRPs) experienced during transitions to an assisted living facility (ALF) were evaluated. Data was collected from pharmacy records for transitions to an ALF over three months, including demographics, medications, potentially inappropriate medications, and MRPs. MRPs were categorized and summarized using descriptive statistics. Forty-five patients (71% female) experienced 59 transitions. Average age was 85.6 years. Median length of stay away from the ALF was three days. There were averages of 18.3 pre-transition medications, 12.5 medications in the discharge orders and/or upon ALF admission, and 15.9 final medications. 979 MRPs were identified, mostly no indication documented, followed by underuse, overuse, and non-adherence. Many of the identified MRPs are potentially preventable. Interventions are needed to reduce MRPs during ALF transitions.

Thesis advisor: Rosanna DeMarco / Abstract Testing the Efficacy of A Nurse-Led, Patient Self-Management Intervention to Decrease Rehospitalization in Older Adults Merrily Evdokimoff, Ph.D. Rosanna DeMarco, Ph.D., Committee Chair Rehospitalization rates of 20% within 30 days of hospital discharge and 27% within 60 days are one of the highest strains on the federal Medicare budget. The Center for Medicare and Medicaid Services (CMS) has responded by imposing financial disincentives in reimbursement regulations directed to those providers deemed responsible for preventable rehospitalizations. Identifying cost-effective interventions that are appropriate for individuals with chronic illnesses that may be provided within the current home health care system of reimbursement is critical. The purpose of this quasi-scientific intervention study was to test the efficacy of a cost-effective, nurse-led intervention to decrease rehospitalizations of community dwelling older adult Medicare beneficiaries receiving certified home health services following an acute care hospital admission. The intervention was based on Eric Coleman's Care Transition Intervention SM utilizing a personal health record, patient goal setting, and knowledge of "red flags" or changes in condition. Coaching by the home care nurses was added to Coleman's intervention to facilitate support of patient self-management. Three home care agencies, 60 clinicians and 87 patients participated in the study. Findings demonstrated a lower rate of readmission to the hospital in patients receiving the intervention. However, it was not statistically significant. Significant differences were noted between the intervention and the comparison groups including more married or partnered members and higher Case Mix Weight (CMW) or acuity score within the intervention group. Among the rehospitalized participants, provision of a greater number of skilled nursing visits was found. Future replication of the study should include a larger sample and greater time for education of the clinical staff. Inclusion of therapists and productivity adjustments for participating staff during initiation of study is also needed. Further examination of the role of depression in rehospitalization with a larger sample would provide greater understanding of the role depression plays in self-management and rehospitalization. / Thesis (PhD) — Boston College, 2012. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Improving the safety of medicines management when people leave hospital is an international priority. There is evidence that poor co-ordination of medicines between providers can cause preventable harm to patients, yet there is insufficient evidence of the structure and function of the medicines management system that patients experience. This research used a mixed-methods social network analysis to determine the structure, content and function of that system as experienced by patients. Patients’ networks comprised a range of loosely connected healthcare professionals in different organisations and informal, personal contacts. Networks performed multiple functions, including health condition management, and orienting patients concerning their medicines. Some patients experienced safety incidents as a function of their networks. Staff discharging patients from hospital were also observed. Contributory factors that were found to risk the safety of patients’ discharge with medicines included active failures, individual factors and local working conditions. System defences involving staff and patients were also observed. The study identified how patients often co-ordinated a system that lacked personalisation and there is a need to provide more consistent support for patients’ self-management of medicines after they leave hospital. This could be achieved through interventions that include patients’ informal contacts in supporting their medicines use, enhancing their resilience to preventable harm, and developing and testing the role of a ‘medicines key worker’ in safely managing the transfer of care. The role of GP practices in co-ordinating the involvement of multiple professionals in patient polypharmacy needs to be further explored.