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.

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Over 5 million older adults with diabetes are hospitalized each year. Though typically not the index condition that leads to hospitalization, diabetes control often decompensates during the course of an admission and necessitates changes in home self-management plans. The specific transitional care needs of older adults with diabetes have been largely unstudied. Transition theory provided the guiding framework for this research and proposes that each transition is a complex process created by the continuous interaction of personal, community, and societal-level conditions that facilitate or inhibit the health of a transition. Hospitalization has been described as a series of three successive, interrelated transitions. The aims of this study were to determine whether personal and community transition conditions impacted the early and intermediate post-discharge outcomes in a sample of older adults with diabetes. A simultaneous quantitative/qualitative mixed method design was used to identify factors that impacted the home recovery transition experiences in a sample of 96 older adults with a mean age of 75 years. A supplementary content analysis of free-response data gathered during administration of the Post-Discharge Coping Difficulty Scale (PDCDS) clarified difficulties encountered by elders and caregivers during in the first 30 days following discharge. Four overarching themes emerged: "the daily stuff is difficult"; "engineering care at home is difficult"; "life is stressful" and "difficulty managing complex health problems". Difficulties managing a complex medication regimen, regulating blood glucose, and managing a non-diabetes chronic health problem such as hypertension and chronic lung disease were subthemes that emerged during qualitative data analyses. These subthemes were transposed into discrete nominal level variables and served as additional indicators of post-discharge coping difficulty in the descriptive correlational core component of the research project. Participants in this study who experienced an event of recidivism had lower pre-discharge assessments of readiness on the Readiness for Hospital Discharge Scale (RHDS) (t = 2.274, df = 48, p =.028). Higher PDCDS scores were observed in patients who experienced an event of recidivism within 30 days of discharge (t = -3.363, df=24.7, p = .003) and also in respondents who described difficulties with managing medications, controlling diabetes, and managing a chronic illness. Binary logistic regression was used to identify factors that may predict recidivism risk. No condition-specific predictor variables were identified. A statistically significant three-variable model (X2 = 26.737, df = 3, p < .001) revealed that PDCDS scores at 7 days (Wald X2 =3.671, df = 1, p =.050), PDCDS scores at 30 days (Wald X2 = 6.723, df = 1, p =.010), and difficulty managing a chronic health condition (Wald X2 = 8.200, df = 1, p =.004) were predictive of an event of recidivism within 30 days of discharge. Difficulty managing a chronic health problem other than diabetes was particularly predictive of recidivism. The nurse's skill in delivering discharge education was a factor in limiting early postdischarge difficulties. Elders with residual information needs on the day of discharge as measured by scores the Quality of Discharge Teaching Scale (QDTS) reported a lower readiness for discharge (r = -.314, p = .003) and experienced greater difficulties with early post-discharge coping (r =. 288, p = .023). Greater satisfaction with the post-discharge transition was noted in participants with higher QDTS scores (r = .444, p < .001). Outcomes of the hospital-to-home transition experience were impacted by a variety of personal, hospital, and community factors. Findings of this study suggest that there is a need to better understand the sequential nature of the home recovery transition and the fluid needs of older adults during this high-risk phase of care. The environments in which older adults receive post-discharge care are complex and need to be thoroughly considered when planning the postdischarge transition. Metrics of institutional performance of transitional care practices need to extend beyond events to recidivism and include evaluations of post-discharge coping and transition satisfaction. The nurse as the primary provider of discharge education has the potential to significantly promote positive transition outcomes for older adults and their family care providers.

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Background: Transitions out of hospital result in poor outcomes for older people. Research investigating transitions for care home residents living with dementia is limited, even though such residents often have multi-morbidities and frequently use hospital services. Nurses are key care providers. Yet their perspectives on optimising care for people living with dementia transferring back to their care home remains under explored. Aims: This qualitative descriptive study explores hospital and care home nurses’ perspectives on how they optimise care for people living with dementia who transfer from hospital back to their care home, and the alignment of this care with best practice. Methods: Thirty-three nurses participated in either semi structured interviews or focus groups. Data were analysed using qualitative content analysis. Results: Nurses described four roles: 1) exchanging information, 2) assessing and meeting needs, 3) working with families and 4) checking and organising medication. They described care home residents with dementia as having distinct needs and variation in how they provided care. Nurses described interdependent roles, but care home nurses were often excluded from involvement in planning resident’s care on return and were not fully recognised as members of wider healthcare teams. Facilitators for optimising care include: nurses understanding the principles of dementia care, nurse leadership and autonomy, having positive relationships between hospital and care home nurses and opportunities for joint working. The care practices nurses described broadly aligned with best practice. Implications: Hospital and care home nurses require joint working opportunities to understand their roles and build relationships. Care home nurses’ status needs to be addressed with action to support their integration into the wider healthcare system. / Alzheimer’s Society (UK)

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Purpose: Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of healthcare through temporary follow-up after hospital discharge. This study describes the approach and outcomes of two transitional care programs: one is provided by masters-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPC). Existing research has shown that transitional care programs with intensive follow up reduce hospitalizations, emergency room visits, and costs. Few studies, however, have included side-by-side comparisons of the efficacy of transitional care programs varying by health care providers or program focus. Design: This is a retrospective cohort study comparing the number of Emergency Department (ED) visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included difference in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program 9/2014 ' 12/2014 were analyzed (n=98). The average age of participants was 69 and they were 65% female. Data was collected from patients from the PC program from 9/2014 to 4/2015 (n=71). Thirty participants died within 120 days after the intervention and were excluded, the remaining 41 were included in the analysis. Participants had an average age of 81 and were 63% female. Methods: For the CNS program, a secondary analysis of existing data was performed. For the PC program, a review of patient charts was done to collect encounters data. A Wilcoxon Matched-Pair Signed-Rank test was performed to test for significance. Findings: Patients in the CNS intervention had significantly fewer ED visits (p Conclusions: Both transitional programs have value in decreasing health care utilization. The CNS intervention had a more significant effect on ED visits for their target population than the PC program. Further study with randomized control trails is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed.

This thesis is an exploration of the perspectives of recipients and providers of health and criminal justice services about the transitional support needs of arrestees and remand prisoners, leaving short-term custody. The study implements Constructive Grounded Theory Methods, underpinned by the Network Theory of Social Capital as the theoretical framework. Forty-two semi-structured interviews were conducted, with five participant groups; service users (arrestees/remand prisoners), family/carers, mental health staff (criminal justice liaison and mental health in-reach, community mental health teams), criminal justice staff (police/prison officers) and mental health commissioners. Participants provided unique perspectives about the health and social support, available at the transitional points of leaving short-term custody. This was supported by the construction of 11 sociograms for service users, in both arrest (n=5) and remand (n=6) situations, to highlight the availability and functionality of support networks. Transitions are particularly problematic in relation to linking offenders with appropriate community-based mental health services. The over-arching constructed grounded theory is a need for a culture shift within health policy and practice to refocus on transitional care planning to optimise continuous care pathways. Associated themes include ‘lack of practical assistance’, ‘lack of crisis support’, ‘returning to the security of prison’ and ‘poor transition planning’. Critical Time Intervention, a variant of case management has demonstrated benefits when applied to mental health and offender populations, transiting from hospital and prison settings. The programme contains all the components of service that service users, carers and staff identified as important to effectively support transitions from short-term custody to the community.

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