A nurse-led, telehealth transitional care intervention for people with multimorbidity: a feasibility study

To examine the prospective association between device-measured sedentary behavior and risk of emergency department (ED) or hospital readmission among patients with suspected acute coronary syndrome (ACS), independent of moderate to vigorous physical activity (MVPA). 536 patients who were evaluated for suspected ACS were enrolled between September 2016 and March 2020. Sedentary behavior and MVPA were measured via wrist-worn GENEActiv accelerometer for 30-days post-discharge. ED and hospital readmissions between 30 and 365days after discharge were ascertained by chart review and patient contact. Over 1-year follow-up, 198 patients were readmitted. Sedentary behavior was associated with an increased risk of ED or hospital readmission after adjusting for covariates and MVPA [Tertile 1: REF, Tertile 2: HR = 0.89 (95% CI: 0.60-1.32), Tertile 3: HR = 1.73 (95% CI: 1.16-2.58), P-trend = 0.003]. In joint association analyses, high sedentary behavior in combination with low MVPA was associated with the greatest risk of ED or hospital readmission [HR = 2.36 (95%: CI: 1.52-3.68)] compared to the referent group (low sedentary behavior/high moderate to vigorous physical activity). Sedentary behavior was associated with an increased risk of ED or hospital readmission between 30 and 365days after discharge among patients with suspected ACS, independent of MVPA. These findings suggest reducing sedentary behavior should be considered as a modifiable therapeutic target to reduce subsequent ED or hospital readmission in patients following a suspected ACS.

consideration of the first hospital re-admission only and failure to take account of previous hospital stays, which are the two significant limitations when studying risk factors for hospital re-admission. The objective of the study was to use appropriate statistical models to analyse the impact of previous hospital stays on the risk of hospital re-admission among older patients. an exhaustive analysis of hospital discharge and health insurance data for a cohort of patients participating in the PAERPA ('Care Pathways for Elderly People at Risk of Loss of Personal Independence') project in the Hauts de France region of France. All patients aged 75 or over were included. All data on hospital re-admissions via the emergency department were extracted. The risk of unplanned hospital re-admission was estimated by applying a semiparametric frailty model, the risk of death by applying a time-dependent semiparametric Cox regression model. a total of 24,500 patients (median [interquartile range] age: 81 [77-85]) were included between 1 January 2015 and 31 December 2017. In a multivariate analysis, the relative risk (95% confidence interval [CI]) of hospital re-admission rose progressively from 1.8 (1.7-1.9) after one previous hospital stay to 3.0 (2.6-3.5) after five previous hospital stays. The relative risk [95%CI] of death rose slowly from 1.1 (1.07-1.11) after one previous hospital stay to 1.3 (1.1-1.5) after five previous hospital stays. analyses of the risk of hospital re-admission in older adults must take account of the number of previous hospital stays. The risk of death should also be analysed.

The effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among Chinese kidney transplant recipients: A randomized controlled trial

There is solid evidence that Social Determinants of Health (SDoH) contribute to poor patient health outcomes after hospitalization and that transitional care can prevent these adverse outcomes. However, using a standardized strategy for transitional care intervention will result in missed opportunities to enhance positive outcomes for older individuals with chronic illnesses, particularly minority older adults who are greatly affected by adverse SDoH (e.g., food insecurity). Hence, for any transitional care intervention to be effective, it must be adaptable to identify and tackle SDoH issues. In this paper, using the lens of the five domains of the Health People 2023 SDoH framework (Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context), we demonstrate how SDoH can be integrated into an evidence-based transitional care intervention to prevent adverse events such as avoidable emergency room visits and rehospitalization and enhance positive outcomes for patients as they transition from hospital to home or other health care settings. Specifically, we highlight opportunities for the transitional care intervention teams and the health care systems to identify and mitigate SDoH factors using the Transitional Care Model intervention (TCM), a practical and adaptable transitional care intervention, to reduce adverse events and reduce health disparities and health inequities.

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research. ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

The objective of this study was to design and develop a predictive model for 30-day risk of hospital readmission using machine learning techniques. The proposed predictive model was then validated with the two most commonly used risk of readmission models: LACE index and patient at risk of hospital readmission (PARR). The study cohort consisted of 180,118 admissions with 22,565 (12.5%) of actual readmissions within 30days of hospital discharge, from 01 Jan 2015 to 31 Dec 2016 from two Auckland-region hospitals. We developed a machine learning model to predict 30-day readmissions using the model types XGBoost, Random Forests, and Adaboost with decision stumps as a base learner with different feature combinations and preprocessing procedures. The proposed model achieved the F1-score (0.386 ± 0.006), sensitivity (0.598 ± 0.013), positive predictive value (PPV) (0.285 ± 0.004), and negative predictive value (NPV) (0.932 ± 0.002). When compared with LACE and PARR(NZ) models, the proposed model achieved better F1-score by 12.7% compared with LACE and 23.2% compared with PARR(NZ). The mean sensitivity of the proposed model was 6.0% higher than LACE and 41% higher than PARR(NZ). The mean PPV was 15.9% and 14.6% higher than LACE and PARR(NZ) respectively. We presented an all-cause predictive model for 30-day risk of hospital readmission with an area under the receiver operating characteristics (AUROC) of 0.75 for the entire dataset. Graphical abstract.

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers. This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered. Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses. Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

This study aims to explore the combined effect of frailty and the estimated glomerular filtration rate (eGFR) and non-elective hospital readmission in elderly inpatients. A total of 400 elderly patients were selected. The Fried scale was used to assess frailty. The patients were divided into a non-frailty group and a frailty group. They were divided into a normal eGFR group and a eGFR decreased group. Finally, the patients were divided into the following four groups: Group A (no frailty + eGFR normal); Group B (no frailty + eGFR decreased); Group C (frailty + eGFR normal); and Group D (frailty + eGFR decreased). The results of the follow-up survival analysis showed the non-elective hospital readmission within 6 months of discharge. Group A, Group B, Group C, and Group D had an incidence of 21%, 26%, 24%, and 36%, respectively. The Kaplan-Meier curves showed the event-free survival rates of Group A and Group C were higher than that of Group D, and there was no significant difference between Group B and Group D. The risk of non-elective hospital readmission within 6 months in patients with a decreased eGFR was 1.777 times higher than that in patients with a normal eGFR [95% confidence interval (CI): 1.001-3.154], while the risk of non-elective hospital readmission within 6 months in frail patients and non-frail patients did not differ significantly. The multivariate Cox regression analysis showed that the risk of non-elective hospital readmission in Group D was 2.295 times higher than that in Group A (95% CI: 1.096-4.810), and the difference was statistically significant. The risk of non-elective hospital readmission in Group B was 1.401 times of that in Group A (95% CI: 0.665-2.953), while that in Group C was 91.8% (95% CI: 0.403-2.092), but the differences were not statistically significant. A decline in eGFR is associated with non-elective hospital readmission in elderly inpatients within 6 months; however, frailty is not associated with non-elective hospital readmission. The combined effect of frailty and eGFR in elderly inpatients is related to non-elective hospital readmission.

Background: A real-time electronic health record (EHR) predictive model that identifies older patients at risk for readmission and mortality may assist the health care team in improved patient care.

To identify patient groups at risk for unplanned hospital re-admissions and risk factors for re-admission. We analysed the Belgian Hospital Discharge Dataset including data from 1 130 491 patients discharged in 2008. Patient and hospital factors contributing to re-admission rate were analysed using a multivariable model for logistic regression. The overall unplanned re-admission rate was 5.2%. Cardiovascular and pulmonary diagnoses were the most common reasons for re-admission. We found that 10.4% of all re-admissions were due to complications. A high number of previous emergency department (ED) visits proved to be a predictor for re-admission [odds ratio (OR) for patients with at least four ED visits in the past 6 months 4.65; 95% confidence interval (CI) 4.25-5.08]. Patients discharged on Friday (OR 1.05; 95% CI 1.01-1.08) and patients with a long length of stay (OR 1.19; 95% CI 1.15-1.23) also had a higher risk for re-admission. Patients with short lengths of stay were not at risk for re-admission (OR 0.99; 95% CI 0.95-1.02). Actions to reduce re-admissions can be targeted to patient groups at risk, and should be aimed at the caring for chronic cardiovascular or pulmonary diseases, preventing complications and multiple ED visits, and ensuring continuity of care after discharge, especially for patients discharged on Friday.

Objective We aimed to evaluate the effect of transitional care intervention on the quali-ty of life for patients with chronic heart failure. Methods The randomized controlled trials (RCT) on tran-sitional care intervention were researched by the database of Pubmed, Medline and CBM. The influencing factors of transitional care intervention of quality of life of patients with heart failure were analyzed using Stata 12.0 software. Results 12 articles were enrolled in this study. The quality of life in the experimental group was significantly enhanced when comparing with the control group in the total level, physical and emo-tional aspects, SMD values were -0.62, -0.72 and -0.50, the difference had statistical significance. Conclusions Transitional care intervention can improve the quality of life for patients with chronic heart fail-ure and the best effect can be obtained on the 3rd to 6th months. Key words: Transitional care; Heart failure; Quality of life; Meta-analysis

Introduction There are numerous effective transitional care interventions yet they are not routinely implemented. Furthermore, few interventions exist for older adults with dementia. A first step in developing effective interventions for dementia patients and increasing intervention uptake for all patients is to understand the current delivery process of transitional care. Methods A mixed methods study using an explanatory multiphase design was conducted. Guided by provider interviews, medical charts were reviewed to collect information on the day-to-day transitional care being delivered to older adults. Then providers were interviewed again to assess the accuracy of those results and provide context. Results The medical charts of 210 older adults (126 with dementia and 84 without) were reviewed and nine providers representing various professional roles including social work, nursing, and case management were interviewed. Social workers and case managers were primarily involved in discharge planning, communicating with providers outside the hospital, advanced care planning, providing social and community supports, and making follow-up appointments. Registered nurses were the primary providers of patient education and medication safety while physicians were primarily involved in ensuring that necessary information was available in the discharge summary and that it was available in the chart. Discussion This study found distinct patterns in the delivery of transitional care, including the unique roles nursing, social work, and case management have in the process. Furthermore, these patterns were found to differ between patients with and without dementia. These findings are both consistent and inconsistent with the existing literature on transitional care interventions.

To describe the causes of 30-day hospital readmissions among high-risk older adults during implementation of a multicomponent care transitions program. Secondary analysis of data from the evaluation of a multicomponent care transitions program for hospitalized high-risk older adults. A 400-bed community teaching hospital. Patients aged 75 and older admitted to non-intensive care unit beds who met specific criteria for high risk of complications and hospital readmissions. The intervention group included 202 patients, of whom 37 were readmitted to the hospital as an inpatient or on observation status within 30 days of discharge. Root-cause analyses on each readmission were conducted by hospital physicians and post-acute care (PAC) organization staff. Additional data were collected by trained project staff using the medical record and postdischarge telephone or in-person follow-up visits. These data were reviewed and adjudicated among the authors, and each readmission was rated with unanimous agreement as "preventable," "possibly preventable," or "not preventable." No significant differences were found in demographic and clinical characteristics of intervention patients readmitted versus those not readmitted. A higher proportion of the 37 patients who were readmitted did not have a postdischarge visit than the 165 patients who were not readmitted (15 [41%] vs 45 [27%]; P = .11). Among the 37 readmissions, 14 (38%) were rated as not preventable, 14 (38%) as possibly preventable, and 9 (24%) as preventable. Readmissions were rated as preventable or possibly preventable for a variety of reasons that provide insight into how care transitions programs for high-risk older adults might be made more effective. Root-cause analyses of hospital readmissions among high-risk older adults by hospital physicians and PAC providers can identify strategies that might enhance the effectiveness of care transitions interventions in this complex population. J Am Geriatr Soc 68:1307-1312, 2020.

Objective Despite research, national legislation, and clinical guidelines supporting transitional care, there is minimal benefit from existing transitional care interventions for racial/ethnic minorities with traumatic brain injury (TBI) discharged home from acute hospital care. Existing TBI transitional care interventions are not tailored to address the needs/preferences of patients from various racial/ethnic minority groups. The purpose of this study was to describe use of personalization to tailor a TBI transitional care intervention for various racial/ethnic groups. Design Following preliminary intervention manual development, a qualitative descriptive study was conducted using eight focus groups with 40 English-and Spanish-speaking participants (12 patients, 12 caregivers, and 16 providers). Results Three personalization-related themes emerged: 1) what is important to me, 2) finding someone to deliver the intervention who can adapt to my needs, and 3) respect over culture. Findings informed personalization strategies within our final manual. Conclusions We recommend researchers who wish to use personalization to tailor interventions to consider: 1) allowing stakeholders to dictate what is most important and 2) implementing an iterative intervention development process with input from diverse stakeholders. Findings have implications for informing the development of transitional care interventions to increase the likelihood that interventions are inclusive of needs and preferences of various races/ethnicities.

BackgroundThis paper presents a protocol for a randomised controlled trial of the Cardiac-Diabetes Transcare program which is a transitional care, multi-modal self-management program for patients with acute coronary syndrome comorbid with type 2 diabetes. Prior research has indicated people hospitalised with dual cardiac and diabetes diagnoses are at an elevated risk of hospital readmissions, morbidity and mortality. The primary aim of this study is to evaluate the effectiveness (and cost-effectiveness) of a Cardiac-Diabetes Transcare intervention program on 6-month readmission rate in comparison to usual care.Methods/DesignA two-armed, randomised controlled trial with blinded outcome assessment will be conducted to evaluate the comparative effectiveness of two modes of care, including a Usual Care Group and a Cardiac-Diabetes Transcare Intervention (in addition to usual care) Group. The primary outcome is 6-month readmission rate, although a range of secondary outcomes will be collected (including self-efficacy) at baseline, 1, 3 and 6 month reassessments. The intervention group will receive in-hospital education tailored for people recovering from an acute coronary syndrome-related hospital admission who have comorbid diabetes, and they will also receive home visits and telephone follow-up by a trained Research Nurse to reinforce and facilitate disease-management-related behaviour change. Both groups will receive usual care interventions offered or referred from participating hospital facilities. A sample size of 432 participants from participating hospitals in the Australian states of Queensland and Victoria will be recruited for 90% power based on the most conservative scenarios modelled for sample size estimates.DiscussionThe study outlined in this protocol will provide valuable insight into the effectiveness of a transitional care intervention targeted for people admitted to hospital with cardiac-related presentations commencing in the inpatient hospital setting and transition to the home environment. The purpose of theory-based intervention comprising face-to-face sessions and telephone follow up for patients with acute coronary syndrome and type 2 diabetes is to increase self-efficacy to enhance self-management behaviours and thus improve health outcomes and reduce hospital readmissions.Trial registrationThis study has been registered with the Australian New Zealand Clinical Trials Registry dated 16/12/2014: ACTRN12614001317684.