scholarly journals Early Discharge Planning and Improved Care Transitions: Pre-Admission Assessment for Readmission Risk in an Elective Orthopedic and Cardiovascular Surgical Population

2016 ◽  
Vol 16 (2) ◽  
Keyword(s):  
Discharge Planning ◽  
Care Transitions ◽  
Early Discharge ◽  
Readmission Risk

scholarly journals Potential of community-based risk estimates for improving hospital performance measures and discharge planning

2021 ◽  
Vol 10 (2) ◽  
pp. e001230
Author(s):  
Michael Reid ◽  
George Kephart ◽  
Pantelis Andreou ◽  
Alysia Robinson
Keyword(s):  
Discharge Planning ◽  
Care Transitions ◽  
Hospital Setting ◽  
Hospital Performance ◽  
Case Mix ◽  
Readmission Rates ◽  
Mixed Effect ◽  
Adjusted Risk ◽  
Community Risk ◽  
Effect Regression

BackgroundRisk-adjusted rates of hospital readmission are a common indicator of hospital performance. There are concerns that current risk-adjustment methods do not account for the many factors outside the hospital setting that can affect readmission rates. Not accounting for these external factors could result in hospitals being unfairly penalized when they discharge patients to communities that are less able to support care transitions and disease management. While incorporating adjustments for the myriad of social and economic factors outside of the hospital setting could improve the accuracy of readmission rates as a performance measure, doing so has limited feasibility due to the number of potential variables and the paucity of data to measure them. This paper assesses a practical approach to addressing this problem: using mixed-effect regression models to estimate case-mix adjusted risk of readmission by community of patients’ residence (community risk of readmission) as a complementary performance indicator to hospital readmission rates.MethodsUsing hospital discharge data and mixed-effect regression models with a random intercept for community, we assess if case-mix adjusted community risk of readmission can be useful as a quality indicator for community-based care. Our outcome of interest was an unplanned repeat hospitalisation. Our primary exposure was community of residence.ResultsCommunity of residence is associated with case-mix adjusted risk of unplanned repeat hospitalisation. Community risk of readmission can be estimated and mapped as indicators of the ability of communities to support both care transitions and long-term disease management.ConclusionContextualising readmission rates through a community lens has the potential to help hospitals and policymakers improve discharge planning, reduce penalties to hospitals, and most importantly, provide higher quality care to the people that they serve.

scholarly journals The Role of Rehabilitation in Reducing Resource Use and Lowering Hospital Readmission Through Discharge Planning

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 804-804
Author(s):  
Kenneth Miller
Keyword(s):  
Health Care Providers ◽  
Resource Use ◽  
Hospital Readmission ◽  
Discharge Planning ◽  
Care Transitions ◽  
Healthcare Team ◽  
Transition Management ◽  
Care Providers ◽  
Initial Examination ◽  
The Individual

Abstract The transitions between medical settings, the community and back again is a complex and intimidating process for patients, families and caregivers. These transitions are vulnerable points where planning is key and must begin at the initial examination with rehabilitation providers (PTs/OTs,SLPs). These providers are key members of the healthcare team to facilitate effective transition management. In this session, attendees will learn the critical factors rehabilitation providers use to evaluate patients in order to facilitate successful care transitions. An overview of the indications for rehabilitation referral will be presented, as well as evidence for effective rehabilitation strategies. The speaker will present tools from the American Physical Therapy Association Home Health Toolbox and outline a decision-making process for care transitions based on the individual, caregivers, and health care providers to achieve successful transitions that reduce resource use and hospital readmission rates. Attendees will learn strategies to facilitate inter-professional collaboration, communication, and advocacy.

scholarly journals Early discharge and rehabilitation in paediatric acquired brain and neurological injury: a transferable model

2018 ◽  
pp. edpract-2018-315096
Author(s):  
Rachel Keetley ◽  
Laura Kelly ◽  
William P Whitehouse ◽  
Sophie Thomas ◽  
Emily Bennett ◽  
...  
Keyword(s):  
Discharge Planning ◽  
Quality Care ◽  
Acquired Brain Injury ◽  
Early Discharge ◽  
Family Satisfaction ◽  
Neurological Injury ◽  
Children And Young People ◽  
Financial Gain ◽  
Lengths Of Stay ◽  
Improve Patient

Children and young people who require rehabilitation following sustaining an acquired brain injury often experience long lengths of stay (LOS) and potentially poorer recovery outcomes due to limited access to therapy and little proactive discharge planning. After stakeholder enquiry we launched a new team and pathway with a primary aim to reduce LOS. The secondary aims were to pilot an outreach model, reduce cost and improve patient and family satisfaction. We achieved a significantly improved change in quality care with a financial gain and increased patient and family satisfaction.

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Sara Jones ◽  
Anna Kucharska-Newton ◽  
Janet Freburger ◽  
Walter Ambrosius ◽  
...  
Keyword(s):  
Transitional Care ◽  
Discharge Planning ◽  
Care Transitions ◽  
Cluster Randomized Trial ◽  
Stroke Patients ◽  
Care Needs ◽  
Post Discharge ◽  
Exact Test ◽  
Chi Squared

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Psychogeriatric Hospitalization: Terminable or Interminable?

1992 ◽  
Vol 37 (3) ◽  
pp. 157-162
Author(s):  
H.M.R. Meier ◽  
M. Besir ◽  
J.A. Sylph
Keyword(s):  
General Hospital ◽  
Discharge Planning ◽  
Early Discharge ◽  
Positive Outcome ◽  
Community Resources ◽  
Patient Assessment ◽  
Psychogeriatric Patients

This paper takes issue with the stereotype of psychogeriatric patients in the general hospital using beds unnecessarily. With appropriate organization of services involving integrated teamwork, comprehensive patient assessment, early discharge planning and liaison with community resources, a positive outcome and early discharge was achieved with the majority of a group of psychogeriatric patients.

scholarly journals Prediction of Disposition within 48-hours of Hospital Admission Using Patient Mobility Scores

2019 ◽  
Vol 15 (9) ◽  
pp. 540-543 ◽  
Author(s):  
Daniel L Young ◽  
Elizabeth Colantuoni ◽  
Lisa Aronson Friedman ◽  
Jason Seltzer ◽  
Kelly Daley ◽  
...  
Keyword(s):  
Decision Tree ◽  
Hospital Admission ◽  
Discharge Planning ◽  
Classification Tree ◽  
Care Facility ◽  
Predictive Ability ◽  
Early Discharge ◽  
Final Decision ◽  
Patient Mobility ◽  
Machine Learning Classification

Delayed hospital discharges for patients needing rehabilitation in a postacute setting can exacerbate hospital-acquired mobility loss, prolong functional recovery, and increase costs. Systematic measurement of patient mobility by nurses early during hospitalization has the potential to help identify which patients are likely to be discharged to a postacute care facility versus home. To test the predictive ability of this approach, a machine learning classification tree method was applied retrospectively to a diverse sample of hospitalized patients (N = 805) using training and validation sets. Compared with patients discharged to home, patients discharged to a postacute facility were older (median, 64 vs 56 years old) and had lower mobility scores at hospital admission (median, 32 vs 41). The final decision tree accurately classified the discharge location for 73% (95%CI:67%-78%) of patients. This study emphasizes the value of systematically measuring mobility in the hospital and provides a simple decision tree to facilitate early discharge planning.

scholarly journals Acute and Transitional Care or Rehabilitation? Retrospective analysis of discharge planning from a municipal hospital in Switzerland

2019 ◽  
Author(s):  
Lara Kollbrunner ◽  
Rost Michael ◽  
Koné Insa ◽  
Zimmermann Bettina ◽  
Padrutt Yvonne ◽  
...  
Keyword(s):  
Social Service ◽  
Transitional Care ◽  
Discharge Planning ◽  
Patient Discharge ◽  
Early Discharge ◽  
Negative Consequences ◽  
Municipal Hospital ◽  
Care Needs ◽  
Service Workers ◽  
Social Service Workers

Abstract Background Due to rising health care costs, in 2012 Switzerland introduced SwissDRG, a reimbursement system for hospitals based on lump sums per case. To circumvent possible negative consequences like reduction in length of stay, acute and transitional care (ATC) was anchored into the law (Federal act on health insurance) in 2011. ATC as a discharge option is applicable to patients with no capacity for rehabilitation, but are unable to return home and are in need of temporary professional nursing care. ATC is associated with higher out of pocket costs to the patient than rehabilitation. Since social service workers are responsible for organizing discharge of patients with ongoing care needs after hospitalization, the aim of this study was to investigate how social service workers manage patient discharge in light of the new discharge option ATC. Methods Data was collected from 660 medical records of inpatients from Zurich's municipal hospital, Triemli, in 2016. We compared patients discharged to ATC and rehabilitation using inferential statistics and qualitatively analyzed written statements from social service workers. Results Our results showed that patients discharged to rehabilitation had a higher total number of discussions, but a shorter duration of discussions. Patients discharged to rehabilitation faced more delays, above all because of unavailability of free places. Conflicts concerning discharge arose mainly because of costs, discharge placement and too early discharge. Conclusions Our findings demonstrate how important social service workers are in explaining to patients about different discharge options. The newness of SwissDRG and ATC is still likely to cause longer discussion times and, consequently, more workload for social service workers. Only a small fraction of patients disagreed with their place of discharge, mostly due to financial reasons.

scholarly journals Identifying patients with high risk of readmission from the patient navigators’ perspectives: a descriptive qualitative study

2016 ◽  
Vol 26 (3) ◽  
pp. 166-171 ◽  
Author(s):  
Mas Rizalynda Mohd Razali ◽  
Yan Chew Chong ◽  
Nur Zarifah Mustapha ◽  
Yi Xu ◽  
Salimah Mohd Ayoob ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Assessment Tool ◽  
Social Issues ◽  
Discharge Planning ◽  
Community Support ◽  
Unplanned Readmission ◽  
Related Factors ◽  
Patient Navigators ◽  
Predicting Factors ◽  
Readmission Risk

Background: Unplanned readmission incurs additional cost to patients and contributes to the rising healthcare cost of our nation. Although numerous studies have investigated the predicting factors that contribute to hospital readmission, the majority of the studies focused on clinical and patient-related factors, and were not from the perspectives of clinicians such as patient navigators (PNs). Aim: To understand factors that predict patients’ readmission risks from the PNs’ perspectives. Method: Using purposive sampling, PNs with a minimum of 10 years of clinical experience in the adult acute-care setting participated in the focus group interviews. Thematic analysis was adopted. Findings: All 10 PNs agreed that the readmission risk assessment tool was useful as a guide to assess patients’ risk of readmission; however, they also mentioned the use of clinical judgement and experience while assessing their patients. Three themes emerged from this study: (1) looking beyond medical-related issues; (2) social and community support; (3) functional status of patients. Conclusion: Predicting patients’ risk of readmission is closely tied to the patients’ current medical conditions and caregiving needs. Ensuring individualised readmission risk assessment and identifying social issues early are key in ensuring a holistic discharge planning.

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