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Introduction: During the COVID-19 pandemic, discharge timelines were accelerated and patients were moved across the continuum of care, from acute to post-acute care, to relieve the strain in health system capacity. This study aimed to investigate the COVID-19 care pathway from the perspective of patients, caregivers, and healthcare providers to understand their experiences with care and recovery within and across care settings. Methods: A qualitative descriptive study. Patients and their families from an inpatient COVID-19 unit and healthcare providers from an acute or rehabilitation COVID-19 unit were interviewed. Results: A total of 27 participants were interviewed. Three major themes were identified: 1) The perceived quality and pace of COVID-19 care improved from acute care to inpatient rehabilitation; 2) Care transitions were especially distressing; and 3) Recovery from COVID-19 stagnated in the community. Conclusion: Inpatient rehabilitation was viewed as higher quality due to the slower paced care. Care transitions were distressing for stakeholders and enhanced integration between acute and rehabilitation care were suggested to improve patient handover. A lack of rehabilitation access led to recovery stagnating for patients discharged to the community. Telerehab may improve the transition to home and ensure access to adequate rehabilitation and support in the community. [ABSTRACT FROM AUTHOR]

Introduction: In the context of a GP-based care programme, we implemented an admission, discharge and follow-up programme. Description: The VESPEERA programme consists of three sets of components: preadmission interventions, in-hospital interventions and post-discharge interventions. It was aimed at all patients with a hospital stay participating in the GP-based care programme and was implemented in 7 hospitals and 72 general practices in southwest Germany using a range of strategies. Its' effectiveness was evaluated using readmissions within 90 days after discharge as primary outcome. Questionnaires with staff were used to explore the implementation process. Discussion: A statistically significant effect was not found, but the effect size was similar to other interventions. Intervention fidelity was low and contextual factors affecting the implementation, amongst others, were available resources, external requirements such as legal regulations and networking between care providers. Lessons learned were derived that can aid to inform future political or scientific initiatives. Conclusion: Structured information transfer at hospital admission and discharge makes sense but the added value in the context of a GP-based programme seems modest. Primary care teams should be involved in pre- and post-hospital care. [ABSTRACT FROM AUTHOR]

Introduction: Care transitions from hospital to outpatient care are a particularly vulnerable period in the care trajectory especially among minority patients, due to cultural and linguistic barriers that affect the comprehension of medical instructions and the ability to navigate among the various settings. Objectives: The study examines whether quality of the discharge process and transitional-care preparedness mediate the relationship between the cultural factors of patients and readmissions. Methods: A prospective cohort study of 599 internal medicine patients, Hebrew (general population) and Russian, or Arabic native speakers (minority groups), at a tertiary medical center in central Israel (2013 to 2014). The in-hospital baseline questionnaire included sociodemographic, cultural and linguistic characteristics (Internal Health Locus Control [IHLC], Powerful others Health Locus of Control [PHLC], Chance Health Locus of Control [CHLC], family collectivism and health literacy) and physical, mental, and functional health status (control variables). A follow-up telephone survey assessed the quality of the discharge process (parallel mediators): use of the teach-back method, providers’ cultural competence, language concordance and caregiver presence, and the Care Transition Measure [CTM] (serial mediator). Information on chronic conditions, length of stay, prior hospitalization, and 30-day readmissions was retrieved from the healthcare organization’s data warehouse. Testing multiple mediation models was conducted using Hayes PROCESS procedure, model 80. Results: A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors (IHLC, PHLC, CHLC, Family collectivism, Health literacy), except for minority status, were associated with 30-day readmission when no mediators were included (p

Introduction: We all want to have a long healthy and vital life and we all know that in time we will become more and more vulnerable. People do want to stay at home, also if they have more longterm conditions. In case of emergency professionals need to know what the preferences of the elderly are. That is currently not the case. The goal of this research is to extend en enrich the model of integrated care of Kings Fund (2014) en to tailor the model to the local context in the Netherlands. Method: We conducted a multimethod approach: focusgroups with elderly (&). literature review (7 studies in the last year), 20 interviews with experts in hospital, longterm care, homecare, social care and general practitioner, health centre, and Design Thinking method is used in two meetings with all the partners in de room, inclusive vulnerable elderly. Results: We built on the model of Kings Fund (2014) Integrated services to provide personcentred care, to extend this model to more practice based interventions. In design thinking sessions we discovered new working principles to make the shift to prevention and proactive care. Built on practical examples of professionals of different expertise in the emergency care for elderly. Discussions: There is enough ambition to change working in silos and become a more competent elderly care network. Sometimes professionals don't know about good practical examples they can use. Sometimes they don't look 'at the other site of the street' and don't know what (elderly)expertise is available. The awareness of these shortcomings is growing, but a lot of work need to be done. The patient journey and working principles can make a difference to be aware of new opportunities to make the shift to prevention en pro-active care of the view of the elderly themselves. Conclusions: Together we know more, The working principles based on good examples visualize the step forward to prevention and proactive care. Lessons learned: Incorporation of the view of the elderly in research is efficient en give new insights in what is really important to change. Limitations: A multiple approach needs a multi stakeholder commitment. The research done is just made by one partner in this complex field. The next step has to be made in a multiple stakeholder approach. The new steps in prevention are not tested yet. Suggestions for future research: New research has to be done in action-research to follow the new implementation in the chain of elderly care and support.

Introduction and objective: Despite recent interest in care transitions, little is known about how patients are prepared for the self-management tasks following the hospitalization. The objective of the study was to explore how discharge information is prepared and provided to patients in the transition from hospital to home. Method: The discharge process at three hospitals in Sweden was observed over 12 days spread over ten weeks. In total, 30 discharge encounters were observed followed by interviews with patients and professionals. Data were analysed using qualitative content analysis. Results: Much time, effort and resources were used to prepare the discharge; home-going teams and registered nurses planned the practical and social aspects of the discharge and the physicians compiled a plain-language discharge letter. Less focus was given on the actual discharge information to the patients. The discharge encounters lasted for a median of 4:46 minutes and the information had a retrospective focus with information on the hospitalization period, though omitting self-management tasks and life-style advice. Conclusion: The discharge letter constitutes the basis for all patient information at discharge. The focus of the discharge encounter needs to be extended beyond mere information to include patient understanding, motivation and skills for self-management at home.

Introduction and objective: Despite recent interest in care transitions, little is known about how patients are prepared for the self-management tasks following the hospitalization. The objective of the study was to explore how discharge information is prepared and provided to patients in the transition from hospital to home. Method: The discharge process at three hospitals in Sweden was observed over 12 days spread over ten weeks. In total, 30 discharge encounters were observed followed by interviews with patients and professionals. Data were analysed using qualitative content analysis. Results: Much time, effort and resources were used to prepare the discharge; home-going teams and registered nurses planned the practical and social aspects of the discharge and the physicians compiled a plain-language discharge letter. Less focus was given on the actual discharge information to the patients. The discharge encounters lasted for a median of 4:46 minutes and the information had a retrospective focus with information on the hospitalization period, though omitting self-management tasks and lifestyle advice. Conclusion: The discharge letter constitutes the basis for all patient information at discharge. The focus of the discharge encounter needs to be extended beyond mere information to include patient understanding, motivation and skills for self-management at home. [ABSTRACT FROM AUTHOR]

Introduction: We all want to have a long healthy and vital life and we all know that in time we will become more and more vulnerable. People do want to stay at home, also if they have more longterm conditions. In case of emergency professionals need to know what the preferences of the elderly are. That is currently not the case. The goal of this research is to extend en enrich the model of integrated care of Kings Fund (2014) en to tailor the model to the local context in the Netherlands. Method: We conducted a multimethod approach: focusgroups with elderly (&). literature review (7 studies in the last year), 20 interviews with experts in hospital, longterm care, homecare, social care and general practitioner, health centre, and Design Thinking method is used in two meetings with all the partners in de room, inclusive vulnerable elderly. Results: We built on the model of Kings Fund (2014) Integrated services to provide personcentred care, to extend this model to more practice based interventions. In design thinking sessions we discovered new working principles to make the shift to prevention and proactive care. Built on practical examples of professionals of different expertise in the emergency care for elderly. Discussions: There is enough ambition to change working in silos and become a more competent elderly care network. Sometimes professionals don't know about good practical examples they can use. Sometimes they don't look 'at the other site of the street' and don't know what (elderly)expertise is available. The awareness of these shortcomings is growing, but a lot of work need to be done. The patient journey and working principles can make a difference to be aware of new opportunities to make the shift to prevention en pro-active care of the view of the elderly themselves. Conclusions: Together we know more, The working principles based on good examples visualize the step forward to prevention and proactive care. Lessons learned: Incorporation of the view of the elderly in research is efficient en give new insights in what is really important to change. Limitations: A multiple approach needs a multi stakeholder commitment. The research done is just made by one partner in this complex field. The next step has to be made in a multiple stakeholder approach. The new steps in prevention are not tested yet. Suggestions for future research: New research has to be done in action-research to follow the new implementation in the chain of elderly care and support. [ABSTRACT FROM AUTHOR]

Introduction: Care transitions from hospital to outpatient care are a particularly vulnerable period in the care trajectory especially among minority patients, due to cultural and linguistic barriers that affect the comprehension of medical instructions and the ability to navigate among the various settings. Objectives: The study examines whether quality of the discharge process and transitional-care preparedness mediate the relationship between the cultural factors of patients and readmissions. Methods: A prospective cohort study of 599 internal medicine patients, Hebrew (general population) and Russian, or Arabic native speakers (minority groups), at a tertiary medical center in central Israel (2013 to 2014). The in-hospital baseline questionnaire included sociodemographic, cultural and linguistic characteristics (Internal Health Locus Control [IHLC], Powerful others Health Locus of Control [PHLC], Chance Health Locus of Control [CHLC], family collectivism and health literacy) and physical, mental, and functional health status (control variables). A follow-up telephone survey assessed the quality of the discharge process (parallel mediators): use of the teach-back method, providers' cultural competence, language concordance and caregiver presence, and the Care Transition Measure [CTM] (serial mediator). Information on chronic conditions, length of stay, prior hospitalization, and 30-day readmissions was retrieved from the healthcare organization's data warehouse. Testing multiple mediation models was conducted using Hayes PROCESS procedure, model 80. Results: A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors (IHLC, PHLC, CHLC, Family collectivism, Health literacy), except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Path analysis indicated significant indirect effects of the cultural factors on readmission through the quality of the discharge process (parallel mediators) and CTM (serial mediator). Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.949; p=0.021). Discussion: The results show that the association between patients' cultural factors and 30-day readmission is mediated by the quality of the discharge process and care transitions. Conclusions (comprising key findings): Providing high-quality discharge planning tailored to patients' cultural characteristics is related to better care-transition preparedness, which is related to reduced 30-day readmissions. Lessons learned: An understanding of the entire range of factors and their effects on the quality of care transitions may guide policy and practice in improving the quality of care by tailoring the discharge process to patients' personal and cultural needs. Limitations: Generalizability may be limited due to characteristics of the Israeli society. Nonetheless, transitions of minority patients are challenging in various healthcare systems worldwide. Suggestions for future research: future studies should test interventions aimed at improving transitions of minority patients through tailored discharge planning processes and examining the impact on the care transition experience and on readmissions. [ABSTRACT FROM AUTHOR]

Introduction: Of the 25.000 persons suffering a stroke each year in Sweden, 90% are treated in stroke units at hospital. After the hospital, a period of rehabilitation is needed to regain functions that have been affected. However, there is a lack of knowledge on how patients in Sweden perceive the current care transitions. The aim of this study is to explore the perceived quality of care transitions between hospital and the home for patients with stroke. Methods: A total of 200 patients with stroke referred from stroke unit to home rehabilitation will be included. To date, approximately 185 patients have been included from five wards stroke and geriatric at three different hospitals. One week after discharge, the perceived quality of care transitions are assessed with the Care Transitions Measure CTM. The CTM consists of 15 items covering different areas such as critical understanding, preferences important, management preparation, and care plan. Baseline data on age, sex and stroke severity are collected from the patients' hospital medical records. Results: The preliminary results from 80 participants with a mild stroke 53 men, mean age 70 years, show that a majority perceived a high quality of care transitions. However, 26% did not perceive that they had clear health goals or knew how to reach them; 30% did not know what warning signs and symptoms to watch out; and 20% lacked a readable and understandable written healthcare plan. Further, 24% perceived they had a poor understanding about their health and 29% lacked written understandable information about plans after discharge. In addition, 46% had not clearly understood the possible side-effects of their medications. Discussions: These preliminary findings have shown that there is room for improvement regarding the transition process. The participants had a mild stroke and where all discharged to their home for continued rehabilitation in the home environment. This meant that the patients would get home visits from rehabilitation staff but overall manage their rehabilitation training on their own. This stresses the importance of preparing the discharge from the stroke unit to the home. Extra attention should be made stating clear health goals and informing about how further health care needs can be met. Conclusions: The preliminary conclusion is the staff at stroke units should acknowledge the importance of informing about subsequent care and rehabilitation after discharge. Specific attention should also be drawn towards self-monitoring and increasing patient knowledge about potential side-effects of their medications. Lessons learned: Even patients with a mild stroke experience problems in the discharge from hospital to home which emphasize further analysis on patients with more severe forms of stroke. Limitations: A limitation of the study is that the questionnaire was only distributed in Swedish and that no aid was provided to help patients with affected cognitive functions. We hence lack information on how especially vulnerable groups perceive the quality of care transitions. Suggestions for future research: Future research should focus on how the discharge could include patients and family care givers in the goal setting including self-monitoring and medication awareness. [ABSTRACT FROM AUTHOR]

Introduction: Increasing numbers of hospital admissions is a complex issue of significant concern to health systems around the world, as a significant cost driver of healthcare is inpatient cost[i]. In Singapore, patients who are frequently admitted to hospitals, although comprising a small number, account for a disproportionately high use of scarce healthcare resources. While national efforts are currently underway to provide care planning and coordination to such patients, evidence shows that there is a need for case-finding of at-risk patients before they deteriorate[ii]. To date, most predictive models for frequent admissions are derived using administrative and clinical data, and little is known about the psychosocial, behavioural and environmental factors which contribute to frequent admissions in the local context[iii]. Aims: This study aims to Understand how psychosocial, behavioural and environmental factors contribute to frequent admissions, and identify the gaps in current services to address these factors; and Understand how frequent admitters and their caregivers cope with physical, mental and financial stress. Methods: A qualitative approach was used, where in-depth, semi-structured interviews (n=42) and focus group discussions (n=2) were conducted with 41 health and community care providers, and 13 frequent admitters (defined as patients with three or more admissions in a year) and/or caregivers recruited from both the National University Hospital and community care sectors through purposive sampling. Data analysis was done using a deductive approach[iv]. Results and Key Findings: Key psychosocial factors contributing to frequent admissions included social isolation, the lack of caregiver support or capability, anxious caregivers, caregiver stress and perceptionsthat hospital care was superior to community care. Behavioural factors included lack of motivation for self-care while environmental factors included poor communication during care transition between healthcare settings, and financial subsidy schemes which favour hospital rather than community care. Neighbours and friends were found to be an importance source of social support in preventing readmissions, while religion was found to have mixed impact on how patients or caregivers coped with illness. Discussion and Lessons Learnt: This study highlights the importance ofaddressing social isolation, and that informal networks such as neighbours and friends are an often overlooked source of psychosocial support for patients and their caregivers. Secondly, caregiver training, education and provision of respite services should also be in place to support caregivers in the community. Thirdly, a concerted effort is needed to address patients' socio-cultural beliefs and perceptions about healthcare, while concurrently improving care integration between healthcare settings. Limitations: Comparatively more healthcare professionals than patients and caregivers were interviewed in this study, as many patients were too ill to be interviewed. Suggestions for Future Research: The findings of this study could be used to develop asurvey to understand the prevalence of factors identified in this study among frequent admitters. A screening tool could then be developed to screen individuals at-risk for frequent admissions so that pre-emptive interventions could be instituted. [ABSTRACT FROM AUTHOR]

Background: Dedicated care transitions programs target patients after hospitalization to improve care and prevent complications and readmissions. Programs vary widely in the specific intervention, patient population, and implementation. Objective: We compared short-term (30day) and long-term (180day) utilization of participants enrolled in a care transitions program (CTP) versus a matched cohort of eligible but not enrolled. We then sought to determine the effect of baseline characteristics and core interventions objectives on the primary outcome of 30 day readmission. Methods: Retrospective cohort study of 365 patients discharged Jan 1, 2011 till Jun 30, 2013 in a primary care academic practice. Patients at high risk for hospital readmission, an elder risk assessment score over 16 and age (>60) were assigned to CTP follow up by a multidisciplinary team. This included an initial home visit by a nurse practitioner who performed medication reconciliation, assessed functional and cognitive status and safety, identified community resources, created an action plan, discussed goals of care and surrogate decision maker. Further support was provided via phone and home visits as needed. The primary outcome was 30, 90, and 180-day readmissions automatically abstracted from the electronic medical record. Predictors assessed were: demographics, baseline characteristics, comorbid illness, medications (number, changes and class), completion and timing of program process measures and healthcare utilization. Cox-proportional hazard models using propensity score matching were used to assess rehospitalization. Predictors were analyzed using time to event with censoring at death, palliative care, lost to follow up. Results: Compared to referent (n=365), CTP patients exhibited a lower 30-day rehospitalization rate;12.4% (95%CI8.9-15.7) versus 20.1%(95%CI15.8-24.1%), respectively (P=0.002). At 180-days, there was no difference. Significant predictors of lower rehospitalization included completion of advance care planning (HR=0.416, (0.263-0.659)), COPD (HR=0.599;(0.372-0.965)). More than one medication change (HR= 1.619; (1.042-2.514)) and use of opioids (HR=1.609;(1.023-1.529)) predicted higher rehospitalization rate. Conclusions: We observed a reduction in 30 day rehospitalization rates among those enrolled in CTP compared to referent. However, this effect was not sustained at 180 days. Advance care planning lowered the risk of hospitalization while medication changes and high risk medications increased risk of readmissions. Further work to determine factors that promote sustainability and validation of these predictors are needed to design the most effective CTP and prevent hospitalization and bad outcomes in this high risk group. [ABSTRACT FROM AUTHOR]

Introduction: In recent years much attention has been given to care transitions between healthcare settings and to re-hospitalizations. This is not without reason. Errors in medication, therapy, and in follow-up of tests and procedures following hospitalization are not uncommon and the associated costs are profound. Putting effort on increasing patients' knowledge on disease control and symptom management has shown an effect on decreased rehospitalization rates. Yet, little is known about how the information aimed to prepare patients are given to patients during hospital discharge, and how the information make sense to the patients. This study aims to explore how the hospital discharge process provides a learning environment for patients' understanding of their self-management. Theory/Methods: This study uses observational multiple-case study design. The cases - three wards of internal medicine from different hospital types: one regional, one general and one university hospital, all located in the county council of Stockholm, Sweden - were selected to allow inclusion of patients with varying diagnoses and backgrounds. The observations primarily focused on the discharge encounters but included other events where patient self - management learning was considered to either take place or be discussed: medical distribution, bedside rounds, formal/informal meetings between patients and healthcare professionals. After the observed discharge encounters, patients and their present next-of-kin who agreed to participate in the study, and thereafter the discharging healthcare professional were interviewed. Semi-structured interview guides were used. Data was analysed using cross-case synthesis in which the case under study at each units first were analysed separately, using content analysis, where after the analyses were compared and cross-case conclusions drawn. Results: The wards were overall similar in the prerequisites for patient understanding of selfmanagement in the hospital discharge process. Patient understanding of self-management were supported or constrained during the medical distribution by the registered nurses, the bedside rounds and the discharge encounters. Each of these encounters provided opportunities for the patients to learn about self-management, and for the healthcare professionals to gain and provide information to support the patients' self-management. Patients were not involved in the decisions preceding discharge. The bed-side rounds overall focused on giving informations to patients and not on involving patients in the communication. The short hospital stays were considered as barriers for patient self-management learning; the patients were too stressed at the discharge encounters to grasp the information and the healthcare professionals lacked time to grasp the patients' situation and needs. The healthcare professionals used several pedagogical efforts to facilitate patient understanding. The efforts were however not a conscious thought-through strategy and the professionals expressed uncertainty whether the patients had understood the information or not. Upon discharge, patients received a plain language written discharge note and medication list. The oral information followed the structure of the discharge letter, omitting self-management activities. Patients' made several efforts to facilitate their understanding, they checked that they had understood the healthcare professional, asked for clarification and confirmed when they had understood. Discussion: The discharge letter constituted the base of the discharge information, as both the oral and written information given by the physician sprung out of the letter. As we found that the discharge letter overall had a retrospective focus it only gives patients limited understanding of self-management activities post-discharge. Much time and effort was put into providing patients with accurate information and to facilitate the practical details of the discharge. However, only a small amount of effort was given to involve patients in the decisions, to ensure that patients had understood the information and had the skills to manage the self-management needed. Evidence suggests that information alone does not promote patient adherence to medications. A targeted, person-centred communication, in order to reach common ground for decision-making, is far from realized in healthcare. In contrast we found that patients were not actively involved in the planning of their discharge, and that sensemaking rarely came through in the discharge encounters. Conclusion: The information given at discharge was driven by the needs of the staff of communicating information, rather than patients' needs or level of understanding. Simple use of pedagogical teaching and patients' involvement in the decisions preceding discharges with the aim of ensuring patient understanding has the potential to enhance patient selfmanagement knowledge, whereas a system accountability overlapping the gaps could provide patients with comfort to put knowledge into action. [ABSTRACT FROM AUTHOR]

Introduction: Medication reconciliation (MR) is a standardized process of comprehensive evaluation of a patient's medication regimen in an effort to avoid medication errors, such as, omissions or duplications at care transitions, especially at hospital discharge. The output is a complete list of discharge medications for the patient, for the next healthcare provider, and a detailed discharge report with an accurate and up to date medication list of stopped, new, modified and unchanged medications. It sounds simple and straightforward, but it turns out to be very difficult to implement. Discharge prescription is a complex and error prone process, because of the convergence of often conflicting medication information from various sources, frequent hand-outs between professionals and organizations and multiple changes in the treatment plan in a pressure environment. In order to make it easier, we have developed a clinical decision support (CDS) tool integrated in the electronic prescribing process at discharge. In order to assess its impact on patient safety and MR adoption, we measured the number of MR errors per patient at the discharge report using electronic medication reconciliation (eMR) versus manual MR, and we measured MR adoption before and after the eMR tool was available. Methods: Electronic MR process description. At hospital discharge, the eMR tool performs the task of merging two medication lists in one single list: a pre-hospital list imported from our national electronic outpatient prescriptions record, and another one with inpatient active medication immediately before discharge. Merged medications from different lists are identified by different colours and sorted by ATC group. The prescriber then reconciles every medication in the merged list, picking, stopping or modifying them. When completed, the system offers the possibility of adding new prescriptions. All the actions taken are recorded by the computer, so that it automatically generates a text translation of the actions taken with every prescription. If the prescriber confirms that everything is all right, the computer automatically generates a report for the patient, the text must be copied-pasted at the discharge report for the next healthcare provider and prescriptions must be sent to the outpatient electronic medication prescriptions record. Study design. Prospective comparative study of MR information documented at the discharge report of complex patients with multimorbidity, in which MR is mandatory, between an intervention group of prescribers from wards where e-MR tool is available and a control group who performs manual MR. Setting and subjects. All patients discharged from Geriatrics Wards and Internal Medicine Wards from March 1st to March 31st 2015. Exclusion criteria: exitus and hospital transfers. Outcome measured - Medication reconciliation errors/patient identified at the discharge report - MR adoption in the areas where e-MR tool is available before and after its implementation. Results: MR errors reduction. One hundred discharge reports were reviewed during the study period (44 in the intervention group (IG) and 56 in the control group (CG). Medications were completely reconciled in 79.5% (CI 95% 65.5-88.8%) of the discharge reports in the IG and in 37.5% (CI95% 26.0%-50.6%) in the CG. Average number of MR discrepancies per patient discharged was 0.88 (IC95% 0.54-1.23) in the IG versus 1.78 (CI95% 1.22 -2.34) in the CG. MR adoption. At the beginning (March-October 2015), we implemented e-CM tool gradually (one physician at a time) among Geriatrics team. Since november 2015, we offered the tool and trained all Internal Medicine teams. Since November 2015 until March 2016, during full implementation phase, e-MR has been performed in 985 out of 1.212 patients (81% adherence) discharged by Geriatrics/Internal Medicine teams where the tool is available. Conclusion: Our computer-based solution for MR has a major positive impact on the quality of MR process by reducing medication error burden, but also on successful implementation and systematic MR process adherence. Now we plan to extend the use of the e-MR tool to all hospital discharges in order to obtain a significant impact on medication use safety. [ABSTRACT FROM AUTHOR]

Introduction: Strong evidence exists that there are serious quality problems for patients undergoing transitions across sites of care (1). This is a particularly acute and problematic issue at a time when care systems face the challenges brought about by increasingly elder populations (2), translated in rising levels of co-morbidities, chronicity, degenerative illnesses and disabilities, with escalating provision costs, and try to reconfigure the delivery of care services with strong emphasis on deinstitutionalization and community-based support. In Portugal, a number of top down regulated initiatives aiming at implementing integrated care in the country have been attempted in the last years but the care system still presents a remarkable diversity of entry points, inadequate many times duplicated use of scarce and expensive resources and difficult information flow between institutions and professionals. Coordination between health and social care including home-based care settings most of the times depends on the good will of dedicated professionals and the individual is many times left alone to navigate through the fragmented systems and the several care providers he might encounter in the path to rehabilitation. The main goal of this paper is to report on the quality of care transitions including actions intended to activate networks of care from the perspective of the patient, in the context of a randomized control trial on home supported discharge service for stroke patients in Portugal. Theory: A transition of care refers to a patient movement between care locations, providers or different levels of care within the same location as his/her condition and care needs change. It can be seen as a set of actions designed to ensure coordination and continuity of care (1) but also as a point in a care process and in space, to which the time dimension is always associated (3). Many of these care transition episodes are triggered by acute problems that are unplanned. Therefore, neither the patients nor their families know what to expect, and they do not even realize just how vulnerable patients can be during transitions. Nevertheless, coordination and continuity of care during this particularly vulnerable time often falls on family, patients, or other informal caregivers (4). It is therefore crucial to evaluate the quality of care transitions from the patients and/or their informal caregivers perspective. Methods: We have studied the whole patient's course, from the admission to the stroke unit to six months after discharge. A methodology has been developed to assess the quality of care transitions including network activation actions, as the patients progressed from the stroke unit to rehabilitation care, either inpatient, ambulatory or at home and to normal life again. The scale developed also addresses the role of the family doctor as gate keeper. Results: Four fundamental aspects have been researched at the moment of patient discharge from the several units involved in health care: dealing with medication at home, dealing with activities of daily living, finding help in community and dealing with the moment of discharge itself. More precisely, we have addressed patient self-reported ability to deal with these situations, the level of information provided to the patient by the health unit at discharge and the way the process was conducted. Additionally, we have investigated the way each node in the network provided the patient with an anchor contact point in the discharging unit, a referring contact point in the destination unit, a written care summary and plan and a discharge letter addressed to the patient's family doctor. Finally, we addressed the role and the actions of the family doctor, from the perspective of the patient. Conclusions: In this work we have addressed and measured structural and procedural aspects of care transitions, from the point of view of the patients. Outside the RNCCI, the National Network for Integrated Care, that still handles a limited percentage of patients in need of rehabilitation after a stroke there is no integrated information system available to the providers involved in the chain of care. Tools such as case managers or care plans are not in use while discharging and referring letters are the preferred way of communication between hospitals and family doctors based in health centres of family health units. It is not common practice to provide the patients with an anchor contact point in the discharging unit or helping the patients finding help in the community. Based on these results, the widely adoption of a standard framework based on a conceptual model for the measurement of care transition quality is strongly recommended. The measure set should include structural, process and outcome measures and process measures should be paired, addressing both the sending and the receiving providers in order to promote shared accountability (1). As all evaluation efforts carries costs, the right balance between cost and benefit must be found keeping always in mind the logic of network. [ABSTRACT FROM AUTHOR]

Background: Family caregivers play a central yet often under recognized role in ensuring quality and safety during a loved one's transition out of the hospital. Purpose And Objectives: To explore challenges family caregivers face in assuming postdischarge family caregiving roles. Methods: A qualitative study was conducted that included 32 family caregivers with family caregivers whose loved one was recently discharged from hospital. A modified Grounded Theory approach was used to analyze the data. Results: Five central themes related to post discharge caregiving emerged from our analysis: (1) the roles and contributions of family caregivers occur along on a spectrum where the readiness, willingness, and ability of both parties is often dynamic and unrecognized; (2) family caregivers have unique and often incongruent goals from that of the patient; (3) family caregivers feel unprepared and overwhelmed by post-discharge medication reconciliation and management; (4) family caregivers need role clarification and encouragement to assert an identity; (5) family caregivers often assume the responsibility for the sequencing of care plan tasks and anticipating next steps. Discussion: This study highlights a number of unmet and unaddressed needs among family caregivers. These five themes are being incorporated into a widely disseminated evidence-based model of transitional care. [ABSTRACT FROM AUTHOR]