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BackgroundRespiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition.MethodsRetrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events.ResultsThere were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%.ConclusionRespiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes.Level of evidencePrognostic and Epidemiological study, level III.

First-episode services (FES) improve outcomes in recent onset psychosis, but there is growing concern about how patients fare after discharge from these time-limited services.A quality improvement approach (QI) was used to improve patient engagement in the discharge planning process (disposition), and successful engagement in care 3 months after discharge from the FES (transfer). Data from 144 consecutive discharges over 62 months are presented. A planning phase was followed by recurrent Plan-Do-Study-Act cycles (PDSA) that included the introduction of proactive efforts targeting disposition planning (with patients and families) and follow-up to facilitate transfer after discharge. Fisher's exact test was used to compare disposition and transfer outcomes across the QI phases.This QI approach was sustained through a three-fold escalation in discharge volume. Transfer status at 3 months was significantly different between the pre- and post PDSA phases (p = .02). A greater proportion were confirmed transfers post-PDSA (54.3 vs. 37%), but of those with known status at 3 months, similar proportions were successfully transferred (76, 73%). Patients discharged post-PDSA were less likely to have unknown treatment status (26 vs. 51%). Disposition outcomes were also significantly improved post-PDSA (p = .03). Patients were more likely to engage with discharge planning (69.7 vs. 48.6%) and less likely to be lost to follow-up (13.8 vs. 25.7%), or to refuse assistance (11.0 vs. 20.0%).This QI approach offers a feasible way to improve disposition and transfer after FES and can be built upon in efforts to sustain functional gains in onward pathways.

Background: Transition of patients with spinal cord injury (SCI) from hospital to home often involves a shift in caregiving responsibility from health-care providers to family caregivers. Poor care transition may lead to poor care-related outcomes. Objectives: The aim of this study was to explore experiences of care transition from hospital to home among the family caregivers of patients with SCI. Methods: This qualitative study was conducted in 2018–2019. Participants were 17 family caregivers of patients with SCI who were purposively recruited from two specialty SCI care centers in Iran. In-depth semi-structured interviews were held for data collection. Interviews were audio-recorded, transcribed, and analyzed using conventional content analysis. Results: The following four main categories were developed during data analysis: lack of knowledge (with two subcategories), excruciating care (with two subcategories), emotional burden of caregiving (with three subcategories), and need for support (with two subcategories). The nine subcategories of these main categories were lack of medical and care-related information, seeking for information, heavy burden of daily caregiving, need for providing professional care at home, feelings of sadness and sorrow, feeling of insufficiency, restriction of life, limited support by family members and relatives, and limited financial support by the government. Conclusion: Family caregivers of patients with SCI experience many challenges and problems during care transition from hospital to home, which can affect the quality of their care services for their patients. Therefore, they need ongoing support throughout the process of care.

Objective: to summarize and analyze the scientific production on care transition in the hospital discharge of adult patients. Method: integrative review, conducted from May to July 2020, in four relevant databases in the health area: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus and Virtual Health Library (VHL). The analysis of the results occurred descriptively and was organized into thematic categories that emerged according to the similarity of the contents extracted from the articles. Results: 46 articles from national and international journals, with a predominance of descriptive/non-experimental studies or qualitative studies, met the inclusion criteria. Five categories were identified: discharge and post-discharge process; Continuity of post-discharge care; Benefits of care transition; Role of nurses in care transition and Experiences of patients on care transition. Hospital discharge and care transitions are interconnected processes as transitions qualify the dehospitalization process. Different strategies for continuity of care should be adopted, as they offer greater safety to the patient. Studies have shown that nurses play a fundamental role in transitions and, in Brazil, this activity still needs to gain more space. Reduced hospitalizations, mortality, hospital costs and patient satisfaction are benefits of transitions. Conclusion: care transition is an effective strategy for the care provided to the patient being discharged. It points out the need for integration between the care network and assists services in decision-making about the continuity of care on discharge. RESUMEN Objetivo: sintetizar y analizar la producción científica sobre la transición de la atención al alta hospitalaria del paciente adulto. Método: una revisión integradora, realizada de mayo a julio de 2020, en cuatro bases de datos relevantes en el área de la salud: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus y Biblioteca Virtual en Salud (BVS). El análisis de los resultados fue descriptivo y organizado en categorías temáticas que surgieron de acuerdo a la similitud de los contenidos extraídos de los artículos. Resultados: 46 artículos de revistas nacionales e internacionales cumplieron los criterios de inclusión, con predominio de estudios descriptivos / no experimentales o con abordaje cualitativo. Se identificaron cinco categorías: Proceso de alta hospitalaria y posterior al alta; Continuidad de la atención posterior al alta; Beneficios de la transición de la atención״; El papel de la enfermera en la transición de la atención y Experiencias de los pacientes en la transición de la atención. El alta hospitalaria y las transiciones de la atención son procesos interconectados, ya que las transiciones califican el proceso de deshospitalización. Se deben adoptar diferentes estrategias para la continuidad de la atención, ya que ofrecen mayor seguridad al paciente. Los estudios han demostrado que los enfermeros juegan un papel fundamental en las transiciones y, en Brasil, esta actividad aún necesita ganar más espacio. La reducción de los reingresos, la mortalidad, los costos hospitalarios y la satisfacción del paciente son beneficios de las transiciones. Conclusión: la transición de la atención surge como una estrategia efectiva para calificar la atención brindada al paciente que se encuentra en proceso de deshospitalización. Señala la necesidad de integración entre la red de atención y ayuda a los servicios a tomar decisiones sobre la continuidad de la atención al alta. RESUMO Objetivo: sintetizar e analisar a produção científica sobre a transição do cuidado na alta hospitalar de pacientes adultos. Método: revisão integrativa, realizada de maio a julho de 2020, em quatro bases de dados relevantes na área da saúde: Public Medline (PubMed); Scientific Electronic Library Online (SciELO); Scopus e Biblioteca Virtual em Saúde (BVS). A análise dos resultados ocorreu de forma descritiva e organizada em categorias temáticas que surgiram conforme a similaridade dos conteúdos extraídos dos artigos. Resultados: atenderam aos critérios de inclusão 46 artigos, de periódicos nacionais e internacionais, com predomínio de estudos descritivos/não experimentais ou com abordagem qualitativa. Foram identificadas cinco categorias: Processo de alta e pós-alta hospitalar; Continuidade do cuidado pós-alta; Benefícios da transição de cuidado; Papel do enfermeiro na transição de cuidado e Vivências de pacientes sobre a transição de cuidado. A alta hospitalar e as transições de cuidados são processos interligados, pois as transições qualificam o processo de desospitalização. Diferentes estratégias para a continuidade do cuidado devem ser adotadas, pois oferecem maior segurança ao paciente. Estudos mostraram que o enfermeiro tem papel fundamental nas transições e, no Brasil, essa atividade ainda precisa ganhar mais espaço. A redução das reinternações, mortalidade, custos hospitalares e a satisfação dos pacientes são benefícios das transições. Conclusão: a transição do cuidado ascende como estratégia eficaz para a qualificação do cuidado prestado ao paciente que está sendo desospitalizado. Aponta a necessidade de integração entre a rede assistencial e auxilia os serviços na tomada de decisão sobre a continuidade do cuidado na alta.

Background Follow-up visits with clinic providers after hospital discharge may not be feasible for some patients due to functional limitations, transportation challenges, need for physical distancing, or fear of exposure especially during the current COVID-19 pandemic. Methods The aim of the study was to determine the effects of post-hospital clinic (POSH) and telephone (TPOSH) follow-up provider visits versus no visit on 30-day readmission. We used a retrospective cohort design based on data from 1/1/2017 to 12/31/2019 on adult patients (n = 213,513) discharged home from 15 Kaiser Permanente Southern California hospitals. Completion of POSH or TPOSH provider visits within 7 days of discharge was the exposure and all-cause 30-day inpatient and observation stay readmission was the primary outcome. We used matching weights to balance the groups and Fine-Gray subdistribution hazard model to assess for readmission risk. Results Unweighted all-cause 30-day readmission rate was highest for patients who completed a TPOSH (17.3%) followed by no visit (14.2%), non-POSH (evaluation and management visits that were not focused on the hospitalization: 13.6%) and POSH (12.6%) visits. The matching weighted models showed that the effects of POSH and TPOSH visits varied across patient subgroups. For high risk (LACE 11+) medicine patients, both POSH (HR: 0.77, 95% CI: 0.71, 0.85, P P = .03) were associated with 23 and 9% lower risk of 30-day readmission, respectively, compared to no visit. For medium to low risk medicine patients (LACE Conclusions Post-hospital telephone follow-up provider visits had only modest effects on 30-day readmission in high-risk medicine patients compared to clinic visits. It remains to be determined if greater use and comfort with virtual visits by providers and patients as a result of the pandemic might improve the effectiveness of these encounters.

Background The organisation of cancer follow-up is under scrutiny in many countries, and general practice is suggested to become more involved. A central focus is timely detection of recurring previous cancer and new second primary cancer. More knowledge on the patient pathway before cancer recurrence and second primary cancer is warranted to ensure the best possible organisation of follow-up. We aimed to describe the healthcare utilisation in the year preceding a diagnosis of cancer recurrence or second primary cancer. Methods This nationwide register study comprises patients diagnosed with bladder, breast, colorectal, endometrial, lung, malignant melanoma and ovarian cancer in Denmark in 2008–2016. The frequency of healthcare contacts during the 12 months preceding a cancer recurrence or second primary cancer was estimated and compared to the frequency of cancer survivors in cancer remission. The main analyses were stratified on sex and healthcare setting. Furthermore, two sub-analyses were stratified on 1) sex, healthcare setting and age group and on 2) sex, healthcare setting and comorbidity status. Results The study population consisted of 7832 patients with recurrence and 2703 patients with second primary cancer. On average, the patients were in contact with general practice one time per month in the 12th month preceding a new cancer diagnosis (recurrence or second primary cancer). Increasing contact rates were seen from 7 months before diagnosis in general practice and from 12 months before diagnosis in hospitals. This pattern was more pronounced in patients with cancer recurrence, younger patients and patients with no comorbidity. For instance, the contact rate ratios for hospital contacts in non-comorbid women with recurrence demonstrated 30% more contacts in the 12th month before recurrence and 127% more contacts in the 2nd month before recurrence. Conclusions The results show that cancer survivors are already seen in general practice on a regular basis. The increasing contact rates before a diagnosis of cancer recurrence or second primary cancer indicate that a window of opportunity exists for more timely diagnosis; this is seen in both general practice and in hospitals. Thus, cancer survivors may benefit from improvements in the organisation of cancer follow-up.

Background Gestational diabetes increases risk for type 2 diabetes seven-fold, creating a large public health burden in a young population. In the US, there are no large registries for tracking postpartum diabetes screening among women in under-resourced communities who face challenges with access to care after pregnancy. Existing data from Medicaid claims is limited as women often lose this coverage within months of delivery. In this study, we aim to leverage data from electronic health records and administrative claims to better assess postpartum diabetes screening rates among low income women. Methods A retrospective population of 1078 women with gestational diabetes who delivered between 1/1/2010 and 10/8/2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and 1 year of delivery. Initial screening after the first postpartum year was also documented. Results Median age in the final population was 28 (IQR 24–33) years with over-representation of black non-Hispanic and urban women. In the final population, 9.7% of women had a recommended diabetes screening test within 12 weeks and 18.9% were screened within 1 year of delivery. An additional 125 women received recommended screening for the first time beyond 1 year postpartum. The percentage of women who had a postpartum visit (83.9%) and any glucose testing (40.6%) in the first year far exceeded the proportion of women with recommended screening tests. Conclusions Linking electronic health record and administrative claims data provides a more complete picture of healthcare follow-up among low income women after gestational diabetes. While screening rates are higher than reported with claims data alone, there are opportunities to improve adherence to screening guidelines in this population. Electronic supplementary material The online version of this article (10.1186/s12889-019-6475-0) contains supplementary material, which is available to authorized users.

Background The coronavirus disease (COVID-19) pandemic has had a massive impact on individuals globally. The Chinese government has formulated effective response measures, and medical personnel have been actively responding to challenges associated with the epidemic prevention and control strategies. This study aimed to evaluate the effect of the implementation of a care transition pathway on patients that underwent joint replacement during the COVID-19 pandemic. Methods A quasi-experimental study was designed to evaluate the effect of implementing a care transition pathway for patients who underwent joint replacement during the COVID-19 pandemic in the orthopedic department of a tertiary care hospital in Beijing, China. Using a convenient sampling method, a total of 96 patients were selected. Of these, 51 patients who had undergone joint replacement in 2019 and received treatment via the routine nursing path were included in the control group. The remaining 45 patients who underwent joint replacement during the COVID-19 epidemic in 2020 and received therapy via the care transition pathway due to the implementation of epidemic prevention and control measures were included in the observation group. The quality of care transition was assessed by the Care Transition Measure (CTM), and patients were followed up 1 week after discharge. Results The observation group was determined to have better general self-care preparation, written planning materials, doctor-patient communication, health monitoring, and quality of care transition than the control group. Conclusions A care transition pathway was developed to provide patients with care while transitioning through periods of treatment. It improved the patient perceptions of nursing quality. The COVID-19 pandemic is a huge challenge for health professionals, but we have the ability to improve features of workflows to provide the best possible patient care.

Background Patients with acute coronary syndromes often experience non-specific (generic) pain after hospital discharge. However, evidence about the association between post-discharge non-specific pain and rehospitalization remains limited. Methods We analyzed data from the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) prospective cohort. TRACE-CORE followed patients with acute coronary syndromes for 24 months post-discharge from the index hospitalization, collected patient-reported generic pain (using SF-36) and chest pain (using the Seattle Angina Questionnaire) and rehospitalization events. We assessed the association between generic pain and 30-day rehospitalization using multivariable logistic regression (N = 787). We also examined the associations among patient-reported pain, pain documentation identified by natural language processing (NLP) from electronic health record (EHR) notes, and the outcome. Results Patients were 62 years old (SD = 11.4), with 5.1% Black or Hispanic individuals and 29.9% women. Within 30 days post-discharge, 87 (11.1%) patients were re-hospitalized. Patient-reported mild-to-moderate pain, without EHR documentation, was associated with 30-day rehospitalization (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.14–3.62, reference: no pain) after adjusting for baseline characteristics; while patient-reported mild-to-moderate pain with EHR documentation (presumably addressed) was not (OR: 1.23, 95% CI: 0.52–2.90). Severe pain was also associated with 30-day rehospitalization (OR: 3.16, 95% CI: 1.32–7.54), even after further adjusting for chest pain (OR: 2.59, 95% CI: 1.06–6.35). Conclusions Patient-reported post-discharge generic pain was positively associated with 30-day rehospitalization. Future studies should further disentangle the impact of cardiac and non-cardiac pain on rehospitalization and develop strategies to support the timely management of post-discharge pain by healthcare providers.

Background Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge. Methods Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data. Results Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33–60.5] (n = 5 studies) and 50% [interquartile range 39–76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18–40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16–24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2–180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs. Conclusions This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified. Electronic supplementary material The online version of this article (10.1007/s40264-020-00918-3) contains supplementary material, which is available to authorized users.

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.

It is obvious: the fitter the patient before surgery, the better they recover after. Therefore, it is safe to consider an operation as a top sport performance. A performance that you need to start fit: well trained, well fed, well rested. Not an easy job. After all, it often concerns fragile patients at old age with a serious condition in an emotional phase of their lives. Out of understandable compassion, everyone grants such patients "no hassle", also because the time to surgery is often short, 2 to 6 weeks, and the recovery time afterwards is hard. To start training anyway requires a lot from the patient, his mantle (care) and the professionals. Physiotherapy helps. It is important to implement this method nationally and evaluate on macro cost effectiveness. After proof was delivered for this substantially different method with patients prior to major heart, lung, stomach, bowel or joint surgery, Van Beijsterveld succeeded in investigating and implementing this with patients with cancer in the pancreas and liver. Parallel to the existing proof, this study with patients and professionals again demonstrated: the fitter the better. Lower risk of complications, faster recovery and a shorter stay in the hospital.

Background Total joint arthroplasty is a mature and effective treatment for end-stage osteoarthritis. Assisting patients in completing the transition of the perioperative period and improving their satisfaction are important aspects of quality of care. This study aimed to investigate an intervention to improve the quality of care transition for joint arthroplasty patients informed by the knowledge-to-action (KTA) framework. Methods In this quasi-experimental study, a total of 160 patients who underwent joint arthroplasty at a tertiary hospital from September to November 2018 and January to March 2019 were selected as participants using convenience sampling. The control group received routine medical care, while the observation group received medical care based on the KTA framework. Transitional care quality was assessed by the Care Transition Measure (CTM), with follow-up 1 week after discharge. Results The observation group fared significantly better than the control group on general self-care preparation and written plan dimensions, as well as the quality of care transition. There was no significant difference in doctor–patient communication or health monitoring. Conclusions The KTA framework provides a logical, valuable tool for clinical work. Using the KTA framework for joint arthroplasty patients helps to improve the quality of care transition, which is worth promoting.

Background Long-term residential care (LTC) supports the most vulnerable and is increasingly relevant with demographic ageing. This study aims to describe entry to LTC and identify predictive factors for older Māori (indigenous people of New Zealand) and non-Māori. Methods LiLACS-NZ cohort project recruited Māori and non-Māori octogenarians resident in a defined geographical area in 2010. This study used multivariable log-binomial regressions to assess factors associated with subsequent entry to LTC including: self-identified ethnicity, demographic characteristics, self-rated health, depressive symptoms and activities of daily living [ADL] as recorded at baseline. LTC entry was identified from: place of residence at LiLACS-NZ interviews, LTC subsidy, needs assessment conducted in LTC, hospital discharge to LTC, and place of death. Results Of 937 surveyed at baseline (421 Māori, 516 non-Māori), 77 already in LTC were excluded, leaving 860 participants (mean age 82.6 +/− 2.71 years Māori, 84.6 +/− 0.52 years non-Māori). Over a mean follow-up of 4.9 years, 278 (41% of non-Māori, 22% of Māori) entered LTC; of the 582 who did not, 323 (55%) were still living and may yet enter LTC. In a model including both Māori and non-Māori, independent risks factors for LTC entry were: living alone (RR = 1.52, 95%CI:1.15–2.02), self-rated health poor/fair compared to very good/excellent (RR = 1.40, 95%CI:1.12–1.77), depressive symptoms (RR = 1.28, 95%CI:1.05–1.56) and more dependent ADLs (RR = 1.09, 95%CI:1.05–1.13). For non-Māori compared to Māori the RR was 1.77 (95%CI:1.39–2.23). In a Māori-only model, predictive factors were older age and living alone. For non-Māori, factors were dependence in more ADLs and poor/fair self-rated health. Conclusions Non-Māori participants (predominantly European) entered LTC at almost twice the rate of Māori. Factors differed between Māori and non-Māori. Potentially, the needs, preferences, expectations and/or values may differ correspondingly. Research with different cultural/ethnic groups is required to determine how these differences should inform service development.

Background Smoking is the leading cause of preventable death and disease, yet implementation of smoking cessation in inpatient settings is inconsistent. The Technology Inpatient Program for Smokers (TIPS) is an implementation program designed to reach smokers with a mobile health (mHealth) intervention using stakeholder-supported strategies. Objective The purpose of this study was to determine the impact of the TIPS implementation strategies on smoker-level engagement of the mHealth intervention during care transition. Methods We examined varying intensities (passive motivational posters only and posters + active nurse-led facilitation) of TIPS strategies on four hospital units located in two sites. Unit-level and smoker-level adoption was monitored during active implementation (30 weeks) and sustainability follow-up (30 weeks). Process measures reflecting the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework, stakeholder reported adaptations of strategies, and formative evaluation data were collected and analyzed. Results For our smoker-level reach, 103 smokers signed up for the mHealth intervention in-hospital, with minimal decline during sustainability follow-up. While posters + nurse facilitation did not lead to higher reach than posters alone during active implementation (27 vs 30 signed up), it did lead to higher engagement of smokers (85.2% vs 73.3% completion of the full 2-week intervention). TIPS strategy adoption and fidelity varied by unit, including adoption of motivational posters (range: weeks 1 and 5), fidelity of posters (0.4% to 16.2% of posters missing per unit weekly) and internal facilitation of nurse training sessions (average of 2 vs 7.5 by site). Variable maintenance costs of the program totaled US $6.63 (US $683.28/103) per smoker reached. Reported family-member facilitation of mHealth sign-up was an observation of unintended behavior. Conclusions TIPS is a feasible and low-cost implementation program that successfully engages smokers in an mHealth intervention and sustains engagement after discharge. Further testing of nurse facilitation and expanding reach to patient family and friends as an implementation strategy is needed.

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: 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

OBJECTIVE: Specialised follow-up care after cancer treatment is changing towards increased involvement of general practice. To ensure timely detection of new cancer events, knowledge is warranted on the timing of cancer recurrence (CR) and second primary cancer (SPC), including risk factors for CR.METHODS: This population-based register study included 67,092 patients diagnosed with malignant melanoma, bladder, lung, ovarian, endometrial, colorectal and breast cancer in Denmark in 2008-2016. The time from primary cancer to CR or SPC and risk factors for prolonged time to CR were analysed and stratified on sex and primary cancer type.RESULTS: Cancer recurrence proportions ranged from 6% to 35%. The risk of CR increased profoundly within the first 3 years and then levelled off, except for breast cancer. A total of 3%-6% of patients had SPC, with monotonously increasing cumulative incidence proportions. Besides primary tumour characteristics, lower educational level, living alone and comorbidity were associated with earlier CR. For example, in female malignant melanoma, HRs and 95% confidence intervals were 0.47 (0.37-0.61) for high educational level, 1.40 (1.16-1.68) for living alone and 2.38 (1.53-3.70) for high comorbidity.CONCLUSION: The results may inform stratified risk assessment in decision of frequency, location and duration of post-cancer follow-up care.

ObjectiveThe objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.DesignScoping review using Levac et al’s enhancement to Arksey and O’Malley’s framework for conducting scoping reviews.Data sourcesMedline (Ovid), Embase (Ovid), PsycINFO, CINAHL, Cochrane and ISI Web of Science article databases were searched from 1 January 2009 through 28 February 2019.Eligibility criteria for selecting studiesWe included studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, the time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission).Data extraction and synthesisWe assessed review findings through tabular and content analyses of the data extracted from included articles.ResultsOur database search yielded 3478 unique articles, 67 of which were included in our scoping review. The included articles varied widely in their reported readmission time intervals used. They provided limited details regarding which readmissions they considered unnecessary and which risks they accounted for in their measurement. There were no perceptible trends in associations between the variation in these findings and the included studies’ characteristics (eg, target population, type of care transition intervention).ConclusionsThe limited specification with which studies report their approach to unnecessary psychiatric readmissions measurement is a noteworthy gap identified by this scoping review, and one that can hinder both the replicability of conducted studies and adaptations of study methods by future investigations. Recommendations stemming from this review include (1) establishing a framework for reporting the measurement approach, (2) devising enhanced guidelines regarding which approaches to use in which circumstances and (3) examining how sensitive research findings are to the choice of the approach.

Objective: To compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service. \ud \ud Design: Pragmatic randomised controlled trial with an integral health economic study. \ud \ud Settings: Large UK teaching hospital, with community follow-up. \ud \ud Subjects: Frail older people aged 70 years and older admitted to hospital as an acute medical emergency. \ud \ud Measurements: Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis. \ud \ud Results: A total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74–1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI −5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI −1,645 to 1,934). \ud \ud Conclusion: The CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (

Background : Hypoglycemia occurs frequently in patients both in the inpatient and outpatient settings. While most hypoglycemia unrelated to diabetes treatment results from excessive endogenous insulin action, rare cases involve functional and congenital mutations in glycolytic enzymes of insulin regulation. Case : A 21-year-old obese woman presented to the emergency department with complaints of repeated episodes of lethargy, syncope, dizziness, and sweating. She was referred from an outside facility on suspicion of insulinoma, with severe hypoglycemia unresponsive to repeated dextrose infusions. Her plasma glucose was 20 mg/dl at presentation, 44 mg/dl on arrival at our facility, and remained low in spite of multiple dextrose infusions. The patient had been treated for persistent hyperinsulinemic hypoglycemia of infancy at our neonatal facility and 4 years ago was diagnosed as having an activating glucokinase (GCK) mutation. She was then treated with octreotide and diazoxide with improvement in symptoms and blood glucose levels. Conclusion : Improved diagnostication and management of uncommon genetic mutations as typified in this patient with an activating mutation of the GCK gene has expanded the spectrum of disease in adult medicine. This calls for improved patient information dissemination across different levels and aspects of the health care delivery system to ensure cost-effective and timely health care. Keywords: glucose; low plasma glucose; hypoglycemia; genetic; mutation; congenital hyperinsulinism; congenital; adult; care transition; care coordination (Published: 26 October 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 32983 - http://dx.doi.org/10.3402/jchimp.v6.32983

Background When older adults return home from geriatric rehabilitation in a hospital, remembering the plethora of medical advice and medical instructions provided can be overwhelming for them and for their caregivers. Objective The overall objective was to develop and test the feasibility of a novel web-based application called MyPath to Home that can be used to manage the personalized needs of geriatric rehabilitation patients during their transition from the hospital to home. Methods This study involved (1) co-designing a patient- and clinician-tailored web-based application and (2) testing the feasibility of the application to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we followed a user-centered design process integrated with the modern agile software development methodology to iteratively co-design the application. The approach consisted of three cycles in which we engaged patients, caregivers, and clinicians to design a series of prototypes (cycles 1-3). In phase 2, we conducted a single-arm feasibility pilot test of MyPath to Home. Baseline and follow-up surveys, as well as select semistructured interviews were conducted. Results In phase 1, semistructured interviews and talk-aloud sessions were conducted with patients/caregivers (n=5) and clinicians (n=17) to design the application. In phase 2, patients (n=30), caregivers (n=18), and clinicians (n=20) received access to use the application. Patients and their caregivers were asked to complete baseline and follow-up surveys. A total of 91% (21/23) of patients would recommend this application to other patients. In addition, clinicians (n=6) and patients/caregivers (n=6) were interviewed to obtain further details on the value of the web-based application with respect to engaging patients and facilitating communication and sharing of information with the health care team. Conclusions We were successful at designing the MyPath to Home prototype for patients and their caregivers to engage with their clinicians during the transition from geriatric rehabilitation to home. Further work is needed to increase the uptake and usage by clinicians, and determine if this translates to meaningful changes in clinical and functional outcomes. International Registered Report Identifier (IRRID) RR2-10.2196/11031

BackgroundDischarge summaries are essential for communicating patient information from secondary care to general practice on hospital discharge. Although there has been extensive research into their design and completion in secondary care, very little is known about primary care processing of these documents.AimTo explore what general practice staff think are the factors associated with failure to respond to actions requested in discharge summaries and what practices do to mitigate this.Design & settingSemi-structured interviews were undertaken with primary care staff in three geographical regions of England.MethodInterviews with 10 practice managers and 10 GPs (one of each at each of the 10 practices) were undertaken to explore management of discharge summaries.ResultsFive themes emerged from the interviews. The 'secondary care factors' theme describes participants’ perspectives on the design of summaries, which are inconsistent and often require improvement. The 'safety features of processing systems' theme focuses on document handling in primary care. A theme devoted to 'medicines reconciliation' followed. 'Error and harm as a result of faulty processing' is a theme describing ‘human error’ and other factors that participants believed contributed to failure to respond to requested actions. Finally, the 'strategies for safety improvement' theme describes initiatives to prevent failures of safer transitions of care.ConclusionCorrect processing of discharge summaries is essential to ensure patients experience a safe transition of care and not just a hospital discharge. Based on the interview findings, strategies to mitigate against faults in the processing of discharge summaries have been suggested to enhance safer transitions of care.

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.

The purpose of the study was to pilot test a model to reduce hospital readmissions and emergency department use of rural, older adults with chronic diseases discharged from home health services (HHS) through the use of volunteers. The study’s priority population consistently experiences poorer health outcomes than their urban counterparts due in part to lower socioeconomic status, reduced access to health services, and incidence of chronic diseases. When they are hospitalized for complications due to poorly managed chronic diseases, they are frequently readmitted for the same conditions. This pilot study examines the use of volunteer community members who were trained as Health Coaches to mentor discharged HHS patients in following the self-care plan developed by their HHS RN; improving chronic disease self-management behaviors; reducing risk of falls, pneumonia, and flu; and accessing community resources. Program participants increased their ability to monitor and track their chronic health conditions, make positive lifestyle changes, and reduce incidents of falls, pneumonia and flu. Although differences in the ED and hospital admission rates after discharge from HHS between the treatment and comparison group (matched for gender, age, and chronic condition) were not statistically significant, the treatment group’s rate was less than the comparison group thus suggesting a promising impact of the HC program (90 day: 263 comparison vs. 129 treatment; p = 0.65; 180 day 666.67 vs. 290.32; p = 0.19). The community health coach model offers a potential approach for improving the ability of discharged older home health patients to manage chronic conditions and ultimately reduce emergent care.

Background Secure clinical messaging and document exchange utilizing the Direct Protocol (Direct interoperability) has been widely implemented in health information technology (HIT) applications including electronic health records (EHRs) and by health care providers and organizations in the United States. While Direct interoperability has allowed clinicians and institutions to satisfy regulatory requirements and has facilitated communication and electronic data exchange as patients transition across care environments, feature and function enhancements to HIT implementations of the Direct Protocol are required to optimize the use of this technology. Objective To describe and address this gap, we developed a prioritized list of recommended features and functions desired by clinicians to utilize Direct interoperability for improved quality, safety, and efficiency of patient care. This consensus statement is intended to inform policy makers and HIT vendors to encourage further development and implementation of system capabilities to improve clinical care. Methods An ad hoc group of interested clinicians came together under the auspices of DirectTrust to address challenges of usability and create a consensus recommendation. This group drafted a list of desired features and functions that was published online. Comments were solicited from interested parties including clinicians, EHR and other HIT vendors, and trade organizations. Resultant comments were collected, reviewed by the authors, and incorporated into the final recommendations. Results This consensus statement contains a list of 57 clinically desirable features and functions categorized and prioritized for support by policy makers, development by HIT vendors, and implementation and use by clinicians. Conclusion Fully featured, standardized implementation of Direct interoperability will allow clinicians to utilize Direct messaging more effectively as a component of HIT and EHR interoperability to improve care transitions and coordination.

Introduction: Miscommunication during inter-unit handoffs between emergency and internal medicine physicians may jeopardize patient safety. Our goal was to evaluate the impact of a structured communication strategy on the quality of admission handoffs. Methods: We conducted a mixed-methods, pre-test/post-test study at a 560-bed academic health center with 60,000 emergency department (ED) patient visits per year. Admission-handoff best practices were integrated into a modified SBAR format, resulting in the Situation, Background, Assessment, Responsibilities & Risk, Discussion & Disposition, Read-back & Record (SBAR-DR) model. Physician handoff conversations were recorded and transcribed for the 60 days before (n=110) and 60 days after (n=110) introduction of the SBAR-DR strategy. Transcriptions were scored by two blinded physicians using a 16-item scoring instrument. The primary outcome was the composite handoff quality score. We assessed physician perceptions via a post-intervention survey. Results: The composite quality score improved in the post-intervention phase (7.57 + 2.42 vs. 8.45 + 2.51, p=.0085). Three of the 16 individual scoring elements also improved, including time for questions (70.6% vs. 82.7%, p=.0344) and confirmation of disposition plan (41.8% vs. 62.7%, p=.0019). The majority of emergency and internal medicine physicians felt that the SBAR-DR model had a positive impact on patient safety and handoff efficiency. Conclusion: Implementation of the SBAR-DR strategy resulted in improved verbal handoff quality. Agreement upon a clear disposition plan was the most improved element, which is of great importance in delineating responsibility of care and streamlining ED throughput. Future efforts should focus on nurturing broader physician buy-in to facilitate institution-wide implementation.

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.

HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n = 28) and 20 adult clinics that receive transitioning adolescents (n = 30) from August 2015-June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents' transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers' ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes.

It is important for both individual- and population-level health that HIV-infected individuals progress through the Care Continuum. However, HIV-infected youth frequently disengage from care during transition from pediatric/adolescent to adult care; only 50% remain in adult care after 1 year. Understanding how providers define and approach a successful healthcare transition can improve the delivery of HIV-related services during critical years of HIV treatment. We conducted 58 staff interviews across 14 Adolescent Trials Network clinics (n = 30) and 20 adult clinics (n = 28). We used the constant comparative method to examine how providers defined and approached youths' successful transition. Providers identified four components critical to successful transition: (1) clinical outcomes (e.g., medication adherence and viral suppression); (2) youth knowing how to complete treatment-related activities (e.g., refilling prescriptions and making appointments); (3) youth taking responsibility for treatment-related activities and their overall health (e.g., "when they stop reaching out to the adolescent [clinic] to solve all their problems."); and (4) youth feeling a connection and trust toward the adult clinic (e.g., "they feel safe here"), with some providers even prioritizing connectedness over clinical outcomes (e.g., "Even if they're not taking meds but are connected [to care], …that's a success."). The identification of key components of successful transition can guide focused interventions and resources to improve youth maintenance in the HIV Care Continuum as they transition to adult care. Identifying what facilitates successful transitions, and the gaps that interventions can target, will help to ensure HIV-infected youth remain healthy across their lifespan.

BackgroundThere is a need for greater understanding of the epidemiology of primary care patient safety in order to generate solutions to prevent future harm.AimTo estimate the rate of failures in processing actions requested in hospital discharge summaries, and to determine factors associated with these failures.Design and settingThe authors undertook a retrospective records review. The study population was emergency admissions for patients aged ≥75 years, drawn from 10 practices in three areas of England.MethodOne GP researcher reviewed the records for 300 patients after hospital discharge to determine the rate of compliance with actions requested in the discharge summary, and to estimate the rate of associated harm from non-compliance. In cases where GPs documented decision-making contrary to what was requested, these instances did not constitute failures. Data were also collected on time taken to process discharge communications.ResultsThere were failures in processing actions requested in 46% (112/246) of discharge summaries (95% confidence interval [CI] = 39 to 52%). Medications changes were not made in 17% (124/750) of requests (95% CI = 14 to 19%). Tests were not completed for 26% of requests (95% CI = 16 to 35%), and 27% of requested follow-ups were not arranged (95% CI = 20 to 33%). The harm rate associated with these failures was 8%. Increased risk of failure to process test requests was significantly associated with the type of clinical IT system, and male patients.ConclusionFailures occurred in the processing of requested actions in almost half of all discharge summaries, and with all types of action requested. Associated harms were uncommon and most were of moderate severity.

Introduction : Government-run primary healthcare polyclinics in Singapore are often overcrowded and overloaded due to the high fee-for-service (cost gradient) when patients visit private general practitioners (GP: USD22 vs. USD6) and physiotherapists (PT: USD91 vs. USD36). Moreover, patients often experience long wait time before receiving care due in part to limited physiotherapy services in the polyclinics. As a result, patients suffering from low back pain (LBP) and require physiotherapy are often referred to specialist doctors sited at government-run tertiary hospitals, complemented with acute physiotherapy services. However, patients are reluctant to receive follow-up care at the overcrowded polyclinics when their condition was assessed to be stable. There is a need to decongest acute care services for more deserving complex patients. Practice Change Implemented : A tripartite relationship among private GP, PT and public hospital-based orthopaedic surgeons was forged [Delivering-on-Target GP – Allied Health Partnership Programme (DOT GP – AHPP)] to narrow the cost gradient. Stable patients can now be right-sited to less crowded privately-run primary care facilities for follow-up. Aim : We aim to demonstrate that patients receiving care from this new model are satisfied with the cost, quality, and effectiveness of services provided by the DOT-AHPP liaison officers (DALO) and private partners. Methods : Seventy-seven patients suffering from LBP, suitable for conservative treatment, and assessed to be stable by orthopaedic surgeons from Singapore General Hospital (SGH) participated in this new model of care from August 2015 to April 2016. Patient satisfaction with our DALO and AHPP PT were described. Visual analogue pain scores (VAS) were evaluated before and after physiotherapy at AHPP using Wilcoxon signed-rank test. Results : Forty-two (54.6%) and Forty-five (58.5%) patients are very/extremely satisfied with the clarity of information and helpfulness presented by the DALO respectively. Twenty-two (28.6%) patients were referred for physiotherapy at AHPP but only 16 (20.8%) actualised the visit; Twelve (75.0%) patients were either satisfied or very satisfied with the overall affordability, friendliness, knowledge and ambience of the AHPP clinics. Significant improvement in VAS was observed after AHPP physiotherapy [n=9; before: 6.3(1.7); after: 4.0(1.6); P=.007]. Discussion : Patients receiving care from this new model are generally satisfied with the right-siting process. Overall, patients receiving care from AHPP PT reported improvement in their condition and were satisfied with the cost gradient reduction. Further strategies can be implemented to increase the enrolment. These include deepening the AHPP and specialists relationship by governing the care provision, regular case discussion and building trust. Further cost reduction, for example, with government subvention may increase patient enrolment. Limitations : The number of AHPP physiotherapy clinics is limited and most of them are geographically located in central Singapore. This may prohibit patients from enrolling into the new care model. More partners can be co-opted, especially in the northern and western parts of Singapore. These partners should be located close to Mass Rapid Transit (MRT) stations in order to reduce travel inconveniences to patients. Conclusions : The tripartite public-private partnership model has proven useful to decongest acute care services. However, more strategies to increase uptake by patients are needed.

Inaccurate or missing medication information in medical discharge summaries is a widespread and intractable problem. This study evaluated the effectiveness and sustainability of an intervention in which ward-based hospital pharmacists reviewed, contributed and verified medication information in electronic discharge summaries (EDSs) in collaboration with physicians. Retrospective audits of randomly selected EDSs were conducted on seven wards at a major public hospital before and after implementation of the intervention and repeated two years later on four wards where the intervention was incorporated into usual pharmacist care. EDSs for 265 patients (prescribed a median of nine discharge medications) were assessed across the three time points. Pharmacists verified the EDSs for 47% patients in the first post-intervention audit and 68% patients in the second post-intervention audit. Following the intervention, the proportion of patients with one or more clinically significant discharge medication list discrepancy fell from 40/93 (43%) to 14/92 (15%), p &lt, 0.001. The proportion of clinically significant medication changes stated in the EDSs increased from 222/417 (53%) to 296/366 (81%), p &lt, 0.001, and the proportion both stated and explained increased from 206/417 (49%) to 245/366 (67%), p &lt, 0.001. Significant improvements were still evident after two years. Pharmacists spent a median of 5 (range 2&ndash, 16) minutes per patient contributing to EDSs. Logistics, timing and pharmacist workload were barriers to delivering the intervention. Additional staff resources is needed to enable pharmacists to consistently deliver this effective intervention.

IntroductionCare transition for patients being discharged from inpatient mental healthcare to outpatient settings is a growing focus for healthcare delivery systems. Many studies of this inpatient to outpatient transition use the rate of postdischarge readmissions as a patient-level outcome measure to assess the quality of transition. However, it is unclear how studies define the measure, and whether there is a shared understanding by the field regarding which definition is appropriate for which circumstances. This scoping review thus aims to examine how published studies have approached measuring unnecessary psychiatric readmissions.Methods and analysisThe scoping review will be structured according to Levacet al’s enhancement to Arksey and O’Malley’s framework for conducting scoping reviews. The protocol is registered through the Open Science Framework (https://osf.io/5nxuc/). We will search literature databases for studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission). Screening and review of articles will be carried out by two reviewers, first independently then involving a third reviewer as needed for consensus. We will assess review findings through both tabular and thematic analyses, noting prevalent trends in study characteristics and emergent themes across our reviewed studies.Ethics and disseminationThis work comes at a time of heightened interest by many mental healthcare systems in high-quality practices that structure their care processes towards effective inpatient to outpatient transitions. Findings will support the systems’ careful examination of alternative potential transitional interventions, helping to ensure that their often limited quality enhancement resources are put to optimal use. We will focus on disseminating our findings to the healthcare community through strong communication infrastructures and connections with health system stakeholders that our multidisciplinary study consultants will foster throughout this study.

The aim of this study was to gain increased knowledge about nurses’ experiences of care transition of older patients from hospital to municipal health care, based on two research questions: How is nurses’ experience continuity during care transition of older patients from hospital to municipal health care? How would nurses describe an optimal care transition? Nurses have a pivotal role during care transitions of older patients. More knowledge about their experiences is necessary to develop favorable improvements for this important period in the older patient’s treatment and care. The study has a qualitative explorative design with follow-up focus group interviews. Nurses (N = 30) working in hospital (n = 16) and municipal (n = 14) health care were organized in five mixed focus groups during the period October-January 2014/2015. The focus groups met twice, answering the research questions following a previously circulated semi-structured interview guide. The interview analysis was inspired by content analysis. The analysis resulted in the themes “Administrative demands challenge terms for collaboration” and “Essentials for nursing determine optimal care transitions for older patients”. Administrative demands may prevent nurses’ professional dialogue and collaboration across health care levels. Older patients’ best interests should be ensured through a collaborative relationship between hospital and municipal nurses, to form continuous care across health care levels. Clinical practice should be aware of essentials for nursing, which could influence and facilitate a more individualized and continuous transition for older patients.

Colleen E Jackson,1–3 Laura J Grande,1–3 Kelly Doherty,1 Elizabeth Archambault,1 Brittany Kelly,1 Jane A Driver,1,4 William P Milberg,1,2,5 Regina McGlinchey,1,2,5 James L Rudolph6,7 1Geriatric Research, Education and Clinical Center, Department of Veterans Affairs (VA) Boston Healthcare System, Boston, MA, 2Translational Research Center for TBI and Stress Disorders, Department of Veterans Affairs (VA) Boston Healthcare System, Boston, MA, 3Department of Psychiatry, Boston University School of Medicine, Boston, MA, 4Department of Medicine, Harvard Medical School, Boston, MA, 5Department of Psychiatry, Harvard Medical School, Boston, MA, 6Center of Innovation in Long Term Services and Supports, Department of Veterans Affairs (VA) Providence Medical Center, Providence, RI, 7Department of Medicine, Warren Alpert School of Medicine of Brown University, Providence, RI, USA Purpose: Cognitive screening upon hospital admission can provide important information about the patient’s ability to process information during the inpatient stay. The Clock-in-the-Box (CIB) is a rapidly administered cognitive screening measure which has been previously validated with cognitive screening and neuropsychological assessments. The purpose of this study is to demonstrate the predictive validity of the CIB for discharge location among a sample of older medical inpatients. Patients and methods: Hospitalized Veterans (N=218), aged 55 years and older, were recruited on the day after admission after they gave their consent. These participants completed the CIB, the Montreal Cognitive Assessment, and self-report measures of daily functioning. Using logistic regression models, the bivariable and multivariable impact of the cognitive screening and functional assessments were examined for their ability to predict whether the participants did not return home after hospitalization (eg, admission to subacute rehabilitation facilities or nursing facilities). Results: The participants were older (mean 71.5±9.5 years) and predominantly male (92.7%). The CIB score was independently associated with discharge to locations other than home (odds ratio =0.72, 95% confidence interval =0.60–0.87, P=0.001) and remained associated after adjusting for demographics, prehospitalization functional abilities, and Montreal Cognitive Assessment score (adjusted odds ratio =0.55, 95% confidence interval =0.36–0.83, P=0.004). Conclusion: The current evidence, combined with its brevity and ease of use, supports the use of the CIB as a cognitive screen for inpatient older adults, in order to help inform clinical treatment decisions and discharge planning. Keywords: cognition, screening, aging, hospitalization, care transition

Background Medication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions. Methods Systematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models. Results Ten studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity. Conclusion Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results. Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

Background As the population ages, the need for appropriate geriatric rehabilitation services will also increase. Pressures faced by hospitals to reduce length of stay and reduce costs have driven the need for more complex care being delivered in the home or community setting. As a result, a multifaceted approach that can provide geriatric rehabilitation patients with safe and effective person- and family-centered care during transitions from hospital to home is required. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to safely manage their personalized needs during care transitions from hospital to home. Objective The purpose of this study is to design and test the feasibility of a novel Path to Home mobile app to manage the personalized needs of geriatric rehabilitation patients during their transitions from hospital to home. Methods This study will consist of (1) codesigning a patient- and provider-tailored mobile app, and (2) feasibility pilot testing of the mobile app to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we will follow a user-centered design process integrated with a modern agile software development methodology to iteratively codesign the personalized care transition Path to Home mobile app. In phase 2, we will conduct a single-arm feasibility pilot test with geriatric rehabilitation patients using the personalized care transition Path to Home mobile app to manage their needs during the transition from hospital to home. Results The project was funded in May 2018, and enrollment and data analysis are underway. First results are expected to be submitted for publication in 2019. Conclusions Our findings will help validate the use of this technology for geriatric rehabilitation patients discharged from the hospital to home. Future research will more rigorously evaluate the health and economic benefits to inform wide-scale adoption of the technology. Registered Report Identifier RR1-10.2196/11031

International audience; BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

Managing therapy-related side-effects and improving health-related quality of life in patients with colorectal cancer is still challenging. The need for an effective management of adverse events and unmet supportive care needs have been widely discussed. In the past decade, interventions by nursing staff gained more and more importance. Evidence suggests that a majority of patients even in early stages of the disease experience substantial impairments potentially resulting in diminished therapy adherence as well as impaired quality of life. However, evidence for the effectiveness of nurse-led interventions on symptom management and quality of life is still very limited. This especially applies to care transitions between different inpatient and outpatient health care providers throughout the course of treatment and aftercare. Supportive Cancer Care Networkers (SCAN) is a prospective randomized controlled trial conducted in eight large and middle-sized German cancer centers and municipal hospitals. The target population is adults with colorectal cancer UICC I-III after initial R-0 resection scheduled for adjuvant chemotherapy or guideline-based aftercare only. 370 patients will be randomly assigned to either intervention or control group. Patients in the intervention group will receive an additional support by specialized oncology nurses for eight weeks after discharge from hospital by telephone, consisting of symptom monitoring, counselling on self-assessment and self-management and dealing with individual resources for coping and psychosocial well-being. The primary endpoint will be health-related quality of life (HRQoL) at eight weeks after discharge from the initial treating hospital. The presented SCAN trial is to provide information that will be useful to advance our understanding of complex interdependencies between symptom severity, supportive care needs, functioning and the risk for diminished HRQoL. Most importantly, these patient-reported outcomes are not fully implemented in today’s clinical routine practice potentially resulting in therapy cessations and lower chemotherapy treatment rates for colorectal cancer especially in older patients. ClinicalTrials.gov Identifier NCT01651832 .

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. References: 1- Longman JM, Singer JB, Gao Y, Barclay LM, Passey ME, Pirotta JP, et al. Community based service providers' perspectives on frequent and/or avoidable admission of older people with chronic disease in rural NSW: a qualitative study. BMC Health Services Research. 2011Dec;11(1) 2- Ross S, Curry N, Goodwin N. Case management. What it is and how it can best be implemented. London: The King’s Fund; 2011. [Cited 12 Dec 2011]. Available from: http://www.kingsfund.org.uk/publications/case_management.html. 3- Low LL, Liu N, Wang S, Thumboo J, Ong MEH, Lee KH. Predicting frequent hospital admission risk in Singapore: a retrospective cohort study to investigate the impact of comorbidities, acute illness burden and social determinants of health. BMJ Open. 2016;6(10) 4- Pope C. Qualitative research in health care: Analysing qualitative data. BMJ. 2000 Aug;320(7227):114–6

Background: Despite the need for centreand home-based long-term care services (CHLTCS) among patients to be discharged from acute care hospitals, the services take-up rate is about 50% in Singapore. A re-engineered acute-to-CHLTCS transition process that reduces resource duplication and that provides timely and accurate service information is evaluated on its ability to reduce patient waiting time, and increase take-up rate. Methods: Data was obtained from records of patients who were assessed to be likely to benefit from CHLTCS prior to discharge from an acute care hospital. The intervention group comprised 39 patients from six clinical specialty wards, which submitted the highest number of CHLTCS referrals among all wards over the past year, over a fiveand an eight-day period in July and August 2013. CHLTCS referral management staff were deployed alongside the hospital team to assess these patients’ care needs, provide information on alternative services and service providers, and obtain the patients and families’ commitment to a service provider before a CHLTCS referral was submitted via the national referral management system, and a service provider assigned. The comparator group comprised 209 patients from all wards in May and June 2013. These patients underwent the existing care transition process where they were assessed and referred to CHLTCS by only the hospital team. CHLTCS referral management staff assessed the merits of these submitted referrals, checked the patient and family’s preference on service providers, before assigning a service provider. Results: Prior to referral submission, 34% of the intervention group patients declined the CHLTCS referral while none from the comparator group declined. Among patients with a submitted CHLTCS referral, the intervention group’s take-up rate was higher than the comparator group’s (82% v 50%). More patients in the intervention group were referred to CHLTCS service within one day of hospital discharge (77% v 58%) and assigned to service providers on the day of referral submission (76% v 46%). World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116670– http://www.ijic.org/ Discussions: The joint deployment of the hospital and CHLTCS referral management teams reduced the duplication of and streamlined the assessment and referral submission processes between the teams. The timely provision of accurate information on alternative services and service providers allowed informed care decisions to be made by patients and families early, which, in turn, reduced unproductive efforts in referral management. Conclusion: The re-engineered care transition process increased CHLTCS take-up rate substantially, suggesting that there is potential continued need for CHLTCS in Singapore. Lessons learned: The key ingredients of success in this pilot are informed care decisions made early and shorter overall processing time from care needs assessment to service provider assignment. Limitations: The most important limitation in this study was the non-random selection of clinical specialty wards in the intervention group. Additionally, the intervention period was short, resulting in a small study sample taken from only one hospital. Suggestions for future research: Future research should involve random sampling of patients from all hospital wards, and examine the impact of this re-engineered care transition process on the hospital length of stay and re-admission rate of patients.

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.

Stephen Jon Kogut,1 Elaina Goldstein,1 Camille Charbonneau,1 Anita Jackson,1 Gail Patry2 1Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, 2Healthcentric Advisors, Providence, RI, USA Background: Substantial opportunity exists to improve medication management in the period following a hospital discharge. The objective of this study was to assess and improve medication management during care transitions through pharmacist home visits and the use of an electronic personal health record (ePHR) system. Methods: Recently discharged patients aged 50 years or older and having a chronic medical condition were offered the opportunity to meet with a pharmacist in the home setting to review medication instructions and receive a demonstration of an ePHR system. Patients agreeable to using the ePHR system were offered pharmacist support with setting up the ePHR system, having emphasis on documenting and reviewing medication regimens. Medication-related problems identified by the pharmacist during the visit were categorized according to ePHR use and by other characteristics. Results: Thirty recently discharged patients with chronic disease were visited by a pharmacist over a 6-month period. The percentage of medication-related problems identified by the pharmacist was greater among those patients who agreed to use the ePHR system, as compared with patients whose visit did not include use of the ePHR (75% versus 40%, respectively; P=0.06). Differing types of medication-related problems were identified, including therapy duplications, lack of use of clinically important therapies, and patient nonadherence. Conclusion: For some patients, the home setting can be a suitable venue for medication review and education after discharge from hospital. Assisting patients with setting up the ePHR system may enhance pharmacists’ ability to identify and resolve medication-related problems that may lead to rehospitalization. Keywords: medication reconciliation, care transition, electronic personal health record

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.

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.

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 re-hospitalization 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 self-management 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 self-management knowledge, whereas a system accountability overlapping the gaps could provide patients with comfort to put knowledge into action.