In the clinic transitions of care

Annals of Internal Medicine

Volumn 158, Issue 5 PART 1, 2013, Pages 365-

  Kim, Christopher S ^a   Flanders, Scott A ^a  

^a NONE

Author keywords

Diagnosis; To review current evidence for the prevention; Treatment of transitions of care

Indexed keywords

AMBULATORY CARE; ARTICLE; CHARLSON COMORBIDITY INDEX; CLINICAL PRACTICE; CONGESTIVE HEART FAILURE; ELECTRONIC MEDICAL RECORD; ENVIRONMENTAL FACTOR; FOLLOW UP; GENERAL PRACTITIONER; HEALTH CARE DELIVERY; HEALTH CARE FACILITY; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HEALTH CARE SYSTEM; HEALTH CARE UTILIZATION; HEALTH SERVICE; HEART INFARCTION; HOME HEALTH AGENCY; HOMELESSNESS; HOSPITAL COST; HOSPITAL DISCHARGE; HOSPITAL READMISSION; HOSPITALIZATION; HUMAN; LENGTH OF STAY; MEDICAL SOCIETY; MEDICATION THERAPY MANAGEMENT; NURSING HOME; OCCUPATIONAL THERAPY; OUTPATIENT CARE; PATIENT CARE; PATIENT COMPLIANCE; PATIENT INFORMATION; PATIENT SAFETY; PNEUMONIA; PRIMARY MEDICAL CARE; PRIORITY JOURNAL; PROFESSIONAL PRACTICE; QUALITATIVE RESEARCH; QUALITY OF LIFE; RANDOMIZED CONTROLLED TRIAL (TOPIC); REIMBURSEMENT; RISK FACTOR; SOCIAL SUPPORT; SOCIAL WORK; ECONOMICS; FAMILY; HEALTH CARE QUALITY; PATIENT EDUCATION; REVIEW; RISK ASSESSMENT; STANDARD;

CONTINUITY OF PATIENT CARE; FAMILY; HUMANS; MEDICATION RECONCILIATION; PATIENT CARE TEAM; PATIENT DISCHARGE; PATIENT EDUCATION AS TOPIC; PATIENT READMISSION; QUALITY OF HEALTH CARE; RISK ASSESSMENT;

EID: 84874704734     PISSN: 00034819     EISSN: 15393704     Source Type: Journal    
DOI: None     Document Type: Article

References (56)

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354]
2. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345-9. [PMID: 14757670]
3. Payment Policy for In-patient Readmissions. In: Report to the Congress: Promoting Greater Efficiency in Medicare. Medicare Payment Advisory Commission. Washington DC; June, 2007:103-20.
4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. [PMID: 19339721]
5. Goodman DC, Fisher ES, Chang C-H. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. The Dartmouth Institute for Health Policy & Clinical Practice; September, 2011:1-52.
6. Bray-Hall ST. Transitional care: focusing on patient-centered outcomes and simplicity [Editorial]. Ann Intern Med. 2012;157:448-9. [PMID: 22986380]
7. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Inter-ventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155:520-8. [PMID: 22007045]
8. Medicare To Penalize 2,217 Hospitals for Excess Readmissions. Kaiser Health News; August 13, 2012.
9. Allaudeen N, Schniper JL, Orav EJ, Wachter RM, Vidyarthi AR. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011;26:771-6. [PMID: 21399994]
10. Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, et al. Risk prediction models for hospital read-mission: a systematic review. JAMA.2011;306:1688-98. [PMID: 22009101]
11. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182:551-7. [PMID: 20194559]
12. Project BOOST. Philadelphia, PA: Society of Hospital Medicine; 2012.
13. Ho PM, Tsai TT, Mad-dox TM, Powers JD, Carroll NM, Jackevicius C, et al. Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: impli-cations for transitions of care. Circ Cardiovasc Qual Outcomes. 2010;3:261-6. [PMID: 20407117]
14. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360:1102-12. [PMID: 19279342]
15. Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists and care transitions: the divorce of inpatient and outpatient care. Health Aff(Millwood). 2008;27:1315-27. [PMID: 18780917]
16. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-41. [PMID: 17327525]
17. Hesselink G, Vernooij-Dassen M, Pijnenborg L, Barach P, Gademan P, Dudzik-Urbaniak E, et al. Organizational culture: an important context for addressing and improving hospital to community patient discharge. Med Care. 2013;51:90-8. [PMID:23132202]
18. Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121-8. [PMID: 16027454]
19. Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167:1305-11. [PMID: 17592105]
20. LaMantia MA, Scheunemann LP, Viera AJ, Busby-White-head J, Hanson LC. Interventions to improve transitional care between nursing homes and hospitals: a systematic review. J Am Geriatr Soc. 2010;58:777-82. [PMID: 20398162]
21. Shah F, Burack O, Boockvar KS. Perceived barriers to communication between hospital and nursing home at time of patient transfer. J Am Med Dir Assoc. 2010;11:239-45. [PMID: 20439042]
22. Gandara E, Moniz T, Ungar J, Lee J, Chan-Macrae M, O'Malley T, et al. Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. J Hosp Med. 2009;4:E28-33. [PMID: 19827041]
23. Rogers MA, Mody L, Kaufman SR, Fries BE, McMahon LF Jr, Saint S. Use of urinary collection devices in skilled nursing facilities in five states. J Am Geriatr Soc. 2008;56:854-61. [PMID: 18454750]
24. Mody L, Bradley SF, Galecki A, Olmsted RN, Fitzgerald JT, Kauffman CA, et al. Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices. Clin Infect Dis. 2011;52:654-61. [PMID: 21292670]
25. Ouslander JG, Diaz S, Hain D, Tappen R. Frequency and diag-noses associated with 7-and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital. J Am Med Dir Assoc. 2011;12:195-203. [PMID: 21333921]
26. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90. [PMID: 12523921]
27. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, D.C.: The National Academies Press; 2012.
28. Hesselink G, Flink M, Olsson M, Barach P, Dudzik-Urbaniak E, Orrego C, et al. Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Qual Saf. 2012;21 Suppl 1:i39-49. [PMID:23118410]
29. Cumbler E, Carter J, Kutner J. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient. J Hosp Med. 2008;3:349-52. [PMID: 18698595]
30. Misky GJ, Wald HL, Coleman EA. Posthospitalization tran sitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5:392-7. [PMID: 20578046]
31. Doctoroff L. Interval examination: establishment of a hospitalist-staffed discharge clinic. J Gen Intern Med. 2012;27:1377-82. [PMID: 22810356]
32. Bumpus S, Kline-Rogers E, Kosteva A, Smith C, Mont-gomery D, Eagle K, et al. A Nurse Based Bridge Transitional Care Model Reduces Readmissions and ED Visits. Journal of the American College of Cardiology. 2011;57(14):E1182
33. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-28. [PMID: 22986379]
34. Joshi DK, Bluhm RA, Malani PN, Fetyko S, Denton T, Blaum CS. The successful development of a sub-acute care service associated with a large academic health system. J Am Med Dir Assoc. 2012;13:564-7. [PMID: 22748721
35. Chang R, Spahlinger D, Kim CS. Re-engineering the postdischarge appointment process for general medicine patients. Patient. 2012;5:27-32. [PMID: 22217264
36. Physician Orders for Life-Sustaining Treatment Paradigm. 2012:www.ohsu.edu/polst/index.htm
37. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for lifesustaining treatment form. J Am Geriatr Soc. 2011;59:2091-9. [PMID: 22092007]
38. Greenwald JL, Halasyamani LK, Greene J, LaCivita C, Stucky E, Benjamin B, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf 2010;36:504-13, 481. [PMID: 21090020]
39. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medica-tion reconciliation practices: a systematic review. Arch Intern Med. 2012;172:1057-69. [PMID: 22733210]
40. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-12. [PMID: 22111719]
41. Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital dis-charge: a random-ized trial. Ann Intern Med. 2012;157:1-10. [PMID: 22751755]
42. Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169:2003-10. [PMID: 19933963]
43. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71. [PMID: 16534045]
44. van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183:E391-402. [PMID: 21444623]
45. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-8. [PMID: 17000937]
46. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120:999-1006. [PMID: 8185149]
47. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20. [PMID: 10029122]
48. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PMID: 19189907]
49. 2012 Measures Maintenance Technical Report: Acute Myocardial Infarction, Heart Failure, and Pneumonia 30-Day Risk-Standardized Readmission Measure. Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation; 2012.
50. Maynard GA, Budnitz TL, Nickel WK, Greenwald JL, Kerr KM, Miller JA, et al. 2011 John M. Eisen-berg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level. Jt Comm J Qual Patient Saf. 2012;38:301-10. [PMID: 22852190]
51. Boutwell AE, Johnson MB, Rutherford P, Watson SR, Vecchioni N, Auerbach BS, et al. An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Aff (Millwood). 2011;30:1272-80. [PMID: 21734200]
52. Giordano A, Scalvini S, Zanelli E, Corrà U, Longobardi GL, Ricci VA, et al. Multicenter randomised trial on home-based telem-anagement to prevent hospital read-mission of patients with chronic heart failure. Int J Cardiol. 2009;131:192-9. [PMID: 18222552]
53. Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363:2301-9[PMID: 21080835]
54. Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012;172:773-9. [PMID: 22507696]
55. Kertesz SG, Posner MA, O'Connell JJ, Swain S, Mullins AN, Shwartz M, et al. Post-hospital medical respite care and hospital readmission of homeless persons. J Prev Interv Community. 2009;37:129-42. [PMID: 19363773]
56. Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4:364-70. [PMID: 19479781]