Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs

Journal of General Internal Medicine

Volumn 29, Issue 6, 2014, Pages 932-939

  Arbaje, Alicia I ^a   Kansagara, Devan L ^b   Salanitro, Amanda H ^c   Englander, Honora L ^b   Kripalani, Sunil ^c   Jencks, Stephen F ^d   Lindquist, Lee A ^e  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b OREGON HEALTH AND SCIENCE UNIVERSITY   (United States)

^c VANDERBILT UNIVERSITY SCHOOL OF MEDICINE   (United States)

^d Division of Hospital Medicine Oregon Health and Science University ^*  (United States)

^e NORTHWESTERN UNIVERSITY   (United States)

Author keywords

care transitions; geriatrics; healthcare delivery; utilization; vulnerable populations

Indexed keywords

ARTICLE; COGNITIVE DEFECT; DEMENTIA; FAMILY; FRIEND; FUNCTIONAL DISEASE; GERIATRIC CARE; HEALTH CARE COST; HEALTH CARE NEED; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HEALTH CARE UTILIZATION; HEALTH LITERACY; HOME CARE; HOSPITAL DISCHARGE; HOSPITAL READMISSION; HUMAN; MEDICARE; NURSING HOME; PALLIATIVE THERAPY; PATIENT CARE; PATIENT EDUCATION; TELEMONITORING; TRANSITIONAL CARE; VULNERABLE POPULATION; AFTERCARE; AGED; CAREGIVER; CHRONIC DISEASE; COMORBIDITY; CONSUMER; EDUCATION; ELDERLY CARE; FEMALE; HEALTH CARE POLICY; INDEPENDENT LIVING; MALE; ORGANIZATION AND MANAGEMENT; OUTCOME ASSESSMENT; PATIENT CARE PLANNING; PREVENTIVE HEALTH SERVICE; PROCEDURES; STANDARDS; TOTAL QUALITY MANAGEMENT; UNITED STATES;

AFTERCARE; AGED; CAREGIVERS; CHRONIC DISEASE; COMORBIDITY; CONSUMER PARTICIPATION; CONTINUITY OF PATIENT CARE; FEMALE; HEALTH POLICY; HEALTH SERVICES FOR THE AGED; HUMANS; INDEPENDENT LIVING; MALE; OUTCOME ASSESSMENT (HEALTH CARE); PATIENT CARE PLANNING; PATIENT DISCHARGE; PATIENT-CENTERED CARE; PREVENTIVE HEALTH SERVICES; QUALITY IMPROVEMENT; UNITED STATES;

EID: 84901676389     PISSN: 08848734     EISSN: 15251497     Source Type: Journal    
DOI: 10.1007/s11606-013-2729-1     Document Type: Article

References (50)

1. Sato M, Shaffer T, Arbaje AI, Zuckerman IH. Residential and health care transition patterns among older Medicare beneficiaries over time. Gerontologist. 2010;51(2):170-178.
2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
3. Callahan CM, Arling G, Tu W, et al. Transitions in care for older adults with and without dementia. J Am Geriatr Soc. 2012;60(5):813-820.
4. Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation. BMJ Qual Saf. 2011;20(9):773-778.
5. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. NEJM. 1995;333:1190-1195.
6. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675-684.
7. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111(2):179-185.
8. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358-1367.
9. Coleman EA, Smith JD, Frank JC, Min S-J, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817-1825.
10. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620.
11. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004;291(11):1358-1367.
12. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
13. Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004;1:CD000313.
14. Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary CareA systematic review. Ann Intern Med. 2012;157(6):417-428.
15. Englander H, Kansagara D. Planning and designing the care transitions innovation (C-TraIn) for uninsured and Medicaid patients. J Hosp Med. 2012;7(7):524-529.
16. Arbaje AI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist. 2008;48(4):495-504.
17. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551.
18. Anderson G, Horvath J. Chronic conditions: making the case for ongoing care. Baltimore: Robert Wood Johnson Partnership for Solutions; 2002.
19. Fernandez HM, Callahan KE, Likourezos A, Leipzig RM. House staff member awareness of older inpatients' risks for hazards of hospitalization. Arch Intern Med. 2008;168(4):390-396.
20. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219-223.
21. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: "she was probably able to ambulate, but I'm not sure". JAMA. 2011;306(16):1782-1793.
22. Lindquist LA, Go L, Fleisher J, Jain N, Baker D. Improvements in cognition following hospital discharge of community dwelling seniors. J Gen Intern Med. 2011;26(7):765-770.
23. 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(8):831-841.
24. Kane RL. Finding the right level of posthospital care: "we didn't realize there was any other option for him". JAMA. 2011;305(3):284-293.
25. Vasquez MS. Preventing rehospitalization through effective home health nursing care. Home Healthc Nurse. 2008;26(2):75-81.
26. Wier LM, Andrews RM. Hospital utilization among oldest adults, 2008. Rockville: Agency for Healthcare Research and Quality; 2010.
27. Murtaugh CM, Litke A. Transitions through postacute and long-term care settings: patterns of use and outcomes for a national cohort of elders. Med Care. 2002;40(3):227-236.
28. Wolff JL, Meadow A, Weiss CO, Boyd CM, Leff B. Medicare home health patients' transitions through acute and post-acute care settings. Med Care. 2008;46(11):1188-1193.
29. Madigan EA. A description of adverse events in home healthcare. Home Healthc Nurse. 2007;25(3):191-197.
30. Rosati RJ, Huang L. Development and testing of an analytic model to identify home healthcare patients at risk for a hospitalization within the first 60 days of care. Home Health Care Serv Q. 2007;26(4):21-36.
31. Levine C, Albert SM, Hokenstad A, Halper DE, Hart AY, Gould DA. "This case is closed": family caregivers and the termination of home health care services for stroke patients. Milbank Q. 2006;84(2):305-331.
32. Fortinsky RH, Madigan EA, Sheehan TJ, Tullai-McGuinness S, Fenster JR. Risk factors for hospitalization among Medicare home care patients. West J Nurs Res. 2006;28(8):902-917.
33. Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. The Gerontol. 2013;53(3):430-440.
34. Lindquist LA, Cameron KA, Messerges-Bernstein J, et al. Hiring and screening practices of agencies supplying paid caregivers to older adults. J Am Geriatr Soc. 2012;60(7):1253-1259.
35. Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-479.
36. Schoenborn N, Arbaje AI, Eubank KJ, Maynor KA, Carrese JA. Clinician roles and responsibilities during care transitions of older adults. J Am Geriatr Soc. 2013;61(2):231-236.
37. Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157(3):207-210.
38. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306(15):1688-1698.
39. Lindquist LA, Baker DW. Understanding preventable hospital readmissions: masqueraders, markers, and true causal factors. J Hosp Med. 2011;6(2):51-53.
40. DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis: the VA National Center for patient safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28(5):248-267. 209.
41. Carayon P, ed. Handbook of human factors and ergonomics in health care and patient safety. 2nd ed. Boca Raton: CRC Press; 2012.
42. Carayon P, Wood KE. Patient safety - the role of human factors and systems engineering. Stud Health Technol Inform. 2010;153:23-46.
43. Ms B. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates; 1994.
44. Dekker S. Patient safety: a human factors approach. 2011.
45. Givens JL, Selby K, Goldfeld KS, Mitchell SL. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc. 2012;60(5):905-909.
46. Pronovost PJ, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-770.
47. Transitions of Care Measures: Paper by the NTOCC Measures Work Group. National Transitions of Care Coalition. 2008. www.ntocc.org.
48. Care Transitions: Performance Measurement Set (Phase I: Inpatient Discharges & Emergency Department Discharges). Report from the Physician Consortium for Performance Improvement (PCPI). American Medical Association. 2009. http://www.ama-assn.org.
49. McDonald KM, Schultz E, Albin L, et al. Care coordination measures atlas. Rockville: Agency for Healthcare Research and Quality; 2010:11-0023-EF.
50. Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. N Engl J Med. 2011;365(24):2287-2295.