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PubMed1995

The acute and long-term care interface. Integrating the continuum.

Acute and long-term care traditionally have been distinctly different health care services, separated by reimbursement mechanisms, types and numbers of providers, and overall approach to the management of chronic illness. Considerable effort has been made of late, primarily due to financial incentives, to integrate these two levels of care into a "seamless" continuum. Barriers to such an integration process must first be identified. Physician and other health care providers will need to develop the tools and resources necessary to manage frail, chronically ill patients in settings other than the traditional acute care hospital, as well as to develop information systems that allow communication to flow easily between all levels of care. As subacute or transitional care becomes a central piece of a health care delivery system, those tools become critical to the provision of quality, integrated care.

Acute Disease↗
PubMed1997

Post-hospital sub-acute care: an example of a managed care model.

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub-acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract. DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services. SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round-the-clock, 7 days per week admissions for sub-acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities. PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post-cardiovascular accident, post-fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1-year program under report, and 253 were surveyed in regard to their experience. One hundred HealthPartners physicians were surveyed about the program. RESULTS: Post-acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub-acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities. CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.

Aged↗
PubMed1996

Health care: a social contract in transition.

Health care reform around the world is born in considerable measure of the need to reconcile our growing capacity to provide effective health care with diminishing economic means to sustain this capacity indefinitely. It is precisely under these circumstances that the conflict between individual rights to health care and the state's responsibilities to provide it becomes unavoidable. Although it cannot be eliminated, the conflict can be managed. But the task requires us to go beyond formulating economic policies or designing new structural systems for delivering health care. It requires an understanding of the purpose of health care for individuals and society. It includes stipulating limitations for individual rights and state responsibilities. Because of these limitations, the task must be guided by the requirements of justice. Health care as both a private and common good is at the center of a distributive struggle. At one level the focus of this struggle is economic and political. At another level it is moral and revolves around the concept of health itself, considered in its biological, psychological and social dimensions. Here the issue becomes health as a right, together with the implications such a right has for our efforts to balance the freedom of individual health-related behavior with the interests of the public's health. What, in that balance, are the rights of the individual and the responsibilities of the state? Can the individual citizen hold the state accountable for securing the conditions necessary for health? Can the state hold its citizens accountable for irresponsible health-related behavior? A discussion of providing liver transplantation sheds considerable light on these questions, while suggesting a paradigm for use with general health care services. Central to this paradigm is the welfare concept of right, balanced by the understanding that a citizen's claim on health care services is limited. In the final analysis, justice in health care will be achieved through a division of labor, at the center of which there is a set of reasonable and binding expectations shared reciprocally between the individual and the state.

Ethics, Medical↗
PubMed1999

Do advanced practice nurses and physician assistants benefit small rural hospitals?

Advanced practice nurses and physician assistants have offered small, rural hospitals an alternative to scarce primary care physicians for 30 years. This paper uses survey data from 285 small rural hospitals and case studies of 36 of these hospitals to answer questions about the extent to which advanced practice nurses and physician assistants provide primary care in small, rural hospitals, the benefits that might bring to the hospitals as well as the reactions of the public. The study used survey data collected as part of an evaluation of 285 hospitals, which received a Rural Health Care Transition grant from the Health Care Financing Administration in 1993 and 1994. Most of the hospitals used the practitioners; 70 percent used nurse practitioners; 30 percent used physician assistants; and 20 percent used both. There were some negative reactions to the use of the practitioners, but, overall, there was acceptance and benefits to the hospitals in the form of reduced recruitment costs, increased revenues and increased service offerings. These practitioners are beneficial to rural hospitals, and mechanisms to encourage their acceptance should be developed and implemented.

Data Collection↗
PubMed2000

[Psychosocial approach to cystic fibrosis in adults].

Progress in therapeutics has transformed care for cystic fibrosis. Physicians now see adults with a chronic disease requiring more global care. To improve the patient's quality of life, it is essential to take into account the social and occupational aspirations as well as their psychological resistance and self-determination. We emphasize the need for perfect synergy between medical and social care givers and on the importance of careful transition from pediatric to adult care, including during the time of major surgical procedures.

Adaptation, Psychological↗
PubMedDate not supplied

A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care.

OBJECTIVE: The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses' coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care. METHODS: The use of a descriptive qualitative research design with brief selective participant observation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study. RESULTS: MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of "torturing the patient," and conflict with families caused the greatest distress to staff. CONCLUSIONS: MICU nurses are dynamic and resourceful when responding to challenging end-of-life patient care situations.

Adaptation, Psychological↗
PubMed1995

Methods and problems in measuring quality of life.

The US health-care transition demands increased accountability for medical care. This has contributed to increased interest in documenting valued medical outcomes, including improvements in health-related quality of life and treatment satisfaction. These data can only be obtained validly by asking patients directly about their current health state, perception of well-being, and satisfaction with care. A core set of well-validated instruments have been developed to measure health-related quality of life in patients with cancer. As these are employed with increasing frequency, rigorous quality assurance of data collection is critical. Because of the necessity of quality control, patient-reported data collection can be labor-intensive and prohibitively costly. However, time and cost-saving methods, such as centralized telephone survey methods or on-site direct data entry via interactive computer, can guarantee high-quality data while minimizing costs. Justification of the need for these methods and a brief description are provided.

Data Interpretation, Statistical↗
PubMedDate not supplied

Infection control and changing health-care delivery systems.

In the past, health care was delivered mainly in acute-care facilities. Today, health care is delivered in hospital, outpatient, transitional care, long-term care, rehabilitative care, home, and private office settings. Measures to reduce health-care costs include decreasing the number of hospitals and the length of patient stays, increasing outpatient and home care, and increasing long-term care for the elderly. The home-care industry and managed care have become major providers of health care. The role of specialists in health-care epidemiology has changed accordingly.

Aged↗
PubMed1994

Data collection strategies for patient-reported information.

The U.S. health care transition demands increased accountability for medical care. This has contributed to increased interest in documenting medical outcomes, including improvements in health-related quality of life and treatment satisfaction. These data can only be obtained by asking patients directly about their current health state, perception of well-being, and satisfaction with care. Systematic collection of patient-reported data is often poorly done because its demands are underestimated and inadequately supported. Rigorous quality assurance is critical in any clinical trial or treatment delivery evaluation program.

Clinical Trials as Topic↗
PubMed2001

The predictors of unsuccessful transition to foster care.

The placement movements of 235 children entering foster care over a 12-month period were followed up 4 months after referral into care. Baseline and follow-up measures of the 170 children who were still in care at follow-up were also compared. Results indicated that adolescents with mental health or behavioural problems were the least likely to achieve placement stability or to display improved psychological adjustment in care. In fact, unsatisfactory transition to foster care was found to be so prevalent among these children that conventional foster family care should be considered unsuitable for them. The paper concludes that there is an urgent need for a wider range of alternative care options for the adolescent population.

Adaptation, Psychological↗
PubMed1990

Ashley House--faithful care for fragile children.

Ashley House offers an innovative approach to transitional care for medically fragile children, providing skilled nursing care in a homelike environment for children who might otherwise languish in hospitals or nursing homes. Most importantly, the Ashley House program provides comprehensive support for the family, including case management, training in home health care techniques, and grief counseling. The goal of the program is to facilitate a transition home for as many children as possible.

Child↗
PubMed2026

Transitioning to adult care for patients with IBD: the impact of a structured IBD transition program on service engagement.

BACKGROUND AND AIMS: The British Society of Gastroenterology recommend use of structured transition programs to improve control of chronic gastrointestinal disease in adolescents. We sought to determine the impact of attending a structured transition program on engagement of patients with inflammatory bowel disease (IBD) services and disease outcomes. METHODS: We performed a retrospective multicenter study of patients with IBD prior to and post-transfer to adult services. Patients were grouped into those who attended a structured transition program and those who received standard care, transferred with a referral letter. RESULTS: A total of 282 patients were included: 155 patients in our structured transition program cohort and 127 patients in the standard care cohort. Patients who took part in a structured transition program had significantly better engagement with adult IBD services with significantly lower rates of nonattendance at outpatient clinics 1-year post-transfer (12.3% vs 27.2%, P = .002) and significantly lower rates of disengagement with services (4.2% vs 13.1%, P = .015). There were no significant differences seen in rates of biologic failure, need for steroid/surgery or median fecal calprotectin levels between either group. Attending a structured transition program was the only factor that positively impacted engagement with IBD services in a multivariate analysis (OR 4.08, confidence interval 1.41-11.91, P = .01). CONCLUSION: Structured transition programs in IBD can improve engagement of patients with IBD services with significantly lower rates of disengagement with IBD services seen in our study. Large prospective studies are needed in this field to further investigate this and the impact of these programs on disease outcomes.

Humans↗
PubMed1995

Do transition grants help rural hospitals?

Congress introduced the Rural Health Care Transition (RHCT) Grant Program in 1989 to assist financially troubled, small rural hospitals. This article discusses grant effects on the second cohort of hospitals to complete their 3-year grants. Although three-quarters of the grantees implemented all or most of their goals, 11 percent could not implement a viable project. Grantees added or upgraded 523 services with the help of their grants, especially outpatient and social services, most of them financially self-supporting. Except among the largest hospitals, there was no evidence that the grants improved grantee finances. Management appeared unaffected by the grants.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

Visit preferences of middle-aged vs older critically ill patients.

OBJECTIVE: To differentiate between middle-aged and older adults' visiting preferences in critical care settings. DESIGN: Patients' preferences for visiting, perceptions of illness severity and extent of fatigue associated with visiting and an objective measurement of illness severity while in critical care were surveyed within 3 days after transfer from the critical care unit. SETTING: Interviews occurred on the transitional care units with patients who transferred from either the coronary care or surgical intensive care units in a large Northeast teaching hospital. PATIENTS: Fifty-three middle-aged (35 through 65 years) and 46 older (over 65 years) patients were surveyed (N = 99). RESULTS: Both middle-aged and older patients consistently wanted to limit the number of visitors to two or three persons per visit. Compared with middle-aged patients, a greater proportion of older patients preferred to limit visits to once a day and wanted the visit length to be unlimited. A greater proportion of older coronary care unit patients preferred to limit visits to two times a day than older surgical unit patients. CONCLUSIONS: Middle-aged and older patients differed in their preferences for visits, with sufficient variation in responses to warrant tailoring visits to the unique preferences of patients based on age and clinical setting.

Adult↗
PubMed1991

Leadership transitions and the impact on patient care.

Leadership transitions are increasing dramatically in hospitals, both at the very top and in top roles such as nursing, operations, finance, medical staff, and so on. Increasingly, new leaders will articulate the importance of "customer orientations" as one of their strategic themes because of the importance of being more market-driven in today's environment. This article explores the strengths and potential pitfalls in both articulating a theme about becoming more patient-centered and implementing that theme in a complex organization so that it actually shapes transactions between front-line staff and patients. The article closes with a discussion of the dilemmas of sustaining a complex initiative across time when many of the key leaders in an organization will inevitably be changing during that time.

Hospital Administrators↗
PubMed2003

Patient problems, advanced practice nurse (APN) interventions, time and contacts among five patient groups.

PURPOSE: To describe patient problems and APN interventions in each of five clinical trials and to establish links among patient problems, APN interventions, APN time and number of contacts, patient outcomes, and health care costs. DESIGN AND METHODS: Analysis of 333 interaction logs created by APNs during five randomized controlled trials: (a) very low birthweight infants (n = 39); (b) women with unplanned cesarean birth (n = 61), (c) high-risk pregnancy (n = 44), and (d) hysterectomy (n = 53); and (e) elders with cardiac medical and surgical diagnoses (n = 139). Logs containing recordings of all APN interactions with participants, APN time and type of patient contact were content analyzed with the smallest phrase or sentence representing a "unit." These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Groups were compared concerning total amount of APN time, number of contacts per patient, and mean length of time per APN contact. All studies were conducted in the United States. FINDINGS: Groups with greater mean APN time and contacts per patient had greater improvements in patients' outcomes and greater health care cost savings. Of the 150,131 APN interventions, surveillance was the predominant APN function in all five patient groups. Health teaching, guidance, and counseling was the second most frequent category of APN intervention in four of the five groups. In all five groups, treatments and procedures accounted for < 1% of total APN interventions. Distribution of patient problems (N = 150,131) differed across groups reflecting the health care problems common to the group. CONCLUSIONS: Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessing, teaching, counseling, communicating, collaborating, knowing health behaviors, negotiating systems, and having condition-specific knowledge about different patient problems.

Aged↗
PubMed1991

Waiting for placement: an exploratory analysis of determinants of delayed discharges of elderly hospital patients.

This article examines the causes of delayed hospital discharge for 3,111 patients waiting for alternative placement in 80 North Carolina acute care general hospitals during May 1989. Almost all of the patients were elderly: their average age was 77. Delay is defined as the period between the day a patient was judged medically ready for discharge by a discharge planner and the day the patient was discharged (or May 31 if unplaced). The average delay was 16.7 days. The policy-relevant patient characteristics associated with delay are requirement for heavy care, race, source of reimbursement, and whether or not there was a financial problem in arranging discharge. The patient's age and whether or not a problem with behavior or family cooperativeness was noted also were predictors. Along with patient characteristics, hospital features such as bed size, occupancy rate, and total revenues were correlated with delay. Local nursing and rest home (domiciliary) bed supply were insignificant predictors, possibly because of their limited variance: the number of nursing home beds in all North Carolina counties is below the national mean; the number of rest home beds exceeds it. The conclusion reached is that the delay problem warrants more intensive analysis, particularly regarding financial problems encountered at discharge, and race. Guidelines for such an endeavor are provided. Further, there is a need to recognize the increasing preponderance of a new type of heavy care patient via more appropriate reimbursement levels and "transitional care" services.

Aged↗