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PubMed2005

The last 3 months of life: care, transitions and the place of death of older people.

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.

Aged↗
PubMedDate not supplied

Transitional care for older adults: a cost-effective model.

Although the quality of care in hospitals and ambulatory settings is undergoing more scrutiny, far less attention has focused on the care patients receive as they move from one setting to another. Older patients who transition from hospital to home are particularly vulnerable: many of these patients have multiple health problems that continue beyond discharge. In response, investigators at the University of Pennsylvania developed a model of care delivered by nurse experts who follow vulnerable elders though their hospitalization and monitor their progress at home. This Issue Brief summarizes more than a decade of research on this model of transitional care and its effects on the costs and quality of care for hospitalized elderly patients.

Aftercare↗
PubMed2001

Transitional care for young adult survivors of childhood cancer.

OBJECTIVES: To review the obstacles and barriers to providing optimal care to young adult cancer survivors and discuss the transition from pediatric to adult health care system. DATA SOURCES: Published articles and textbook chapters. CONCLUSIONS: More than 70% of children diagnosed with cancer between birth and 14 years of age will be cured of their primary disease. Because of multiple physical and psychosocial risk factors imposed by their therapy and previous disease, childhood cancer survivors require life-long care. IMPLICATIONS FOR NURSING PRACTICE: Health care providers must be aware of the unique needs of these individuals for life-long follow-up and assist in facilitating this transition process.

Adolescent↗
PubMed1992

Development of a model of transitional care for the HIV-positive child and family.

The provision of high-quality, cost-effective care to Human Immunodeficiency Virus (HIV)-infected adults and children is a national priority. During 1991 the number of infected children is expected to increase to over 3,000, with at least 2,000 additional cases manifesting some symptoms of HIV infection. Serious questions exist about the ability of these children's families to acquire the health care services that both they and their children require. This paper will present preliminary findings of a study that describes the physical, behavioral, and developmental responses of children who have a diagnosis of perinatally acquired HIV, as well as the caretaking concerns of the custodial family. Building on this work, a model of transitional home care for these children and their families using pediatric clinical nurse specialist (PCNS) follow-up care will be described.

Child, Preschool↗
PubMedDate not supplied

Transitional care: filling the gap for older patients.

Frequently, when the acute phase of a frail older person's illness resolves, the patient is too weak to function independently and cannot be discharged from hospital. Acute care staff often lack the ability and resources to deal adequately with these situations. A program of transitional (or subacute) care at Ontario's Mississauga Hospital has been shown to fill this gap in the continuum of care by improving the functional level of frail elders and ensuring better bed utilization.

Activities of Daily Living↗
PubMed2003

Profiles in patient safety: emergency care transitions.

A 59-year-old man presented to the emergency department (ED) with the chief complaint of "panic attacks." In total, he was evaluated by 14 faculty physicians, 2 fellows, and 16 residents from emergency medicine, cardiology, neurology, psychiatry, and internal medicine. These multiple transitions were responsible, in part, for the perpetuation of a failure to accurately diagnose the patient's underlying medical illness. The case illustrates the discontinuity of care that occurs at transitions, which may threaten the safety and quality of patient care. Considerable effort must be directed at making transitions effective and safe. Recommendations to improve transitions include a heightened awareness of cognitive biases operating at these vulnerable times, improving team situational awareness and communication, and exploring systems to facilitate effective transfer of relevant data.

Diagnostic Errors↗
PubMed2004

Health care transition in congenital heart disease: the providers' view point.

Unfortunately, despite recommendations for educational training of ACHD health care providers and the goal to create regional ACHD centers, current needs still far outweigh appropriate available services. From a practical standpoint, we will need to work from our current models of health care delivery, which vary because of geographic and institutional issues and the availability of appropriate resources, toward the ideal goal of regional ACHD centers. Successful transition of adolescents and adults with CHD requires collaboration and planning between the pediatric health care team and the ACHD health care team. Good communication and an atmosphere of mutual respect are essential. All members of the ACHD health care team need to be committed to improving the process of transition for the adolescent and adult with CHD. The advanced practice nurse (CNS or ARNP) from both the pediatric program and the adult program are often key players in this process. As ACHD health care providers, we must work toward decreasing barriers to care and become organized advocates for our patients. Ultimately, our goal is not only to provide a smooth transition from one model of care to another, it is to create a health care delivery system that will maximize the lifelong potential and function of adults with congenital heart disease.

Adolescent↗
PubMed1998

Transitional care: hospital to home.

Contemporary acute hospital care of older adults must include special attention to the transitional, or peridischarge, phase of hospitalization. This article reviews the evidence from outcomes data and economic factors that demonstrate that precise transitional planning is a critical element in the care of older hospitalized adults. Some of the promising initiatives being explored around the country are reviewed.

Aged↗
PubMed1986

[Chronification of neuroses--on the critical phase of the inpatient-ambulatory care transition].

The contribution deals with the critical transition from ward treatment and follow-up care as an outpatient. Patients with primary psychic maldevelopment are compared with those of a secondary psychic development. Changes in symptoms and personality were measured with a battery of tests during a pre-post follow-up study (intervals of eight weeks between tests). Special attention is paid to changes after discharge from hospital and deterioration, which was common among the patients with secondary psychic maldevelopment, is discussed.

Ambulatory Care↗
PubMedDate not supplied

Physicians as barriers to successful transitional care.

There has been a dramatic increase in the number of sufferers of chronic childhood diseases surviving into adulthood. Effective transition of these children from paediatric to adult medical services is a considerable challenge. A lack of integrated planning for this event can present barriers to successful transition. These barriers may be generated by the patient, his family or by political or logistical factors. However, physicians themselves can also become barriers in this process. Paediatricians may resist the transition process as they lack confidence in their adult colleagues. Emotional, academic, financial and cultural issues will also influence both child and adult physician's attitude to the hand-over of care. Increasingly poor understanding of their disease process by Paediatric trained doctors, makes transfer of care essential for adolescents. The move towards a culture of personal responsibility for health care is also crucial for the promotion of the maturing patient's independence. Development of adolescent services and closer links between the services could do much to enhance the transition experience of emerging adults.

Adolescent↗
PubMed2006

Specialist services and transitional care in paediatric endocrinology in the UK and Ireland.

OBJECTIVE: To assess current provision of specialist and transitional paediatric endocrine services in the UK and Ireland. DESIGN: A questionnaire was sent to paediatric endocrinologists requesting details of patients receiving GH and also details of specialist and transitional services. RESULTS: Of 72 questionnaires received, 56 [21 from historical growth centres (group 1), 10 from other teaching hospitals (group 2) and 25 from district general hospitals (DGHs) (group 3)] were analysed. A total of 4758 children [3709 (78%) in group 1] currently receive GH in the UK. Fifty-six per cent of units (90% in groups 1 and 2) provide transfer clinics: transition (N = 27), adolescent (10), young adult (11) and adult (3). In 90% of the paediatric units, the paediatric and adult endocrinologist sit together, and 58% of clinics are held in the paediatric unit. Clinic entry is based on final height (33%), age (51%), both (14%), and other (2%). Fifty-five per cent of units transfer all GH-treated patients, the remainder transfer only those non-GH-deficient on retesting. Eighty per cent retest prior to transfer using the insulin tolerance test (ITT) [N = 27 (including three DGHs)], glucagon (22), arginine (4), clonidine (2) and other (5). Apart from intersex clinics (13), there are few specialist clinics for other paediatric endocrine patients, including only three for Turner syndrome (TS). Adult TS transfer is to multidisciplinary clinics (N = 11), adult endocrinology (27), gynaecology (14), cardiology (5) and general practitioner (GP) (1). CONCLUSIONS: We have confirmed more GH-treated patients than before; many remain within historic growth centres. Although in the UK and Ireland transition services are established in many larger units, current guidelines are not always adhered to. Provision of specialist paediatric endocrine clinics for all groups remains variable.

Adolescent↗
PubMed2004

Transitional care of GH deficiency: when to stop GH therapy.

While the benefits of growth hormone (GH) therapy in adult hypopituitary patients with GH deficiency (GHD) are established, the role of continued GH therapy after final height in adolescent GH-deficient patients remains unclear. Preliminary data suggest that cessation of GH on completion of linear growth may be associated with impairment of somatic development and adverse changes in body composition. For the present time, the decision whether to continue GH treatment in adolescent patients with GHD is best made on an individual basis. For such patients, continuity of care is crucial. Children and adults with GHD are usually managed by physicians in separate departments, who may focus on different aspects of treatment and care. Close collaboration between paediatric and adult physicians is essential to ensure smooth transition and to minimize the drop-out rate from follow-up. Given the previous period of treatment during childhood, paediatric physicians should be best placed to discuss the potential benefits of continuing GH therapy and instigate retesting of GH secretion. Many children with isolated idiopathic GHD will produce normal GH responses if retested at adult height. Patients with multiple pituitary hormone deficits are more likely to have ongoing GHD, as are patients who have received CNS irradiation. Quality of life does not appear to be decreased in adolescents with GHD who stop treatment, so achievement of satisfactory bone mass is a major determinant of the decision whether to continue therapy.

Adolescent↗