Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home

ObjectivesTo adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home.DesignQuality improvement intervention.Setting and ParticipantsVeterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility.MethodsWe used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse–driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact.ResultsBetween October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity—review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge.Conclusions and ImplicationsWe successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.     

The Effect of Medication Reconciliation via a Patient Portal on Medication Discrepancies: A Randomized Noninferiority Study

BackgroundMedication reconciliation has become standard care to prevent medication transfer errors. However, this process is time-consuming but could be more efficient when patients are engaged in medication reconciliation via a patient portal.ObjectivesTo explore whether medication reconciliation by the patient via a patient portal is noninferior to medication reconciliation by a pharmacy technician.Design (including intervention)Open randomized controlled noninferiority trial. Patients were randomized between medication reconciliation via a patient portal (intervention) or medication reconciliation by a pharmacy technician at the preoperative screening (usual care).Setting and ParticipantsPatients scheduled for elective surgery using at least 1 chronic medication were included.MeasuresThe primary endpoint was the number of medication discrepancies compared to the electronic nationwide medication record system (NMRS). For the secondary endpoint, time investment of the pharmacy technician for the medication reconciliation interview and patient satisfaction were studied. Noninferiority was analyzed with an independent t test, and the margin was set at 20%.ResultsA total of 499 patients were included. The patient portal group contained 241 patients; the usual care group contained 258 patients. The number of medication discrepancies was 2.6 ± 2.5 in the patient portal group and 2.8 ± 2.7 in the usual care group. This was not statistically different and within the predefined noninferiority margin. Patients were satisfied with the use of the patient portal tool. Also, the use of the portal can save on average 6.8 minutes per patient compared with usual care.Conclusions and ImplicationsMedication reconciliation using a patient portal is noninferior to medication reconciliation by a pharmacy technician with respect to medication discrepancies, and saves time in the medication reconciliation process. Future studies should focus on identifying patient characteristics for successful implementation of patient portal medication reconciliation.     

Optimizing primary care telephone access and patient satisfaction

Telephone medicine is often preferred by patients to meet primary care needs and may be associated with high patient satisfaction. This article presents findings about incoming patient calls to primary care for medically based reasons during office hours and reports factors independently associated with telephone encounter satisfaction, considering patient characteristics, call reasons, and staff responsiveness, for a national cohort of primary care users. Interviews were conducted with patients from 18 nationwide primary care clinics during the fall of 2009. Calling for an urgent medical issue was associated with dissatisfaction. Odds of call satisfaction were greater when patients thought staff was friendly (10×), call answer was timely (5×), and needed medical information was provided (7×). These findings can be used for interventions to optimize telephone access and patient satisfaction which is beneficial because satisfactory telephone encounters reduce primary care use and satisfied patients are more likely to be engaged in their health care.     

Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial.

OBJECTIVE: To determine the impact of a hospital-coordinated discharge care plan, involving a multidisciplinary team of primary health care providers, on hospital length of stay, quality of life, and both patient and general practitioner inclusion in, and satisfaction with, discharge procedures. DESIGN: This investigation comprised a prospective, randomized, controlled, clinical trial. SETTING: This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia. PARTICIPANTS: Patients (n = 189) with chronic cardiorespiratory diagnoses were recruited from respiratory, cardiovascular, and general medical wards at two tertiary hospitals. INTERVENTION: Subjects were randomly assigned to one of two groups. Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package, completed before discharge and sent to the patient's general practitioner and other community service providers for review. Control patients were discharged under existing hospital processes. Outcome measures. Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures. Hospital length of stay was also determined. RESULTS: Significant improvements in discharge planning involvement, health service access, confidence with discharge procedures, and opinion of discharge based on previous experience were seen for patients who received the discharge care plan. Further, improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients. Length of stay showed no difference between groups. Extent and speed of hospital-general practitioner communication were significantly improved via the intervention. CONCLUSIONS: Our results indicate that a multidisciplinary discharge care plan, initiated before separation, improves quality of life, involvement, and satisfaction with discharge care, and hospital-general practitioner integration. As such, it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill populations.     

Can a house call by a public health nurse improve the quality of the discharge process for geriatric patients?

OBJECTIVE: To determine whether there was any benefit from a single house call by a health visitor (a public health nurse) to an elderly person after discharge home from a geriatric hospital. METHODS: A randomized controlled trial with blind assessments at 28 days was conducted. Subjects included residents of Bath, England, with an average age of 83 years, who were discharged consecutively from a geriatric hospital to their homes. Intervention was a single visit by a health visitor 72 hours after discharge, to ensure the patient was settled at home, or normal post-discharge care. Outcome measures taken at 28 days by a research nurse included survival, hospital readmissions, nursing home admissions, cognitive and physical function, services requested and supplied, and drug therapy. RESULTS: There were no important differences between the intervention and control groups at 28 days on any of the outcome measurements. The control subjects did better than the study subjects on many of the outcome measures. CONCLUSION: A house call by a health visitor to elderly patients after discharge from geriatric wards does not measurably improve the quality of the discharge.     

How post-call resident doctors perform, feel and are perceived in out-patient clinics

Medical Education 2011: 45 : 669–677 Context Recently, in the USA, the Accreditation Council for Graduate Medical Education guidelines limited residents’ consecutive duty to 24 hours. In Europe, the European Working Time Directive limits the average working week to 48 hours. Objectives This study aimed to examine the performance of post‐call residents in out‐patient interviews using subjective and objective measures and to assess residents’ subjective feelings. Methods We conducted a cross‐sectional analysis of a systematic sample of 170 paediatric primary care consultations conducted during 117 clinic sessions served by 47 residents at a teaching hospital, including 34 consultations conducted during 23 sessions by 20 post‐call residents. Interviews were audiotaped and quantitatively analysed using the Roter Interactional Analysis System (RIAS). Residents and patients’ parents gave subjective appraisals of the visits using short questionnaires. Major covariates are resident gender and the timing of the clinic. Results Results did not show significant differences between post‐call residents and their peers who had left the hospital on time in most components of the out‐patient interview. Subtle yet probably important differences emerged with findings that post‐call residents were significantly less likely to ask a parent to repeat what she had just said, and parents seeing post‐call residents were more likely to request the resident to repeat what he or she had just said and to check if the resident understood what they had said. Post‐call residents were rated by objective coders as having better attitudes than their left‐on‐time counterparts, yet subjectively felt less satisfied and more fatigued. Female post‐call residents felt less competent, less productive and less energetic; male post‐call residents felt more challenged, more demoralised and busier. Conclusions The changes in activating and partnering talk that occur in post‐call residents are consistent with findings concerning sleep deprivation and speech. Female and male residents tended to attribute their post‐call performance to different factors. Setting limits on working hours might help to avoid potential negative impacts on post‐call resident feelings, and the impact of working hours on resident performance warrants further exploration.     

The effect of the COACH program (Continuity Of Appropriate pharmacotherapy,patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients

Background  

Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department.     

新医改背景下上海市居民对基层医疗卫生服务满意度的调查研究

目的 了解新医改背景下上海市居民对基层医疗卫生服务的满意度.方法 采用分层抽样方法,选取上海市中心城区、城乡结合区和郊区9家社区卫生服务中心,采用自行设计问卷对2 250名门诊患者就其对基层医疗卫生服务满意度进行测评.结果 居民对新医改的满意率为85.2％;对基本医疗保障制度的满意率为85.0％;对基层医疗服务比较满意,满意率为96.5％;对基本公共卫生服务的满意率为95.1％.年龄、城乡、职业、文化程度和收入是居民对基层医疗卫生服务满意度的主要影响因素.结论 总体而言,上海市居民对基层医疗卫生服务满意度较高,但也存在一些问题值得关注,如基本医疗保险保障水平和报销手续仍有待提高、基层医疗卫生机构的诊疗费用仍需合理控制和基本药物无法完全满足基层医疗机构的用药需要.     

A comparison study of career satisfaction and emotional states between primary care and speciality residents

OBJECTIVE: To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Education's (ACGME) duty hour requirements. DESIGN: Cross-sectional survey. MEASUREMENTS: All 581 residents in the academic health centre were asked to participate voluntarily in a confidential survey; 327(56%) completed the survey. RESULTS: Compared to their primary care colleagues, speciality residents had higher levels of satisfaction with career choice, feelings of competence and excitement, lower levels of inferiority and fatigue and different perceptions of positive and negative training experiences. However, 77% of all respondents were consistently or generally pleased with their career choices. The most positive residents' experiences related to interpersonal relationships and their educational value; the most negative experiences related to interpersonal relationships and issues perceived to be outside of residents' control. Age and training level, but not gender also influenced career satisfaction, emotional states and positive and negative opinions about residency. CONCLUSIONS: Less satisfaction with career choice and more negative emotional states for primary care residents compared to speciality residents probably relate to the training experience and may influence medical students' selections of careers. The primary care residents, compared to speciality residents, appear to have difficulty in fulfilling their ideals of professionalism in an environment where they have no control. These data provide baseline information with which to compare these same factors after the implementation of the ACGME duty hours' and competency requirements.     

Evidence of a non-linear influence of patient age on satisfaction with hospital care.

BACKGROUND: Patient age is the main socio-demographic factor influencing patient satisfaction with care but the nature of the relationship between age and patient satisfaction is controversial. OBJECTIVE: This study aims to clarify whether the association of age with satisfaction is linear or shows some other configuration. METHODS: Data were obtained from two different satisfaction studies conducted in 27 short-stay teaching hospitals. Study 1 included 1547 inpatients, who completed the EQS-H questionnaire at the time of discharge. Study 2 included 7624 inpatients interviewed by phone at home after discharge, who answered the SAPHORA questionnaire. On the basis of the results of the exploratory analysis, three models for adjustment of age on satisfaction were compared: a simple linear model, a five-group step function and a linear model with a change in slope. RESULTS: The most suitable model for adjusting patient age to satisfaction scores for quality of medical and nursing care, whether for the EQS-H or the SAPHORA scale, was not a linear relationship: patient age was linearly and positively correlated to satisfaction before 65 years and negatively thereafter. Adjustment of patient age to accommodation and premises satisfaction scores proved to be different, closer to a linear relationship. CONCLUSION: These results suggest considering the patient age variable as a non-linear factor for adjusting satisfaction scores, in particular in relation to care. Further studies are needed to confirm the evidence of a threshold around 65 years beyond which satisfaction scores for the quality of medical and nursing care decrease.     

The significance of patients' perceptions of physician conduct

The provision of high quality medical care and the insurance of patient satisfaction depend in part upon the ability and willingness of physicians to establish rapport with their patients and to develop effective physician-patient communication. In this study, patients' overall satisfaction with their physicians' care was assessed in relation to their perceptions of their physicians' (1) proficiency at communicating and listening to details of the illness and medical treatment, (2) capability of providing affective care, and (3) technical competence. Perceptions of physician behaviors were measured by a questionnaire administered to 329 patients of 54 residents in a family practice center. The relationship between the perceptions of patients and their satisfaction with medical care was examined both for the entire sample and among groups of patients with differing demographic characteristics. Results indicate an important link between patients' perceptions of socioemotional aspects of the physician-patient relationship and their reported satisfaction with medical care. Noticeable differences were found to exist in the importance that patients with different demographic characteristics placed on various aspects of their physicians' conduct.     

Continuity of care in a family practice residency program. Impact on physician satisfaction

One of the primary benefits of continuity of care is its influence upon patient and physician satisfaction. This prospective pilot study involved a cohort of 14 second- and third-year family practice residents and 4 full-time faculty at a community hospital-based family practice residency in Cleveland, Ohio. Rates of continuity that physicians experience were calculated using the usual provider continuity (UPC) measure of continuity, and were correlated with physician satisfaction with outpatient care using a practice satisfaction scale (PSS) developed specifically for this purpose. Residents and faculty were also asked to rank order the importance of several aspects of outpatient care, including continuity of care. The results indicate that both residents and faculty value continuity of care highly compared with other aspects of outpatient care. The average continuity rates were 59% for second-year residents, 54% for third-year residents, and 82% for faculty. The UPC continuity measure correlated highly with the PSS scores (corrected r2 = .55; P less than .001). The data support the hypothesis that continuity of care with patients is an important determinant of resident and faculty physician satisfaction with their outpatient experience.     

Examining health equity through satisfaction and confidence of patients in primary healthcare in the Republic of Trinidad and Tobago

Surveys of patient satisfaction are widely used for identifying priorities and problems in healthcare reforms. The present study examined satisfaction and confidence of patients in public healthcare in Trinidad and Tobago. Data were gathered by interviewing a random sample (n = 280) of primary healthcare (PHC) patients. Level of patient satisfaction was high but not constant. Results of interviews showed that patients with a higher monthly income (p = 0.032) and patients who most recently used private medical care (p = 0.037) had lower levels of satisfaction with health services. Employment had an effect on satisfaction (p = 0.065), significant among patients who had recently accessed private medical care (p = 0.039). Patients using PHC clinics preferred private care to public care. Confidence in public care decreased with increasing complexity of the medical condition. These preliminary results support continued efforts in health-sector reforms and call for the enhancement of data on satisfaction through more comprehensive qualitative data-collection methods.     

医院管理中出院患者电话回访的作用

目的：探讨电话回访在医院管理中的作用。方法：将出院患者电话回访满意度和在院患者满意度调查作比较。结果：出院患者电话回访满意度呈上升状态，在院患者满意度呈波动状态。结论：电话回访有利于医院得到真实信息，促进工作改进，加强医患沟通。     

Metodología de conciliación del tratamiento farmacológico en pacientes pluripatológicos

ObjectiveTo carry out a bibliographic review in order to identify the different methodologies used along the reconciliation process of drug therapy applicable to polypathological patients.DesignWe performed a literature review.Data sources The bibliographic review (February 2012) included the following databases: Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME). The different methodologies, identified on those databases, to measure the conciliation process in polypathological patients, or otherwise elderly patients or polypharmacy, were studied.Study selection Two hundred and seventy three articles were retrieved, of which 25 were selected.Data extraction Specifically: the level of care, the sources of information, the use of registration forms, the established time, the medical professional in charge and the registered variables such as errors of reconciliation.ResultsMost of studies selected when the patient was admitted into the hospital and after the hospital discharge of the patient. The main sources of information to be highlighted are: the interview and the medical history of the patient. An established time is not explicitly stated on most of them, nor the registration form is used. The main professional in charge is the clinical pharmacologist. Apart from the home medication, the habits of self-medication and phytotherapy are also identified. The common errors of reconciliation vary from the omission of drugs to different forms of interaction with other medicinal products (drugs interactions).ConclusionsThere is a large heterogeneity of methodologies used for reconciliation. There is not any work done on the specific figure of the polypathological patient, which precisely requires a standardized methodology due to its complexity and its susceptibility to errors of reconciliation.     

Risk of Medication Errors at Hospital Discharge and Barriers to Problem Resolution

SUMMARY

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.     

Home care: a key to the future of family medicine?

This essay is about my transition from family medicine residency into house call/home-based primary care practice. Though some aspects of making home visits have been difficult and uncomfortable, I have found a higher level of satisfaction and sense of purpose than I had as a resident in a traditional outpatient clinic. This enhanced satisfaction is, in part, due to my discovery that a lower-volume, time-intensive house call practice is a more appropriate way than the brief office visit to care for older patients who have multiple morbidities. In light of the aging population, advances in portable medical technology, and changes in Medicare reimbursement, home care could become a key to the future success and ongoing relevance of family medicine.