The Experts below are selected from a list of 10548 Experts worldwide ranked by ideXlab platform
Mary D Naylor - One of the best experts on this subject based on the ideXlab platform.
-
Transitional Care from skilled nursing facilities to home study protocol for a stepped wedge cluster randomized trial
Trials, 2021Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Laura C Hanson, Morris Weinberger, J Covington, J S PreisserAbstract:Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on Caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute Care use is over 50% within 90 days of discharge, yet these patients and their Caregivers often do not receive the quality of Transitional Care that prepares them to manage serious illnesses at home. The study will test the efficacy of Connect-Home, a successfully piloted Transitional Care intervention targeting seriously ill SNF patients discharged to home and their Caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their Caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and Caregiver preparedness for Caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual Care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute Care use and (b) Caregivers’ burden and distress. Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve Transitional Care for seriously ill SNF patients and their Caregivers, (b) prevent avoidable days of acute Care use in a population with persistent risks from chronic conditions, and (c) advance the science of Transitional Care within end-of-life and palliative Care trajectories of SNF patients and their Caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their Caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. ClinicalTrials.gov NCT03810534 . Registered on January 18, 2019.
-
cost impact of the Transitional Care model for hospitalized cognitively impaired older adults
Journal of Comparative Effectiveness Research, 2018Co-Authors: Mark V Pauly, Karen B Hirschman, Alexandra L Hanlon, Liming Huang, Kathryn H Bowles, Christine Bradway, Kathleen Mccauley, Mary D NaylorAbstract:AIM The goal of this study was to compare postacute Care costs of three Care management interventions. MATERIALS & METHODS A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Model. The Lin method was used to estimate costs at 30 and 180 days postindex hospital discharge. RESULTS The Transitional Care Model had significantly lower costs than the Augmented Standard Care group at both 30 (p < 0.001) and 180 days (p = 0.03) and significantly lower costs than Resource Nurse Care at 30 days (p = 0.02). CONCLUSION These findings suggest that the Transitional Care Model can reduce both the amount of other postacute Care and the total cost of Care compared with alternative services for cognitively impaired older adults. Clinicaltrials.gov : NCT00294307.
-
adaptations of the evidence based Transitional Care model in the u s
Social Science & Medicine, 2018Co-Authors: Mary D Naylor, Karen B Hirschman, Mark Toles, Elizabeth Shaid, Olga F Jarrin, Mark V PaulyAbstract:Abstract Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the Care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 Transitional Care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering Care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.
-
connect home Transitional Care of skilled nursing facility patients and their Caregivers
Journal of the American Geriatrics Society, 2017Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Josephine Asafuadjei, Laura C HansonAbstract:Background Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional Care of SNF patients (i.e., time-limited services to ensure coordination and continuity of Care) is poorly understood. Objective To determine the feasibility and relevance of the Connect-Home Transitional Care intervention, and to compare preparedness for discharge between comparison and intervention dyads. Design A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family Caregivers. Setting Three SNFs in the Southeastern United States. Participants Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. Intervention The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver Transitional Care of patient and Caregiver dyads. Measurements Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). Results The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). Conclusion Connect-Home is a promising Transitional Care intervention for older patients discharged from SNF Care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.
-
components of comprehensive and effective Transitional Care
Journal of the American Geriatrics Society, 2017Co-Authors: Mary D Naylor, Kathleen Mccauley, Elizabeth Shaid, Deborah Carpenter, Brianna Gass, Carol Levine, Ann Malley, Huong Q Nguyen, Heather L Watson, Jane BrockAbstract:Transitional Care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients’ and Caregivers’ needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In Care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and Caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable MediCare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and Caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, Caregiver engagement, complexity and medication management, patient education, Caregiver education, patients' and Caregivers' well-being, Care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and Caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all MediCare beneficiaries.
Janet E Mcdonagh - One of the best experts on this subject based on the ideXlab platform.
-
eular pres standards and recommendations for the Transitional Care of young people with juvenile onset rheumatic diseases
Annals of the Rheumatic Diseases, 2017Co-Authors: Helen E Foster, Janet E Mcdonagh, Daniel Clemente, Leticia Leon, Kirsten Minden, Sylvia Kamphuis, Karin Berggren, Philomine A Van Pelt, Carine WoutersAbstract:To develop standards and recommendations for Transitional Care for young people (YP) with juvenile-onset rheumatic and musculoskeletal diseases (jRMD). The consensus process involved the following: (1) establishing an international expert panel to include patients and representatives from multidisciplinary teams in adult and paediatric rheumatology; (2) a systematic review of published models of Transitional Care in jRMDs, potential standards and recommendations, strategies for implementation and tools to evaluate services and outcomes; (3) setting the framework, developing the process map and generating a first draft of standards and recommendations; (4) further iteration of recommendations; (5) establishing consensus recommendations with Delphi methodology and (6) establishing standards and quality indicators. The final consensus derived 12 specific recommendations for YP with jRMD focused on Transitional Care. These included: high-quality, multidisciplinary Care starting in early adolescence; the integral role of a transition co-ordinator; transition policies and protocols; efficient communications; transfer documentation; an open electronic-based platform to access resources; appropriate training for paediatric and adult healthCare teams; secure funding to continue treatments and services into adult rheumatology and the need for increased evidence to inform best practice. These consensus-based recommendations inform strategies to reach optimal outcomes in Transitional Care for YP with jRMD based on available evidence and expert opinion. They need to be implemented in the context of individual countries, healthCare systems and regulatory frameworks.
-
the challenges and opportunities for Transitional Care research
Pediatric Transplantation, 2010Co-Authors: Janet E Mcdonagh, Deirdre KellyAbstract:The provision of healthCare for young people with solid organ transplants as they move into adult-centered services has received increasing attention over recent years particularly as non-adherence and graft loss increase after transfer. Despite medical advances and that Transitional Care is now well established on national and international health agendas, progress in the research arena has unfortunately been slow. The aims of this paper are to consider why this is and discuss the particular challenges facing clinical researchers working within the area.
-
young people s satisfaction of Transitional Care in adolescent rheumatology in the uk
Child Care Health and Development, 2007Co-Authors: Karen L Shaw, Janet E Mcdonagh, T R Southwood, Adolescent RheumatologyAbstract:Background To examine the quality of Transitional health Care from the perspectives of young people with juvenile idiopathic arthritis (JIA) and their parents. Methods Adolescents with JIA and their parents were recruited from 10 major UK rheumatology centres. Satisfaction with health-Care delivery was measured prior to, and 12 months after, the implementation of a structured and co-ordinated programme of Transitional Care using self-completed questionnaires designed for this study. Results Of 359 families invited to participate, 308 (86%) adolescents with JIA and 303 (84%) parents/guardians accepted. A fifth of adolescents had persistent oligoarthritis. Median age was 14.2 (11–18) years with median disease duration of 5.7 (0–16) years. Young people and their parents rated provider characteristics more important than aspects of the physical environment or process issues. Staff honesty and knowledge were rated as the most essential aspects of best practice. Prior to implementing the programme of Transitional Care, parents rated service delivery for all items significantly worse than best practice. Overall satisfaction improved 12 months after entering the programme. However, while parent satisfaction improved for 70.4% of items, significant improvements were only observed for three (13.6%) items rated by adolescents. Conclusion The perceived quality of health Care for young people with JIA and their parents was significantly lower than what they would like. Satisfaction with many aspects of Care during transition from paediatric to adult services can be improved through the implementation of a structured, co-ordinated programme of Transitional Care.
-
the impact of a coordinated Transitional Care programme on adolescents with juvenile idiopathic arthritis
Rheumatology, 2007Co-Authors: Janet E Mcdonagh, T R Southwood, Karen L ShawAbstract:Objective. There is an extensive evidence base for the need of Transitional Care, but a paucity of robust outcome data. The aim of the study was to determine whether the quality of life of adolescents with juvenile idiopathic arthritis (JIA) could be improved by a co-ordinated, evidence-based programme of Transitional Care. Methods. Adolescents with JIA aged 11, 14 and 17yrs and their parents were recruited from 10 rheumatology centres in the UK. Data were collected at baseline, 6 and 12 months including core outcome variables. The primary outcome measure was health-related quality of life (HRQL): Juvenile Arthritis Quality of Life Questionnaire (JAQQ). Secondary outcome measures included: knowledge, satisfaction, independent health behaviours and pre-vocational experience. Results. Of the 359 families invited to participate, 308 (86%) adolescents and 303 (84%) parents accepted. A fifth of them had persistent oligoarthritis. Median disease duration was 5.7 (0-16) yrs. Compared with baseline values, significant improvements in JAQQ scores were reported for adolescent and parent ratings at 6 and 12 months and for most secondary outcome measures with no significant deteriorations between 6 and 12 months. Continuous improvement was observed for both adolescent and parent knowledge with significantly greater improvement in the younger age groups at 12 months (P=0.002). Conclusions. This study represents the first objective evaluation of an evidence-based Transitional Care programme and demonstrates that such Care can potentially improve adolescents' HRQL.
-
growing up and moving on in rheumatology development and preliminary evaluation of a Transitional Care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis
Journal of Child Health Care, 2006Co-Authors: Janet E Mcdonagh, Karen L Shaw, T R SouthwoodAbstract:This article describes the development and initial evaluation of an evidence-based Transitional Care programme recently implemented in a multicentre controlled trial in the United Kingdom. The individual components of the programme are described. Evaluation of the acceptability and utilization of these components employed questionnaires administered to users (adolescents with juvenile idiopathic arthritis and their parents) and providers (rheumatology health professionals). The results confirm the acceptability and utilization of the programme components in addition to further innovative developments during the course of the study. In conclusion, the evidence-based Transitional Care programme components reported here are acceptable and useful to both user and provider and are potentially feasible in clinical practice in a revised format.
Laura C Hanson - One of the best experts on this subject based on the ideXlab platform.
-
Transitional Care from skilled nursing facilities to home study protocol for a stepped wedge cluster randomized trial
Trials, 2021Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Laura C Hanson, Morris Weinberger, J Covington, J S PreisserAbstract:Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on Caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute Care use is over 50% within 90 days of discharge, yet these patients and their Caregivers often do not receive the quality of Transitional Care that prepares them to manage serious illnesses at home. The study will test the efficacy of Connect-Home, a successfully piloted Transitional Care intervention targeting seriously ill SNF patients discharged to home and their Caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their Caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and Caregiver preparedness for Caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual Care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute Care use and (b) Caregivers’ burden and distress. Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve Transitional Care for seriously ill SNF patients and their Caregivers, (b) prevent avoidable days of acute Care use in a population with persistent risks from chronic conditions, and (c) advance the science of Transitional Care within end-of-life and palliative Care trajectories of SNF patients and their Caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their Caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. ClinicalTrials.gov NCT03810534 . Registered on January 18, 2019.
-
connect home Transitional Care of skilled nursing facility patients and their Caregivers
Journal of the American Geriatrics Society, 2017Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Josephine Asafuadjei, Laura C HansonAbstract:Background Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional Care of SNF patients (i.e., time-limited services to ensure coordination and continuity of Care) is poorly understood. Objective To determine the feasibility and relevance of the Connect-Home Transitional Care intervention, and to compare preparedness for discharge between comparison and intervention dyads. Design A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family Caregivers. Setting Three SNFs in the Southeastern United States. Participants Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. Intervention The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver Transitional Care of patient and Caregiver dyads. Measurements Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). Results The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). Conclusion Connect-Home is a promising Transitional Care intervention for older patients discharged from SNF Care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.
-
Transitional Care of older adults in skilled nursing facilities a systematic review
Geriatric Nursing, 2016Co-Authors: Mark Toles, Cathleen S Colonemeric, Josephine Asafuadjei, Elizabeth Moreton, Laura C HansonAbstract:Transitional Care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether Transitional Care interventions, as compared to usual Care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that Transitional Care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of Transitional Care in SNFs, and methodological challenges to studying Transitional Care for SNF patients.
-
interventions to improve Transitional Care between nursing homes and hospitals a systematic review
Journal of the American Geriatrics Society, 2010Co-Authors: Michael A Lamantia, Leslie P Scheunemann, Anthony J Viera, Jan Busbywhitehead, Laura C HansonAbstract:Transitions between healthCare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve Transitional Care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality Transitional Care.
Karen L Shaw - One of the best experts on this subject based on the ideXlab platform.
-
young people s satisfaction of Transitional Care in adolescent rheumatology in the uk
Child Care Health and Development, 2007Co-Authors: Karen L Shaw, Janet E Mcdonagh, T R Southwood, Adolescent RheumatologyAbstract:Background To examine the quality of Transitional health Care from the perspectives of young people with juvenile idiopathic arthritis (JIA) and their parents. Methods Adolescents with JIA and their parents were recruited from 10 major UK rheumatology centres. Satisfaction with health-Care delivery was measured prior to, and 12 months after, the implementation of a structured and co-ordinated programme of Transitional Care using self-completed questionnaires designed for this study. Results Of 359 families invited to participate, 308 (86%) adolescents with JIA and 303 (84%) parents/guardians accepted. A fifth of adolescents had persistent oligoarthritis. Median age was 14.2 (11–18) years with median disease duration of 5.7 (0–16) years. Young people and their parents rated provider characteristics more important than aspects of the physical environment or process issues. Staff honesty and knowledge were rated as the most essential aspects of best practice. Prior to implementing the programme of Transitional Care, parents rated service delivery for all items significantly worse than best practice. Overall satisfaction improved 12 months after entering the programme. However, while parent satisfaction improved for 70.4% of items, significant improvements were only observed for three (13.6%) items rated by adolescents. Conclusion The perceived quality of health Care for young people with JIA and their parents was significantly lower than what they would like. Satisfaction with many aspects of Care during transition from paediatric to adult services can be improved through the implementation of a structured, co-ordinated programme of Transitional Care.
-
the impact of a coordinated Transitional Care programme on adolescents with juvenile idiopathic arthritis
Rheumatology, 2007Co-Authors: Janet E Mcdonagh, T R Southwood, Karen L ShawAbstract:Objective. There is an extensive evidence base for the need of Transitional Care, but a paucity of robust outcome data. The aim of the study was to determine whether the quality of life of adolescents with juvenile idiopathic arthritis (JIA) could be improved by a co-ordinated, evidence-based programme of Transitional Care. Methods. Adolescents with JIA aged 11, 14 and 17yrs and their parents were recruited from 10 rheumatology centres in the UK. Data were collected at baseline, 6 and 12 months including core outcome variables. The primary outcome measure was health-related quality of life (HRQL): Juvenile Arthritis Quality of Life Questionnaire (JAQQ). Secondary outcome measures included: knowledge, satisfaction, independent health behaviours and pre-vocational experience. Results. Of the 359 families invited to participate, 308 (86%) adolescents and 303 (84%) parents accepted. A fifth of them had persistent oligoarthritis. Median disease duration was 5.7 (0-16) yrs. Compared with baseline values, significant improvements in JAQQ scores were reported for adolescent and parent ratings at 6 and 12 months and for most secondary outcome measures with no significant deteriorations between 6 and 12 months. Continuous improvement was observed for both adolescent and parent knowledge with significantly greater improvement in the younger age groups at 12 months (P=0.002). Conclusions. This study represents the first objective evaluation of an evidence-based Transitional Care programme and demonstrates that such Care can potentially improve adolescents' HRQL.
-
growing up and moving on in rheumatology development and preliminary evaluation of a Transitional Care programme for a multicentre cohort of adolescents with juvenile idiopathic arthritis
Journal of Child Health Care, 2006Co-Authors: Janet E Mcdonagh, Karen L Shaw, T R SouthwoodAbstract:This article describes the development and initial evaluation of an evidence-based Transitional Care programme recently implemented in a multicentre controlled trial in the United Kingdom. The individual components of the programme are described. Evaluation of the acceptability and utilization of these components employed questionnaires administered to users (adolescents with juvenile idiopathic arthritis and their parents) and providers (rheumatology health professionals). The results confirm the acceptability and utilization of the programme components in addition to further innovative developments during the course of the study. In conclusion, the evidence-based Transitional Care programme components reported here are acceptable and useful to both user and provider and are potentially feasible in clinical practice in a revised format.
-
unmet education and training needs of rheumatology health professionals in adolescent health and Transitional Care
Rheumatology, 2004Co-Authors: Janet E Mcdonagh, T R Southwood, Karen L ShawAbstract:Objectives To determine the perceived education and training needs of health professionals involved in Transitional Care for adolescents with juvenile idiopathic arthritis (JIA). Methods Two distinct questionnaires to identify Transitional issues in JIA were distributed to key health professionals (n = 908) and clinical personnel involved in the implementation of a Transitional Care programme (n = 22). Results The first survey was completed by 263 professionals. Education needs were reported by 114 (43%) of health professionals. Transition issues and informational resources were the most frequently reported areas of need. The second survey was completed by 22 clinical personnel who rated 'lack of training', 'lack of teaching materials geared towards adolescents' and 'limited clinic time' as the main barriers to providing developmentally appropriate Care to adolescents. Conclusion Unmet education and training needs of health Care professionals exist in key areas of Transitional Care and provide useful directions for the development of future training programmes.
Mark Toles - One of the best experts on this subject based on the ideXlab platform.
-
Transitional Care from skilled nursing facilities to home study protocol for a stepped wedge cluster randomized trial
Trials, 2021Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Laura C Hanson, Morris Weinberger, J Covington, J S PreisserAbstract:Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on Caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute Care use is over 50% within 90 days of discharge, yet these patients and their Caregivers often do not receive the quality of Transitional Care that prepares them to manage serious illnesses at home. The study will test the efficacy of Connect-Home, a successfully piloted Transitional Care intervention targeting seriously ill SNF patients discharged to home and their Caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their Caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and Caregiver preparedness for Caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual Care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute Care use and (b) Caregivers’ burden and distress. Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve Transitional Care for seriously ill SNF patients and their Caregivers, (b) prevent avoidable days of acute Care use in a population with persistent risks from chronic conditions, and (c) advance the science of Transitional Care within end-of-life and palliative Care trajectories of SNF patients and their Caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their Caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. ClinicalTrials.gov NCT03810534 . Registered on January 18, 2019.
-
adaptations of the evidence based Transitional Care model in the u s
Social Science & Medicine, 2018Co-Authors: Mary D Naylor, Karen B Hirschman, Mark Toles, Elizabeth Shaid, Olga F Jarrin, Mark V PaulyAbstract:Abstract Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the Care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 Transitional Care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering Care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.
-
connect home Transitional Care of skilled nursing facility patients and their Caregivers
Journal of the American Geriatrics Society, 2017Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Josephine Asafuadjei, Laura C HansonAbstract:Background Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional Care of SNF patients (i.e., time-limited services to ensure coordination and continuity of Care) is poorly understood. Objective To determine the feasibility and relevance of the Connect-Home Transitional Care intervention, and to compare preparedness for discharge between comparison and intervention dyads. Design A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family Caregivers. Setting Three SNFs in the Southeastern United States. Participants Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. Intervention The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver Transitional Care of patient and Caregiver dyads. Measurements Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). Results The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). Conclusion Connect-Home is a promising Transitional Care intervention for older patients discharged from SNF Care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.
-
Transitional Care of older adults in skilled nursing facilities a systematic review
Geriatric Nursing, 2016Co-Authors: Mark Toles, Cathleen S Colonemeric, Josephine Asafuadjei, Elizabeth Moreton, Laura C HansonAbstract:Transitional Care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether Transitional Care interventions, as compared to usual Care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that Transitional Care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of Transitional Care in SNFs, and methodological challenges to studying Transitional Care for SNF patients.
-
Transitional Care in skilled nursing facilities a multiple case study
BMC Health Services Research, 2016Co-Authors: Mark Toles, Mary D Naylor, Cathleen S Colonemeric, Julie Barroso, Ruth A AndersonAbstract:Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital Care within 30 days. Transitional Care services, that provide continuity and coordination of Care as older adults transition between settings of Care, decrease complications during transitions in Care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered Transitional Care to identify opportunities for improvement. In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family Caregivers participated in data collection activities, which included observations of Care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in Transitional Care provided in the SNFs as well as organizational structures and the quality of Care-team interactions that supported staff who delivered Transitional Care services. Staff in Case 1 completed most key Transitional Care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for Transitional Care, used formal Transitional Care team meetings and tracking tools to plan Care, and engaged in robust team interactions. Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based Transitional Care services. Findings suggest practical approaches to develop new Care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver Transitional Care.
