National Healthcare Quality and Disparities Report
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Topics
- Asthma (1)
- Care Coordination (1)
- Care Management (1)
- Children/Adolescents (1)
- Chronic Conditions (1)
- Clinician-Patient Communication (1)
- Home Healthcare (1)
- (-) Hospital Discharge (5)
- Hospital Readmissions (2)
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- (-) Transitions of Care (5)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 5 of 5 Research Studies DisplayedBrajcich BC, Shallcross ML, Johnson JK
Barriers to post-discharge monitoring and patient-clinician communication: a qualitative study.
This study used semi-structured interviews and focus groups to identify barriers to post-discharge monitoring and patient-clinician communication. Participants were gastrointestinal surgery patients and clinicians, with a total of 15 patients and 17 clinicians. Four themes and four barriers were identified from patient and clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences. Clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency.
AHRQ-funded; HS026385.
Citation: Brajcich BC, Shallcross ML, Johnson JK .
Barriers to post-discharge monitoring and patient-clinician communication: a qualitative study.
J Surg Res 2021 Dec;268:1-8. doi: 10.1016/j.jss.2021.06.032..
Keywords: Hospital Discharge, Clinician-Patient Communication, Care Management, Transitions of Care
Parikh K, Richmond M, Lee M
Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma.
The purpose of this study was to evaluate a multi-component hospital-to-home (H2H) transition program for children hospitalized with an asthma exacerbation. A pilot prospective randomized clinical trial of guideline-based asthma care with and without a patient-centered multi-component H2H program was conducted among children enrolled in K-8(th) grade on Medicaid hospitalized for an asthma exacerbation. The investigators concluded that the pilot data suggested that comprehensive care coordination initiated during the inpatient stay was feasible and acceptable.
AHRQ-funded; HS024554.
Citation: Parikh K, Richmond M, Lee M .
Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma.
J Asthma 2021 Oct;58(10):1384-94. doi: 10.1080/02770903.2020.1795877..
Keywords: Children/Adolescents, Patient-Centered Healthcare, Transitions of Care, Asthma, Hospital Discharge, Care Coordination, Chronic Conditions
Manges KA, Ayele R, Leonard C
Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.
This study’s objective was to explore differences between low- and high-performing hospitals and skilled nursing facilities (SNFs) pairs and postacute care outcomes. The authors used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. Hospitals were classified based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals and five corresponding SNFs. High-performing sites differed in each stage from low-performing sites by focusing on 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to an SNF as an iterative team-based process and 3) anticipating barriers with knowledge of transitional and SNF care processes.
AHRQ-funded; HS026116.
Citation: Manges KA, Ayele R, Leonard C .
Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.
BMJ Qual Saf 2021 Aug;30(8):648-57. doi: 10.1136/bmjqs-2020-011204..
Keywords: Transitions of Care, Hospitals, Nursing Homes, Hospital Readmissions, Hospital Discharge
Misra-Hebert AD, Rothberg MB, Fox J
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
This retrospective cohort study assessed the association of home visits by advanced practice registered nurses (APRNs) and paramedics with healthcare utilization and mortality of patients released home after hospital discharge The authors looked at adult medical patients discharged to home from November 2017-September 2019. They assessed outcomes for home visit vs. matched comparison patients at 30, 90, and 180 days, including hospital admission, emergency department (ED) use, and death using two phases. Phase 1 was defined as APRN or paramedic visits assigned by geographic location and Phase 2 defined as APRN and paramedic visit teams assigned to patients. They also compared patients who declined home visits with those accepting them. Phase 1 outcomes showed no differences in readmissions, ED visits, or death at 30,90, and 180 days. Phase 2 showed patients who had home visits had fewer 30-day readmissions and no differences in other outcomes. Patients who accepted home visits had lower odds of readmission compared to patients who declined. Forty-four interviews were also conducted, and themes of Medication Understanding, Knowledge Gap after Discharge, Patient Medical Complexity, Social Context, and Patient Engagement/Need for Reassurance emerged.
AHRQ-funded; HS024128.
Citation: Misra-Hebert AD, Rothberg MB, Fox J .
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
Healthc 2021 Mar;9(1):100518. doi: 10.1016/j.hjdsi.2020.100518..
Keywords: Home Healthcare, Transitions of Care, Hospital Discharge, Hospital Readmissions
Gonzalez MR, Junge-Maughan L, Lipsitz LA
ECHO-CT: an interdisciplinary videoconference model for identifying potential postdischarge transition-of-care events.
In this paper, data collected through the Extension for Community Health Outcomes- Care Transitions (ECHO-CT) model were used to identify and classify transition-of-care events (TCEs). Findings showed that the TCEs identified highlight areas in which providers can work to reduce issues arising during the course of discharge to post-acute care facilities. Recommendations included standardized processes to identify, record, and report TCEs in order to provide high-quality, safe care for patients as they move across care settings.
AHRQ-funded; HS025702.
Citation: Gonzalez MR, Junge-Maughan L, Lipsitz LA .
ECHO-CT: an interdisciplinary videoconference model for identifying potential postdischarge transition-of-care events.
J Hosp Med 2021 Feb;16(2):93-96. doi: 10.12788/jhm.3523..
Keywords: Transitions of Care, Hospital Discharge, Quality Improvement, Quality of Care