Assessing Patient Readiness for Hospital Discharge, Discharge Communication, and Transitional Care Management.

Background: Discharge communication between hospitalists and primary care clinicians is essential to improve care coordination, minimize adverse events, and decrease unplanned health services use. Health-related social needs are key drivers of health, and hospitalists and primary care clinicians value communicating social needs at discharge.

Objective: To 1) characterize the current state of discharge communications between an academic medical center hospital and primary care clinicians at associated clinics; 2) seek feedback about the potential usefulness of discharge readiness information to primary care clinicians.

Impact of Social Risk Screening on Discharge Care Processes and Postdischarge Outcomes: A Pragmatic Mixed-Methods Clinical Trial During the COVID-19 Pandemic.

Background: Social risk screening during inpatient care is required in new CMS regulations, yet its impact on inpatient care and patient outcomes is unknown.

Objectives: To evaluate whether implementing a social risk screening protocol improves discharge processes, patient-reported outcomes, and 30-day service use.

Research Design: Pragmatic mixed-methods clinical trial.

Tailoring of Health-Promotion Video Messaging for Reproductive-Aged Women at Risk for Developing Cardiometabolic Disease: Qualitative Focus-Groups Study.

Background: Targeting reproductive-aged women at high risk for type 2 diabetes (T2D) provides an opportunity for prevention earlier in the life course. A woman's experiences during her reproductive years may have a large impact on her future risk of T2D. Her risk is 7 to 10 times higher if she has had gestational diabetes (GDM).

Impact of COVID-19 visitation policies and hospital capacity on discharge readiness in medicine patients.

Background: COVID-19 impacted the experience of being hospitalized with the widespread adoption of strict visitation policies to ensure healthcare worker safety. One result was decreased time of caregivers at the bedside of hospitalized patients.

Objective: To understand the impact of pandemic-related system effects on patient-reported discharge preparation.

Perceptions about future health trajectories among women at risk for developing cardiometabolic disease: A qualitative study.

Background: The reproductive years provide a window into future risk for Type 2 Diabetes (T2DM); women's risk is seven to 10 times higher after gestational diabetes (GDM) and two to four times higher after a hypertensive disorder of pregnancy (HDP). Targeting reproductive-aged women at high risk for T2DM could reduce future T2DM incidence. However, little is known about such women's diabetes risk perceptions, or their knowledge or barriers/motivators of lifestyle change-information essential to understanding how to engage these at-risk women in tailored prevention programs promoting long-term health.

Using Continuous Glucose Monitoring and Data Sharing to Encourage Collaboration Among Older Adults With Type 1 Diabetes and Their Care Partners: Qualitative Descriptive Study.

Background: Persons with diabetes use continuous glucose monitoring (CGM) to self-manage their diabetes. Care partners (CPs) frequently become involved in supporting persons with diabetes in the management of their diabetes. However, persons with diabetes and CP dyads may require more communication and problem-solving skills regarding how to share and respond to CGM data.

Mixed-methods study examining family carers' perceptions of the relationship between intrahospital transitions and patient readiness for discharge.

Introduction: Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals.

Caregiver Inclusion in IDEAL Discharge Teaching: Implications for Transitions From Hospital to Home.

Purpose: Despite recognition that unpaid (e.g., family, friends) caregivers (caregivers) play an important role in successful transitions home after hospitalization, limited information is available about whether and how caregiver experiences of discharge align with current strategies for providing high-quality discharge processes, and how these experiences at discharge impact successful transitions home.

SHARE : Delivering a Telehealth CGM Data-Sharing Intervention to Older Adults and Their Care Partners.

Care partners of older adults with type 1 diabetes often become part of the diabetes care team but lack knowledge of how to become involved with glucose management. This article describes a study confirming the feasibility of SHARE , a telehealth intervention involving continuous glucose monitoring and data-sharing to assist these individuals in working together on diabetes management. The intervention provides a strategy for increasing remote patient monitoring and facilitating care partner involvement in diabetes management.

Feasibility and usefulness of the going home toolkit, an mhealth app, during hospital discharge: patient and clinician perspectives.

Feasibility and Usefulness of the Going Home Toolkit, an mHealth App, during Hospital Discharge: Patient and Clinician Perspectives. Objective Communication gaps during discharge planning contribute to post-discharge outcomes. mHealth Apps may allow health systems to provide resources to fill patients' needs.

Hospital Discharge During COVID-19: The Role of Social Resources.

This study is a part of a parent study: Social Needs and Resources in the Evaluation and Enhancement of Discharge Support. The trial registry is clinicaltrials.gov, number NCT04248738.

A Pilot Observational Exploratory Study of Well-Being in Hospice Interdisciplinary Team Members.

Introduction: Well-being and turnover intent represent key aspects to the promotion of a healthy workforce. Alarming levels of burnout and low levels of well-being have been documented in health professionals across care settings. Not only do high levels of burnout, low well-being and high turnover affect health professionals, but they are associated with poor patient care.

"You Feel Very Isolated": Effects of COVID-19 Pandemic on Caregiver Social Connections.

One in five individuals in the United States provides care and support to ill, disabled, and aging family members in the home, leading to feelings of burden, stress, and poor health and well-being. Social support represents an important buffer for family caregivers that allows them to feel less isolated and more positive about their caregiving role. This sequential mixed-methods study aimed to examine the effect of the COVID-19 pandemic on family caregivers' social connections.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement.

Objectives: Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

Methods: GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations.

A Limited Opportunity: COVID-19 and Promotion of Advance Care Planning.

Little is known about how COVID-19 has influenced the role of family caregivers in advance care planning (ACP). To explore the experiences of family caregivers and ACP in the United States during the COVID-19 pandemic. Exploratory sequential mixed-methods design of caregiver characteristics and pandemic response to ACP.

Health Care Professionals' Experiences as Family Caregivers During Intra-Hospital Transitions.

Family caregivers are often perceived as inexperienced family members assuming caregiving duties. However, health care professionals may also find themselves in an informal caregiving role as older adult relatives or friends are hospitalized and experience intra-hospital transitions. The purpose of the current study was to describe the experiences of health care professionals assuming the role of informal caregiver during intra-hospital transitions.

An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care.

Objectives: The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees.

Findings of Sequential Pilot Trials of Aliviado Dementia Care to Inform an Embedded Pragmatic Clinical Trial.

Background And Objectives: Many investigators of Alzheimer's disease and related dementias (AD/ADRD) are unfamiliar with the embedded pragmatic clinical trials (ePCTs) and the indispensable pilot phase preceding ePCTs. This paper provides a much-needed example for such a pilot phase and discusses implementation barriers and additional infrastructure and implementation strategies developed in preparation for a nationwide AD/ADRD ePCT.

Research Design And Methods: Two pilot trials were conducted in 2 hospices sequentially to refine and test Aliviado Dementia Care-Hospice Edition, a complex quality improvement intervention for advanced dementia symptom management.

Family- and Person-Centered Interdisciplinary Telehealth: Policy and Practice Implications Following Onset of the COVID-19 Pandemic.

With the onset of the COVID-19 pandemic, telehealth was thrust to the forefront, becoming one of the most predominant forms of care almost overnight. Despite years of research, practice, and policymaking, tenets for providing telehealth in an interdisciplinary, family- and person-centered fashion, and across a wide breadth of settings remain underdeveloped. In addition, although telehealth has the potential to increase equity in care, it can also further exacerbate disparities.

The Impact of Aliviado Dementia Care-Hospice Edition Training Program on Hospice Staff's Dementia Symptom Knowledge.

Context: As the aging population grows, the incidence of dementia continues to increase substantially. However, the lack of a significant geriatric health care workforce as well as little dementia training among generalist health care workers leads to suboptimal care for persons living with dementia (PLWD). In particular, few evidence-based interventions exist to improve the quality of dementia care among hospice interdisciplinary teams caring for PLWD.

Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers.

Introduction: Persons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD.

Intervention: This protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition.

A Scoping Review of Dementia Symptom Management in Persons with Dementia Living in Home-based Settings.

Background: A large proportion of our older adults live with Alzheimer's Disease and Related Dementias and the number of those diagnosed in the future is expected to increase dramatically as the population ages. Persons with dementia bring unique healthcare challenges due to the manifestation of behavioral and psychological symptoms associated with the disease. The lack of geriatric clinicians as well as a properly trained non-geriatric specialist workforce capable of addressing the symptoms persons with dementia exacerbate the challenge of providing effective care.

A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions.

Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions.

Geriatric nurse involvement during intra-hospital transitions.

Geriatric nurses are skilled in the special needs of hospitalized older adults. While significant focus has been placed on improving care transitions upon discharge, less attention has been placed on intra-hospital transitions. Intra-hospital transitions represent transfers occurring between hospital units or rooms.

Family Caregivers' Experiences of Within-Hospital Handoffs for Older Adults in Acute Care.

Family caregivers' experiences during within-hospital handoffs between acute care units are not well understood. Qualitative description methodology was employed to describe family caregivers' experiences during their loved ones' handoffs. Semistructured interviews were conducted with 10 caregivers of hospitalized older adults.