Physician Perceptions of Disposition Decision-making for Older Adults in the Emergency Department: A Preliminary Analysis.

Disposition decision-making in the emergency department (ED) is critical to patient safety and quality of care. Disposition decision-making has particularly important implications for older adults who comprise a significant portion of ED visits annually and are vulnerable to suboptimal outcomes throughout ED care transitions. We conducted a secondary inductive content analysis of interviews with ED physicians (N= 11) to explore their perceptions of who they involve in disposition decision-making and what information they use to make disposition decisions for older adults.

Disparate perspectives: Exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

Care transitions that occur across healthcare system boundaries represent a unique challenge for maintaining high quality care and patient safety, as these systems are typically not aligned to perform the care transition process. We explored healthcare professionals' mental models of older adults' transitions between the emergency department (ED) and skilled nursing facility (SNF). We conducted a thematic analysis of interviews with ED and SNF healthcare professionals and identified three themes: 1) ED and SNF healthcare professionals had misaligned mental models regarding communication processes and tools used during care transitions, 2) ED and SNF healthcare professionals had misaligned mental models regarding healthcare system capability, and 3) Misalignments led to individual and organizational consequences.

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery.

Background: Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery.

Approach: The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC).

Improving Diabetes Self-Management Support: Goal-Setting Across the Continuum of Care.

Goal-setting has consistently been promoted as a strategy to support behavior change and diabetes self-care. Although goal-setting conversations occur most often in outpatient settings, clinicians across care settings need to better understand and communicate about the priorities, goals, and concerns of those with diabetes to develop collaborative, person-centered partnerships and to improve clinical outcomes. The electronic health record is a mechanism for improved communication and collaboration across the continuum of care.

Improving Patient-Centered Transitional Care after Complex Abdominal Surgery.

Background: Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol.

Initiation of a Transitions Program: "Two Million Melvins".

This article summarizes the plan and process to develop a transitions in care initiative at an academic health center (AHC) located in the Midwest. Provided are recommendations for nurse executives who want to implement a transitions model of care in their organization through the adoption of an evidence based, phone follow up process using a protocol. Early findings of implementing the transitions program include improvements in patients’ understanding of their plan of care, satisfaction and appreciation of the phone contact, mitigation of medication discrepancies and a reduction in 30 day readmissions.

Harnessing Protocolized Adaptation in Dissemination: Successful Implementation and Sustainment of the Veterans Affairs Coordinated-Transitional Care Program in a Non-Veterans Affairs Hospital.

The Department of Veterans Affairs (VA) Coordinated-Transitional Care (C-TraC) program is a low-cost transitional care program that uses hospital-based nurse case managers, inpatient team integration, and in-depth posthospital telephone contacts to support high-risk patients and their caregivers as they transition from hospital to community. The low-cost, primarily telephone-based C-TraC program reduced 30-day rehospitalizations by one-third, leading to significant cost savings at one VA hospital. Non-VA hospitals have expressed interest in launching C-TraC, but non-VA hospitals differ in important ways from VA hospitals, particularly in terms of context, culture, and resources.

Innovative use of electronic health record reports by clinical nurse specialists.

Purpose: The purpose of the study was to demonstrate how clinical nurse specialists (CNSs) can use information pulled from the electronic health record (EHR) in innovative ways to improve nursing care of vulnerable older adults.

Background: As the number of older adults increases, the need will grow for easier access to evidence-based practice nursing interventions for the older population. Clinical nurse specialists are the experts in evaluating research and will also need to find innovative ways to bring the evidence-based practice pertinent to the care of older adults to the bedside nurse.