With the guidance of healthcare policy and advances in medical technology, the average length of stay in hospitals continues to decrease. In this context, expectations for nurse-led interventions for patients discharged home are increasing. However, few systematic reviews of nurse-led transitional care have focused on patients discharged from acute care hospitals. This systematic review aimed to assess the effects of nurse-led transitional care interventions on readmission rates, unscheduled outpatient-visit rates, and quality of life (QOL) of adult patients discharged from acute care hospitals, compared with usual care.

Four electronic databases were searched for articles published through October 2023. Individual and cluster randomized controlled trials (RCTs) examining the effectiveness of nurse-led transitional care interventions were included. Independent reviewers performed study selection, data extraction, risk of bias assessment, and certainty of evidence using the GRADE approach.

Sixteen RCTs were included. In a meta-analysis of RCTs with readmission rates as the outcome, readmission rates were significantly reduced in the intervention group when the data collection period exceeded 12 weeks (RR 0.67; 95% CI, 0.49-0.92; P = 0.01; I² = 66%; certainty: moderate). The rate of emergency room visits was also significantly reduced in the intervention group (RR 0.63; 95% CI, 0.49-0.81; P = 0.0003; I² = 0%; certainty: high). QOL measured with the SF-36 was significantly higher after 5 weeks (MD 1.27; 95% CI, 0.52-2.02; P = 0.0009, I² = 0%; certainty: low) and after 6 weeks (MD 2.46; 95% CI, 1.67-3.25; P = 0.00001; I² = 19%; certainty: low), both showing a possibility of improvement in the intervention group. However, the number of studies and samples included in the meta-analysis, particularly for readmission rates and QOL, were small, and the results should be interpreted with caution due to differences in subjects, institutions, and types of interventions.

Nurse-led transitional care interventions effectively reduced readmission and emergency department visit rates and improved QOL in adult patients discharged from acute care hospitals.

Social determinants of health (SDOH) may influence 30-day readmission or emergency department (ED) use following acute myocardial infarction (AMI) hospitalizations. Understanding this relationship will promote the development of interventions and policies to reduce readmissions.

The aim of the study was to test associations between SDOH and readmission after AMI.

In this cross-sectional study, we analyzed 753 adults ≥65 years from the Reasons for Geographic and Racial Differences in Stroke study discharged after an AMI between 2003 and 2019. Participants were categorized into 3 groups (0/1, 2, and 3+) based on the number of SDOHs. Poisson models were used to determine relative risks (RRs) and corresponding 95% CI for the associations between SDOH and risk of readmission/ED visit.

Of participants, 39.1% (295/753) were women, 27.5% (207/753) were Black, and the median age was 77 years (72-82 years). There were 219 (29.1%) individuals with readmission/ED visit. Of 612 participants with validated SDOH counts, 273 (44.6%) had 0/1 SDOH, 117 (19.1%) had 2 SDOH, and 222 (36.3%) had 3+ SDOH. After adjusting for age and region, increasing number of SDOHs was associated with elevated readmission/ED visit risk (2 SDOH: RR: 1.15; 95% CI: 0.83-1.60; 3+ SDOH: RR: 1.56; 95% CI: 1.20-2.01; P trend = 0.001). Similar results were observed in the fully adjusted model (2 SDOH: RR: 1.12; 95% CI: 0.81-1.56; 3+ SDOH: RR: 1.37; 95% CI: 1.04-1.80; P trend = 0.026).

A cumulative burden of SDOHs is associated with an increased risk of readmission/ED visits after AMI hospitalization. SDOH burden may be a useful approach in identifying individuals presenting with AMI who are most vulnerable for readmission.

Surgical recovery after hospital discharge often presents challenges for patients and caregivers. Postoperative complications and poorly managed pain at home can lead to unexpected visits to the emergency department (ED) and readmission to the hospital. Digital home monitoring (DHM) may improve postoperative care compared to standard methods.

We conducted a feasibility study for a randomized controlled trial (RCT) to assess DHM's effectiveness following thoracic surgical procedures compared to standard care.

We conducted a 2-arm parallel-group pilot RCT at a single tertiary care center. Adult patients undergoing thoracic surgical procedures were randomized 1:1 into 2 groups: the DHM group and the standard of care (control group). We adhered to the intention-to-treat analysis principle. The primary outcome was predetermined RCT feasibility criteria. The trial would be feasible if more than 75% of trial recruitment, protocol adherence, and data collection were achieved. Secondary outcomes included 30-day ED visit rates, 30-day readmission rates, postoperative complications, length of stay, postdischarge 30-day opioid consumption, 30-day quality of recovery, patient-program satisfaction, caregiver satisfaction, health care provider satisfaction, and cost per case.

All RCT feasibility criteria were met. The trial recruitment rate was 87.9% (95% CI 79.4%-93.8%). Protocol adherence and outcome data collection rates were 96.3% (95% CI 89.4%-99.2%) and 98.7% (95% CI 92.9%-99.9%), respectively. In total, 80 patients were randomized, with 40 (50%) in the DHM group and 40 (50%) in the control group. Baseline patient and clinical characteristics were comparable between the 2 groups. The DHM group had fewer unplanned ED visits (2.7% vs 20.5%; P=.02), fewer unplanned admission rates (0% vs 7.6%; P=.24), lower rates of postoperative complications (20% vs 47.5%, P=.01) shorter hospital stays (4.0 vs 6.9 days; P=.05), but more opioid consumption (111.6, SD 110.9) vs 74.3, SD 71.9 mg morphine equivalents; P=.08) compared to the control group. DHM also resulted in shorter ED visit times (130, SD 0 vs 1048, SD 1093 minutes; P=.48) and lower cost per case (CAD $12,145 [US $ 8436.34], SD CAD $8779 [US $ 6098.20] vs CAD $17,247 [US $11,980.37], SD CAD $15,313 [US $10,636.95]; P=.07). The quality of recovery scores was clinically significantly better than the controls (185.4, SD 2.6 vs 178.3, SD 3.3; P<.001). All 37 patients who completed the intervention answered the program satisfaction survey questionnaires (100%; 95% CI 90.5%-100%). Only 36 out of 80 caregivers responded to the caregiver satisfaction questionnaires at the end of the fourth week post hospital discharge (47.7%; 95% CI 35.7%-59.1%). Health care providers reported a 100% satisfaction rate.

This pilot RCT demonstrates the feasibility of conducting a full-scale trial to assess DHM's efficacy in improving postoperative care following thoracic surgery. DHM shows promise for enhancing continuity of care and warrants further investigation.

ClinicalTrials.gov NCT04340960; https://clinicaltrials.gov/study/NCT04340960.

Addressing the growing challenge of hospitalizing chronic multimorbid patients, this study examines the strain these conditions impose on healthcare systems at a local level, focusing on a pilot program. Chronic diseases and complex patients require comprehensive management strategies to reduce healthcare burdens and improve patient outcomes. If proven effective, this pilot model has the potential to be replicated in other healthcare settings to enhance the management of chronic multimorbid patients.

To evaluate the effectiveness of the high complexity unit (HCU) in managing chronic multimorbid patients through a multidisciplinary care model and to compare it with standard hospital care.

The study employed a descriptive longitudinal approach, analyzing data from the Basic Minimum Data Set (BMDS) to compare hospitalization variables among the HCU, the Internal Medicine Service, and other services at Antequera Hospital throughout 2022. The HCU, designed for patients with complex chronic conditions, integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.

The study employed a descriptive longitudinal approach, analyzing data from the BMDS to compare hospitalization variables among the HCU, the Internal Medicine Service, and other services at Antequera Hospital throughout 2022. The HCU, designed for patients with complex chronic conditions, integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.

This study demonstrates the effectiveness of the HCU in managing patients with complex chronic diseases through a multidisciplinary approach. The coordinated care provided by the HCU results in improved patient outcomes, reduced unnecessary hospitalizations, and better management of patient complexity. The superiority of the HCU compared to standard care is evident in key outcomes such as fewer readmissions and higher patient satisfaction, reinforcing its value as a model of care to be replicated.

Early physician follow-up after hospital discharge is commonly recommended, though whether it mitigates adverse events is unclear. We conducted a systematic review and meta-analysis to examine the association between physician follow-up within 30 days of hospital discharge and risk of hospital readmission, emergency department (ED) visits, or mortality in medical patients.

MEDLINE, EMBASE, and CINAHL electronic databases were searched from inception to April 2023. Inclusion criteria were original studies that reported association(s) between outpatient physician visit within 30 days of hospital discharge and at least one outcome of interest (emergency department visit, readmission, or mortality) for adult medical patients. Two investigators independently completed screening, extracted data, and assessed study quality using an adapted Down's and Black tool. Meta-analyses were conducted for each outcome using random effects models.

Sixty-six studies were included in the review. Early physician follow-up was significantly associated with reduced odds of hospital readmission (pooled OR 0.69 [95% CI 0.58, 0.81], n=54) and mortality (pooled OR 0.71 [95% CI 0.55, 0.90], n=21) but not emergency department visits (pooled OR 0.77 [95% CI 0.59, 1.01], n=10). A majority of studies were at high risk of selection bias or residual confounding or both. When pooling only studies at low risk of bias in these domains or when only pooling randomized controlled trials, associations between early physician follow-up and 30-day readmission were not statistically significant (pooled OR 1.01 [95% CI 0.93, 1.09], n=11; and 1.07 [95% CI 0.85, 1.36], n=5; respectively).

While meta-analysis suggests that early physician follow-up may be associated with reduced readmissions and mortality, there is a need to interpret these results with caution given that a majority of included studies were observational in nature and were at high risk of bias. It therefore remains unclear whether early physician follow-up is effective in reducing post-discharge adverse events of readmission, emergency department visits, and mortality.

PROSPERO CRD42022334467.

Improving the care of decompensated cirrhosis is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). The secondary aims were to assess model effects on quality-of-care and patient-reported outcomes.

The study design was a 2-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a decompensated cirrhosis admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. A total of 147 participants (intervention=75, control=71) were recruited with a median Model for End-Stage Liver Disease score of 19. For the primary outcome, there was no difference in the overall LREA rate for the intervention group versus the control group (incident rate ratio 0.89; 95% CI: 0.53-1.50, p =0.666) or in actuarial survival (HR=1.14; 95% CI: 0.66-1.96, p =0.646). However, there was a reduced risk of LREA due to encephalopathy in the intervention versus control group (HR=1.87; 95% CI: 1.18-2.96, p =0.007). Significant improvement in quality-of-care measures was seen for the performance of bone density ( p <0.001), vitamin D testing ( p <0.001), and HCC surveillance adherence ( p =0.050). For assessable participants (44/74 intervention, 32/71 controls) significant improvements in patient-reported outcomes at 3 months were seen in self-management ability and quality of life as assessed by visual analog scale ( p =0.044).

This CDM intervention did not reduce overall LREA events and may not be effective in decompensated cirrhosis for this end point.

Complications of open reduction and internal fixation (ORIF) of mandibular fractures are influenced by several patient factors. A postoperative surgeon phone call could modify these factors through education and reinforcement of instructions, but its effect has not been studied.

The purpose of this study was to measure and compare the frequencies of postoperative inflammatory complications (POICs) following ORIF of mandibular fractures in patients who did and did not receive a postoperative surgeon phone call.

The authors conducted an ambispective cohort study consisting of patients with mandibular fractures treated with ORIF at a large urban trauma hospital with the prospective cohort from January 1, 2021 to March 31, 2022 and a retrospective cohort from April 1, 2020 to December 31, 2020. Prisoners and patients with gunshot wounds were excluded.

The primary predictor variable was the surgeon call group. After January 2021, a postoperative call was implemented 1-3 days following fracture repair to review instructions, such as nonchew diet and oral hygiene, and provide education, such as reviewing expectations. Prior to January 2021, patients were not called. This resulted in 3 categories: Not Called, Called and Answered, and No Answer.

The primary outcome variable was POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation.

Demographic variables, injury-related variables, and treatment-related variables were also measured.

Statistical analysis was performed using Fisher's exact and Wilcoxon rank-sum tests, as well as multivariable logistic regression. A P value was considered significant if < .05.

Of the 178 patients in the study, 137 (77%) were male and the average age was 39.9 ± 12.6 years. Sixty-five patients (36.5%) were not called. Of the patients called, 79 (44.4%) answered and 34 (19.1%) did not answer. POICs occurred in 9.2% of the Not Called group and 8.9% of the Called and Answered group (P = .99). In the No Answer group, 29.4% had POICs, which was higher than the other 2 groups (P = .01).

A surgeon phone call was not associated with complication rates; however, patients in the No Answer group were significantly more likely to experience a POIC.

Reducing hospital readmission offer potential benefits for patients, providers, payers, and policymakers to improve quality of healthcare, reduce cost, and improve patient experience. We investigated effectiveness of remdesivir in reducing 30-day coronavirus disease 2019 (COVID-19)-related readmission during the Omicron era, including older adults and those with underlying immunocompromising conditions.

This retrospective study utilized the US PINC AI Healthcare Database to identify adult patients discharged alive from an index COVID-19 hospitalization between December 2021 and February 2024. Odds of 30-day COVID-19-related readmission to the same hospital were compared between patients who received remdesivir vs those who did not, after balancing characteristics of the two groups using inverse probability of treatment weighting (IPTW). Analyses were stratified by maximum supplemental oxygen requirement during index hospitalization.

Of 326 033 patients hospitalized for COVID-19 during study period, 210 586 patients met the eligibility criteria. Of these, 109 551 (52%) patients were treated with remdesivir. After IPTW, lower odds of 30-day COVID-19-related readmission were observed in patients who received remdesivir vs those who did not, in the overall population (3.3% vs 4.2%, respectively; odds ratio [95% confidence interval {CI}]: 0.78 [.75-.80]), elderly population (3.7% vs 4.7%, respectively; 0.78 [.75-.81]), and those with underlying immunocompromising conditions (5.3% vs 6.2%, respectively; 0.86 [.80-.92]). These results were consistent irrespective of supplemental oxygen requirements.

Treating patients hospitalized for COVID-19 with remdesivir was associated with a significantly lower likelihood of 30-day COVID-19-related readmission across all patients discharged alive from the initial COVID-19 hospitalization, including older adults and those with underlying immunocompromising conditions.

Patients with advanced cancer are at increased risk for multiple hospitalizations and often have considerable needs postdischarge. Interventions to address patients' needs after transitioning home are lacking.

We sought to demonstrate the feasibility and acceptability of a postdischarge intervention for this population.

We conducted a single-arm pilot trial (n = 54) of a postdischarge intervention, consisting of a video visit with an oncology nurse practitioner (NP) within three days of discharge to address symptoms, medications, hospitalization-related issues, and care coordination. We enrolled English-speaking adults with advanced breast, gastrointestinal, genitourinary, or thoracic cancers experiencing an unplanned hospitalization and preparing for discharge home. The intervention was deemed feasible if ≥70% of approached patients enrolled and ≥70% of enrolled patients completed the intervention within three days of discharge. Two weeks after discharge, patients rated the ease and usefulness of the video technology on a 0-10 scale (higher scores indicate greater ease of use). NPs completed postintervention surveys to assess protocol adherence.

We enrolled 54 of 75 approached patients (77.3%). Of enrolled patients (median age = 65.0 years), 83.3% participated in the intervention within three days of discharge. The median ease of participating in the intervention was 9.0 (IQR: 6.0-10.0) and the median usefulness of the intervention was 7.0 (IQR: 4.5-8.0). The majority of visits focused on symptom management (85.7%), followed by posthospital medical issues (69.0%).

An oncology NP-delivered intervention immediately after hospital discharge is a feasible and acceptable approach to providing postdischarge care for hospitalized patients with advanced cancer.

Text messaging has emerged as a popular strategy to engage patients after hospital discharge. Little is known about how patients use these programs and what types of needs are addressed through this approach.

The goal of this study was to describe the types and timing of postdischarge needs identified during a 30-day automated texting program.

The program ran from January to August 2021 at a primary care practice in Philadelphia. In this mixed-methods study, two reviewers conducted a directed content analysis of patient needs expressed during the program, categorizing them along a well-known transitional care framework. We describe the frequency of need categories and their timing relative to discharge.

A total of 405 individuals were enrolled; the mean (SD) age was 62.7 (16.2); 64.2% were female; 47.4% were Black; and 49.9% had Medicare insurance. Of this population, 178 (44.0%) expressed at least one need during the 30-day program. The most frequent needs addressed were related to symptoms (26.8%), coordinating follow-up care (20.4%), and medication issues (15.7%). The mean (SD) number of days from discharge to need was 10.8 (7.9); there were no significant differences in timing based on need category.

The needs identified via an automated texting program were concentrated in three areas relevant to primary care practice and within nursing scope of practice. This program can serve as a model for health systems looking to support transitions through an operationally efficient approach, and the findings of this analysis can inform future iterations of this type of program.

Although coordination of care and integrated care models aim to enhance patient satisfaction and perceived care quality, evidence regarding their practical implementation remains scarce. Understanding the nuances of collaboration across care providers to achieve effective coordination of care is imperative for seamless care integration. The aim of this study was to construct a grounded theory of how inter-organizational collaboration is performed to support coordination of care for patients with complex care needs.

A qualitative design with a constructivist grounded theory approach was applied. In total, 86 participants with diverse backgrounds were recruited across multiple care settings, including hospitals, ambulance services, primary care centers, municipal home healthcare and home care services. The grounded theory was developed iteratively, based on a combination of observations and interviews, and using constant comparative analysis.

Coordination of care, a complex process that occurs across interconnected healthcare organizations, is manifested as "Negotiating care in organizational borderlands." Care coordination evolves through a spectrum of inter-organizational collaboration, ranging from "Dividing care by disease-specific expertise" to "Establishing paths for collaboration" and ultimately "Co-constructing a comprehensive whole." These categories highlight the challenges of coordinating care across both professional and organizational boundaries. In the multifaceted healthcare landscape, effective care coordination occurs when healthcare professionals actively bridge the divides, leveraging their collective expertise. Importantly, organizational boundaries may serve a purpose and should not be dissolved to facilitate effective care coordination.

The key to effective care coordination lies in robust inter-organizational collaboration. Even when patients receive integrated care, healthcare professionals may have fragmented roles. This research emphasizes the importance of clearly defined lines of accountability, reinforcing mutual responsibility and facilitating bridging of professional and organizational boundaries. Healthcare professionals and policymakers can use these insights to effectively utilize inter-organizational collaboration in supporting care coordination for patients with complex care needs.

To assess whether post-discharge telemonitoring reduces hospital readmission in patients participating in the diabetes care program.

This retrospective cohort study was conducted from June 2021 to December 2022 and included patients who were enrolled in the Diabetes Program under a hyperglycemia treatment protocol and eligible for post-discharge telemonitoring. The variables included age, sex, diagnosis, hospital stay, LACE Score, and readmission rate.

Among 165 patients who underwent telemonitoring, significant differences emerged in hospital readmission rates between those with and without telemonitoring (p=0.015), with a 15.4% lower readmission rate in the telemonitoring group (95%CI= 3.0-27.9%). Subgroup analyses revealed higher readmission rates in men without telemonitoring (15.2% difference; 95%CI= 0.4-30.0%; p=0.045), and in age groups ≤60 and ≥75 years without telemonitoring (24.2% difference; 95%CI= 4.5-43.9%; p=0.016 for ≤60 years; 37.1% difference; 95%CI= 9.9% to 64.2%; p=0.007 for ≥75 years). Additionally, patients with prolonged hospital stays (>7 days) without telemonitoring had higher readmission rates (19.5% difference; 95%CI= 4.5%-34.5%; p=0.011).

This study suggests that post-discharge telemonitoring can effectively lower hospital readmission rates in diabetes management programs, potentially offering improved health outcomes, cost savings, and enhanced healthcare delivery to patients.

Patients receiving inpatient palliative care often face physical and psychological uncertainties during transitions out of the hospital. Family caregivers often take on responsibilities to ensure patient safety, quality of care, and extend palliative care principles, but often without support or training, potentially compromising their health and well-being.

This study tested an eight-week intervention using video visits between palliative care nurse interventionists and caregivers to assess changes in caregiver outcomes and patient quality of life.

This randomized controlled trial, conducted from 2018 to 2022, enrolled adult caregivers in rural or medically underserved areas in Minnesota, Wisconsin, and Iowa. Eligible caregivers included those caring for patients who received inpatient palliative care and transitioned out of the hospital. The intervention group received teaching, guidance, and counseling from a palliative care nurse before and for eight weeks after hospital discharge. The control group received monthly phone calls but no intervention. Caregiver outcomes included changes in depression, burden, and quality of life, and patient quality of life, as reported by the caregiver.

Of those consented, 183 completed the intervention, and 184 completed the control arm; 158 participants had complete baseline and eight-week data. In unadjusted analyses, the intervention group and their care recipients showed statistically significant improvements in quality of life compared to the control group. Improvements persisted in adjusted analyses, and depression significantly improved. No differences in caregiver burden were observed.

Addressing rural caregivers' needs during transitions in care can enhance caregiver outcomes and improve patient quality of life.

In 2013, the Centers for Medicare and Medicaid Services (CMS) introduced codes to reimburse outpatient providers for post-discharge transitional care management (TCM). Understanding the implications of TCM reimbursement on outcomes is crucial for evaluating CMS's investment and guiding future policy. We analyzed the association between physician organization (PO) TCM code use and post-discharge readmissions and mortality using 100% fee-for-service Medicare claims. Using a difference-in-differences approach we compared 1131 "high-TCM" POs (top quartile of TCM code use from 2015-2017) to 1133 "low-TCM" POs (bottom quartile) from before (2012) and after (2015-2017) TCM code implementation, controlling for PO and beneficiary attributes and readmission risk. TCM code use was associated with decreased 30- and 90-day readmissions (-0.31 [95%CI: -0.52, -0.09] and -0.42 [95% CI: -0.71, -0.14] percentage points, respectively), but no significant difference in mortality. Year-by-year, 2017 saw greatest readmission reduction, with a slight mortality reduction in that year only. Readmission reductions were greatest in POs not affiliated with health systems, Accountable Care Organizations (ACOs), or academic medical centers, and least in those with fewer primary care physicians. Narrow, indirect interventions like fee-for-service TCM billing code reimbursement may have limited potential to improve post-discharge outcomes overall. However, small independent practices may derive somewhat greater benefit from this support for post-discharge care.

Unplanned hospital readmissions (UHRs) constitute a persistent health concern worldwide. A high level of UHRs imposes a burden on individuals, their families, and health care system budgets. This systematic review and meta-analysis aimed to evaluate the effectiveness of discharge interventions in the transition from hospital to home in the context of reducing UHRs.

The study design was a meta-analysis of randomized and nonrandomized controlled trials. Eight databases were searched. The effect on UHR rates (odds ratio [OR]) of discharge interventions in the transition from hospital to home was calculated at a 95% confidence interval (95% CI) based on meta-regression and meta-analysis of random-effects models.

Results showed that discharge interventions were effective in reducing rehospitalizations (effectiveness/OR =1.39; 95% CI, 1.24-1.55). It was furthermore determined that the studies showed heterogeneous characteristics (P ≤ .001, Q = 50.083, I2 = 44.093; df = 28). According to Duval and Tweedie's trim and fill results, there was no publication bias. Interventions in which telephone communications and hospital visits (OR = 1.64; 95% CI, 1.25-2.16; P < .001) were applied together were effective among patients with cardiovascular diseases (OR = 1.54; 95% CI, 1.28-2.09; P < .001), and it was found that UHRs were reduced within a period of 90 days (OR = 1.68; 95% CI, 1.16-2.42; P < .001). It was also found that discharge interventions applied to transitions from hospital to home had a diminishing effect on UHRs as the publication dates of the reviewed studies advanced from the past to the present (OR = 0.015; 95% CI, 0.002-0.003; P < .001).

Supporting and facilitating cooperation between health care professionals and families should be a key focus of discharge interventions.

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

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

Pragmatic mixed-methods clinical trial.

Overall, 4130 patient discharges (2383 preimplementation and 1747 postimplementation) from general medicine and surgical services at a 528-bed academic medical center in the Intermountain United States and 15 attending physicians.

Documented family interaction, late discharge, patient-reported readiness for hospital discharge and postdischarge coping difficulties, readmission and emergency department visits within 30 days postdischarge, and coded interviews with inpatient physicians.

A multivariable segmented regression model indicated a 19% decrease per month in odds of family interaction following intervention implementation (OR=0.81, 95% CI=0.76-0.86, P<0.001), and an additional model found a 32% decrease in odds of being discharged after 2 pm (OR=0.68, 95% CI=0.53-0.87, P=0.003). There were no postimplementation changes in patient-reported discharge readiness, postdischarge coping difficulties, or 30-day hospital readmissions, or ED visits. Physicians expressed concerns about the appropriateness, acceptability, and feasibility of the structured social risk assessment.

Conducted in the immediate post-COVID timeframe, reduction in family interaction, earlier discharge, and provider concerns with structured social risk assessments likely contributed to the lack of intervention impact on patient outcomes. To be effective, social risk screening will require patient/family and care team codesign its structure and processes, and allocation of resources to assist in addressing identified social risk needs.

Care transitions from hospital to home are a critical period for patients and their families, especially after a stroke. The aim of this study was to assess the feasibility, fidelity and acceptability of a co-designed care transition support for stroke survivors.

A non-randomised controlled feasibility study recruiting patients who had had stroke and who were to be discharged home and referred to a neurorehabilitation team in primary healthcare was conducted. Data on the feasibility of recruitment and fidelity of the intervention were collected continuously during the study with screening lists and checklists. Data on the perceived quality of care transition were collected at 1-week post-discharge with the Care Transition Measure. Data on participant characteristics, disease-related data and outcomes were collected at baseline (hospitalisation), 1 week and 3 months post-discharge. Data on the acceptability of the intervention from the perspective of healthcare professionals were collected at 3 months using the Normalisation Measure Development Questionnaire.

Altogether, 49 stroke survivors were included in the study: 28 in the intervention group and 21 in the control group. The recruitment and data collection of patient characteristics, disease-related data, functioning and outcomes were feasible. The fidelity of the intervention differed in relation to the different components of the co-designed care transition support. The intervention was acceptable from the perspective of healthcare professionals. Concerns were raised about the fidelity of the intervention. A positive direction of effects of the intervention on the perceived quality of the care transition was found.

The study design, data collection, procedures and intervention were deemed feasible and acceptable. Modifications are needed to improve intervention fidelity by supporting healthcare professionals to apply the intervention. The feasibility study showed a positive direction of effect on perceived quality with the care transition, but a large-scale trial is needed to determine its effectiveness.

Stroke survivors, significant others and healthcare professionals were involved in a co-design process, including the joint development of the intervention's components, contextual factors to consider, participant needs and important outcomes to target.

ClinicalTrials.gov ID: NCT0292587.

Early rehospitalization of frail older adults after hospital discharge is harmful to patients and challenging to hospitals. Mobile integrated health (MIH) programs may be an effective solution for delivering community-based transitional care. The objective of this study was to assess the feasibility and implementation of an MIH transitional care program.

Pilot clinical trial of a transitional home visit conducted by MIH paramedics within 72 hours of hospital discharge.

Patients aged ≥65 years discharged from an urban hospital with a system-adapted eFrailty index ≥0.24 were eligible to participate.

Participants were enrolled after hospital discharge. Demographic and clinical information were recorded at enrollment and 30 days after discharge from the electronic health record. Data from a comparison group of patients excluded from enrollment due to geographical location was also abstracted. Primary outcomes were intervention feasibility and implementation, which were reported descriptively. Exploratory clinical outcomes included emergency department (ED) visits and rehospitalization within 30 days. Categorical and continuous group comparisons were conducted using χ2 tests and Kruskal-Wallis testing. Binomial regression was used for comparative outcomes.

One hundred of 134 eligible individuals (74.6%) were enrolled (median age 81, 64% female). Forty-seven participants were included in the control group (median age 80, 55.2% female). The complete protocol was performed in 92 (92.0%) visits. Paramedics identified acute clinical problems in 23 (23.0%) visits, requested additional services for participants during 34 (34.0%) encounters, and detected medication errors during 34 (34.0%). The risk of 30-day rehospitalization was lower in the Paramedic-Assisted Community Evaluation after Discharge (PACED) group compared with the control (RR, 0.40; CI, 0.19-0.84; P = .03); there was a trend toward decreased risk of 30-day ED visits (RR, 0.61; CI, 0.37-1.37; P = .23).

This pilot study of an MIH transition care program was feasible with high protocol fidelity. It yields preliminary evidence demonstrating a decreased risk of rehospitalization in frail older adults.

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme 'Communication' highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme 'System Pressure' referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The 'Continuing Care' theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process.

To assess the direct hospital costs for unplanned re-admissions within 30 days of hospitalisations with heart failure in Australia; to estimate the proportion of these costs attributable to potentially preventable re-admissions.

Retrospective cohort study; analysis of linked admitted patient data collections data.

People admitted to hospital (all public and most private hospitals in Australia) with primary diagnoses of heart failure, 1 January 2013 - 31 December 2017, who were discharged alive and re-admitted to hospital at least once (any cause) within 30 days of discharge.

Estimated re-admission costs based on National Hospital Cost Data Collection, by unplanned re-admission category based on the primary re-admission diagnosis: potentially hospital-acquired condition; recurrence of heart failure; other diagnoses related to heart failure; all other diagnoses. The first two groups were deemed the most preventable.

The 165 612 eligible hospitalisations of people with heart failure during 2013-2017 (mean age, 79 years [standard deviation, 12 years]; 85 964 men [51.9%]) incurred direct hospital costs of $1881.4 million (95% confidence interval [CI], $1872.5-1890.2 million), or $376.3 million per year (95% CI, $374.5-378.1 million per year) and $11 360 per patient (95% CI, $11 312-11 408 per patient). A total of 41 125 people (24.8%) experienced a total of 58 977 unplanned re-admissions within 30 days of discharge from index admissions; these re-admissions incurred direct hospital costs of $604.4 million (95% CI, $598.2-610.5 million), or 32% of total index admission costs; that is, $120.9 million per year (95% CI, $119.6-122.1 million per year), and $14 695 per patient (95% CI, $14 535-14 856 per patient). Re-admissions with potentially hospital-acquired conditions (21 641 re-admissions) accounted for 40.1% of unplanned re-admission costs, recurrence of heart failure (18 666 re-admissions) for 35.6% of re-admission costs.

Unplanned re-admissions after hospitalisations with heart failure are expensive, incurring costs equivalent to 32% of those for the initial hospitalisations; a large proportion of these costs are associated with potentially preventable re-admissions. Reducing the number of unplanned re-admissions could improve outcomes for people with heart failure and reduce hospital costs.

Patients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings. TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care.

This multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to September 1, 2020), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC.

There were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.6 (SD 0.7) treatments, commonly transitioning from surgery to radiotherapy (21.2%). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over the study period. Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average = 70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: (1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, (2) Relational head and neck cancer care which encompasses patient expectations and relationships, and (3) System and individual impact of transitions in care.

This study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.

Investigation of the factors that contribute to hospital readmissions has focused largely on individual level factors. We extend the knowledge base by exploring macrolevel factors that may contribute to readmissions. We point to environmental, behavioral, and socioeconomic factors that are emerging as correlates to readmissions. Data were taken from publicly available reports provided by multiple agencies. Partial Least Squares-Structural Equation Modeling was used to test the association between economic stability and environmental factors on opioid use which was in turn tested for a direct association with hospital readmissions. We also tested whether hospital access as measured by the proportion of people per hospital moderates the relationship between opioid use and hospital readmissions. We found significant associations between Negative Economic Factors and Opioid Use, between Environmental Factors and Opioid Use, and between Opioid Use and Hospital Readmissions. We found that Hospital Access positively moderates the relationship between Opioid Use and Readmissions. A priori assumptions about factors that influence hospital readmissions must extend beyond just individualistic factors and must incorporate a holistic approach that also considers the impact of macrolevel environmental factors.

Improving transitions in care is a major focus of health care planning. In the research team's prior intervention study, the length of stay (LOS) was reduced when patients at high risk for readmission were identified early in their acute care stay and received complex management.

This study will describe the characteristics of patients receiving complex case management in an urban acute care hospital.

Acute care hospital.

This was a retrospective chart review of patients in a previous quality assurance study. A random selection of patients who previously underwent high-risk screening using the LACE (Length of stay; Acuity of the admission; Comorbidity of the patient; Emergency department use) index and received complex case management (the intervention group) were reviewed. The charts of a random selection of patients from the previous comparison group were also reviewed. Patient characteristics were collected and compared using descriptive statistics.

In the intervention group, more patients had their family physicians (FPs) documented (93.1% [81/87] vs. 89.2% [66/74]). More patients in the intervention group (89.7% [77/87] vs. 85.1% [63/74]) lived at home prior to admission. More patients in the intervention group had a family caregiver involved (44.8% [39/87] vs. 41.9% [31/74]). At discharge, more patients in the intervention group (87.1% [74/85]) were discharged home compared with the comparison group (78.4% [58/74]).

(1) Having an identified FP, living at home, and having family caregiver(s) characterized those with lower LOS and discharged home. (2) Case management, risk screening, and discharge planning improve patient outcomes. (3) This study identified the importance of having a FP and engaged family caregivers in improving care outcomes.

Sepsis survivors experience high morbidity and mortality. Though recommended best practices have been established to address the transition and early post hospital needs and promote recovery for sepsis survivors, few patients receive recommended post-sepsis care. Our team developed the Sepsis Transition and Recovery (STAR) program, a multicomponent transition intervention that leverages virtually-connected nurses to coordinate the application of evidence-based recommendations for post-sepsis care with additional clinical support from hospitalist and primary care physicians. In this paper, we present findings from a qualitative pre-implementation study, guided by the Consolidated Framework for Implementation Research (CFIR), of factors to inform successful STAR implementation at a large learning health system prior to effectiveness testing as part of a Type I Hybrid trial.

We conducted semi-structured qualitative interviews (n = 16) with 8 administrative leaders and 8 clinicians. Interviews were transcribed and analyzed in ATLAS.ti using a combination deductive/inductive strategy based on CFIR domains and constructs and the Constant Comparison Method.

Six facilitators and five implementation barriers were identified spanning all five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process). Facilitators of STAR included alignment with health system goals, fostering stakeholder engagement, sharing STAR outcomes data, good communication between STAR navigators and patient care teams/PCPs, clinician promotion of STAR with patients, and good rapport and effective communication between STAR navigators and patients, caregivers, and family members. Barriers of STAR included competing demands for staff time and resources, insufficient communication and education of STAR's value and effectiveness, underlying informational and technology gaps among patients, lack of patient access to community resources, and patient distrust of the program and/or health care.

CFIR proved to be a robust framework for examining facilitators and barriers for pre-implementation planning of post-sepsis care programs within diverse hospital and community settings in a large LHS. Conducting a structured pre-implementation evaluation helps researchers design with implementation in mind prior to effectiveness studies and should be considered a key component of Type I hybrid trials when feasible.

Clinicaltrials.gov, NCT04495946 . Registered August 3, 2020.

The association between rurality of patients' residence and hospital experience is incompletely described. The objective of the study was to compare hospital experience by rurality of patients' residence.

From a US Midwest institution's 17 hospitals, we included 56,685 patients who returned a post-hospital Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We defined rurality using rural-urban commuting area codes (metropolitan, micropolitan, small town, rural). We evaluated the association of patient characteristics with top-box score (favorable response) for 10 HCAHPS items (six composite, two individual, two global). We obtained adjusted odds ratios (aOR [95% CI]) from logistic regression models including patient characteristics. We used key driver analysis to identify associations between HCAHPS items and global rating (combined overall rating of hospital and recommend hospital).

Of all items, overall rating of hospital had lower odds of favorable response for patients from metropolitan (0.88 [0.81-0.94]), micropolitan (0.86 [0.79-0.94]), and small towns (0.90 [0.82-0.98]) compared with rural areas (global test, P = .003). For five items, lower odds of favorable response was observed for select areas compared with rural; for example, recommend hospital for patients from micropolitan (0.88 [0.81-0.97]) but not metropolitan (0.97 [0.89-1.05]) or small towns (0.93 [0.85-1.02]). For four items, rurality showed no association. In metropolitan, micropolitan, and small towns, men vs. women had higher odds of favorable response to most items, whereas in rural areas, sex-based differences were largely absent. Key driver analysis identified care transition, communication about medicines and environment as drivers of global rating, independent of rurality.

Rural patients reported similar or modestly more favorable hospital experience. Determinants of favorable experience across rurality categories may inform system-wide and targeted improvement.

It is expected but unknown whether machine-learning models can outperform regression models, such as a logistic regression (LR) model, especially when the number and types of predictor variables increase in electronic health records (EHRs). We aimed to compare the predictive performance of gradient-boosted decision tree (GBDT), random forest (RF), deep neural network (DNN), and LR with the least absolute shrinkage and selection operator (LR-LASSO) for unplanned readmission. We used EHRs of patients discharged alive from 38 hospitals in 2015-2017 for derivation and in 2018 for validation, including basic characteristics, diagnosis, surgery, procedure, and drug codes, and blood-test results. The outcome was 30-day unplanned readmission. We created six patterns of data tables having different numbers of binary variables (that ≥5% or ≥1% of patients or ≥10 patients had) with and without blood-test results. For each pattern of data tables, we used the derivation data to establish the machine-learning and LR models, and used the validation data to evaluate the performance of each model. The incidence of outcome was 6.8% (23,108/339,513 discharges) and 6.4% (7,507/118,074 discharges) in the derivation and validation datasets, respectively. For the first data table with the smallest number of variables (102 variables that ≥5% of patients had, without blood-test results), the c-statistic was highest for GBDT (0.740), followed by RF (0.734), LR-LASSO (0.720), and DNN (0.664). For the last data table with the largest number of variables (1543 variables that ≥10 patients had, including blood-test results), the c-statistic was highest for GBDT (0.764), followed by LR-LASSO (0.755), RF (0.751), and DNN (0.720), suggesting that the difference between GBDT and LR-LASSO was small and their 95% confidence intervals overlapped. In conclusion, GBDT generally outperformed LR-LASSO to predict unplanned readmission, but the difference of c-statistic became smaller as the number of variables was increased and blood-test results were used.

The objective of this study is to assess the effects of social determinants of health (SDOH) and race-ethnicity on readmission and to investigate the potential for geospatial clustering of patients with a greater burden of SDOH that could lead to a higher risk of readmission.

A retrospective study of inpatients at five hospitals within Henry Ford Health (HFH) in Detroit, Michigan from November 2015 to December 2018 was conducted.

This study used an adult inpatient registry created based on HFH electronic health record data as the data source. A subset of the data elements in the registry was collected for data analyses that included readmission index, race-ethnicity, six SDOH variables and demographics and clinical-related variables.

The cohort was composed of 248 810 admission patient encounters with 156 353 unique adult patients between the study time period. Encounters were excluded if they did not qualify as an index admission for all payors based on the Centers for Medicare and Medicaid Service definition.

The primary outcome was 30-day all-cause readmission. This binary index was identified based on HFH internal data supplemented by external validated readmission data from the Michigan Health Information Network.

Race-ethnicity and all SDOH were significantly associated with readmission. The effect of depression on readmission was dependent on race-ethnicity, with Hispanic patients having the strongest effect in comparison to either African Americans or non-Hispanic whites. Spatial analysis identified ZIP codes in the City of Detroit, Michigan, as over-represented for individuals with multiple SDOH.

There is a complex relationship between SDOH and race-ethnicity that must be taken into consideration when providing healthcare services. Insights from this study, which pinpoint the most vulnerable patients, could be leveraged to further improve existing models to predict risk of 30-day readmission for individuals in future work.

Care transitions are high-risk processes, especially for people with complex or chronic illness. Discharge letters are an opportunity to provide written information to improve patients' self-management after discharge. The aim of this study is to determine the impact of discharge letter content on unplanned hospital readmissions and self-rated quality of care transitions among patients 60 years of age or older with chronic illness.

The study had a convergent mixed methods design. Patients with chronic obstructive pulmonary disease or congestive heart failure were recruited from two hospitals in Region Stockholm if they were living at home and Swedish-speaking. Patients with dementia or cognitive impairment, or a "do not resuscitate" statement in their medical record were excluded. Discharge letters from 136 patients recruited to a randomised controlled trial were coded using an assessment matrix and deductive content analysis. The assessment matrix was based on a literature review performed to identify key elements in discharge letters that facilitate a safe care transition to home. The coded key elements were transformed into a quantitative variable of "SAFE-D score". Bivariate correlations between SAFE-D score and quality of care transition as well as unplanned readmissions within 30 and 90 days were calculated. Lastly, a multivariable Cox proportional hazards model was used to investigate associations between SAFE-D score and time to readmission.

All discharge letters contained at least five of eleven key elements. In less than two per cent of the discharge letters, all eleven key elements were present. Neither SAFE-D score, nor single key elements correlated with 30-day or 90-day readmission rate. SAFE-D score was not associated with time to readmission when adjusted for a range of patient characteristics and self-rated quality of care transitions.

While written summaries play a role, they may not be sufficient on their own to ensure safe care transitions and effective self-care management post-discharge.

Clinical Trials. giv, NCT02823795, 01/09/2016.

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research.

Discharging older adult patients from the hospital poses risks due to their vulnerable conditions, complex instructions and limited health literacy. Insufficient information about medication side effects adds to patient concerns. To address this, a post-discharge information summary system was developed. While it has shown positive impacts, concerns exist regarding implementation fidelity.

This study employed a theory-driven approach to understand health providers' perspectives on effective implementation.

Individual semi-structured interviews were conducted via telephone with nurses, doctors and pharmacists from local public hospitals. All interviews were audio-recorded and transcribed verbatim. Theoretical Domains Framework (TDF) was applied for direct content analysis. Belief statements were generated by thematic synthesis under each of the TDF domains.

A total of 98 participants were interviewed. Out of the 49 belief statements covering eight TDF domains, 19 were determined to be highly relevant to the implementation of the post-discharge information summary system. These TDF domains include knowledge, skills, social/professional role and identity, beliefs about consequences, intentions, memory, attention and decision processes, environmental context and resources and social influences.

Our study contributes to the understanding of determinants in implementing discharge interventions for older adult patients' self-care. Our findings can inform tailored strategies for frontline staff, including aligning programme rationale with stakeholders, promoting staff engagement through co-creation, reinforcing positive programme outcomes and creating default settings. Future research should employ rigorous quantitative designs to examine the actual impact and relationships among these determinants.

Twenty-three percent of people with human immunodeficiency virus (HIV, PWH) die within 6 months of hospital discharge. We tested the hypothesis whether a series of structured home visits could reduce mortality.

We designed a disease neutral home visit package with up to 6 home visits starting 1-week post-hospitalization and every 2 weeks thereafter. The home visit team used a structured assessment algorithm to evaluate and triage social and medical needs of the participant and provide nutritional support. We compared all-cause mortality 6 months following discharge for the intervention compared to usual care in a pilot randomized trial conducted in South Africa. To inform potential scale-up we also included and separately analyzed a group of people without HIV (PWOH).

We enrolled 125 people with HIV and randomized them 1:1 to the home visit intervention or usual care. Fourteen were late exclusions because of death prior to discharge or delayed discharge leaving 111 for analysis. The median age was 39 years, 31% were men; and 70% had advanced HIV disease. At 6 months among PWH 4 (7.3%) in the home visit arm and 10 (17.9%) in the usual care arm (P = .09) had died. Among the 70 PWOH enrolled overall 6-month mortality was 10.1%. Of those in the home visit arm, 91% received at least one home visit.

We demonstrated feasibility of delivering post-hospital home visits and demonstrated preliminary efficacy among PWH with a substantial, but not statistically significant, effect size (59% reduction in mortality). Coronavirus disease 2019 (COVID-19) related challenges resulted in under-enrollment.

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

The transition of patients between care contexts poses patient safety risks. Discharges to home from inpatient care can be associated with adverse patient outcomes. Quality in discharge processes is essential in ensuring safe transitions for patients. Current evidence relies on bivariate analyses and neglects contextual factors such as treatment and patient characteristics and the interactions of potential outcomes. This study aimed to investigate the associations between the quality and safety of the discharge process, patient safety incidents, and health-related outcomes after discharge, considering the treatments' and patients' contextual factors in one comprehensive model.

Patients at least 18 years old and discharged home after at least three days of inpatient treatment received a self-report questionnaire. A total of N = 825 patients participated. The assessment contained items to assess the quality and safety of the discharge process from the patient's perspective with the care transitions measure (CTM), a self-report on the incidence of unplanned readmissions and medication complications, health status, and sociodemographic and treatment-related characteristics. Statistical analyses included structural equation modeling (SEM) and additional analyses using logistic regressions.

Higher quality of care transition was related to a lower incidence of medication complications (B = -0.35, p < 0.01) and better health status (B = 0.74, p < 0.001), but not with lower incidence of readmissions (B = -0.01, p = 0.39). These effects were controlled for the influences of various sociodemographic and treatment-related characteristics in SEM. Additional analyses showed that these associations were only constant when all subscales of the CTM were included.

Quality and safety in the discharge process are critical to safe patient transitions to home care. This study contributes to a better understanding of the complex discharge process by applying a model in which various contextual factors and interactions were considered. The findings revealed that high quality discharge processes are associated with a lower likelihood of patient safety incidents and better health status at home even, when sociodemographic and treatment-related characteristics are taken into account. This study supports the call for developing individualized, patient-centered discharge processes to strengthen patient safety in care transitions.

The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home.

This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis.

The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge.

The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.