The transition of care (TOC) represents the system of actions that healthcare providers carry out to ensure care continuity and coordination for patients who transfer between different levels of care. Within the transition from the hospital to the home setting, there could be many gaps, such as inadequate planning, the lack of patient and/or family education, as well as fragmented or limited access to essential healthcare services. Besides, it is notable that gaps in care provision are often accompanied by limitations in financial resources, inadequate insurance coverage, and limited social support. In acute conditions care, TOC is imperative for ensuring good care continuity, especially in terms of patient education and the strengthening of connections between patients and providers. The aim of this annotated bibliography is to explore the issue of TOC for patients with acute conditions leaving the hospital setting.
The researchers investigated transitions of care interventions’ impact in terms of patients with acute health conditions being admitted to hospitals. The acute conditions include cardiovascular disease, stroke, breast cancer, COPD, and kidney disease, and many others. The authors of the study mentioned that the participants reported having issues finding community support services and groups in their local communities, which is why it is crucial for healthcare providers working in the hospital setting to cater to the unmet needs of the population (Oyesanya et al., 2021). A recommended approach to TOC for individuals with acute conditions entails a more personalized and comprehensive plan of recovery developed by a multidisciplinary team. Besides, to ensure that patients have the optimal number of resources and support for navigating the complicated health services system, they should have personalized care plans. It was found that most care continuity interventions emphasized patient and family education and self-management, based on patient assessment, as core recovery methods. The researchers note that further studies are necessary for examining the feasibility and cost-effectiveness of personalized care plans for individuals with acute health conditions.
The researchers focused on various perspectives available on the post-acute transition of care for patients who have undergone cardiac surgery. The problem is important to study because the majority of patients undergoing cardiac surgery do not require further intensive care in the hospital setting and are discharged home (Stoicea et al., 2017). The challenges in care continuity occur as a result of racial and gender disparities, patients’ physical and mental health, as well as the financial burden in TOC. To address these challenges, several recommendations for transitions of care have been identified in the article. Specifically, establishing closer connections between skilled nursing facilities (SNF) and hospitals that have carried out the surgeries is proposed. Hospitals are expected to affiliate with high-quality SNFs, which are incentivized to improve care quality and maximize hospital referral rates. Improved discharge planning is another recommendation for TOC improvement that should be implemented, especially regarding the utilization of e-health and other platforms. Overall, the critical objective of effective TOC for acute patients such as those undergoing cardiac surgery is establishing patient-centered programs using the latest technologies and solutions for care continuity.
In their study, the researchers explored TOC from hospital-facilitated pulmonary rehabilitation due to acute COPD in patients to the home setting. The primary variable on which the study focused was the experiences of study participants with care transitions between pulmonary rehabilitation and home transition. The factors affecting TOC for COPD patients included providers’ knowledge, communication skills, interprofessional collaboration, and patients’ emotional and physical state, knowledge, and motivation, as well as system-level challenges such as service fragmentation and inconsistent care pathways (Miranda et al., 2020). The recommendations for facilitating an effective transition from hospital to the home included the enhanced support at home, the implementation of self-management strategies before discharge, as well as the improvement of physical and mental health. An effective program of pulmonary rehabilitation as related to TOC improvement implies a specific focus on patients’ behavior change to preserve the benefits of care, even though the approach is challenging to implement in practice. In the study, the majority of healthcare professionals carrying out TOC noted the need to place greater emphasis on problem-solving to prepare patients for the unpredictable nature of mundane life at home.
In their study, the researchers explored the barriers to implementing quality improvement projects targeting stroke patients’ care transition from the hospital setting to the home. TOC is crucial for stroke patients because prolonged hospital stays are costly overall and do not offer the desired functional outcomes. Thus, quality improvement interventions are necessary for avoiding delays in hospital discharge and facilitating care transition from rehabilitation settings to the home context (Zimmerman et al., 2021). It was found that a transitions of care coordination program for stroke patients was a feasible method for improving patient outcomes and their satisfaction. Besides, in hospitals that are classified as comprehensive stroke centers, there are often more stroke nurse navigators, which enables the implementation of nurse-driven quality improvement studies.
In their article, the researchers focused on transitions of care for patients with kidney disease. The main challenge with the acute health problem is that many patients tend to experience unplanned, chaotic, and psychologically traumatic treatment initiation. The recommended intervention for the patient target population is the Patient-Centered Kidney Transitions Care program. It aims to overcome the barriers to TOC in patients with kidney disease by improving the infrastructure of health systems, using educational programs for enhancing behavioral approaches, and helping patients to be well-prepared to make informed decisions about their care (Green et al., 2018). Besides, the program enables patients to achieve their preference-aligned goals of treatment in time and without delays. The intervention can be aligned with the use of electronic health technologies, which could serve as effective facilitators of improved health continuity and adjustment of care strategies as needed.
The annotated bibliography on the studies focusing on TOC for patients with acute health conditions revealed that the effective transition from a hospital to a home setting is patient-centered and thus considers the specific needs and expectations of the patient. There is no one-fits-all approach, especially since acute conditions may have different outcomes for individuals. Besides, there has been a challenge for healthcare providers to address the needs of patient populations who experience health disparities in access to care and cannot find the right providers who can guarantee effective care continuity. However, there is a common theme in the studies that healthcare providers must develop trusting connections with their patients and act as educators and advocates within care continuity. It is crucial to facilitate the adequate preparation of patients to ensure that they can make well-informed decisions about their care independently or under the guidance of a healthcare provider.
Green, J., Ephraim, P. L., Hill-Briggs, F. F., Browne, T., Strigo, T. S., Hauer, C. L., …Boulware, E. L. (2018). Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial. Contemporary Clinical Trials, 73, 98-110. Web.
Miranda, J., Underwood, D., Kuepfer-Thomas, M., Coulson, D., Park, A. C., Butler, S. J., … Guilcher, S. (2020). Exploring transitions in care from pulmonary rehabilitation to home for persons with chronic obstructive pulmonary disease: A descriptive qualitative study. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 23(2), 414-422. Web.
Oyesanya, T. O., Loflin, C., Byom, L., Harris, G., Daly, K., Rink, L., & Bettger, J. P. (2021). Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: A systematic literature review. Health and Quality of Life Outcomes, 19(1), 36. Web.
Stoicea, N., You, T., Eiterman, A., Hartwell, C., Davila, V., Marjoribanks, S., … Rogers, B. (2017). Perspectives of post-acute transition of care for cardiac surgery patients. Frontiers in Cardiovascular Medicine. Web.
Zimmerman, W. D., Grenier, R. E., Palka, S., Monacci, K. J., Lantzy, A. K., Leutbecker, J. A. … Denny, M. C. (2021). Transitions of care coordination intervention identifies barriers to discharge in hospitalized stroke patients. Frontiers in Neurology. Web.