N550 Module 5 Assignment Annotated Bibliography

N550 Module 5 Assignment Annotated Bibliography

Student Name

Aspen University

N550

Professor Name

Date

Annotated Bibliography

Bae-Shaaw, Y. H., Eom, H., Chun, R. F., & Steven Fox, D. (2020). American Journal of Health-System Pharmacy, 77(7), 535–545. https://doi.org/10.1093/ajhp/zxaa012

This review examined the impact of a pharmacist managed program on hospitalisation of readmission rate from the acute care setting. The readmission of the patients was common to those with acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure (CHF), and pneumonia. The study adopted a retrospective cohort design with a difference in methodology in order to establish the difference in outcomes before and after the implementation of the program. Intervention site patients included 1,776 in the 2013-2017 sample, while the number was 2,969 at control sites. A total of 3% of the number of candidates at the intervention site were covered with the intervention. This study revealed that the odds of 30 days of readmission were reduced by (OR = 0. 65) among the study participants who received the intervention. The 90-day readmission chances also improve (OR = 0. 75), though they are not statistically significant. Compared to the control, the intervention lowered both 30-day readmissions among CHF patients to 14% and 90-day readmissions to 13%; OR = 0. 52 and 0. 47, respectively. This review is related to my project because it explores how a pharmacist-managed program reduces hospital readmission rates for individuals with acute myocardial infarction, COPD, CHF, and pneumonia. Similar to transitional care programs, focused interventions may minimize readmission rates in skilled nursing facilities, suggesting comprehensive care solutions may be beneficial.

This review systematically compiled and summarised findings from existing systematic reviews regarding hospital-based interventions designed to prevent or reduce acute problems in community-dwelling older adults (age ≥ 65). Among them were 29 review articles that also addressed different kinds of interventions: medication reviews, discharge planning, geriatric assessment, and more. This way, the findings imply that in addition to discharge planning and transitional care, most interventions were not relatively effective in reducing the number of readmissions within this age group. This suggests a poor impact of existing hospital environmental interventions aimed at reducing risks of readmissions to older adults. Consequently, the current review emphasizes the importance of investing in additional research on what could be the more suitable intervention for this at-risk group due to their complex health and care needs. Because the majority of hospital-based treatments, excluding discharge planning and transitional care, fail to reduce older adult readmissions, which is relevant to my study. This suggests that transitional care programs may enhance outcomes for skilled nursing facility discharges. Following my project’s aims, the results highlight the necessity for further study into effective treatments for this vulnerable population.

Li, Y., Fang, J., Li, M., & Luo, B. (2021). European Journal of Cardiovascular Nursing. https://doi.org/10.1093/eurjcn/zvab105

The purpose of this study was to evaluate the outcomes of transitional care interventions by nurses for patients while in the community and on mortality, quality of life, self-care, and quality of emotional life. Seventy-seven articles that met the inclusion criteria were identified with the MEDLINE, EMBASE, and Cochrane library databases. The authors of the study stated that the patients who received nurse-led TCIs had a 21% reduced risk of death and a better health-related quality of life than the patients who received the usual care. However, they did not play an influential role in shaping the emotional health of a person. Furthermore, the research showed that increased decentralization and the complexity of TCIs presented a correlation with a more marked decrease in mortality risk. However, none of these factors has been found to predict consistent elements of outcomes such as mortality and quality of life. This review is related to my project because it explores nurse-led TCIs and demonstrates insertion in managing HF by possibly reducing mortality rate and improving QOL and self-care behaviors; however, additional and more rigorous research is still required to improve these interventions.

Lee, J. Y., Yang, Y. S., & Cho, E. (2022). Geriatric Nursing, 43, 64–76. https://doi.org/10.1016/j.gerinurse.2021.11.003 

The management of transitional care for older adults, which involves helping them when they are discharged from the hospital, has been addressed in studies. Some of these care programs are different in their implementation and success rates. However, it can help to decrease rehospitalization at six months but not at other timeframes or other indicators such as mortality rates or quality of life. This review is related to my project because it explores that the elderly are especially vulnerable, and this poses a challenge concerning their health, especially after discharge from the hospital. They require more time and interventions to regain their functional status so they can get back to their routine. This is where transitional care comes in, to offer the required support to help bridge the gap between hospital and home. In this review, 14 trials were compared, focusing on readmission, mortality, function, and quality of life. The findings were positive, including a slight reduction in readmissions but no significant changes in other benchmarks. Thus, there is a lack of more research-based practical strategies for developing initial transitional care interventions for frail older adults.

Li, M., Li, Y., Meng, Q., Li, Y., Tian, X., Liu, R., & Fang, J. (2021). Effects of nurse-led transitional care interventions for patients with heart failure on healthcare utilization: A meta-analysis of randomized controlled trials. PLOS ONE, 16(12), e0261300. https://doi.org/10.1371/journal.pone.0261300

Heart failure is an acute condition that is a major challenge for patients and healthcare providers. To assist with this, models of nurse-led hospital-to-home transitional care have been developed. This study examined the efficacy of these interventions for the patients with HF that are being led by the nurses. The electronic databases for published studies were identified from January 2000 to June 2020 and used information related to hospital readmission rates, emergency department visits, and the length of the hospital stays. They comprised 25 trials with a total of 8422 patients. The findings highlighted that all-cause readmissions decreased by 9%, and readmission due to heart failure decreased by 29% when patients were given care led by nurses. It also reduced the length of hospital stay by an average of two days. However, such programs failed to produce a meaningful decrease in emergency room admissions. This review is related to my project because it explores the study that increased and intensified nurse-led care goes even more distance in lessening heart failure-specific readmissions.

Li, J., Clouser, J. M., Brock, J., Davis, T., Jack, B., Levine, C., Mays, G. P., Mittman, B., Nguyen, H., Sorra, J., Stromberg, A., Du, G., Dai, C., Adu, A., Vundi, N., & Williams, M. V. (2022). Effects of different transitional care strategies on outcomes after hospital discharge—trust matters, too. The Joint Commission Journal on Quality and Patient Safety, 48(1), 40–52. https://doi.org/10.1016/j.jcjq.2021.09.012

Health systems are shifting to value-based care, meaning that it is important to avoid readmissions and enhance patient outcomes. However, an understanding of optimal interactions between transitional care strategies is still lacking that are derived from the literature review. The project aims to determine which of the transitional care strategies are effective in optimizing patient outcomes from a prospective cohort analysis. The sample was 42 different hospitals in the U.S. The sample size includes 7939 Medicare beneficiaries who were discharged from medical/surgical units. The findings on the effect of five classes of transitional care strategies on the patients were also compared to the control groups. The main studied variables included 30-day readmissions, 7-day post-discharge ED visits, and physical and mental health, pain, and daily physical activity participation according to patient. This review is related to my project because it explores the exposure to a transitional care group with hospital-based trust, plain language, and coordination outcomes that led to a reduced number of 30-day readmissions.

PLOS ONE, 16(7), e0254573. https://doi.org/10.1371/journal.pone.0254573

This study was to assess the impact of the nurse-led transitional care intervention against the usual care for older Oontarians with multiple chronic conditions and depressive symptoms who were being discharged from the hospital to their home. These comprised home visits by registered nurses covering health promotion and management over a six-month period, follow-up phone calls, and assistance in managing health care systems. Some patients were on mental function gain, while the secondary was on physical function, depression, anxiety, perceived social support, patient satisfaction, and healthcare expenses. Thus, even though 127 participants were recruited, of which 85% had six or more comorbidities, only 99 actually completed the study due to attrition. Outcomes did not reveal any differences between the two groups in mental and physical performance changes in the 6th month of the study. However, participants in the intervention group expressed enhanced perceived facilitation to access health and social service information. This review is related to my project because it explores the lower recruitment than anticipated and the investigation of the effects of the intervention in greater detail.

BMC Geriatrics, 20(1), 1–18. https://doi.org/10.1186/s12877-020-01747-w

The demographic transformation is occurring in industrialized societies, although the aging population has emerged as a major issue. Germany has the largest proportion of the aging population in Europe. People between the ages of 66 and 99 years constituted 20% of the total population in 2014 and are projected to be 33% in 2060. It is a change that sets considerable pressure on both the macro and micro levels of public health policy for individuals and patients. For geriatric patients, usually aged 65 and older, with multiple comorbidities, there’s an issue of lack of continuity of care. Common among the elderly, multimorbidity causes decreased quality of life and higher caregiving requirements. This resulted in transitional care, namely care of patients who are being transferred from one care setting to another. Successful transitional interventions like the Transitional Care Model (TCM) contribute towards the reduction of hospital readmissions and enhance patients’ status. This review is related to my project because it explores that the model requires the collaboration of efforts such as discharge planning and patient counseling. However, these strategies are still in the experimental stage and require further research to establish how they can be better applied to more clients, given the increasing number of elderly clients in today’s societies.

Suksatan, W., & Tankumpuan, T. (2021). The effectiveness of transition care interventions from hospital to home on rehospitalization in older patients with heart failure: An integrative review. Home Health Care Management & Practice, 34(1), 108482232110238. https://doi.org/10.1177/10848223211023887

Chronic heart failure commonly results in rehospitalization and heightened mortality rates, specifically among seniors. This review focuses on Transition Care Interventions (TCI) along the hospital-to-home continuum. It is important to know how well the TCIs worked at reducing the 30-day readmission rate among the elderly with HF. A total of 15 articles that included more than 10,000 heart failure patients published within the year 2011 to 2021 were included in the current review. They discovered that TCIs that include nurses, pharmacists, and groups of healthcare providers reduce the re-hospitalization percentage and overall cost of care. TCIs are prominent in patient education, risk appraisal, and maintenance of care during the post-discharge vulnerable period. This review is related to my project because it explores my project in particular, it aids patients to control their episodes at home and enhances their general care. The results of the present study indicate the need for policymakers to incorporate these interventions into discharge planning to manage older patients more efficiently.

Simge Coskun. (2021). OUP accepted the manuscript. European Journal of Cardiovascular Nursing, 3. https://doi.org/10.1093/eurjcn/zvab005

The purpose of this paper was to evaluate the ability of the nurse-led transitional Care Model to enhance elderly patients’ postoperative recovery after surgery. They conducted a randomized trial with 66 elderly patients, dividing them into two groups: the first one being the patient to be discharged and receive transitional care while the second patient receives the standard care. The transitional care group also benefited from the support of the nursing team nine weeks after discharge from the hospital. Self-report of the severity of dependence and their level of occupational functioning and quality of life was assessed using defined scales. They noted that the patients who participated in the transitional care improved their scores in these areas more so than the ones in the standard care group. In addition, the patients who received transitional care had lower readmission rates within the first six months of surgery than the other group. This review is related to my project because it explores how the process of adopting a nurse-led transitional care model can go a long way to increase elderly patients’ LOS after open surgery and decrease hospital readmission.

Sezgin, D., O’Caoimh, R., Liew, A., O’Donovan, M. R., Illario, M., Salem, M. A., Kennelly, S., Carriazo, A. M., Lopez-Samaniego, L., Carda, C. A., Rodriguez-Acuña, R., Inzitari, M., Hammar, T., & Hendry, A. (2020). European Geriatric Medicine. https://doi.org/10.1007/s41999-020-00365-4

This scoping review aims to identify the literature that reveals the ways through which intermediate care, including transitional care interventions, supports middle-aged and older adults during the transitions between different healthcare settings. They planned to measure the effects of these components on function and healthcare, as well as costs. The review analyzed 133 articles published between 2002 and 2019 and concerns different types of care models such as hospital transitional care, home-based care models, and community care models. Data indicated that, at times, these interventions lowered the time that patients spent in the hospital, but the overall impact was mixed. Some of the services that used follow-up calls and coaching seemed to be useful in reducing readmissions to the hospital. This review is related to my project because it explores interdisciplinary team care with home rehabilitation was also considered to enhance the patient’s quality of life by increasing their level of function. The review pointed out that there was significant variability across studies for the type of methods used and the kind of care being offered.

Schapira, M., Outumuro, M. B., Giber, F., Pino, C., Mattiussi, M., Montero-Odasso, M., Boietti, B., Saimovici, J., Gallo, C., Hornstein, L., Pollán, J., Garfi, L., Osman, A., & Perman, G. (2021). Aging Clinical and Experimental Research. https://doi.org/10.1007/s40520-021-01893-0

Frail older adults tend to be at increased risk of poor outcomes during hospitalization, and there is a dearth of knowledge regarding the most efficient care provision in Latin America. This research was designed to assess the effects of applying geriatric co-management alongside transitional care intervention in a hospital in Argentina for frail older patients within 30-day readmissions compared to conventional practices. This research was a single-blinded randomized control trial that involved 120 participants in both the intervention and the control groups. Usual care comprised of a senior internal medicine specialist with timely access to the specialists, hospital care, hospital at home, or home-based primary care post-discharge. This usual care was compared to an intervention group, which also received care from a geriatric co-management team that included assessment, individualized recommendations, and coordination of expected care transitions. In this case, a counselor provided the needed consistency at home. Lower in the intervention group 7%, (18. 3 vs. 35. 0) respectively; those who had emergency room visits within six months were 27, respectively 43. 3% and 60. 0 %, and there was a significant difference of 8%. While not a significant finding, the intervention group also experienced a decline in six-month mortality (25. 0% compared to 35. 0%).

Toles, M., Colón-Emeric, C., Hanson, L. C., Naylor, M., Weinberger, M., Covington, J., & Preisser, J. S. (2021). Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial. Trials, 22(1). https://doi.org/10.1186/s13063-021-05068-0

Residents in skilled nursing facilities (SNFs) have multimorbidities and require some form of assistance from caregivers. More than half of the patients get readmitted or die within the next 90 days after being discharged from this facility, and their caregivers and patients are not ready to handle post-hospitalization management at home. This study aims to determine the feasibility of the connect-home program, which is aimed at providing transitional care for seriously ill SNF patients and their caregivers. This research will be conducted in six SNFs from North Carolina. Connect-Home has two main steps: SNF staff develop an individualized transition plan of care, and a nurse conducts a home visit to begin meeting patient needs according to the plan. Participants will consist of 360 patients and 360 caregivers, with questionnaires being completed during usual care and throughout the connect-home intervention. This review is related to my project because it explores the emphasis put on how ready the patients were for discharge and how ready the caregivers were to assume their responsibilities.

Journal of the American Geriatrics Society, 71(4), 1068–1080. https://doi.org/10.1111/jgs.18218

The study was to identify hospital readmissions among patients who are discharged from skilled nursing facilities (SNFs) within a short period and the problems they encounter in home care. Connect-Home had the goal of enhancing patient and caregiver-related home care. For this study, a randomized trial design was employed, with the intervention being compared with usual discharge planning practice in six SNFs and six home health treatments. Most of the 327 patient-caregivers in the study’s intervention group joined the clinical trial as soon as they contracted COVID-19. It was done through offering tools, training, and support for transitional care within SNFs and at home. This review is related to my project because it explores that the assessments that took place 30 and 60 days post-discharge are effective and comprised of quality of life.

Tyler, N., Hodkinson, A., Planner, C., Angelakis, I., Keyworth, C., Hall, A., Paul Pascall Jones, Wright, O., Keers, R. N., Blakeman, T., & Panagioti, M. (2023).  JAMA Network Open, 6(11), e2344825–e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825

As hospital care has been experiencing a rise in demand, patients are being discharged to the community before adequate services are available to help them. This can result in unsafe transfer of care, especially as documented during the current Coronavirus disease (COVID-19) outbreak. To enhance healthcare use and patient experiences during transitions, transitional care interventions have been attempted. It may include one or several components delivered prior to or following discharge-care coordination or medication management. Although it has been indicated in systematic reviews that these interventions are effective, many of the findings are confined to certain settings and populations with no clear comparative outcomes available. This review is related to my project because it explores the present systematic review and network meta-analysis intended to evaluate different degrees of intervention to determine which could be the most beneficial in increasing healthcare access and patients’ outcomes from hospital to community settings. Patients and caregivers were involved throughout this study to make sure that the study focused on the findings and recommendations that would be appropriate.