Charting a Course for High Quality Care Transitions

Learn how to ensure quality and safety for vulnerable older adults Transitional care is crucial to older adults with complex care needs who are moving between different locations or different levels of care. Charting a Course for High Quality Care Transitions addresses this problem by providing leading experts and leaders in the field discussing practical strategies that ensure care quality and safety for transitioning vulnerable older adults. This helpful resource comprehensively discusses current research, quality improvement, risk targeting, risk identification, patterns of care, care coordination, and performance assessment. Lowering the inherent risks for adverse events when moving patients can be challenging. Numerous unforeseen variables such as possible mismanagement of medication or staff shortages can often jeopardize patient safety. Charting a Course for High Quality Care Transitions offers practical approaches to address several of the main challenges encountered by health professionals. This book focuses on various ways to provide the highest quality patient-centered care through advancements in research, practice, and data measurement. This informative text is extensively referenced and contains numerous tables to clarify and illustrate important data. Topics in Charting a Course for High Quality Care Transitions include: a semantic framework for overcoming quality improvement issues stemming from inconsistent use of terms a tool for home health agencies to identify home health care patients at risk for hospital readmission medical and social factors that contribute to poor quality care transitions a successful Advanced Practice Nurse transitional care model that can improve outcomes to cognitively impaired older adults unrecognized needs of older adults living in residential care facilities patient-centered performance measurement early results of the Reducing Acute Care Hospitalization National Demonstration Collaborative gaps in research that need to be addressed in the future Charting a Course for High Quality Care Transitions is an important resource for home care professionals, hospital discharge planners, public health nurses, geriatric health services researchers, and health care professionals of all types.

Eric A. Coleman, MD, MPH, is an Associate Professor of Medicine within the Divisions of Health Care Policy and Research and Geriatric Medicine at the University of Colorado at Denver and Health Sciences Center. As a board-certified geriatrician, Dr. Coleman maintains direct patient care responsibility for older adults in ambulatory, acute, and subacute care settings. Dr. Coleman’s research focuses on enhancing the role of patients and caregivers in improving the quality of their care transitions across acute and post-acute settings; measuring the quality of care transitions from the perspective of patients and caregivers; implementing system-level practice improvement interventions; and using health information technology to promote safe and effective care transitions.

Preface Introduction (Marian Essey) Discharge Planning, Transitional Care, Coordination of Care, and Continuity of Care: Clarifying the Use and Terms from the Hospital Perspective (Diane E. Holland and Marcelline R. Harris) Development and Testing of an Analytic Model to Identify Home Healthcare Patients at Risk for a Hospitalization Within the First 60 Days of Care (Robert J. Rosati and Liping Huang) Bouncing-Back: Rehospitalization in Patients with Complicated Transitions in the First Thirty Days After Hospital Discharge for Acute Stroke (Amy J. H. Kind, Maureen A. Smith, Nancy Pandhi, Jennifer R. Frytak, and Michael D. Finch) Care Coordination for Cognitively Impaired Older Adults and Their Caregivers (Mary D. Naylor, Karen B. Hirschman, Kathryn H. Bowles, M. Brian Bixby, JoAnne Konick-McMahan, and Caroline Stephens) Patterns of Emergency Care Use in Residential Care Settings: Opportunities to Improve Quality of Transitional Care in the Elderly (Pamela Parsons and Peter A. Boling) The Central Role of Performance Measurement in Improving the Quality of Transitional Care (Eric A. Coleman, Carla Parry, Sandra A. Chalmers, Amita Chugh, and Eldon Mahoney) ReACH National Demonstration Collaborative: Early Results of Implementation (Patricia Simino Boyce and Penny Hollander Feldman) A Research and Policy Agenda for Transitions from Nursing Homes to Home (Peter A. Boling and Pamela Parsons) Index Reference Notes Included