There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital home community-based care. Operationalization these varied widely as hospitals have customized care into innovative roles functions. This article presents model conceptualizing components preparation ensure attention full range needed comprehensive strategy discharge.

Hospital discharge planning is a key element of continuity care for persons leaving the hospital. Yet many important questions regarding processes and effects have not been addressed, in part because multiple terms associated with consistently defined or used. Failure to clearly name, define, use creates barrier that inhibits scientific progress best practice. This article reviews definitions compares concepts hospital across documents frequently referenced by hospitals. A conceptual model...

Purpose: This study reviews staffing standards from the 50 states and District of Columbia to determine if these are related nursing home levels. Design Methods: Rules regulations for states' were obtained Columbia. Nurse data Centers Medicare Medicaid Services On-Line Survey, Certification, Reporting (known as OSCAR) database. The minimum hours per resident day (HPRD) each state categorized according following: no state-specific HPRD standard (adheres only federal guidelines); low (≤ 2.5...

We compared the effects of evidence-based disease management guidelines delivered to patients with heart failure and diabetes using three different modalities: in-person visits alone (Control), a telephone intervention (Telephone), telemonitoring (Telemonitoring). Patients were randomized groups. There 112 in Control group, 93 Telephone group 98 Telemonitoring group. During first 60 days, 10% rehospitalized, 17% 16% Having receiving more significantly related readmission time readmission....

Purpose of Study: The purpose this study was to determine the extent which patients discharged "home self care" experienced problems and unmet needs. A secondary aim explore potential differences in needs between medical surgical patients. Primary Practice Setting: setting acute care 2 hospitals that were part a large academic center Midwest. Methodology Sample: prospective, cohort survey designed with systematic sampling strategy identify 130 cognitively intact adults hospitalized for...

Purpose of the Study: Hospital clinicians are overwhelmed with volume patients churning through health care systems. The study purpose was to determine whether alerting case managers about high-risk by supplying decision support results in better discharge plans as evidenced time first hospital readmission. Primary Practice Setting: Four medical units at one urban, university center. Methodology and Sample: A quasi-experimental including a usual experimental phase hospitalized...

Abstract Challenges to recruitment of family caregivers exist and are amplified when consent must occur in the context chaotic healthcare circumstances, such as transition from hospital home. The onset COVID-19 pandemic during our randomized controlled trial provided an opportunity for a natural experiment exploring examining different processes caregiver recruitment. purpose this publication is describe (in-person versus virtual) compare diversity rates care recipient’s hospitalization. We...

Noise has been shown to interfere with the healing process and can disrupt patient's experience. This study assessed patients' staff's perceptions of noise levels sources in hospital environment identified interventions reduce level. The significantly reduced as perceived by patients staff. Identification a structured identify standardization measurement methods improve patient

The purpose of the study was to determine whether a difference exists in patient-reported problems and unmet needs after discharge when standardized planning assessment is added usual care by staff nurses. Two groups 130 adult patients were enrolled while hospitalized. intervention group reported fewer (P = .01) had complying with their instructions .04). Standardizing assessments nurses may improve identification continuing needs.

Aims and objectives. The purpose of the study was to describe ability an evidence‐based discharge planning (DP) decision support tool identify prioritise patients appropriate for early DP intervention. Specifically, we aimed determine whether with a high Early Screen Discharge Planning (ESDP) score report more problems continuing care needs in first few weeks after than low ESDP scores. Background. Improved methods are needed efficiently accurately hospitalised at risk complex plans. Design....

Background: Electronic health records (EHRs) provide a clinical view of patient health. EHR data are becoming available in large sets and enabling research that will transform the landscape healthcare research. Methods needed to incorporate wellbeing dimensions strengths sets. The purpose this study was examine potential alignment Wellbeing Model with interface terminology standard, Omaha System, for documenting assessments. Objective: To map System use assessment evaluate feasibility...

In this Perspective, we contend bold action is needed to improve transitions from hospitals home for aging patients and their family caregivers living in rural underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed over 40 US states, intended provide of hospitalized with the knowledge skills safe efficient transitions. It has broken important ground who assist patient care. may fall short, however, addressing unique needs We that realize safety, cost, care quality...

ABSTRACT Objective To assess how patient and caregiver factors influence readiness for hospital discharge in palliative care patients. Study Setting Design This transitional study uses cross‐sectional data from a randomized controlled trial conducted 2018 to 2023 testing an intervention caregivers of hospitalized adult patients with serious or life‐limiting illness who received consult prior transitioning out the hospital. Data Sources Analytical Sample Caregiver was measured Family...

Background: Patients with severe and life-limiting illnesses transitioning out of the hospital often rely on family caregivers (FCGs) to manage communication health care teams during hospitalizations outpatient care. However, FCGs infrequently receive adequate training or support prepare for these responsibilities. Effective between is critical preparing reducing risks poor outcomes. This study tested an eight-week intervention improve FCG preparedness practices transitions hospital....

Background: There is no rigorously developed and empirically validated screening tool to identify, early in the hospital stay, those adults who will use specialized discharge planning services. Objectives: To develop validate a screen using admission clinical data that discriminates between do not Methods: Subjects consisted of prospectively sampled adult patients admitted two hospitals located Midwestern United States city 1998 (tool development sample, n = 991) 2002 (validation 303)....

Abstract Background Rural family caregivers (FCGs) in the United States often experience high economic costs. This randomized controlled trial compared a transitional palliative care intervention (TPC) to support FCGs of seriously ill recipients (CRs) an attention control condition. We evaluated TPC's effect on healthcare use and out‐of‐pocket spending for both CRs. Methods TPC received teaching, guidance, counseling via video calls 8 weeks following CR discharge from hospital. After...

Purpose: Family caregivers of a loved one with life-limiting or terminal illness are often overwhelmed by, and underprepared for, their responsibilities. They need help from family members friends to provide comprehensive care. When death occurs, funerals other death-related rituals bring communities together honor the life mourn needed support caregivers. These collective deeply rooted in culturally-bound values can facilitate grief make sense about loss. Rituals act as bridge-building...