• Faith community nurse
• Hospital readmission
• Length of stay
• Transition of care

• Humans
• Propensity Score
• Male
• Female
• Patient Readmission/statistics & numerical data
• Length of Stay/statistics & numerical data
• Middle Aged
• United States
• Aged
• Parish Nursing/statistics & numerical data
• Adult
• Transitional Care/statistics & numerical data
• Patient Discharge/statistics & numerical data

• Church Health Congregational Care Transition Project Grant Church Health

• Malnutrition
• Older adults
• Rehospitalization

• Humans
• Aged
• Patient Readmission
• Patient Discharge
• Malnutrition/complications
• Malnutrition/epidemiology
• Malnutrition/diagnosis
• Hospitalization
• Nutritional Status

• Early hospital readmissions
• Incidence and trends
• Kidney
• Post-transplant outcomes
• Transplantation

• MC_PC_21015 Medical Research Council
• MC_PC_21055 Medical Research Council
• MR/V033654/1 Medical Research Council
• UK Research and Innovation

• Hospital charges
• Length of stay
• Mortality
• Nationwide readmissions database

• Humans
• Adult
• United States/epidemiology
• Patient Readmission
• Retrospective Studies
• Pancreatitis/chemically induced
• Pancreatitis/diagnosis
• Pancreatitis/epidemiology
• Acute Disease
• Hospitalization
• Risk Factors
• Databases, Factual

• Chronic pancreatitis
• Frailty
• Hospital Frailty Risk Score (HFRS)
• Mortality
• Readmission

• Acute readmission
• Comorbidity
• Geriatric
• Patient characteristics
• Polypharmacy

• Aged
• Frailty
• Geriatric Assessment
• Humans
• Malnutrition
• Patient Discharge
• Prospective Studies
• Risk Factors

Introduction

Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity.

Aim

To implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.

Methods

To address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called “power plan”), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.

Results

Our intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our “power plan” promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.

Conclusion

The management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

The mortality of older patients after early discharge from hospitals is sparsely described. Information on factors associated with mortality can help identify high-risk patients who may benefit from preventive interventions. The aim of this study was to examine whether demographic factors, comorbidity and admission diagnoses are predictors of 30-day mortality among acutely admitted older patients discharged within 24 h after admission.

All medical patients aged ≥65 years admitted acutely to Danish hospitals between 1 January 2013 and 30 June 2014 surviving a hospital stay of ≤24 h were included. Demographic factors, comorbidity, discharge diagnoses and mortality within 30 days were described using data from the Danish National Patient Registry and the Civil Registration System. Cox regression was used to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for all-cause mortality.

A total of 93,295 patients (49.4% men) with a median age of 75 years (interquartile range: 69–82 years), were included. Out of these, 2775 patients (3.0%; 95% CI 2.9–3.1%) died within 30 days after discharge. The 30-day mortality was increased in patients with age 76–85 years (aHR 1.59; 1.45–1.75) and 86+ years (aHR 3.35; 3.04–3.70), male gender (aHR 1.22; 1.11–1.33), a Charlson Comorbidity Index of 1–2 (aHR 2.15; 1.92–2.40) and 3+ (aHR 4.07; 3.65–4.54), and unmarried status (aHR 1.17; 1.08–1.27). Discharge diagnoses associated with 30-day mortality were heart failure (aHR 1.52; 1.17–1.95), respiratory failure (aHR 3.18; 2.46–4.11), dehydration (aHR 2.87; 2.51–3.29), constipation (aHR 1.31; 1.02–1.67), anemia (aHR 1.45; 1.27–1.66), pneumonia (aHR 2.24; 1.94–2.59), urinary tract infection (aHR 1.33; 1.14–1.55), dyspnea (aHR 1.57; 1.32–1.87) and suspicion of malignancy (aHR 2.06; 1.64–2.59).

Three percent had died within 30 days. High age, male gender, the comorbidity burden, unmarried status and several primary discharge diagnoses were identified as independent prognostic factors of 30-day all-cause mortality.

• Acute medicine
• Anemia
• Comorbidity
• Constipation
• Dehydration
• Early discharge
• Geriatrics
• Heart failure
• Length of stay
• Respiratory failure

• aged
• evidence-based practice
• geriatric nursing
• nursing homes
• public health nursing practice
• safety

• Aged
• COVID-19/epidemiology
• COVID-19/nursing
• Humans
• New Jersey/epidemiology
• Nursing Care/organization & administration
• Nursing Homes

• Aged
• Aged, 80 and over
• Atrial Fibrillation/epidemiology
• Comorbidity
• Data Analysis
• Diabetes Mellitus, Type 2/epidemiology
• Female
• Germany/epidemiology
• Heart Failure/epidemiology
• Humans
• Insurance Claim Review
• Insurance, Health
• Male
• Myocardial Infarction/epidemiology
• Osteoporosis/epidemiology
• Patient Readmission
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Retrospective Studies
• Risk Factors
• Stroke/epidemiology
• Time Factors

• German Innovation Funds
• Physician-Scientist Programme of Heidelberg University, Faculty of Medicine

• Aged
• Community-dwelling
• Geriatric hospital care
• Hospitalisation
• Readmission
• Risk factors

• geriatric medicine
• internal medicine
• preventive medicine

• Aftercare
• Aged
• Humans
• Outcome Assessment, Health Care
• Patient Discharge
• Patient Readmission
• Transitional Care

• Fund for the advancement of health research in Central Denmark Region

• chronic heart failure
• hospitalization
• nomogram
• prediction model
• readmission

• Admission diagnosis
• Discharge diagnosis
• Hospital databases

• cardiovascular disease
• cardiovascular medicine
• inpatient patient satisfaction
• patient outcomes
• patient satisfaction
• post-discharge outcomes
• quality improvement

• Cancer
• Discharge
• Hospital admission
• Inpatient care
• Medical oncology

• Adolescent
• Adult
• Aged
• Emergency Service, Hospital/statistics & numerical data
• Female
• Hospitalization/trends
• Hospitals/statistics & numerical data
• Humans
• Intensive Care Units/statistics & numerical data
• Male
• Medical Oncology/statistics & numerical data
• Middle Aged
• Neoplasms/therapy
• Patient Admission/statistics & numerical data
• Patient Discharge/statistics & numerical data
• Referral and Consultation/statistics & numerical data
• Retrospective Studies
• Young Adult

Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components’ role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes).

Randomized controlled trials (sample size ≥50 participants per group; intervention period ≥30 days), with geriatric patients were included. Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Central Register of Controlled Trials) were searched from January 1994 to December 2019 published in English or German. A qualitative synthesis of the findings as well as a systematic assessment of the interventions intensities was performed.

Three articles met the inclusion criteria. One of the included trials applied all of the nine Transitional Care Model components described by Hirschman and colleagues and obtained a high-intensity level of intervention in the intensities assessment. This and another trial reported reductions in the readmission rate (p < 0.05), but the third trial did not report significant differences between the groups in the longer follow-up period (up to 12 months).

Our findings suggest that high intensity multicomponent and multidisciplinary interventions are likely to be effective reducing readmission rates in geriatric patients, without increasing cost. Components such as type of staffing, assessing and managing symptoms, educating and promoting self-management, maintaining relationships and fostering coordination seem to have an important role in reducing the readmission rate. Research is needed to perform further investigations addressing geriatric patients well above 65 years old, to further understand the importance of individual components of the TCM in this population.

• Geriatric patients
• Readmission
• Systematic review
• Transitional care
• Transitional care model

• 30 day readmission
• 90 day mortality
• African-American
• Commercial health insurance
• Medicaid
• Medicare
• Post-discharge
• Transitions of care

• health services administration & management
• organisation of health services
• quality in health care

• Aftercare
• Aged
• Cross-Sectional Studies
• Hospitals
• Humans
• London
• Patient Discharge
• Patient Readmission
• United Kingdom

Remote home monitoring might fill the perceived surveillance gap after hospital discharge. However, it is unclear whether older oncologic patients will be able to use the required new digital technologies. The study aimed to assess the feasibility of postoperative remote home monitoring for this population.

This observational cohort study recruited patients aged 65 years or older scheduled for oncologic surgery. The study patients used a mobile application and activity tracker preoperatively until 3 months postoperatively. A subset of the patients used additional devices (thermometer, blood pressure monitor, weight scale) and completed electronic health questionnaires 2 weeks after hospital discharge. Feasibility was assessed by the study completion rate, compliance in using components of the information technology system, acceptability [Net Promotor Score (NPS)] and usability [System Usability Scale (SUS)]. The NPS score varied from − 100 to + 100. An SUS higher than 68 was considered above average.

Of 47 participants (mean age, 72 years; range, 65–85 years), 37 completed a follow-up assessment, yielding a completion rate of 79%. Compliance in using the activity tracker (n = 41) occurred a median of 81 days [interquartile range (IQR), 70–90 days] out of 90 post-discharge days. Compliance in measuring vital signs and completing health questionnaires varied from a median of 10.5 days (IQR, 4.5–14.0 days) to 12 days (IQR, 5–14 days) out of 14 days. The NPS was + 29.7%, and the mean SUS was 74.4 ± 19.3.

Older oncologic patients in the study considered postoperative home monitoring acceptable and usable. Once they consented to participate, the patients were compliant, and the completion rate was high.

The online version of this article (10.1245/s10434-020-08705-1) contains supplementary material, which is available to authorized users.

Knowledge of unplanned readmission rates and prognostic factors for readmission among older people after early discharge from emergency departments is sparse. The aims of this study were to examine the unplanned readmission rate among older patients after short-term admission, and to examine risk factors for readmission including demographic factors, comorbidity and admission diagnoses.

This cohort study included all medical patients aged ≥65 years acutely admitted to Danish hospitals between 1 January 2013 and 30 June 2014 and surviving a hospital stay of ≤24 h. Data on readmission within 30 days, comorbidity, demographic factors, discharge diagnoses and mortality were obtained from the Danish National Registry of Patients and the Danish Civil Registration System. We examined risk factors for readmission using a multivariable Cox regression to estimate adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for readmission.

A total of 93,306 patients with a median age of 75 years were acutely admitted and discharged within 24 h, and 18,958 (20.3%; 95% CI 20.1 - 20.6%) were readmitted with a median time to readmission of 8 days (IQR 3 - 16 days). The majority were readmitted with a new diagnosis. Male sex (aHR 1.15; 1.11 - 1.18) and a Charlson Comorbidity Index ≥3 (aHR 2.28; 2.20 - 2.37) were associated with an increased risk of readmission. Discharge diagnoses associated with increased risk of readmission were heart failure (aHR 1.26; 1.12 - 1.41), chronic obstructive pulmonary disease (aHR 1.33; 1.25 - 1.43), dehydration (aHR 1.28; 1.17 - 1.39), constipation (aHR 1.26; 1.14 - 1.39), anemia (aHR 1.45; 1.38 - 1.54), pneumonia (aHR 1.15; 1.06 - 1.25), urinary tract infection (aHR 1.15; 1.07 - 1.24), suspicion of malignancy (aHR 1.51; 1.37 - 1.66), fever (aHR 1.52; 1.33 - 1.73) and abdominal pain (aHR 1.12; 1.05 - 1.19).

One fifth of acutely admitted medical patients aged ≥65 were readmitted within 30 days after early discharge. Male gender, the burden of comorbidity and several primary discharge diagnoses were risk factors for readmission.

• Comorbidity
• Emergencies
• Geriatrics
• Patient discharge
• Patient readmission

This study aimed to estimate the incidence of 28-day unplanned readmission among older women, and associated factors. Data were used from the 1921–1926 birth cohort of the Australian Longitudinal Study on Women’s Health. Linkage of self-reported survey data with the Admitted Patient Data Collection allowed the identification of hospital admissions for each woman and the corresponding baseline characteristics. The Cox proportional-hazards model was used to identify factors associated with time to unplanned readmission, using SAS software V 9.4. (SAS Institute, Cary, NC, USA). Of 2056 women with index unplanned admission, 363 (17.5%) were readmitted within 28 days of discharge, and of these 229 (11.14%) had unplanned readmission. Among women with unplanned readmission, 24% were for the same condition as for the index hospitalisation. Cardiovascular diseases were the main diagnoses for the index admission and readmission. Unplanned readmission risk was higher if not partnered (hazard ratio (HR) = 1.43, 95% confidence interval (CI): 1.05–1.95), of non-English speaking background (HR = 1.62%, 95% CI: 1.07–2.47), more than three days length of stay on index admission (HR = 1.41%, 95% CI: 1.04–1.90) and one or two of the assessed chronic diseases (HR = 1.68, 95% CI: 1.19–2.36). At least one in ten women had unplanned readmission at some time between ages 75–95 years. Women who are not partnered, not of English-speaking background, with longer hospital stay and those with multi-morbidity, may need further efforts during their stay and on discharge to mitigate unplanned readmission.

• Australia
• Cox regression
• older people
• unplanned readmission
• women

• clinical pharmacology
• clinical trials
• geriatric medicine

• Aged
• Drug-Related Side Effects and Adverse Reactions
• Humans
• Medication Reconciliation
• Patient Readmission
• Pharmaceutical Preparations
• Pharmacists
• Quality of Life
• Randomized Controlled Trials as Topic

• Region Västerbotten
• Vetenskapsrådet
• Svenska Läkaresällskapet
• Forskningsrådet om Hälsa, Arbetsliv och Välfärd
• Umeå University Foundation for Medical Research