Seamless Care: Safe Patient Transitions From Hospital to Home

摘要: Background: “Seamless care” is a smooth and safe transition of patient from the hospital to home. Our goal was identify ways maximize improvement in postdischarge outcomes. This research targeted patients at risk for unscheduled readmissions, examined delivery system processes, identified possible interventions providing more seamless care. Methods: pilot study included three phases. In first phase, we selected readmissions using extant administrative databases fiscal year 2001 two facilities, Department Veterans Affairs (VA) private, nonprofit hospital. We characteristics that were associated with high readmission within 30 days discharge Diagnosis Related Groups (DRGs) (127-Heart Failure, 89-Pneumonia (> 17 years), 109-Coronary Artery Bypass Graft without catheterization). Survival analyses other statistical techniques used. An expert panel focus group provided insights into planning processes. Finally, these DRGs hospitals who discharged had an interviewed obtain their perceptions factors might have contributed readmissions. Results: Factors varied by DRG. Numbers secondary diagnoses, length stay, Clinical Classification Software (CCS) category most consistent predictors readmission. Age, gender, race not predictive. Qualitative analysis several themes centered on communication issues between providers, providers caregivers, different providers. Patients' what prevented longer stay ensure stabilization, enhanced education involvement decisionmaking process, increased assurance medication/treatment effectiveness prior discharge, home health nursing, staffing, timeliness followup appointments. Conclusions: Despite very organizational structures found similar populations, factors, outcomes hospitals. The linkages care facilities barriers transitional confirm findings studies. Patient each High-risk targeting, improved communications (including greater emphasis language cultural differences), better coordination could potentially prevent some when transitioning