Care Coordination Relating to Elderly Patients After Discharge From Emergency Room or Hospital Annotated Bibliography

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Care Coordination Relating to Elderly Patients With Congestive Heart Failure After Discharge From Emergency Room or Hospital Within 30 Days

A growing body of evidence supports the need for careful care coordination for elderly patients who suffer from congestive heart failure, diabetes, and/or hypertension for at least 30 days following their discharge from a hospital or emergency room. To determine the current best practices and guidance in this area, a summary of the relevant literature is provided below in an annotated bibliographic format, followed by a summary of the research and important findings in the conclusion.

Bisognano, M. & Boutwell, A. (2009). Improving transitions to reduce readmissions. Frontiers of Health Services Management, 25(3), 3-5.

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Authors report that a growing body of research confirms the high rates of readmissions for patients with conditions such as heart failure, chronic obstructive pulmonary disease, and depression. Among the populations studied by authors, congestive heart failure (CHF) 30-day readmission rates were shown to be especially high at between 20-24%. Authors cite following as being proven effective interventions: (a) early assessment of discharge needs; (b) enhanced patient and care-giver education, specifically focused on understanding the management of the patient's condition; (c) timely and complete communication between clinicians at the time of transfer; (d) early post-acute follow up within 48-72 hours for high-risk patients with either a physician or nurse; (e) early post-discharge nurse phone calls to confirm understanding of follow-up plan; (f) appropriate referral for home care services when needed; (g) appropriate advanced care planning; (h) remote monitoring; (i) improved transfer processes between facilities; and (j) effective medication management.

Boughton, B. & Halliday, L. (2009). Home alone: Patient and carer uncertainty surrounding discharge with continuing clinical care needs. Contemporary Nurse: a Journal for the Australian Nursing Profession, 33(1), 30-32.

Annotated Bibliography on Care Coordination Relating to Elderly Patients After Discharge From Emergency Room or Hospital Assignment

Authors report that timely discharge planning is an important ingredient in patient care and is of particular importance to short stay or early discharge patients. Discharge planning is widely regarded as being the primary mechanism whereby the post-hospitalization discharge needs of the elderly are addressed.

Byrnes, J. & Fifer, J. (2010). Recommendations for responding to changes in reimbursement policy. Frontiers of Health Services Management, 27(1), 3-5.

Authors report that there is a fundamental need for after-discharge hospital assessment at admission to include key family members and community support organizations with the goal of beginning discharge planning on arrival and to have a completed plan by discharge. Authors add that electronic medical record screens have also been improved to facilitate communication between all caregivers involved in this process, including primary care physicians, medication planning (especially important) and/or coordination of transition to another facility.

Callaly, T., Hyland, M., Trauer, T., Dodd, S. & Berk, M. (2010). Readmission to an acute

psychiatric unit within 28 days of discharge: Identifying those at risk. Australian Health

Review, 34(3), 282-290.

Authors note that elderly with a history of hospital readmissions should be targeted for specialized attention during the immediate post-discharge period, with many previous readmissions being preventable with more effective discharge planning.

Chugh, A., Williams, M.V., Grigsby, J. & Coleman, E.A. (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management,

25(3), 11-13.

Authors provide a series of case studies of the elderly hospitalized for various heart conditions. Authors emphasize the need to ensure that the elderly are able to thoroughly understand the directions they are given for the post-discharge period, a process that can be constrained by hearing loss, cultural or language barriers, and recommend the use of human or computerized assistants to conduct follow-up telephone calls to the patients during the early post-discharge period.

Clairborne, N. & Vandenburgh, H. (2001). Social workers' role in disease management. Health and Social Work, 26(4), 217-219.

A client-centered disease management model seeks to coordinate healthcare resources across the entire delivery system rather than separated services within a fragmented health care system. This model includes a case manager who helps coordinate care across the entire range of services, including inpatient, outpatient, and community-based. The advantage of this approach is that the case manager can help ensure seamless care coordination regardless of service location.

Chugh, A., Williams, M.V., Grigsby, J. & Coleman, E.A. (2009). Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management,

25(3), 11-13.

Authors report that a number of the constraints to providing effective discharge instructions following hospitalization are attributable to the healthcare system or the individual practitioner. Numerous studies have shown that clinicians' use of medical terms, together with patients' limited ability to understand complicated health terminology, result in inadequate and even confusing communications between provider and patients. Based on primary data collected for this study, authors conclude that repetition of instructions, post-discharge follow up and reminders, and the use of a computerized assistant that calls patients at home after discharge are essential elements for post-discharge planning, as well as simplifying written materials by using common language, using larger fonts, including diagrams and pictures, tailoring information to the patient's learning strengths, and paying attention to how information is organized; not all such post-discharge information can be simplified in this fashion, though.

Kovner, A.R. & Knickman, J.R. (2005). Jonas and Kovner's health care delivery in the United

States. New York: Springer.

Authors reports that tracking of emergency department visits can help identify problem areas in primary care settings that can be used by healthcare providers to help prevent exacerbations of medical conditions such as congestive heart failure following discharge from the emergency room.

Kumar, S. & Grimmer-Somers, K. (2007). A synthesis of the secondary literature on effectiveness of hospital avoidance and discharge programs. Australian Health Review,

31(1), 34-37.

Authors report that their analysis of post-discharge needs of frail elderly, patients with chronic obstructive pulmonary disease, elderly congestive heart failure indicates that these patients require individualized, multidisciplinary post-discharge planning. For many elderly, post-discharge plans will involve community-based resources.

Mark, D.D. (2000). Health policy and case management. Care Management Journals, 2(3),

160 -- 162.

Author reports that improved functional outcomes have been demonstrated using case management for patients with Alzheimer's disease, myocardial infarctions, congestive heart failure, coronary artery bypass graft surgery, and chemotherapy; although such outcomes were not as pronounced, aftercare planning following ED or hospital discharge also improved outcomes for elderly patients. The need to include family members in the education process concerning how to navigate the health care system during the transition process is highlighted, as well as the need for individualized care coordinator post-discharge.

McLean, R., Mendis, K. & Canalese, J. (2008). A ten-year retrospective study of unplanned hospital readmissions to a regional Australian hospital. Australian Health Review, 32(3),


Authors' analysis of 10 years' of unplanned hospital readmissions identified the length of initial hospital as being of the factors that could influence subsequent unplanned hospitalizations. Authors cite the need to trend unplanned readmissions to identify opportunities for improvement in coordination of post-discharge planning.

McGaw, J.L. (2008). Whole patient care: Reaching beyond traditional healthcare. Frontiers of Health Services Management, 25(2), 39-41.

Authors report that aftercare considerations for the elderly are especially important because of the numerous comorbidities that may be involved; more than 10% of patients discharged from tertiary healthcare facilities with diabetes also suffer from deficiency anemias, congestive heart failure, chronic lung disease, renal failure, or peripheral vascular disease. Consequently, the transition from the hospital to another setting can result in acute problems, but many unforeseen outcomes are preventable through informed aftercare planning.

Medicare Rights Center. (2007). Making medication therapy management a cornerstone of community-based care for people with Alzheimer's disease and other forms of dementia.

Care Management Journals, 8(2), 87-89.

The need for individualized care coordination following discharge from an emergency department or hospital has been cited as an increasingly necessary tool to help improve health and quality of life as well as in lowering overall health care costs; among all patients with Medicare who suffer from Alzheimer's disease or dementia, (a) 30% also had coronary heart disease; (b) 21% also had diabetes; (c) 28% also had congestive heart failure; and (d) 17% also had chronic obstructive pulmonary disease.

Shay, K. & Schectman, G. (2010). Primary care for older veterans. Generations, 34(2), 35-37.

Authors report that the VA uses an electronic medical record implemented in 2001 to facilitate post-care transitions from medical centers to other care settings. Various reminders, for instance, alert primary care providers of the need for post-discharge follow-up, a feature especially important for its geriatric population with comorbid conditions such as CHF.

Scott, I.A. (2010). Preventing the rebound: Improving care transition in hospital discharge processes. Australian Health Review, 34(4), 445-447.

Author presents the results of a review of studies of patient and carer perceptions of the hospital discharge process to identify the most commonly reported complaints; these included: (a) poor communication and consultation by staff (10% not told purpose of medications; 44% not told of sentinel side effects; 41% not told of danger signs suggesting disease relapse), (b) inadequate notice of discharge timing, inadequate assessment of home circumstances, (c) lack of involvement in discharge arrangements, and (d) uncertainty concerning the coordination of post-discharge… [END OF PREVIEW] . . . READ MORE

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