Improving Care Continuity : The Effect Of Discharge Handoff Communication

Improving the quality of discharge planning in acute care include addressing the lack of appropriate staff and patient education about appropriate planning for discharge (4). This includes implementing proper discharge teaching regarding signs and symptoms to seek medical attention, management and care of medical equipment, and access to community resources (4, 5). Other challenges are patients with complex comorbidities too difficult to discharge as well as lack of community supports and equipment for newly discharge patients and lack of rehabilitation and nursing home beds (4). Consequently, acute care units are pressured to vacate hospital beds in response to the growing elderly population. Hospital professionals tend to focus discharge teaching and preparation on medical areas such as diet, activity, treatments, and medications (5). Community referrals to appropriate services at the time of hospital discharge does not often happen contributing to poorer patient outcomes and re-hospitalizations

Discharge planning is used to create a plan of care for a patient who is leaving a care setting. An evaluation is done to determine the patient’s continuing care needs once they have left the care facility. When patients are send back home or to a facility that does not require full time nursing care assistance, programs need to be put into place to ensure that the patient is receiving the proper continuation of care post discharge. Proper discharge planning can decrease the chances of a hospital readmit, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare family or caregivers to assume proper post discharge care. According to the Family Caregiver Alliance, “It is important, not only for patients, but family

Patient-Centered Medical Homes (PCMH) are growing in popularity as the right thing to do improve patient care. PCMH are growing in popularity, as there is early evidence of their effectiveness (Egge, M. 2012). The PCMH concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions. This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the limitations of the current healthcare system (Wang, J. et al 2014). Currently, primary care in the United States is focused on acute and episodic illness, it inadvertently limits comprehensive, coordinated, preventive and chronic care (Bleser, W. et al 2014). The PCMH address these limitations through organizing patient care, emphasizing team work, and coordinating data tracking (Bleser, W. et al 2014). A PCMH and HMO have some similarities but are markedly different.

Documentation and communication are constant challenges that healthcare providers face when seeking continuity of care for their patients. Every time a patient moves from a hospital to a nursing home, or from a skilled nursing facility to home health or hospice, the staff that cares for the patient is at risk for a gap in patient care and communication. Home health and hospice agencies rely heavily on Medicaid and other insurance for reimbursements in order to continue to provide care for their patients and keep the doors to their agencies open. Thorough and timely documentation is the key to ensuring proper reimbursement for nursing services and other therapies provided from insurance agencies. This same

In 2011, there were approximately 3.3 million readmissions to hospitals, raising healthcare costs and negatively impacting patient health. Two important contributors are discharge planning and education. Many patients do not receive enough of either, and are sent home misinformed about their diagnosis and medications. In order to decrease readmissions, hospitals should utilize interactive patient systems to educate patients while they are in the hospital. This will increase patient knowledge of their diagnosis, as well as make it easier for nurses to go over discharge teachings with the patient. This gives

The significance of the study is to discuss and clarify why bedside reporting is the best method of patient handoff. The benefits associated with this kind of bedside reporting and if implemented, how it will be of help to

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

This systemic review was completed to evaluate articles that discussed nursing handoff. 95 articles met the inclusion criteria and 20 of those articles involved research on nursing handoffs. A Quality Scoring System went on to assess each article with scores ranging from 1 to 16. “Quality assessment scores for the 20 research studies ranged from 2 to 12” (Riesenberg et al, 2010, p. 28). This goes to show us that there is a lack of high-quality articles on the subject matter of nursing handoff. From this article the reader can also learn about barriers and strategies of effective handoff in more depth.

In a study conducted by Chow and Wong (2014), they analyzed a case management team led by nurses and the effectiveness of the care coordination regarding older adults whom are diagnosed with co-morbidities. Utilizing a randomized controlled trial during 2010 to 2012, the researchers analyzed older adults who suffered from at least two chronic illnesses (Chow & Wong, 2014). Those chosen to be analyzed were then further divided into three groups, including one control groups and two study groups (Chow & Wong, 2014). Baseline data was gathered and collected at four weeks and then again at twelve weeks from the two hundred and eighty one patients participating (Chow & Wong, 2014). The two study groups in which interventions in which nurse led case management occurred, resulted in lower readmission rates within an eighty four day frame after discharge from hospitalization. Additionally these participants rated their health and self- sufficiency at a higher level than the control group (Chow & Wong, 2014). Conclusions gathered from research indicates that care coordination after discharge led by nurses whom empower patients are effective in improving clinical outcomes for older patients with co-morbidities (Chow & Wong, 2014). This research conducted is crucial to my selected topic as is provides evidence that coordination of care after discharge can improve outcomes.

To improve patient compliance with care plans a telemedicine pilot project is taking place with patients who cannot access care due to their inability to travel to their primary care physician’s office due to physical limitation. Rather than attempt travel, a telemedicine appointment will take place with a primary care provider at the Providence Physician Group. The Providence group was chosen out of the three largest primary care groups in the area because they have the most patients enrolled in the MIH/CP program. Also, Providence has system wide implementation of Epic EHR on a single instance which means that all their electronic health records are transferrable amongst providers across the entire Providence network. Primary care providers,

Abstract: aims and goal – The study conducted with eight family members in one rehab ward in Queensland, Australia, in 2009. It is showing, bedside nursing handover provides an opportunity to the family members to participate and improve the accuracy off handover communication. It also helping them to understand the situation, patient condition, treatment, and feeling like informed.

This evidenced-base proposal paper is to address the lack of communication with the multidisciplinary team with home healthcare cases. This is a problem that is faced everyday by home healthcare nurses and other providers. Home healthcare is independent care provided at home these services can be provided over time and across geographic locations. Home care nurses tackle many responsibilities that include not only the patients but also family concerns and problems. Nurses are at the home front on a daily basis with individuals and need a decision/guidance support system to manage the different levels of care demands. One of the most important factors in maintaining continuity of care is the compliance with documentation. In order for providers to communicate with one another documentation needs to be clear and also requires a standardized nursing language (SNL) (Lee Eun, Lee, & Moorhead , 2009).

Continuity of patient care during unit transition is highly significant for patient safety. This can only be achieved by continuous, well-coordinated communication amongst nurses. Transfer to another unit should not compromise the continuity of patient care. So, proper nursing handoff is a vital component in continuity of patient care. Nursing handoff or handover is the exchange of information about a patient and transferring of responsibility of that patient from one nurse to another (Drach-Zahavy & Hadid, 2015). Research has identified handoff as risky time in care process where information can be lost, misinterpreted or distorted (Drach-Zahavy & Hadid, 2015). There are three different modes of handoff: written, verbal and tape recorded.

Communication breakdowns in health centres can prompt postponements in treatment, genuine damage or even death. By giving attendants a protected communication framework that incorporates voice, content informing, email and videoconferencing, cell phones empower them to impart the correct data to the correct colleagues progressively.

Fragmentation of care during the transition of older adults from hospital to home results in high rates of poor outcomes after discharge including rehospitalizations. About one-quarter to one-third of these rehospitalizations can be prevented if we focus on improving transitional care. Therefore, the period surrounding health care transitions is a potentially profitable area for mediating actions aimed at reducing unnecessary readmissions. Moreover patients and caregivers feel disgruntlement with the way transitional process happens. They also feel that their needs are not met at various levels which lead to dissatisfaction.(Naylor, 2000, 2004; Naylor et al., 2004)