When hospitals adopt this model they can tailor components to align with their unique needs, priorities,available resources, and culture. There is a toolkit that includes resources to address areas of the discharge process that are predisposed to result in adverse events. Implementation outcomes (e.g., organizational change, reduced hospital readmissions) are estimated for 12 and 24 months post- discharge. After the model is adopted, the hospital becomes part of a QI collaborative network through which they can communicate with and learn from other BOOST members around the country. Additionally, a BOOST Data Center allows users to store and benchmark data against control units andother providers. BOOST is intended for use by all clinicians involved in the hospital discharge process (physicians, nurses, case managers, social workers), with a core team consisting of a team leader (nurse, case manager, social worker, or physician), QI facilitator, project manager, process owners (frontline staff involved in providing safe, effective care transitions in the hospital, including pharmacy, nursing, and case management staff), and information technology experts. • The BOOST toolkit: • Participant Implementation Guidance • Patient Risk Assessment • Universal Patient Discharge Checklist • General Assessment of Preparedness • The Patient Preparation to Address Situations Successfully • Discharge Patient Education • Teach Back Curriculum • Discharge Instructions for Providers • Guidance for a 72-Hour Post- Discharge Follow-Up Call andAppointment • General Guidance for MedicationReconciliation In 2013, Hansen et al. evaluated the effect of BOOST on Medicare beneficiaries’ readmission rates and length of stay in a sample of 11 hospitals of varying size, academic affiliation, and location. 121 They found that BOOST was associated with a 3% decrease in 30-day readmissions (p=.010) after 12 months of implementation. The length of stay did not change significantly. CTI: Care Transitions Intervention Dr. Eric Coleman developed the Care Transitions Intervention in 2002 to improve continuity of care across care settings and providers. CTI is a patient-centered, multi-component program that has since been implemented in hospitals across the country. 122 Developed based on input from patients and their caregivers, CTI aims to improve the efficiency and quality of care in the transition from hospital to home by providing patients with tools and support to navigate the healthcare system and effectively manage their health conditions. CTI is a 4-week, low-cost, low-intensity self- management program designed to provide patients discharged from an acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self- management needs are met.
The intervention targets patients age 65 years and older, who often have acute or chronic health conditions such as congestive heart failure, chronic pulmonary disease, diabetes, stroke, hip fractures, pulmonary embolism, and deep vein thrombosis. CTI begins when the patient is in the hospital. A Transitions Coach sets up a meeting to discuss the patient’s concerns and to engage the patient and family to begin participating in the program. Next, the Transitions Coach conducts a follow-up home visit and a series of three phone calls in order to help the patient increase self-management skills and attain personal goals, and to provide the patient and his or her family continuity across the transition. Transition coaches can be advanced practice nurses (APNs), registered nurses, social workers, student nurses, community workers, or trained volunteers. Patient/ caregiver is knowledgeable about prescribed medication(s) and establishes a medication management process. • Dynamic Patient-Centered Health Record: CTI’s Four Pillars of Care: • Medication Self-Management: Patient (with assistance from caregiver, if necessary) uses the Personal Health Record to communicate with and consult about continuity-of-care providers from across different settings. • Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visits with the providers (i.e., primary care provider or specialist) and is empowered to actively participant throughout. • Knowledge of Red Flags: Patients understand indicators for when their condition is worsening and know how to respond. TCM: Transitional Care Model Developed in 1981 at the University of Pennsylvania’s School of Nursing by a team led by Dr. Mary Naylor, the Transitional Care Model 123 is a nurse-led intervention designed to improve the outcomes of chronically ill older adults who transition from hospital to home and are at risk of readmission based on the following factors: • One or more chronic illnesses • More than one hospital visit within the last 6 months • Multiple prescribed medications to treat multiple conditions (i.e., polypharmacy) • Living alone The model is implemented through the use of individualized, multidisciplinary, evidence-based clinical protocols that help to prevent declines in health and to reduce 30–60 day hospital readmissions. In addition to reducing rates of readmissions, TCM also aims to enable patients and their family caregivers to manage their conditions themselves. Although originally designed for older adults at risk of readmission, the model has been recently adapted and tested with other populations, including individuals who are eligible for Medicaid and patients with psychiatric diagnoses in addition to chronic and other comorbidities.
Patients who fit the criteria for the intervention meet with an advanced practice nurse either in the hospital prior to discharge or within 48 hours after discharge. The APN conducts home visits and telephone support, and is available 7 days a week through the length of the intervention (usually extending for 2 months after discharge). The APN uses the initial visit to assess the patient and develop a plan of care based on medical needs and patient values. Subsequently, the APN focuses on active engagement and education of patients and family caregivers. APNs educate patients about their health conditions and risks, including how to recognize and manage symptoms of worsening. They use home visits to monitor symptoms and do medication reconciliation. APNs serve as liaisons between patients/family caregivers and healthcare providers to ensure that follow-up visits are scheduled with primary or specialist providers after discharge from the hospital. APNs are available to accompany patients to these follow up visits, if requested. Key findings related to transitions of care Moving patients from one care setting to another can pose significant risk. Implementing transitional care models such as BOOST, CTI, and TCM, which place an emphasis on medication management, transition planning, patient/family engagement and education, communication and transferring information, follow-up care, healthcare provider engagement, and shared accountability across providers and organizations, is a patient safety practice that appears to have great potential. Evidence shows that implementing these models results in standardization in discharge protocol, ultimately leading to a decrease in hospital readmissions and an increase in associated cost savings. However, more diverse studies using these models are needed to establish a firm evidence base in a variety of care settings. Studies focusing on model implementation in a variety of care settings, including rural hospitals, patient-centered medical homes, accountable care organizations, and community-based palliative care programs, would lead to stronger clinical evidence and improved implementation. Existing studies primarily focus on Medicare populations in large urban academic medical centers. Future research on implementation of these models in a variety of settings with diverse patient populations is critical for understanding opportunities and outcomes associated with multi-element models designed to improve transitional care. Venous thromboembolism Venous thromboembolism (VTE) is a disorder that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). A DVT occurs when a blood clot forms in a deep vein, usually in the lower leg, thigh, or pelvis. A PE occurs when a clot breaks loose and travels through the bloodstream to the lungs.
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