The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery.

To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companion Program (DCP), a pharmacist- and nurse-coordinated interprofessional, collaborative TOC program. Adult patients (18 years and older) from a single hospital, discharged with at least one qualifying diagnosis, were eligible for this service. The hospital transitional care coordinator nurse referred qualified patients to the DCP nurse coordinator, who scheduled telephonic medication therapy management (MTM) reviews with the DCP pharmacist at one- and three-weeks postdischarge. Hospital records and DCP documentation were reviewed to describe respective interventions and assess the impact on 30-day readmissions. A total of 456 patients were referred to the DCP between 31 August, 2015 and 7 September, 2016. Of the 340 patients who participated (DCP group), 44 (13%) compared to 17% (n = 20) of the usual care, were readmitted within 30-days postdischarge. The DCP pharmacists conducted 1242 clinical interventions with participants, demonstrating the benefits of an interprofessional TOC model involving multiple, pharmacist-delivered MTM intervention touchpoints within 30 days post-hospital discharge.

[Wishes of nursing home residents for their dying]. / Wünsche von Bewohnern stationärer Altenhilfeeinrichtungen für ihr Sterben.

BACKGROUND: Institutions of inpatient geriatric care are dependent on specific and practicable concepts for the terminal care of old people, because residential and nursing homes are places for the last phase of life. OBJECTIVE: The objective of this study was to identify the wishes of residents for their dying who live in a residential or nursing home. METHOD: The analysis was based on 10 semi-structured expert interviews with residential and nursing home residents. The interviews were evaluated using the method of qualitative summarizing content analysis. Based on the grounded theory a procedure was selected in which data were collected, prepared and evaluated in parallel. RESULTS AND DISCUSSION: Residents expressed, inter alia, the following wishes: not to receive life-prolonging measures, not to have pain, not to be in need of care or bedridden, to receive affection while dying and to find forgiveness and reconciliation as well as to die peacefully in the residential and/or nursing home. In addition, there were a variety of wishes, which, due to their diversity make a unified approach to the palliative care of older people in residential and/or nursing homes impractical. The study showed that residents are thinking about dying and/or death, have desires for their dying and are also willing to talk about it. The recording and the translation of these wishes and also the response to the residents' fears can be achieved by the implementation of a palliative culture and the training of employees.

The Discharge Companion Pilot Program.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a pilot project aimed at improving overall quality of care and reducing readmissions for patients discharged from a community hospital in Arizona.

[Gedächtniszentrum Erlangen (Memory Centre Erlangen) - Gerontopsychiatric Day-Care] / Gedächtniszentrum Erlangen - eine teilstationäre gerontopsychiatrische Einrichtung.

Two years ago the multiprofessional team of the Memory Centre Erlangen took up its work. Besides complete diagnoses of the cause of memory impairment, the work of the Memory Centre focusses on a special cognitive stimulation intervention. After completing assessment, namely self- and non-self anamnesis, psychometric tests and medical examinations, an individual treatment program for every patient will be development. In most instances the treatment program includes the participation in a special cognitive training. Adapting the SIMA-Program, psychomotor exercises, encoding strategies, retrieval techniques, attention and general cognitive speed arc trained in a group of 10 memory-impaired patients. After the 12-week treatment period a postintervention assessment is conducted in the same order as the preintervention assessment to evaluate the efficacy of the treatment. The data of a first evaluating study limited by sample size (20 patients) reveale that this intervention effects in a positive way the patient's cognitive performance. Patients with MCI (Mild Cognitive Impairment) show significant improvement in attention, general cognitive speed and short-term memory. Even patients with a dementia-diagnosis appeare to benefit from the cognitive stimulating intervention: After a 12-week time period no deterioration of cognitive ability is observed. Besides in attention, general cognitive speed and short-term memory an improvement can be reported.

[Erlangen Memory Center--a partial inpatient gerontopsychiatric facility]. / Gedächtniszentrum Erlangen--eine teilstationäre gerontopsychiatrische Einrichtung.

Two years ago the multiprofessional team of the Memory Centre Erlangen took up its work. Besides complete diagnoses of the cause of memory impairment, the work of the Memory Centre focusses on a special cognitive stimulation intervention. After completing assessment, namely self- and non-self anamnesis, psychometric tests and medical examinations, an individual treatment program for every patient will be development. In most instances the treatment program includes the participation in a special cognitive training. Adapting the SIMA-Program, psychomotor exercises, encoding strategies, retrieval techniques, attention and general cognitive speed arc trained in a group of 10 memory-impaired patients. After the 12-week treatment period a postintervention assessment is conducted in the same order as the preintervention assessment to evaluate the efficacy of the treatment. The data of a first evaluating study limited by sample size (20 patients) reveal that this intervention effects in a positive way the patient's cognitive performance. Patients with MCI (Mild Cognitive Impairment) show significant improvement in attention, general cognitive speed and short-term memory. Even patients with a dementia-diagnosis appeare to benefit from the cognitive stimulating intervention: After a 12-week time period no deterioration of cognitive ability is observed. Besides in attention, general cognitive speed and short-term memory an improvement can be reported.