The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital. METHODS: We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge. RESULTS: Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen. CONCLUSION: An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital.

OBJECTIVES: To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age. DESIGN: Cross-sectional analysis. SETTING: Safety-net hospital in San Francisco, California. PARTICIPANTS: English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699). MEASUREMENTS: At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors. RESULTS: Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability. CONCLUSION: Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Support from hospital to home for elders: a randomized trial.

BACKGROUND: Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success. OBJECTIVE: To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital. DESIGN: Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532). SETTING: Publicly funded urban hospital in Northern California. PATIENTS: Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese). INTERVENTION: Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner. MEASUREMENTS: Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals. RESULTS: There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days). LIMITATIONS: This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered. CONCLUSION: A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population. PRIMARY FUNDING SOURCE: Gordon and Betty Moore Foundation.

"Missing pieces"--functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home.

OBJECTIVES: To describe barriers to recovery at home for vulnerable older adults after leaving the hospital. DESIGN: Standard qualitative research techniques, including purposeful sampling of participants according to age, sex, race, and English proficiency, were used to ensure a wide breadth of experiences. All participants were interviewed in their native language (English, Spanish, or Chinese). Two investigators independently coded interviews using the constant comparative method. The entire research team, with diverse backgrounds in primary care, hospital medicine, geriatrics, and nursing, performed thematic analysis. SETTING: Urban public safety-net teaching hospital. PARTICIPANTS: Vulnerable older adults (low income and health literacy, limited English proficiency) enrolled in a larger discharge interventional study. MEASUREMENTS: Qualitative data (participant quotations) were organized into themes. RESULTS: Twenty-four individuals with a mean age of 63 (range 55-84), 66% male, 67% nonwhite, 16% Spanish speaking, 16% Chinese speaking were interviewed. An overarching theme of "missing pieces" was identified in the plan for postdischarge recovery at home, from which three specific subthemes emerged: functional limitations and difficulty with mobility and self-care tasks, social isolation and lack of support from family and friends, and challenges from poverty and the built environment at home. In contrast, participants described mostly supportive experiences with traditional focuses of transition, care such as following prescribed medication and diet regimens. CONCLUSION: Hospital-based discharge interventions that focus on traditional aspects of care may overlook social and functional gaps in postdischarge care at home for vulnerable older adults. Postdischarge interventions that address these challenges may be necessary to reduce readmissions in this population.

Safe sobering: San Francisco's approach to chronic public inebriation.

Dedicated to the care of alcohol dependent people, the San Francisco Sobering Center cares for intoxicated clients historically treated via emergency services. With 29,000 encounters and 8,100 unduplicated clients, the Sobering Center safely and efficiently provides sobering and health care services to some of the City's most vulnerable people.

The bridge clinic.

A nurse-led postdischarge clinic improves care transitions in a public hospital.

Leaving before discharge from a homeless Medical Respite program: predisposing factors and impact on selected outcomes.

BACKGROUND: Medical Respite addresses care needs of homeless patients post-hospital discharge and is linked to reduced rehospitalization compared with standard discharge. However, outcomes may differ for Respite patients who exit before completing post-acute treatment and discharge plans. METHODS: Using administrative data from a San Francisco Medical Respite center (2007-2010), this retrospective study compares patient characteristics, post-Respite connections to community services, and likelihood of rehospitalization within 90 days of Respite exit between patients who choose to leave before discharge and all other Respite patients (logistic regression, odds ratio). FINDINGS: Of 860 encounters, 31% ended when patient chose to leave before discharge. Female gender (OR 1.65), living on the street immediately prior to Respite (OR 1.36) and substance use (OR 1.55) were associated with increased risk of leaving early. Patients who left early were more likely than others to decline referrals to services and more likely to be re-admitted within 90 days.