Assessing Patient Readiness for Hospital Discharge, Discharge Communication, and Transitional Care Management

References

1. 1.↵
   The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert 2017;1–6.
2. 2.↵
   Transitional Care Management Services. Centers for Medicare and Medicaid Services 2022.
3. 3.↵
   1. Misky GJ,
   2. Wald HL,
   3. Coleman EA

   . Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up. J Hosp Med 2010;5:392–7.

   OpenUrlCrossRefPubMed
4. 4.↵
   1. Kripalani S,
   2. Jackson AT,
   3. Schnipper JL,
   4. Coleman EA

   . Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2007;2:314–23.

   OpenUrlCrossRefPubMedWeb of Science
5. 5.↵
   1. Robelia PM,
   2. Kashiwagi DT,
   3. Jenkins SM,
   4. Newman JS,
   5. Sorita A

   . Information transfer and the hospital discharge summary: national primary care provider perspectives of challenges and opportunities. J Am Board Fam Med 2017;30:758–65.

   OpenUrlAbstract/FREE Full Text
6. 6.↵
   1. Kattel S,
   2. Manning DM,
   3. Erwin PJ,
   4. Wood H,
   5. Kashiwagi DT,
   6. Murad MH

   . Information transfer at hospital discharge: a systematic review. J Patient Saf 2020;16:e25–e33.

   OpenUrlCrossRefPubMed
7. 7.↵
   1. Kripalani S,
   2. LeFevre F,
   3. Phillips CO,
   4. Williams MV,
   5. Basaviah P,
   6. Baker DW

   . Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831–41.

   OpenUrlCrossRefPubMedWeb of Science
8. 8.↵
   1. O'Malley AS,
   2. Grossman JM,
   3. Cohen GR,
   4. Kemper NM,
   5. Pham HH

   . Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med 2010;25:177–85.

   OpenUrlCrossRefPubMedWeb of Science
9. 9.↵
   1. Munchhof A,
   2. Gruber R,
   3. Lane KA,
   4. Bo N,
   5. Rattray NA

   . Beyond discharge summaries: communication preferences in care transitions between hospitalists and primary care providers using electronic medical records. J Gen Intern Med 2020;35:1789–96.

   OpenUrlPubMed
10. 10.↵
    1. Whitman A,
    2. De Lew N,
    3. Chappel A,
    4. Aysola V,
    5. Zuckerman R,
    6. Sommers B

    . Addressing social determinants of health: examples of successful evidence-based strategies and current federal efforts. Assistant Secretary for Planning and Evaluation – Office of Health Policy, HP-2022-12. April 2022;1.
11. 11.↵
    1. Bobay KL,
    2. Weiss ME,
    3. Oswald D,
    4. Yakusheva O

    . Validation of the registered nurse assessment of readiness for hospital discharge scale. Nurs Res 2018;67:305–13.

    OpenUrlPubMed
12. 12.↵
    1. Weiss ME,
    2. Costa LL,
    3. Yakusheva O,
    4. Bobay KL

    . Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Serv Res 2014;49:304–17.

    OpenUrlCrossRefPubMed
13. 13.↵
    1. Harris PA,
    2. Taylor R,
    3. Thielke R,
    4. Payne J,
    5. Gonzalez N,
    6. Conde JG

    . Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.

    OpenUrlCrossRefPubMedWeb of Science
14. 14.↵
    1. Harris PA,
    2. Taylor R,
    3. Minor BL

    , REDCap Consortiumet al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

    OpenUrlCrossRefPubMed
15. 15.↵
    1. Sheu L,
    2. Fung K,
    3. Mourad M,
    4. Ranji S,
    5. Wu E

    . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med 2015;10:307–10.

    OpenUrlCrossRefPubMed
16. 16.↵
    1. Riffin C,
    2. Wolff JL,
    3. Butterworth J,
    4. Adelman RD,
    5. Pillemer KA

    . Challenges and approaches to involving family caregivers in primary care. Patient Educ Couns 2021;104:1644–51.

    OpenUrlPubMed
17. 17.↵
    1. Boch S,
    2. Keedy H,
    3. Chavez L,
    4. Dolce M,
    5. Chisolm D

    . An integrative review of social determinants of health screenings used in primary care settings. J Health Care Poor Underserved 2020;31:603–22.

    OpenUrlPubMed
18. 18.↵
    1. Riffin C,
    2. Wolff JL,
    3. Pillemer KA

    . Assessing and addressing family caregivers’ needs and risks in primary care. J Am Geriatr Soc 2021;69:432–40.

    OpenUrlPubMed
19. 19.↵
    1. Tong ST,
    2. Liaw WR,
    3. Kashiri PL,
    4. et al

    . Clinician experiences with screening for social needs in primary care. J Am Board Fam Med 2018;31:351–63.

    OpenUrlAbstract/FREE Full Text
20. 20.↵
    StataCorp. Stata Statistical Software: Release 17. StataCorp LLC; 2021.
21. 21.↵
    1. Braun V,
    2. Clarke V

    . Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.

    OpenUrlCrossRefPubMed
22. 22.↵
    1. Elo S,
    2. Kyngäs H

    . The qualitative content analysis process. J Adv Nurs 2008;62:107–15.

    OpenUrlCrossRefPubMedWeb of Science
23. 23.↵
    1. Lincoln YS,
    2. Guba E

    . Naturalistic Inquiry. 1st ed. SAGE Publications; 1985.
24. 24.↵
    1. Saunders B,
    2. Sim J,
    3. Kingstone T,
    4. et al

    . Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant 2018;52:1893–907.

    OpenUrlCrossRefPubMed
25. 25.↵
    1. Morse JM

    . Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res 2015;25:1212–22.

    OpenUrlCrossRefPubMed
26. 26.↵
    Epic. Organizations on the Care Everywhere Network. Accessed March 3, 2023. Available at: https://www.epic.com/careeverywhere/.
27. 27.↵
    1. Davis MM,
    2. Devoe M,
    3. Kansagara D,
    4. Nicolaidis C,
    5. Englander H

    . “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med 2012;27:1649–56.

    OpenUrlCrossRefPubMed
28. 28.↵
    1. Unnewehr M,
    2. Schaaf B,
    3. Marev R,
    4. Fitch J,
    5. Friederichs H

    . Optimizing the quality of hospital discharge summaries: a systematic review and practical tools. Postgrad Med 2015;127:630–9.

    OpenUrl
29. 29.↵
    Why more evidence is needed on the effectiveness of screening for social needs among high-use patients in acute care settings. Health Affairs Blog May 23, 2019. Accessed August 28, 2023. Available at: http://10.1377/hblog20190520.243444.
30. 30.↵
    1. Garg A,
    2. Byhoff E,
    3. Wexler MG

    . Implementation considerations for social determinants of health screening and referral interventions. JAMA Netw Open 2020;3:e200693.

    OpenUrlPubMed
31. 31.↵
    1. Garg A,
    2. Boynton-Jarrett R,
    3. Dworkin PH

    . Avoiding the unintended consequences of screening for social determinants of health. JAMA 2016;316:813–4.

    OpenUrlCrossRefPubMed
32. 32.↵
    1. Villeneuve Y,
    2. Courtemanche F,
    3. Firoozi F,
    4. et al

    . Impact of pharmacist interventions during transition of care in older adults to reduce the use of healthcare services: a scoping review. Res Social Adm Pharm 2021;17:1361–72.

    OpenUrlPubMed
33. 33.↵
    1. Hirschman K,
    2. Shaid E,
    3. McCauley K,
    4. Pauly M,
    5. Naylor M

    . Continuity of care: the transitional care model. Online J Issues Nurs 2015;20.
34. 34.↵
    1. Straßner C,
    2. Hoffmann M,
    3. Forstner J,
    4. Roth C,
    5. Szecsenyi J,
    6. Wensing M

    . Interventions to improve hospital admission and discharge management: an umbrella review of systematic reviews. Qual Manag Health Care 2020;29:67–75.

    OpenUrlPubMed
35. 35.↵
    1. Clarke MA,
    2. Moore JL,
    3. Steege LM,
    4. et al

    . Toward a patient-centered ambulatory after-visit summary: identifying primary care patients’ information needs. Inform Health Soc Care 2018;43:248–63.

    OpenUrlPubMed
36. 36.↵
    1. Federman AD,
    2. Jandorf L,
    3. DeLuca J,
    4. et al

    . Evaluation of a patient-centered after visit summary in primary care. Patient Educ Couns 2018;101:1483–9.

    OpenUrlPubMed
37. 37.↵
    1. Agarwal SD,
    2. Barnett ML,
    3. Souza J,
    4. Landon BE

    . Medicare’s care management codes might not support primary care as expected. Health Aff (Millwood) 2020;39:828–36.

    OpenUrlPubMed