Background

Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients’ reported needs.

Objectives

The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service.

Methods

The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service.

Results

Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n = 22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy).

Conclusions

Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

中文翻译：

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门诊护理诊所的护理过渡：实施科学方法

背景

护理转换 (TOC) 问题导致大约 76% 的可预防医院再入院。医疗保险和医疗补助服务中心 (CMS) 专注于通过 TOC 服务提高护理质量。研究并未同时使用实施科学和患者意见来开发满足 CMS 标准并满足患者报告需求的 TOC 计划。

目标

研究目标是 I) 制定符合 CMS 标准的 TOC 计划，识别和补救过程中的障碍，以及 II) 进行需求评估并获得患者对 TOC 服务的看法。

方法

选择实施科学方法来完善一所大学医学中心门诊诊所的 TOC 服务。在患者护理期间，在现场发现了 TOC 计划中阻止遵循 CMS 标准的障碍。药房居民和 TOC 团队及时实施了变更。对出院时间少于 90 天的患者进行了一项前瞻性的九项开放式回答调查。数据被收集、分类并提交给 TOC 团队，以纳入 TOC 服务。

结果

在 2019 年 11 月至 2020 年 1 月期间接受服务的 19 名患者的样本中发现了护理方面的障碍和差距。并非所有患者都符合 CMS 标准和既定的 TOC 方案。在整个 TOC 过程中揭示了八个障碍。解决方案是通过服务中的每月提醒以及驻地药剂师与员工的沟通来实施的。患者对需求评估的反应（n = 22）表明希望加强 TOC 教育（出院药物和治疗）。

结论

通过实施科学，TOC 程序适应了 CMS 标准和 TOC 协议。需求评估强调了 TOC 患者期望的变化。需要研究长期结果，以确定在该站点实施的更改是否可持续。