HCR 426 Module 1 Annotated Bibliography on a Care Coordination Issue Example

Annotated Bibliography: Unsafe Transitions From Hospital to Home

Student Name

BS in Health Care Coordination, Arizona State University

HCR 426: Health Care Coordination Capstone

Instructor Name

Month Day, Year

Annotated Bibliography: Unsafe Transitions From Hospital to Home

Issue Statement

Leaving the hospital is a handoff with no single owner. Patients go home with changed medicines, new instructions and appointments that someone may or may not have made, while their primary care physician often has no record of what happened in the hospital. Injuries, return visits and confusion follow. My capstone will design a coordination solution for the discharge of adult medical patients from a community hospital to its affiliated primary care clinics.

Annotations

1. Injuries in the Weeks After Discharge

Summary: Researchers followed 400 consecutive patients sent home from the general medical service of an academic hospital, reviewing records and telephoning them about three weeks later (Forster et al., 2003). Seventy-six (19%) had an injury caused by their medical care, about a third of those injuries could have been prevented or made less severe, and two-thirds were drug-related. Evaluation: A prospective design and independent physician review make the counts credible, but this is one teaching hospital and the follow-up window is short. Use: This study will establish the size of the problem in my impact section and justify putting medication review at the center of the solution.

2. The Missing Conversation Between Hospital and Clinic

Summary: This systematic review pooled 55 observational studies and 18 intervention studies (Kripalani et al., 2007). Across the studies, a direct call or conversation between the two physicians happened at somewhere between one discharge in five and one in thirty, and at most about a third of first clinic visits took place with the hospital's summary available. When summaries did arrive, many omitted tests still awaiting results or what was supposed to happen next. Evaluation: The review is broad and careful, though its studies are mostly older and observational. Use: It documents the information gap my coordinator role will close and supports sending a summary to the clinic before the first visit.

3. Project RED: A Discharge Bundle Put to a Randomized Test

Summary: In Project RED, 749 English-speaking adults on the general medicine service of a Boston safety-net hospital were randomized (Jack et al., 2009). A nurse discharge advocate arranged follow-up, reconciled medicines and taught from a personal booklet that was also sent to the primary care provider, and a pharmacist phoned two to four days after discharge. Emergency visits and readmissions within 30 days fell from 0.451 to 0.314 per person per month. Evaluation: Randomization and blinded follow-up staff are strengths; one center, English speakers only and some self-reported outcomes are limits. Use: Project RED will be the model for my program and the subject of my research critique.

4. Sorting Readmission Interventions Into a Taxonomy

Summary: Reviewing 43 studies, the authors sorted readmission interventions into things done before discharge, after discharge and across the two settings, and found that no single activity on its own reliably reduced 30-day returns (Hansen et al., 2011). Evaluation: Many included studies were single-site quality projects rather than trials, so the review describes more than it measures. Use: Its taxonomy will organize my solution table, and its main finding explains why my program bundles several activities instead of relying on one.

5. Forty-Two Trials Pooled

Summary: Pooling 42 randomized trials, this meta-analysis found that discharge interventions lowered the risk of returning within 30 days by about 18% (relative risk 0.82) (Leppin et al., 2014). Programs with more components, more people involved and support for patients' capacity to care for themselves did better, while newer trials showed smaller effects than older ones. Evaluation: This is the strongest summary of trial evidence I found, though the programs it pools vary widely. Use: It supports a multicomponent design and warns me to expect a modest effect rather than a dramatic one.

6. Fifteen Medicare Telephone Programs

Summary: Fifteen Medicare demonstration programs, most built on nurses calling patients by telephone, were tested against usual care (Peikes et al., 2009). Thirteen made no significant difference to hospitalizations, and none saved Medicare money once program fees were counted. Evaluation: Randomization across many sites gives the null findings weight. Use: This is my cautionary source; it explains why my program keeps face-to-face contact at discharge instead of relying on phone calls alone.

Synthesis

Together the sources show that the days after discharge injure a meaningful share of patients, mostly through medicines, that hospitals and clinics rarely talk at the moment it matters and that bundles of discharge services work modestly while single steps or telephone programs alone usually do not. Project RED offers a tested bundle my capstone can adapt.

References

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007

Hansen, L. O., Young, R. S., Hinami, K., Leung, A., & Williams, M. V. (2011). Interventions to reduce 30-day rehospitalization: A systematic review. Annals of Internal Medicine, 155(8), 520-528. https://doi.org/10.7326/0003-4819-155-8-201110180-00008

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., Wang, Z., Erwin, P. J., Sylvester, T., Boehmer, K., Ting, H. H., Murad, M. H., Shippee, N. D., & Montori, V. M. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. https://doi.org/10.1001/jamainternmed.2014.1608

Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA, 301(6), 603-618. https://doi.org/10.1001/jama.2009.126