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Researchers study transition to community successes
Study offers predictors
Researchers who reviewed thousands of studies have found that enhanced hospital discharge support might prevent or delay hospital readmissions for heart failure and stroke patients.1
Other predictors of a positive outcome upon discharge include patients having a positive attitude, family support, self-care ability, self-confidence, and being younger and independent, says Lolita Jacob, DNP, a family nurse practitioner at Monmouth Medical Center in Long Branch, NJ. Jacob co-authored the study.
"If patients have confidence in themselves and can do self-care, then they are the kind of people who have a successful transition to the community," Jacob says. "Those who have a negative perception toward the future and life and who might go home and say they cannot do this at the outset, then those are the kind of patients who will have problems during their transition and are most likely to be readmitted or to have unscheduled emergency visits."
Some of the studies Jacob reviewed found that patients with a heart failure diagnosis could have a more successful transition to community care if they were given discharge preparation and support.1
The research also showed that increased age, length of hospital stay, and Medicaid enrollment were among the risk factors for a poor transition among stroke patients.1
The research has implications for discharge planners, suggesting that they might predict whether a patient will transition to the community successfully based on the patient's attitude.
For example, patients who talk cheerfully about the discharge while still in a hospital bed and are eager to return to work or to their families might be the ones who have the most successful transitions to community, Jacob says.
"Some people are not so eager to go home because of poor family support or a lack of confidence in their ability to care for themselves," Jacob explains.
For some of these patients, the discharge planner or case manager might have to help the patient find additional community support, or else the patient soon will be rehospitalized.
"But there also are patients you cannot satisfy," Jacob says.
"I see those kinds of people," she adds. "They want to be coached every time, or they live with a family member who doesn't understand their illness and who doesn't give them support."
When case managers see patients with this mindset, then it might be best to keep the patient hospitalized a little longer until arrangements can be made to send them to a skilled nursing facility where they might have more time to improve physically and in self-confidence before they are sent home, Jacob suggests.
In other cases, it might be the family members who present the obstacle to a successful transition to community care.
For instance, Jacob has had a case where the patient is disabled, uninsured, and in need of palliative care because there is no real possibility of recovery.
"Every time the patient is moved to the skilled nursing facility, the family member complains that the nursing facility didn't give the patient the right medication," she adds.
1. Jacob L, Poletick EB. Systematic review: predictors of successful transition to community-based care for adults with chronic care needs. Case Man J. 2008;9(4):154-165.
For more information, contact:
Lolita Jacob, DNP, family nurse practitioner, Monmouth Medical Center, Long Branch, NJ. Telephone: (732) 222-5200. Email: email@example.com.