The researchers analyzed 31 stories from Patient Opinion about elderly patients' discharge from the hospital to identify common themes. They found 9 key themes: 1) timing of discharge, 2) lack of consultation with patients/relatives, 3) medication issues, 4) poor communication, 5) negative staff attitude, 6) transport problems, 7) insufficient post-discharge care, 8) readmissions, and 9) emotional impact. The stories reflected issues found in other reports such as gaps in services, failures in communication, and lack of coordination during transitions in care. The researchers will use the information to plan research to improve discharge processes and involve patients/relatives more.
Informed refusal: You are doing it wrongRobert Cole
Refusals are commonly regarded as one of the more risk and liability-laden parts of the
emergency medical services (EMS) job. A refusal, in the context of this discussion, is an
implied, implicit, or explicit decision by the patient to forgo all or part of medical care provided
by a healthcare provider, in this context, EMS providers. For the purposes of this discussion,
transport to a medical facility via EMS is also considered part of the medical care provided.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
"The Physician Experience: Contrasting Insurance-Driven healthcare with DPC "Hint
Dr. Scott of Halcyon Health DPC discusses the key differences between insurance-driven healthcare and direct primary care from a physician's perspective.
Watch her session at: http://video.hint.com/dr-emilie-scott-the-physician
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Lecture on the definition and the principles of Breaking Bad News in clinical practice, prepared and presented by Prof. Faisal Ghani to Alfarabi Medical College Students
This is the handout for a 60 minute workshop with roleplay for the KUMC Palliative Medicine Fellowship lecture series. There is no accompanying slideset as this was a small group workshop.
Please contact with questions and see this disclaimer. This is not medical advice.
Research indicates that individuals with severe mental illness are overrepresented in jails and prisons in the U.S. The prevalence of severe mental disorders in correctional facilities range between 6 and 9%, and are significantly higher than the rate of 2.8% in the general population. Individuals who exhibit symptoms of a mental illness at the time of an encounter with the criminal justice system are more likely to be arrested. Persons with serious mental illness are jailed more often than hospitalized.People with serious mental illness spend longer in jail for similar convictions than those without serious mental illness. Many offenses that lead to incarceration for individuals with SMI are minor. Individuals with serious mental illness who experience things not directly related to their illness (i.e. homelessness) are more likely to return to jail. Forensic Case management can lead to a reduction in arrests and incarceration.
Informed refusal: You are doing it wrongRobert Cole
Refusals are commonly regarded as one of the more risk and liability-laden parts of the
emergency medical services (EMS) job. A refusal, in the context of this discussion, is an
implied, implicit, or explicit decision by the patient to forgo all or part of medical care provided
by a healthcare provider, in this context, EMS providers. For the purposes of this discussion,
transport to a medical facility via EMS is also considered part of the medical care provided.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
"The Physician Experience: Contrasting Insurance-Driven healthcare with DPC "Hint
Dr. Scott of Halcyon Health DPC discusses the key differences between insurance-driven healthcare and direct primary care from a physician's perspective.
Watch her session at: http://video.hint.com/dr-emilie-scott-the-physician
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Lecture on the definition and the principles of Breaking Bad News in clinical practice, prepared and presented by Prof. Faisal Ghani to Alfarabi Medical College Students
This is the handout for a 60 minute workshop with roleplay for the KUMC Palliative Medicine Fellowship lecture series. There is no accompanying slideset as this was a small group workshop.
Please contact with questions and see this disclaimer. This is not medical advice.
Research indicates that individuals with severe mental illness are overrepresented in jails and prisons in the U.S. The prevalence of severe mental disorders in correctional facilities range between 6 and 9%, and are significantly higher than the rate of 2.8% in the general population. Individuals who exhibit symptoms of a mental illness at the time of an encounter with the criminal justice system are more likely to be arrested. Persons with serious mental illness are jailed more often than hospitalized.People with serious mental illness spend longer in jail for similar convictions than those without serious mental illness. Many offenses that lead to incarceration for individuals with SMI are minor. Individuals with serious mental illness who experience things not directly related to their illness (i.e. homelessness) are more likely to return to jail. Forensic Case management can lead to a reduction in arrests and incarceration.
Transition of Patient from Hospital to Home/Next Level of CareKaiser Permanente
A unique opportunity is available when caring for our patients and families experiencing end of life decisions. Authentic presence, listening, and problem solving empower our patients along their journey.
Enhancing Mental Health Care Transitions: A Recovery-Based ModelAllina Health
Enhancing Mental Health Care Transitions: A Recovery-Based Model - Mental Health Care Navigators and Inpatient Psychiatry presented by Christina Schwartz, BA Psychology, MHP, Mental Health Navigator and Heather Sievers, RN, MSN, MA Counseling Psychology, PI Advisor
We at Pathways to Care are here to help guide families facing the difficult choices associated with the care and needs of their aging loved ones. We provide a safe pathway across all levels of care by having expertise in the following areas...
This is a presentation given by Dirk-Jan Rutten and Florentijn Hogerwerf at the React-Amsterdam Winter Event held on the 23rd of February 2017 (https://www.meetup.com/React-Amsterdam/events/237423993/).
Transforming End of Life Care in Acute Hospitals AM Workshop 2: AMBER Care Bu...NHS Improving Quality
Transforming End of Life Care in Acute Hospitals AM Workshop 2: AMBER Care Bundle by Dr Irene Carey, Susanna Shouls, Guy’s and St Thomas’ NHS Foundation Trust
AETCOM module: Bioethics for Undergraduate Medical Studentslavanyasumanthraj
The Attitude, Ethics & Communication module introduced by the National Medical Commission is being followed in Medical Colleges. Here's a simple understanding of aspects on Bioethics & solution to Phase 2 MBBS modules
SOC313 Introduction to the Miller Family Sarah (40 y.docxjensgosney
SOC313
Introduction to the Miller Family
Sarah (40 yrs) and Joe Miller (43 yrs) are at the center of this family. [See the geneology maps (family
trees) for both Sarah and Joe below.] They are a middle aged couple, married 21 years with three
children. Their children are Lucy (20 yrs), Josh (17 yrs), and Abe (12 yrs). Lucy has had struggles with
substance abuse, along with having been diagnosed with bipolar disorder. Josh has been sneaking away
with friends and smoking pot. Abe is a good student but has started to act out recently.
Sarah’s parents are Donna and Manny Maldonado. Manny is third generation Hispanic American from
Mexico. Donna has long suffered from her “moods” which is mostly frustrating to Manny. He says it’s
“brujeria” (related to witches and magic). He worries that someone puts spells on her. They both are
fluent in Spanish, Donna having learned as a result of being with Manny and around his family. Sarah is
their oldest daughter followed by her brother, Mike (36) and then sister Becky (33). Becky, divorced,
has one child, Elías (10 yrs old) who was recently diagnosed with Leukemia. Mike is alone, having
recently suffered the loss of his companion of many years to AIDS. He is secretly also concerned that he
might be HIV+.
Joe’s parents are Ella and John Miller. Ella is at the center of our story as she has been trying to heal
herself from breast cancer through the use of a variety of natural means. She was raised on a farm and
is not very trusting of “modern medicine.” Her husband, (Joe’s father) John is of American Indian origin.
He uses a variety of traditional methods for health and well being and as a means of banishing bad
spirits from their home. Ella’s mother passed away over ten years ago but her father is still alive. He is
often referred to as the “shakey grandpa” by the grandchildren and great grandchildren due to the
manifestation of some symptoms of his Parkinson’s disease.
Joe has a sister, Lila (45 yrs), who has diabetes and who has always struggled with her weight. She and
her husband have one child, Alisha (20), who’s currently in college. Joe’s older brother Sam (50 yrs), was
married and then divorced years ago, has one son from whom he is estranged. He is an alcoholic who
hasn’t been able to keep a job for years.
The family and extended family get along well for the most part though the many cultural traditions and
backgrounds do clash from time to time. Manny, for example, has been known to say, “They’re crazy!”
when the family discusses some of the health issues that are going on and how they are being handled.
At one time, for example, Ella’s skin turned orange due to the amount of carrot and other juices she was
consuming in order to get rid of her cancer.
Sarah has been married to Joe long enough to know her well and when her sister Becky’s son Elias was
recently diagnosed with Leukemia, Ella was hopef.
A new survey of negative patient experiences finds that patients rank unpleasant waiting areas as a bigger reason for not returning to a facility than long wait times. Here’s more:
•Waiting areas: Some 30% of respondents said dirty waiting areas at urgent care and primary care facilities would keep them from returning. Some 11% said the same for waiting times at urgent care centers, while 6% said so for primary care.
•Urgent care: Patients visiting these facilities were twice as likely to report dissatisfaction if they had to see more than two health professionals during a visit.
•Primary care: Women were 2.5 times more likely than men to say they wouldn’t want to return if the doctor or nurse forgets their name. At the same time, men were five times more likely to not want to return because of waiting rooms that lack entertainment options.
1. Understanding the discharge process from the patient and
relative perspective
Alex Howat, Rebecca Lawton and Jane Heyhoe
Bradford Institute for Health Research
Why we used Patient Opinion
Planning a large scale research project requires input from patients and their families. The Quality
and Safety Research Group at the Bradford Institute for Health Research have a patient panel who
help to prioritise research topics and provide guidance from a patient perspective. However, few of
our patient panel members had any recent experience of discharge for elderly patients and so we
felt we needed to look elsewhere to understand what issues are important for patients at this critical
time and to elicit information about the positive and negative experiences of patients and their
relatives.
To do this we turned to Patient Opinion. Below we report on what we did.
What we wanted to know more about
Being in hospital can be quite an unsettling experience, particularly for the elderly, and it is not
surprising that many are eager to get back home. For most elderly patients, the transition of care
from hospital to home is fairly smooth and uneventful. However, for some the experience is more
difficult which can have a negative impact on the physical and mental well-being of both the patient
and their relatives/carers.
We wanted to know more about patients’ and/or their relatives’/carers’ experiences, both positive
and negative, of discharge from hospital to home, as well as find out exactly what types of issues
they were facing during this process. We also wanted to know if there were common positive and
negative experiences so that we could identify ways to improve experience and safety in this area.
How we used the stories on Patient Opinion
We searched the Patient Opinion website for stories which included the terms “elderly”, “elderly
patient”, “discharge” and “transfer”. This search resulted in 2,880 stories. These were then filtered
to identify only those stories that were about the discharge of elderly patients.
We found 31 stories that were relevant. We then analysed the stories by coding each one and
drawing out themes which reflected patterns or similarities in the stories. The themes were then
reviewed by the research team and collated to produce a set of broader categories that captured the
key points emerging from the stories.
What we found
From the 31 stories we collected from Patient Opinion, we identified nine key themes which
frequently reoccurred in people’s experiences of the discharge of elderly patients from hospital to
home. Below we present each theme using examples of what patients or relatives said.
Timing of Discharge
Issues concerning timing of an elderly patient’s discharge procedure. For example, some patients
experienced delays, whilst others felt they were discharged too soon.
Understanding the discharge process from the patient and relative perspective Page 1
2. “My mother in law was allowed to leave and go home at last at 8-45pm. I think
that this is not acceptable and after being told at 10am as well makes it even
worse.”
“…and was expected to be able to turn up at short notice from a long distance to
discharge my mother…”
“I was told Mum could not be discharged without a discharge letter and the Doctor
doing this was on the other side of the hospital and it would probably be another
few hours.”
Staff Consultation of Patients and Relatives Regarding Discharge
This theme refers to whether hospital staff have talked with and thought about the patient’s and/or
relatives’ wishes when putting together a discharge plan
“If only the family had been fully consulted on her future care, all this emotional
trauma could have been avoided as it is purely evident to anyone with even half a
brain, that she needs admission to a Community Hospital for complete
rehabilitation.”
Medication
Refers to issues concerning a patient’s medication during discharge. These issues might be about
medication needed before discharge or problems experienced when returning home.
“…was discharged on a Sunday morning from ... but had to wait in the hospital
waiting room until 6pm for a prescription to arrive internally.”
“Discharge procedure was good with all drugs ready”
Communication Regarding Patient’s Discharge
Communication between staff or between staff and patient or relatives about the discharge.
“…asked if a message could be passed to mum informing her I would be there at
approx. 7pm, no such message was given and mum sat in distress wondering
where we were until we actually arrived. She informed me she had been told I
would be there at 3pm, something I did not say to anyone, as I was waiting to be
told when she could be discharged.”
“Then the discharge liaison did not contact me as requested, hence mum was left
home alone, not able to get to the toilet on her own or get a drink. She was also in
a great deal of pain.”
“My grandmother was ensured the district nurse and GP would visit the following
day. Neither were even aware of her discharge.”
“…before being sent home with…incorrect antibiotics”
“We have not been given any information about how to support her medical needs
or how to manage her medical intervention.”
Staff Attitude
How staff interacted with patients and relatives/carers during discharge procedure
Understanding the discharge process from the patient and relative perspective Page 2
3. “At one point they scared us all and said if you call the ambulance again- we will
not re-admit you!”
Transport from Hospital to Home
Transportation of the patient from hospital to home when being discharged
“…he was then returned home but to the wrong address…”
“We waited ages for hospital transport as relatives were expected to provide this”
Care after Discharge
Care received by patient after they have been sent home. This related to both social support and
healthcare:
“The hospital wants to discharge without explanation or consultation of family of
this elderly, sick patient back home to their equally elderly partner”
“She was sent home to a flat that did not contain food or support”
“…has been sent home with a catheter…When I phoned and asked about the lack
of phone call and the catheter I was told they had been too busy to phone me and
that he had had the "education" for dealing with the catheter and seemed to
manage.”
“…even though the hospital administration knew he lived alone they sent him
home with no care package or assessment of his situation…”
Readmission
Patient has returned to hospital after soon after being discharged.
“Kept sending elderly relative home only to be re-admitted next day or within a
week with a failed discharge.”
“She was re-admitted four days later, because of bowel issues, leading to a further
period in hospital of more than one week.”
Emotional Impact of Discharge Procedure
How the patient’s discharge has affected the feelings of people involved
“She is weak, confused and emotionally traumatised by her experience, as are, to
be perfectly honest, the family who have spent many hours without sleep and full
of worry!!”
Discussion of findings
When a patient moves between different care organisations e.g. from hospital to community, they
are particularly vulnerable to risk and they often report a poor experience of care.
The experiences of patients who have submitted stories about the discharge of elderly patients from
hospital to Patient Opinion are reflected in recent reports on this topic.
Indeed, the NHS Future Forum reported that too often patients experience gaps in service provision,
failures in communication, and poor transitions between services. The lack of co-ordination and
failures of communication at discharge are central features of the stories patients tell. Patient
Understanding the discharge process from the patient and relative perspective Page 3
4. experience of care is a key indicator of quality and safety (Bouding et al, 2011; Doyle et al, 2013) and
so an important focus for research.
The strong relationship between patient experience and outcomes has led some proponents to
suggest that those interested in improving health outcomes (quality, safety and cost savings) should
strive first to improve patient experiences by focusing on activities such as care co-ordination and
patient engagement. However, despite a growing emphasis on shared care and patient
empowerment (O'Hara and Isden, 2013) the involvement of patients in their care before, during and
after transitions is lacking, with patients feeling that they are not always listened to and that they did
not have a 'lot of say' in their care (Jeffs et al, 2012; Hanratty et al, 2012; Lawrie and Battye, 2012).
Again the lack of patient involvement at discharge is reflected in many of the stories posted on
Patient Opinion, where families remained in the dark about what was happening with the patient.
The potential repercussions of poor transitional care are that the patient may be readmitted to
hospital or return to the emergency department. Readmissions to hospital are increasing generally
across the NHS, but are particularly high for elderly patients. In 2008, 14% of elderly patients (over
75) were readmitted within 30 days (Zerdevas and Dobson, 2012), compared to 9% of people under
75, costing the NHS £2.6 billion (Nuffield Trust, 2012). Indeed, a number of the stories on Patient
Opinion focused specifically on the readmission of elderly patients to hospital, reflecting that this
arose from problems in care at discharge or in the immediate period after discharge.
How will we use this information?
We have already used the information from Patient Opinion as the starting point for a focus group
discussion with staff about the safety of transitions from hospital to home. We will use the data
collected from Patient Opinion as one source of information in the planning of a research project
which will help to improve the transition process for elderly patients by involving them and their
relatives more in this process.
We will then apply for some funding to help us to test whether this improves safety and patient
experience of discharge processes.
Using Patient Opinion as a research tool
Patient Opinion provides rich and varied qualitative data, allowing researchers to easily access first-
hand patient and relative experiences spanning a number of years. Accessing qualitative data also
speeds up the research process and means that information can be obtained unobtrusively without
raising any ethical concerns.
The website’s search functions are user friendly allowing a search for stories using specific keywords.
However, searching using this method resulted in large numbers of stories being found which were
not always relevant to the research question. This meant a lot of time was spent filtering and
excluding those stories that were not relevant. A system that allow for combinations of keywords
may help to increase the specificity of searches.
Little detail is available about the characteristics of those people who submit stories to Patient
Opinion. As a public forum where anonymity is important this is entirely appropriate, but where
researchers might be attempting to reflect the views of a particular group of patients and/or
relatives (for example those of a particular age or socio-demographic status) or where they may
want to be convinced that they are collating the views of a representative sample, ‘Patient Opinion’
may not be the most appropriate method for gathering data.
Understanding the discharge process from the patient and relative perspective Page 4