An Estimate of Care Transition Measure received by Hospitalized Older Adults with Cardiovascular Diseases (CVDs) admitted to Sultan Qaboos University Hospital

The average lifespan of mankind is increasing worldwide. There has been a 15.4 percent increase in older adults in Oman from 2013 to 2017. Cardiovascular diseases (CVDs) among older adults have been recorded as the most common cause of admission among older adults in Oman. In spite of the growing population of older adults and the escalation of CVD among them, transitional care is primitive in the Sultanate of Oman. Discharge instructions are provided at varying intensities and frequencies. A need to explore the extent to which transitional care domains are provided for this population requires investigation. Such investigations will help health care providers to tailor a transitional care protocol for older adults with CVDs. Effective transitional care services for older adults with CVDs have been reported to prevent re-admissions, improve quality of life, and reduce caregiver burden. The reduction in health care expenditure is also forecasted. A prospective design will be employed to estimate the care transition received by hospitalized older adults with CVDs. Older adults previously admitted to Sultan Qaboos University Hospital for treatment of cardiovascular symptoms will serve as the study population. Purposive and convenient sampling technique will be utilized to support the achievement of the estimated sample size (200). The care transition measure (CTM-15) will be used to assess the quality of care transitions, during their visit to the outpatient department. The occurrence of adverse health outcomes will be estimated at the time of the interview.

The average lifespan of mankind is increasing worldwide. There has been a 15.4 percent increase in older adults in Oman from 2013 to 2017. Cardiovascular diseases (CVDs) among older adults have been recorded as the most common cause of admission among older adults in Oman. In spite of the growing population of older adults and the escalation of CVD among them, transitional care is primitive in the Sultanate of Oman. Discharge instructions are provided at varying intensities and frequencies. A need to explore the extent to which transitional care domains are provided for this population requires investigation. Such investigations will help health care providers to tailor a transitional care protocol for older adults with CVDs. Effective transitional care services for older adults with CVDs have been reported to prevent re-admissions, improve quality of life, and reduce caregiver burden. The reduction in health care expenditure is also forecasted. A prospective design will be employed to estimate the care transition received by hospitalized older adults with CVDs. Older adults previously admitted to Sultan Qaboos University Hospital for treatment of cardiovascular symptoms will serve as the study population. Purposive and convenient sampling technique will be utilized to support the achievement of the estimated sample size (200). The care transition measure (CTM-15) will be used to assess the quality of care transitions, during their visit to the outpatient department. The occurrence of adverse health outcomes will be estimated at the time of the interview.

According to Naylor et al (2011) Transitional Care refers to a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another (Naylor et al, 2011). Need for Transitional Care Older adults admitted to acute care setting, are at high risk for the worsening of their disability (Gill et al, 2015). The phase immediately following transition from hospital to home could be confounding and ambiguous to the patient and their caregivers. This span of time can be of heightened risk for older adults and those with complex health care needs (Coleman et al, 2003; Coleman et al, 2005 and Naylor et al, 2004). The most common adverse outcomes encountered during this phase includes medication errors, nursing home placement, caregiver burden and increased health care costs (Coleman et al, 2006; Forster et al, 2003). From the empirical preview, poor transitions have been repeatedly cited as the core reason for re-admission among the older adults. Re-admission was prevalent among older adults; skilled nursing facility use; leaving the emergency department against medical advice; and being diagnosed with end stage renal disease, chronic renal disease, and congestive heart failure (Gabayan et al, 2015). In Oman, one in two patients with Acute Heart Failure were re-hospitalized within a 12-month period (Panduranga et al, 2016). The escalating health care cost has necessitated shorter hospital stay which places more demands on the older adults owing to their comorbidities and limited functional capacities (Aminzadeh and Dalziel, 2002). The diversification of the health care delivery system, has created the scope and room for supportive health services in the community. Transitional Care (TC) Interventions Enormous empirical evidences were surveyed and crystallized into TC interventions performed at pre-discharge and post-discharge phases of older adults admitted to hospitals. Literature magnifies that best practices of TC have been initiated early during the admission of older adults to hospitals. Pre-discharge Interventions Assessment: a major focus highlighted in literature is the importance of assessing older adults during their hospitalization phase. Assessment provides a strong foundation for the development and implementation of an individualized care plan based on the care needs identified during assessment. The tools commonly used to assess the needs of older adults before discharge to prepare a comprehensive discharge plan includes Comprehensive Geriatric Assessment (CGA), functional capacity assessment (Fairhall et al, 2011), nutritional assessment, Geriatric Depression Scale and Mini Mental Status Examination. Development of a discharge plan: the discharge plan serves as the framework for effective implementation of TC interventions. The drafting of the discharge plan is a wholesome experience, requiring an individualized approach utilizing efficient coordination and collaboration processes. Two empirically successful models are quoted to illuminate the creation and validation of an effective discharge plan. Preen and colleagues (2005) tested a hospital coordinated discharge plan with the involvement of the General Practitioner (GP). The Enhanced Discharge Planning Program (EDPP) is mediated by a social worker who reviews the medical record of the patient to identify medical and psychosocial interventions required by the patient after discharge (Altfeld et al, 2013). Health education is the core content of transitional care intervention delivered to the patient and their caregivers during their pre-discharge time frame (Weinberger et al, 1996; Enguidanos et al, 2012). The core themes infused in these sessions include symptom management, self-management, goal setting, and medical management (Naylor et al, 2004; Legrain et al, 2011). Post-discharge Interventions Follow up: The core themes threaded during the post-discharge phase is follow up. The period, nature and methods followed are negotiable and literature magnifies manifold variations. The time frame advocated in most TC interventions ranges between 4 weeks (Naylor et al, 1994) to 3 months (Naylor et al, 2004). Goal Attainment Scaling (GAS) is often advocated by multidisciplinary teams during the initial follow up visits (Conroy et al, 2011), to develop an individualized plan of care based on the multifaceted needs of older adults after their hospitalization episode. Periodical follow-ups are more dispersed and focuses on the need for support services (Fairhall et al, 2011), and to liaison with the service providers for successful care transitions (Altfeld et al, 2013). Adherence with the Therapeutic Requiremnts of the Primary Care Provider: Another significant component during the post-discharge phase is the adherence of older adults to their first appointment with their primary care provider. Arranging and scheduling the visit is the prime task of the discharge coordinator (Altfeld et al, 2013). During the visit, re-evaluation and modification of the care plan is considered based on the current health standards, requirements, and confidence of the caregivers in administering the care to older adults (Chhabra et al, 2012). Medication review is an integral part of TC interventions in the post-discharge phase of older adults. The comorbid states expereince by older adults and the transfer between health care settings can make medical reconcilation difficult to comply with. A contemporary study findings reported that 66 % of adverse events from a hospital care transition were adverse drug events; and 42 % were found to have medication continuity errors within 2 months of a hospital discharge (Malone et al, 2014). Empowering older adults with self-management skills is a core element required for the success of a TC intervention. Electronic personal health record serves as a strong platform for enhancing the self-management of patients and their caregivers. It also enhances their ability for early detection of complications and to seek prompt interventions (Archer et al, 2011). Home-monitoring of weight, blood pressure, heart rate and symptoms for older adults with heart failure was significantly associated with improvement in health-related quality of life, and decline in 30-day re-admission rates (Black et al, 2014). Outcomes of Transitional Care Interventions The beneficial effects of TC interventions have been creatively classified by Allen et al (Allen et al, 2014). The quality indicators coined by the author comprehensively encompasses the outcomes assessed in multiple randomized control trials involving TC interventions. The outcomes for the quality indicators of efficiency, effectiveness and safety were grouped by the author as re-hospitalization rates, length of stay, and costs of care. Significant reductions in six-month re-hospitalization rates were documented for the recipients of transitional care. Three studies (Naylor et al, 2004; Enguidanos et al, 2012 and McInnes et al, 1999) which studied the effectiveness of TC interventions reported reduction in health care costs. Lim et al (2003) found reduced length of stay when older people were re-admitted following the intervention. Enguidanos et al (2012) found fewer visits to general practitioners were required for those people who received the intervention. Re-hospitalization was nominated by many reviewers as an outcome capturing the safety following transitional care (Mansah et al, 2009). Other quality indicators empirically evaluated were functional status (Naylor et al, 2004; Naylor et al, 1999), depression symptoms, symptom management, and quality of life (Black et al, 2014). The predictors of person and family centered care were patient satisfaction and care giver burden. Substantial empirical evidences support the escalated patient satisfaction (Preen 2005, Weinberger 1996 and Black 2014) and reduced caregiver burden (Naylor et al, 2004) for the participants who experienced TC interventions. Timeliness and equity were evaluated through the satisfaction perceived by the general practitioners towards the timely communication incorporated in transitional care interventions (Preen 2005). Equity and access to services were ascertained by the revelation that recipients of transitional care interventions were referred to community-based services accessible to them. Transitional care in the context of older adults with CVDs The primary insult resulting from hypertensive and coronary heart diseases is heart failure. The global estimate of heart failure is around 23 million (Shah et al, 2013). Nearly 80% of the patients with heart failure are older adults. This is due to the progressive aging of the population as well as improved and better survival after cardiac insults, such as myocardial infarction, especially in developed countries (D?ez-Villanueva and Alfonso, 2016). Individuals with heart failure are frequently re-hospitalized due to their inability to self-manage their therapeutic regimen; and recognize and report signs of complications (Stamp et al, 2014). Nursing assessment should incorporate assessment of older adults at risk for heart failure, in order to implement strategies to investigate further and individualize the treatment plan. Chaudhry and colleagues (2013) have identified individual risk factors for re-admissions among older adults with heart failure, which includes diabetes mellitus, New York Heart Association functional class III or IV, chronic kidney disease, slow gait, depressed ejection fraction, depression, and muscle weakness. Nursing literature increasingly focusses on empowering older adults with heart failure as the most prominent method to prevent re-hospitalizations; and to improve their quality of life. Gellis et al (2012) highlights the empirical significance of daily monitoring of weight, noninvasive blood pressure, pulse, oxygen saturation, and temperature at a preset scheduled time for older adults with heart failure. The data of the patient are telecasted to a home health care agency, who intervene appropriately with ambulatory or telephone support services. Feltner and colleagues (2014) report that home-visiting programs and multidisciplinary clinics reduced all-cause readmission and mortality among older adults with heart failure. The Patient Centered Care (PCC) model has empirically established its beneficial effects in strengthening the older adults with heart failure. The interventions in the model requires the initiation of a partnership between the health care provider and the patient. The end result of the partnership is the development of an individualized care plan addressing planned investigations, treatment goals, and length of stay. The working phase of the partnership requires the clients to self-rate their symptoms of dyspnea and fatigue on a daily basis. The partnership is safeguarded by effective documentation of the processes. The benefits of the model include shorter hospital stay, optimal functional performance, decreased risk of re-admissions and improved health related quality of life (Ekman et al, 2012).