What is the clinical evidence from this study?

Study design: Review. Population: Cardiac surgery. Intervention: Post-acute care transition strategies.

November 27, 2017Open Access

Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients

NSNicoleta StoiceaThe Ohio State University TYTian YouThe Ohio State University AEAndrew EitermanThe Ohio State University Wexner Medical Center

Key Result

Improved hospital-post-acute care linkages reduced hospital readmissions by 25%, and regular home visits by healthcare providers decreased readmission rates for cardiac surgery patients.

Structured PICO

Do transitional care efforts and strategies improve outcomes and reduce hospital readmissions in cardiac surgery patients?

Population

A review of post-acute care transition strategies and their impact on recovery, readmission, and survival rates in cardiac surgery patients.

Intervention

Transitional care efforts and strategies (e.g., hospital-PAC linkages, improved discharge planning, regular home visits)

Outcome

Hospital readmission, morbidity, mortality, and patient recovery

Widespread adoption of improvements in transitional care, such as hospital-PAC linkages and home visits, can significantly reduce hospital readmissions and improve recovery for cardiac surgery patients.

Limitations

Lack of shared electronic health records between acute care and post-acute care facilities
Underutilization of cardiac rehabilitation programs due to financial and social barriers
Racial and gender disparities in post-acute care utilization and outcomes

Abstract

Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.

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