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Background: Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk., Objective: Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality improvement., Methods: We conducted focus group interviews to facilitate a process mapping exercise with clinical teams in six academic health centres in the USA, Poland, Sweden, Italy, Spain and the Netherlands., Findings: At a high level, the process of patient admission to the hospital through the emergency department, inpatient care, and discharge back in the community were comparable across sites. In addition, the process maps highlighted similar barriers to providing information to primary care physicians, inaccurate or incomplete information on referral and discharge, a lack of time and priority to collaborate with counterpart colleagues, and a lack of feedback to clinicians involved in the handovers., Conclusions: Process mapping is effective in bringing together key stakeholders and makes explicit the mental models that frame their understanding of the clinical process. Exploring the barriers and facilitators to safe and reliable patient transitions highlights opportunities for further improvement work and illustrates ideas for best practices that might be transferrable to other settings.

Background: Much of the research on improving patient handovers has focused on enhancing communication within the hospital system, but there have been relatively few efforts aimed at addressing the challenges at the interface between the hospital and the primary care setting., Methods: A qualitative thematic analysis using a clinical microsystems lens applied to 28 semi-structured key stakeholder interviews in the Netherlands. Data were organised into seven 'virtual' clinical microsystem datasets composed of patients, hospital-based physicians, hospital-based nurses and community-based general practitioners., Results: Five themes that contributed to effective or ineffective handovers emerged from our analysis: (1) lack of adequate information; (2) healthcare professionals' availability and opportunity for personal contact; (3) feedback, teaching and protocols related to handovers; (4) information technology facilitated communication solutions; and (5) the role and responsibility of patients. Our analysis suggests that each healthcare professional attempted to provide the best care possible, but did this largely in isolation, and without the benefit of the knowledge and expertise of the other members of the microsystem., Conclusions: The microsystem approach offers an innovative organisational construct and approach to assess the gaps in 'hospital to community' patient handovers, by viewing the hospital to the community interface as a clinical microsystem continuum. Our application of the microsystem approach confirms and extends earlier findings about the impact of barriers on the continuity and safety of patient transitions and their impact on the quality of patient care.

Background: Patient safety experts have postulated that increasing patient participation in communications during patient handovers will improve the quality of patient transitions, and that this may reduce hospital readmissions. Choosing strategies that enhance patient safety through improved handovers requires better understanding of patient experiences and preferences for participation., Objective: The aim of this paper is to explore the patients' experiences and perspectives related to the handovers between their primary care providers and the inpatient hospital., Methods: A qualitative secondary analysis was performed, based on individual and focus group patient interviews with 90 patients in five European countries., Results: The analysis revealed three themes: patient positioning in the handover process; prerequisites for patient participation and patient preferences for the handover process. Patients' participation ranged from being the key actor, to sharing the responsibility with healthcare professional(s), to being passive participants. For active participation patients required both personal and social resources as well as prerequisites such as information and respect. Some patients preferred to be the key actor in charge; others preferred their healthcare professionals to be the key actors in the handover., Conclusions: Patients' participation is related to the healthcare system, the activity of healthcare professionals' and patients' capacity for participation. Patients prefer a handover process where the responsibility is clear and unambiguous. Healthcare organisations need a clear and well-considered system of responsibility for handover processes, that takes into account the individual patient's need of clarity, and support in relation to his/hers own recourses.

Background: Evidence shows that suboptimum handovers at hospital discharge lead to increased rehospitalizations and decreased quality of health care., Purpose: To systematically review interventions that aim to improve patient discharge from hospital to primary care., Data Sources: PubMed, CINAHL, PsycInfo, the Cochrane Library, and EMBASE were searched for studies published between January 1990 and March 2011., Study Selection: Randomized, controlled trials of interventions that aimed to improve handovers between hospital and primary care providers at hospital discharge., Data Extraction: Two reviewers independently abstracted data on study objectives, setting and design, intervention characteristics, and outcomes. Studies were categorized according to methodological quality, sample size, intervention characteristics, outcome, statistical significance, and direction of effects., Data Synthesis: Of the 36 included studies, 25 (69.4%) had statistically significant effects in favor of the intervention group and 34 (94.4%) described multicomponent interventions. Effective interventions included medication reconciliation; electronic tools to facilitate quick, clear, and structured summary generation; discharge planning; shared involvement in follow-up by hospital and community care providers; use of electronic discharge notifications; and Web-based access to discharge information for general practitioners. Statistically significant effects were mostly found in reducing hospital use (for example, rehospitalizations), improvement of continuity of care (for example, accurate discharge information), and improvement of patient status after discharge (for example, satisfaction)., Limitations: Heterogeneity of the interventions and study characteristics made meta-analysis impossible. Most studies had diffuse aims and poor descriptions of the specific intervention components., Conclusion: Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects., Primary Funding Source: The European Union, the Framework Programme of the European Commission.