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Psychiatric rehabilitation for people with severe mental illness (SMI) has many documented benefits, but less is known about cultural related aspects. To date, no comparison of psychiatric rehabilitation outcomes between Israeli Jews and Israeli Arabs has been carried out. Thus, the purpose of the present study was to compare the outcome measures of Israeli Arabs and Israeli Jews consuming psychiatric rehabilitation services. As part of the Israeli Psychiatric Rehabilitation Reported Outcome Measurement project (PR-ROM), a cross-sectional study comparing different ethnic-religious groups was performed. Data is based on 6,751 pairs of psychiatric rehabilitation consumers and their service providers. The consumers filled questionnaires on quality of life (QoL) and functioning, and their providers completed mirroring instruments. The findings revealed that QoL and functioning ratings were lower among Muslim Arabs compared to Jews on both consumers' and providers' ratings. Among Muslim Arabs, differences in outcomes according to the service's location were indicated. The observed differences between Israeli Arabs and Israeli Jews with SMI in the PR-ROM point to the need for culturally adapted rehabilitation services that take into account how cultural differences may affect the benefits of such services. [ABSTRACT FROM AUTHOR]

Background: The high rates of psychiatric re-hospitalizations (also termed "revolving door") presents a "wicked problem" which requires a systematic and holistic approach to its resolution. Israel's mental-health rehabilitation law provides a comprehensive set of services intended to support the ability of persons with severe mental illness to rely on community rather than in-patient facilities for their ongoing care needs. Guided by the Health Behavior Model, we examined the relationship between psychiatric re-hospitalizations and the three Health Behavior Model factors (predisposing factor: socio-demographic characteristics and health beliefs; enabling factor: personal and social/vocational relationships facilitated by rehabilitation interventions and services; and need factor: outcomes including symptoms, and mental health and functional status) among persons with severe mental illness receiving rehabilitation services. Methods: Logistic regression models were used to measure the association between re-hospitalization within a year and variables comprising the three Health Behavior Model factors on the sample of consumers utilizing psychiatric services (n = 7,165). The area under the curve for the model was calculated for each factor separately and for all three factors combined. Results: A total of 846 (11.8%) consumers were hospitalized within a year after the study began. Although multivariable analyses showed significant associations between re-hospitalization and all three Health Behavior Model factors, the magnitude of the model's area under the curve differed: 0.61 (CI = 0.59–0.64), 0.56 (CI = 0.54–0.58), 0.78 (CI = 0.77–0.80) and 0.78 (CI = 0.76–0.80) for predisposing, enabling, need and the full three-factor Health Behavior Model, respectively. Conclusion: Findings revealed that among the three Health Behavior Model factors, the need factor best predicted re-hospitalization. The enabling factor, comprised of personal relationships and social/vocational activities facilitated by interventions and services representing many of psychiatric rehabilitation's key goals, had the weakest association with reduced rates of re-hospitalization. Possible explanations may be inaccurate assessments of consumers' personal relationships and social/vocational activities by the mental healthcare professionals, problematic provider-consumer communication on the consumers' involvement in social/vocational activities, or ineffective methods of facilitating consumer participation in these activities. Clearly to reduce the wicked "revolving-door" phenomenon, there is a need for targeted interventions and a review of current psychiatric rehabilitation policies to promote the comprehensive integration of community rehabilitation services by decreasing the fragmentation of care, facilitating continuity of care with other healthcare services, and utilizing effective personal reported outcomes and experiences of consumers with severe mental illness. [ABSTRACT FROM AUTHOR]

Background: COVID-19 is disproportionately affecting disadvantaged populations, with greater representation and worse outcomes in low socioeconomic and minority populations, and in persons from marginalized groups. General health care system approaches to inequity reduction (i.e., the minimization of differences in health and health care which are considered unfair or unjust), address the major social determinants of health, such as low income, ethnic affiliation or remote place of residents. Yet, to effectively reduce inequity there is a need for a multifactorial consideration of the aspects that intersect and generate significant barriers to effective care that can address the unique situations that people face due to their gender, ethnicity and socioeconomic situation. Main body: To address the health equity challenges of diverse population groups in Israel, we propose to adopt an intersectional approach, allowing to better identify the needs and then better tailor the infection prevention and control modalities to those who need them the most. We focus on the two main ethnic – cultural—religious minority groups, that of Arab Palestinian citizens of Israel and Jewish ultra-orthodox (Haredi) communities. Additionally, we address the unique needs of persons with severe mental illness who often experience an intersection of clinical and sociodemographic risks. Conclusions: This perspective highlights the need for responses to COVID-19, and future pandemic or global disasters, that adopt the unique lens of intersectionality and equity. This requires that the government and health system create multiple messages, interventions and policies which ensure a person and community tailored approach to meet the needs of persons from diverse linguistic, ethnic, religious, socioeconomic and cultural backgrounds. Under-investment in intersectional responses will lead to widening of gaps and a disproportionate disease and mortality burden on societies' most vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Nurse champions are front-line practitioners who implement innovation and reconstruct policy. Purpose: To understand through a network theory lens the factors that facilitate nurse champions' engagement with radical projects, representing their actions as street-level bureaucrats (SLBs). Materials and methods: A personal-network survey was employed. Ninetyone nurse champions from three tertiary medical centers in Israel participated. Findings: Given high network density, high levels of advice play a bigger role in achieving high radicalness compared with lower levels advice. High network density is also related to higher radicalness when networks have high role diversity. Discussion: Using an SLB framework, the findings suggest that nurse champions best promote adoption of innovation and offer radical changes in their organizations through professional advice given by colleagues in their field network. Healthcare organizations should establish the structure and promote the development of dense and heterogeneous professional networks to realize organizations' goals and nurses' responsibility to their professional employees, patients, and society. [ABSTRACT FROM AUTHOR]

Background: Oral anticancer therapy (OACT) poses adherence-related challenges to patients while generating a setting in which both primary care physicians (PCPs) and oncologists are involved in the active treatment of cancer. Continuity of care (COC) was shown to be associated with medication adherence. While maintaining COC is a central role of the PCP, how this affects continuity with oncologists, and jointly affects OACT adherence, is yet unknown.Objectives: To explore how aspects of COC act together to promote OACT adherence. Specifically, to examine whether better personal continuity with the PCP leads to better personal continuity with the oncologist, which together lead to better cross-boundary continuity between the oncologist and the PCP, jointly leading to good adherence to OACT.Design and Setting: A prospective cohort study conducted in five oncology centers in Israel. A bootstrapping method was used to test the serial mediation model.Participants: Adult patients (age > 18 years) receiving a first OACT prescription (n = 119) were followed for 120 days.Main Measures: The Nijmegen Continuity Questionnaire was used to assess patients' perceived personal and cross-boundary continuity. The medication possession ratio was used to measure adherence.Key Results: Better personal continuity with the PCP was associated with better personal continuity with the oncologist (B = 0.35, p < 0.001), which was associated with better cross-boundary continuity (B = 0.33, p < 0.001), which, in turn, was associated with good adherence to OACT (B = 0.46, p = 0.03). Additionally, the indirect effect of personal continuity with the PCP on adherence to OACT through the mediation of personal continuity with the oncologist and cross-boundary continuity was found to be statistically significant (B = 0.053, 95% CI 0.0006-0.17).Conclusions: In a system where the PCP is the case manager, cancer patients' perceived personal continuity with the PCP has an essential role for initiating a sequence of care delivery events that positively affect OACT adherence. [ABSTRACT FROM AUTHOR]

Background: Parents of children following traumatic medical events (TMEs) are known to be at high risk for developing severe post-traumatic stress symptoms (PTSS). Findings on the negative impact of TMEs on parents' PTSS have been described in different cultures and societies. Parents from ethnic minority groups may be at particularly increased risk for PTSS following their child's TME due to a host of sociocultural characteristics. Yet, differences in PTSS manifestation between ethnic groups following a child's TME has rarely been studied. Objectives: We aimed to examine: (1) differences in PTSS between Israeli-Arab and Israeli-Jewish mothers, following a child's TME, and (2) risk and protective factors affecting mother's PTSS from a biopsychosocial approach. Methods: Data were collected from medical files of children following TMEs, hospitalized in a Department of Pediatric Rehabilitation, between 2008 and 2018. The sample included 47 Israeli-Arab mothers and 47 matched Israeli-Jewish mothers. Mothers completed the psychosocial assessment tool (PAT) and the post-traumatic diagnostic scale (PDS). Results: Arab mothers perceived having more social support than their Jewish counterparts yet reported higher levels of PTSS compared to the Jewish mothers. Our prediction model indicated that Arab ethnicity and pre-trauma family problems predicted higher levels of PTSS among mothers of children following TMEs. Conclusions: Despite reporting higher social support, Arab mothers reported higher levels of PTSS, as compared to the Jewish mothers. Focusing on ethnic and cultural differences in the effects of a child's TME may help improve our understanding of the mental-health needs of mothers from different minority groups and aid in developing appropriate health services and targeted interventions for this population. [ABSTRACT FROM AUTHOR]

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Objective: Persons with serious mental illnesses are at increased risk for co-occurring physical comorbidities. Patient-reported outcome measures are increasingly used in routine assessments of persons with serious mental illnesses, yet the relation of patient-reported outcome measures to physical health outcomes has not been comprehensively investigated. We examined the association between patient-reported outcome measures and self-reported physical health at 1-year follow-up.Design: A retrospective cohort study.Setting: Data were collected as part of the Israeli Psychiatric Rehabilitation Patient-Reported Outcome Measurement program in Israel.Participants: A total of 2581 psychiatric rehabilitation service users assessed between April 2013 and January 2016.Main Outcome Measures: Self-reports on two consecutive years of physical health dichotomized as poor versus good.Results: More than one-third of participants reported having poor physical health. Multivariate regression analysis showed that quality of life (odds ratio [OR] = 0.71; 95% confidence interval [CI]: 0.60-0.84) and lack of effect of symptoms on functioning (OR = 0.81; 95%CI: 0.74-0.89) predict subsequent physical health, controlling for all other factors. Compared to a multivariate model with personal characteristics and self-reports on physical health at baseline (Model A), the model which also included patient-reported outcome measures (Model B) showed slightly better discrimination (c-statistic: 0.74 vs. 0.76, respectively).Conclusions: These results suggest that patient-reported outcome measures contribute to the prediction of poor physical health and thus can be useful as an early screening tool for people with serious mental illnesses living in the community, who are at risk of physical health problems. [ABSTRACT FROM AUTHOR]

Aim: To assess the relationship between continuity in nursing assignment in older adults' acute hospitalization and patient experience and functional decline. Background: In‐hospital functional decline affects up to 40% of hospitalized older adults. Nurses are responsible for performing functioning‐preserving interventions. Whether continuity of nursing care contributes to patients' functional outcomes is unclear. Method: A retrospective observational study of 609 patients aged ≥70 admitted to internal medicine units. Patients were surveyed on their functional (cognitive and physical) status and satisfaction with the hospital care experience. Dispersion and sequence of nursing assignment were measured by the Continuity of Care Index and Sequential Continuity Index. Multivariate logistic regressions were modelled for each continuity score and outcome. Results: Achieving 25% of the maximum Continuity of Care Index was associated with lower odds of cognitive decline (OR = 0.64, 95% CI = 0.43–0.94) and higher odds of satisfaction (OR = 1.52, 95% CI = 1.06–2.17). Achieving 25% of the maximum Sequential Continuity Index was associated only with higher odds of satisfaction (OR = 1.43, 95% CI = 1.01–2.02). Continuity scores were not associated with physical functioning decline. Conclusion: Continuity in nursing assignment is related to a positive patient experience and cognitive functioning of hospitalized older adults. Implications for Nursing Management: Continuity should be prioritized in scheduling and assignment algorithms. [ABSTRACT FROM AUTHOR]

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field. [ABSTRACT FROM AUTHOR]

Background: Predictive models based on electronic health records (EHRs) are used to identify patients at high risk for 30-day hospital readmission. However, these models' ability to accurately detect who could benefit from inclusion in prevention interventions, also termed "perceived impactibility", has yet to be realized.Objective: We aimed to explore healthcare providers' perspectives of patient characteristics associated with decisions about which patients should be referred to readmission prevention programs (RPPs) beyond the EHR preadmission readmission detection model (PREADM).Design: This cross-sectional study employed a multi-source mixed-method design, combining EHR data with nurses' and physicians' self-reported surveys from 15 internal medicine units in three general hospitals in Israel between May 2016 and June 2017, using a mini-Delphi approach.Participants: Nurses and physicians were asked to provide information about patients 65 years or older who were hospitalized at least one night.Main Measures: We performed a decision-tree analysis to identify characteristics for consideration when deciding whether a patient should be included in an RPP.Key Results: We collected 817 questionnaires on 435 patients. PREADM score and RPP inclusion were congruent in 65% of patients, whereas 19% had a high PREADM score but were not referred to an RPP, and 16% had a low-medium PREADM score but were referred to an RPP. The decision-tree analysis identified five patient characteristics that were statistically associated with RPP referral: high PREADM score, eligibility for a nursing home, having a condition not under control, need for social-services support, and need for special equipment at home.Conclusions: Our study provides empirical evidence for the partial congruence between classifications of a high PREADM score and perceived impactibility. Findings emphasize the need for additional research to understand the extent to which combining EHR data with provider insights leads to better selection of patients for RPP inclusion. [ABSTRACT FROM AUTHOR]

The two components of hope (i.e., hope‐agency defined as the ability to envision and believe in one's ability to achieve goals; hope‐pathway defined as belief in one's ability to devise strategies to achieve one's goals) propel adolescents toward well‐being, academic achievement and personal fulfillment. This study compares levels of hope and its components, for different groups of immigrant and ethnic non‐immigrant youths, while adjusting for and measuring the impact of racism, school and family characteristics, and the youth's unique individual attributes. Using a community‐based participatory research approach and a cross‐sectional study design, data were collected from immigrant and non‐immigrant youth (n = 567) between May 2015 and December 2015 at three Israeli public high schools. The study included five groups of youth based on their self‐descriptions: Ethiopian immigrant (n = 48), Russian immigrant (n = 145), Israeli‐born Mizrachi/Sephardi (n = 59), Israeli‐born Ashkenazi (n = 49), or Israeli‐born Unspecified (n = 266). Linear regression models showed that Ethiopian immigrant youth, compared to Russian immigrant youth and all Israeli‐born groups of youth, had significantly lower hope‐agency, hope‐pathway and overall hope. However, an interaction effect between racism and ethnicity indicated that adolescents who perceived racism and self‐identified as Ethiopian had higher hope‐agency, hope‐pathway and overall hope. This effect was not found with Russian immigrant or Israeli‐born youth. Immigrants of color compared to other immigrants and ethnicities have less overall hope; but those who acknowledge racism feel more control over their future (hope‐agency), able to devise strategies to surmount barriers blocking goals (hope‐pathway), and have greater overall hope. [ABSTRACT FROM AUTHOR]

Objective: We examined whether patients' ratings of their in-hospital discharge briefing and their post-discharge Primary Care Physicians' (PCP) review of the discharge summary are associated with 30-day readmissions.Methods: A prospective study of 594 internal-medicine patients at a tertiary medical-center in Israel. The in-hospital baseline questionnaire included sociodemographic characteristics, physical, mental, and functional health status. Patients were surveyed by phone about the discharge and post-discharge processes. Clinical data and health-service use was retrieved from a central data-warehouse. Multivariate regressions modeled the relationship between in-hospital baseline characteristics, discharge briefing, PCP visit indicator, the PCP discharge summary review, and 30-day readmissions.Results: The extent of the PCPs' review of the hospital discharge summary at the post-discharge visit was rated higher than the in-hospital discharge briefing (3.46 vs. 3.17, p = 0.001) and was associated with lower odds of readmission (OR=0.35, 95% CI 0.26-0.45). The model that included this assessment performed better than the in-hospital baseline, the in-hospital discharge-briefing, and the PCP visit models (C-statistic = 0.87, compared with: 0.70, 0.81, 0.81, respectively).Conclusions: Providing extensive post-discharge explanations by PCPs serves as a significant protective factor against readmissions.Practice Implications: PCPs should be encouraged to thoroughly review the discharge summary letter with the patient. [ABSTRACT FROM AUTHOR]

Aims: To identify the sociodemographic attributes, project characteristics and champion strategies that differentiate formal from informal nursing champions, and to test their success in terms of project spread and novelty. Background: Champions spread innovation in healthcare organizations. Empirical research has not explored the differences between formal and informal champions in terms of their antecedents and success. Design: A quantitative cross‐sectional design. Method: Data were collected on 93 nursing champions in three hospitals from 2015 ‐ 2016. Champions were identified according to a validated approach; data on their sociodemographic attributes, project characteristics and strategies were assembled through interviews and validated questionnaires. Their success in terms of novelty and spread was assessed via expert ratings and validated questionnaire. Findings: Informal champions had longer tenure and were involved mainly in bottom‐up projects aimed mostly at improving human resources and services; formal champions were mostly involved in top‐down projects aimed at quality control. Informal champions expressed more enthusiasm and confidence about the innovation; formal champions tended to use more online resources and peer‐monitoring strategies. Projects of informal champions were more novel than those of formal champions. Project spread did not differ between the two groups. Conclusion: Formal and informal champions differ in their characteristics and implementation strategies. To encourage project's innovation, the organizational climate should encourage the emergence of informal champions; formal and informal champions should be chosen wisely, assuring that they possess enough organizational resources; and coaching programmes for junior champions should be planned to equip them with championing behaviours. [ABSTRACT FROM AUTHOR]

Few studies have assessed healthcare experiences in apparently healthy adolescents, or whether healthcare attitudes are linked to the two leading adolescent health indicators, smoking and obesity. Even fewer have examined these relationships in adolescent immigrant groups or made comparisons to adolescent non-immigrants. Using a cross-sectional study, healthcare experiences were compared among three groups of adolescents (n = 589) including Russian immigrants (n = 154), Ethiopian immigrants (n = 54), and non-immigrants (n = 381). Bootstrap estimates indicated positive healthcare experiences were less common among Russian adolescent immigrants (OR = 0.38, CI = 0.17, 0.86) compared to non-immigrants, unless the Russian adolescent immigrants reported above average socioeconomic status, in which case they were more likely than non-immigrant adolescents to report positive healthcare experiences (OR = 3.22, CI = 1.05, 9.85). Positive healthcare experiences were less likely among adolescents who were smokers (OR = 0.50, CI = 0.27, 0.91), and more likely for adolescents with a normal or low BMI (OR = 3.16, CI = 1.56, 6.40) and for those relying on parents for health information (OR = 1.97, CI = 1.05, 3.70).Conclusion: Findings suggest a social gradient in which positive healthcare experiences were more common among adolescence with higher socioeconomic status for some immigrants (Russian adolescents) but not for others. The two leading health indicators were related to healthcare experiences, but as adolescent smokers were less likely to have positive healthcare experiences, proactive efforts are needed to engage this group. What is Known: • Health indicators (such as obesity) and healthcare attitudes are linked to healthcare service use among adolescents sampled from outpatient and inpatient populations. What is New: • A social gradient involving socioeconomic status and being an adolescent immigrant was found regarding risky health indicators (i.e., smoking, use of internet as the primary source of health information). • Problematic health indicators, such as smoking, is linked to less positive healthcare attitudes in apparently healthy adolescents (both immigrants and non-immigrants). [ABSTRACT FROM AUTHOR]

Background: Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.Objective: To evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.Design and Participants: We used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.Main Measures: Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.Results: In 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P < 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.Conclusions: Benzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups. [ABSTRACT FROM AUTHOR]

Background: post-hospitalisation functional decline is a widely described phenomenon, yet factors related to new disability in instrumental activities of daily living (IADL) in previously independently functioning older adults are rarely studied. Objective: to test whether change in cognitive status from admission to discharge during short-term acute-care hospitalisation is associated with the incidence of medium-term post-hospitalisation IADL dependency. Design: prospective cohort study. Setting: internal medicine wards in two Israeli medical centres. Subjects: two hundred and seventy-two hospitalised older adults (≥70) who were independent in self-care and mobility activities at admission, at discharge and 1 month after discharge, and who were independent in IADL pre-admission. Methods: cognitive status was evaluated at admission and at discharge using Pfeiffer's Short Portable Mental Status Questionnaire (SPMSQ). One-month post-discharge, IADL was assessed using Lawton and Brody's scale by telephone. Results: incidence of IADL dependency was 74/272 (27.2%). Controlling for length of stay, co-morbidities, re-hospitalisation and age, a one-unit decrease in SPMSQ score during hospital stay was associated with 1.57 higher odds (95% CI, 1.14-2.15) of post-hospitalisation new IADL dependency. The odds of new IADL dependency were also significantly higher in participants who were rehospitalised within the previous month (odds ratio = 2.65; 95% CI, 1.25-5.62). Conclusions: decline in SPMSQ score during acute hospitalisation has a detrimental effect on functional decline after acute hospitalisation, defined by incidence IADL dependency. This finding emphasises the need to identify cognitive decline during hospitalisation to allow timely intervention to prevent post-discharge functional decline in this population. [ABSTRACT FROM AUTHOR]

Objective: To assess a quality improvement disparity reduction intervention and its sustainability.Data Sources/study Setting: Electronic health records and Quality Index database of Clalit Health Services in Israel (2008-2012).Study Design: Interrupted time-series with pre-, during, and postintervention disparities measurement between 55 target clinics (serving approximately 400,000 mostly low socioeconomic, minority populations) and all other (126) clinics.Data Collection/extraction Methods: Data on a Quality Indicator Disparity Scale (QUIDS-7) of 7 indicators, and on a 61-indicator scale (QUIDS-61).Principal Findings: The gap between intervention and nonintervention clinics for QUIDS-7 decreased by 66.7 percent and by 70.4 percent for QUIDS-61. Disparity reduction continued (18.2 percent) during the follow-up period.Conclusions: Quality improvement can achieve significant reduction in disparities in a wide range of clinical domains, which can be sustained over time. [ABSTRACT FROM AUTHOR]

Around hospitalization, older adults often experience functional decline which can be a reflection of their need for nursing care. Given a shortage of nurses, determining the relationship between functional change and patients' satisfaction with nursing care can help to gauge the need for care. We assessed this relationship in a mixed prospective-correlational cohort study with 393 patients, 70 years or older. The art, tangible aspects and general satisfaction with nursing care were measured through interviews conducted at discharge. Patients' functional status was assessed at admission and discharge. Decline in functioning during hospitalization was the most powerful predictor of higher satisfaction with art and tangible aspects of nursing care in multivariate regression (β = 0.17-0.19, P < 0.01). This finding suggests that patients whose functioning deteriorates during hospitalization, have a greater need for and more contact with professional nursing care, and therefore report higher satisfaction with specific aspects of nursing care. [ABSTRACT FROM AUTHOR]

In this article we present the design, development and implementation of the Psychiatric Rehabilitation Routine Outcome Measurement (PR-ROM) project, the first systematic effort to implement mental health routine outcome measures in Israel. The goal of the PR-ROM is to provide updated information about the process and impact of psychiatric rehabilitation services in Israel and to establish a sustainable infrastructure and foundation for routine outcome monitoring of rehabilitation services to improve care, inform policy, generate incentives for service improvement, increase informed decision-making and provide data for research purposes. The rehabilitation services evaluated and the characteristics of the population being served are described and the methods and nature of the collected data as well as some preliminary findings are presented. We discuss the major barriers encountered, our efforts to deal with them and lessons learned during the process. We conclude with a description of the current state of the initiative and plans for the future. [ABSTRACT FROM AUTHOR]

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient's acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability. [ABSTRACT FROM AUTHOR]

Objective: This study tested concordance between consumers' and providers' reports of personal goal setting and its relationship to self-reported goal attainment.Methods: Data are from the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. Consumers (N=2,885) and the providers who were most knowledgeable about their care indicated two domains from a list of ten in which consumers had set goals during the previous year. Consumers reported on goal attainment in each domain.Results: A total of 2,345 consumers (82%) reported a personal goal. Overall, consumer-provider concordance reached 54%. Concordance was greatest in the employment (76%), housing (71%), and intimate relationship (52%) domains and lowest in family relationships (23%) and finances (15%). For most domains, concordance was less than 50%. On average, 75% of consumers reported having achieved their goals. Consumer-provider concordance was associated with goal attainment (p<.001).Conclusions: These findings emphasize the importance of agreed-upon goals and call for conceptualizing goal setting as an interpersonal process central to recovery. [ABSTRACT FROM AUTHOR]

The current study aimed to develop a patient selection process for muiltimorbid care management that balances the needs to accurately identify patients who are at risk for future high costs and assures that those selected can clinically benefit from proactive care management. Six physicians were surveyed on characteristics of their current (2012) patients to elicit clinical considerations for high-risk patient identification. Data from 2010-2011 were extracted from Clalit Health Services' (Israel's largest managed care organization) comprehensive database to derive the Adjusted Clinical Groups (ACG) predictive model risk scores for risk of future high costs. Model discriminatory power was assessed using the c-statistic and positive predictive value (PPV), before and after application of the clinical exclusion criteria. Inclusion criteria were refined based on physician input from a survey on 375 patients. Recommended reasons for exclusion: active cancer, schizophrenia, dialysis, residence in nursing homes or long-term care facilities, and age 95 years or older. The high-risk group included 5341 patients (mean 50 patients per physician). The c-statistic of the ACG model before and after exclusions applied was 0.80 and 0.75, respectively. After exclusion, the PPV for the 6% highest risk patients was 40%. High-risk patients' age, number of chronic conditions, and utilization were substantially higher than those of all other patients. This study shows that a validated predictive modeling tool provides acceptable discriminatory power for selecting multimorbid patients for participation in proactive care management, even after some of the highest risk patients are excluded because of priori clinical considerations. ( Population Health Management 2015;18:15-22) [ABSTRACT FROM AUTHOR]

Objectives To investigate the combined contribution of processes of hospitalization and preadmission individual risk factors in explaining functional decline at discharge and at 1-month follow-up in older adults with nondisabling conditions. Design Prospective cohort study. Setting Internal medicine wards in two Israeli medical centers. Participants Six hundred eighty-four individuals aged 70 and older admitted for a nondisabling problem. Measurements Functional decline was measured according to change in modified Barthel Index from premorbid to discharge and from premorbid to 1 month after discharge. In-hospital mobility, continence care, sleep medication consumption, satisfaction with hospital environment, and nutrition intake were assessed using previously tested self-report instruments. Results Two hundred eighty-two participants (41.2%) reported functional decline at discharge and 317 (46.3%) at 1 month after discharge. Path analysis indicated that in-hospital mobility (standardized maximum likelihood estimate ( SMLE) = −0.48, P < .001), continence care ( SMLE = −0.12, P < .001), and length of stay ( LOS) ( SMLE = 0.06, P < .001) were directly related to functional decline at discharge and, together with personal risk factors, explained 64% of variance. In-hospital mobility, continence care, and LOS were indirectly related to functional decline at 1 month after discharge through functional decline at discharge ( SMLE = 0.45, P < .001). Nutrition consumption ( SMLE = −0.07, P < .001) was significantly related to functional decline at 1 month after discharge, explaining, together with other risk factors, 32% of variance. Conclusion In-hospital low mobility, suboptimal continence care, and poor nutrition account for immediate and 1-month posthospitalization functional decline. These are potentially modifiable hospitalization risk factors for which practice and policy should be targeted in efforts to curb the posthospitalization functional decline trajectory. [ABSTRACT FROM AUTHOR]

Objectives: To explore the effects of four types of support (psychological support, instrumental support, supervision of instrumental support, and explanation of medical care) on the level of depressive symptoms among hospitalized older adults. Method: The sample consisted of 468 older adults admitted to the internal medicine units of a large tertiary care medical center in northern Israel. Respondents filled out self-report questionnaires upon admission and discharge. Information regarding severity of illness, chronic health status, and length of hospital stay was gathered from their medical records. Multivariate regression was used to test the association between the four types of caregiving support and depressive symptoms. Results: Psychological support from informal caregivers was found to be negatively related to depressive symptoms, and instrumental support to be positively related to depressive symptoms among respondents who were more independent in their functioning before the hospitalization. These relationships remained significant after controlling for previously-identified precursors of depressive symptoms: age, gender, education, widowhood, functional and cognitive status, severity of illness, co-morbidities, and length of hospital stay. Supervision of instrumental support and explanation of medical care were not related to depressive symptoms. Conclusion: Results of this study suggest that functional status, the kind of support, and the setting in which it is given are important in understanding the influence of informal support on the well-being of older adults. The potentially positive as well as negative consequences of various types of support in the hospital setting should be recognized and addressed. [ABSTRACT FROM AUTHOR]

gur-yaish n., zisberg a., sinoff g. & shadmi e. (2011) Development and psychometric testing of a measure of informal caregiving for hospitalized older adults. Journal of Advanced Nursing 68(4), 931-938. Abstract Aim. This paper is a report of the development and psychometric testing of the questionnaire evaluating informal caregiving for hospitalized older adults. Background. Informal caregiving of hospitalized older adults is an understudied phenomenon that lacks a valid and reliable measure to capture its multi-dimensionality. Methods. An instrument development procedure, followed by an empirical study, was conducted from February to November 2009. Instrument development included item generation and content validity, which was established by five experts. The validation study utilized a retrospective between-patients design. The sample consisted of 279 patients, aged 70 and older, who were hospitalized in a large medical centre in northern Israel. The internal consistency reliability, construct, convergent and divergent validity of the measure were tested. Results. The 14-item scale describes various aspects of informal caregiving for older adults in the hospital setting. The scale has four dimensions: Instrumental care, Supervision of care, Psychological support and Ensuring and Explaining care. Confirmatory factor analysis supported the theoretical model of the four dimensions of care. Reliability analysis revealed acceptable-to-high estimates for the total and for the dimensional scores (ranging from 0·78 to 0·89). The convergent and divergent validity coefficients were all in the expected direction. Conclusions. The preliminary psychometric properties of the measure showed acceptable results. The measure should be further explored in different cultural settings and for its ability to link between caregiving attributes, as captured by the measure, and hospitalization outcomes in older adults. [ABSTRACT FROM AUTHOR]

Objective. To describe an organization-wide disparity reduction strategy and to assess its success in quality improvement and reduction of gaps in health and health care. Study Setting. Clalit Health Services, Israel's largest non-for-profit insurer and provider serving 3.8 million persons. Study Design. Before and after design: quality assessment before and 12-month post-initiation of the strategic plan. A composite weighted score of seven quality indicators, measuring attainment of diabetes, blood pressure, and lipid control, lack of anemia in infants, and performance of mammography, occult blood tests, and influenza vaccinations.Data Extraction Methods. Quality indicator scores, derived from Clalit's central data warehouse, based on data from electronic medical records. Principal Findings. Low-performing clinics, of low-socioeconomic and minority populations, were targeted for intervention. Twelve months after the initiation of the project continuous improvement was observed coupled with a reduction of 40 percent of the gap between disadvantaged clinics, serving ∼10 percent of enrollees, and all other medium-large clinics. Conclusion. The comprehensive strategy, following a quality improvement framework, with a top-down top-management incentives and monitoring, and a bottom-up locally tailored interventions, approach, is showing promising results of overall quality improvement coupled with disparity reduction in key health and health care indicators. [ABSTRACT FROM AUTHOR]

To describe the types of continence aids that older adults hospitalized in acute medical units use and to test the association between use of continence aids and development of new urinary incontinence (UI) at discharge. Prospective cohort study. A 900-bed teaching hospital in Israel. Three hundred fifty-two acute medical patients aged 70 and older who were continent before admission. In-hospital use of continence aids was assessed according to participant self-report on use of urinary catheters (UCs) or adult diapers or of self-toileting. The development of new UI was defined as participant report of inability to control voiding at discharge. Multivariate analyses modeled the association between use of continence aids (vs self-toileting) and the development of new UI, controlling for baseline functional and cognitive status, disease severity, age, and length of stay. Of the 352 participants, 58 (16.5%) used adult diapers, and 27 (7.7%) had a UC during most of the hospital stay. Sixty (17.1%) participants developed new UI at discharge. The odds of developing new UI were 4.26 (95% confidence interval (CI)=1.53-11.83) times higher for UC users and 2.62 (95% CI=1.17-5.87) times higher for adult diaper users than for the self-toileting group, controlling for the above risk factors. The use of adult diapers and UCs during acute hospitalization is associated with the development of new UI at discharge. The management of continence in hospitalized older adults requires more diligence, and further investigation is needed to devise continence promotion methods in hospital settings. [ABSTRACT FROM AUTHOR]

Introduction: Care transitions from hospital to outpatient care are a particularly vulnerable period in the care trajectory especially among minority patients, due to cultural and linguistic barriers that affect the comprehension of medical instructions and the ability to navigate among the various settings. Objectives: The study examines whether quality of the discharge process and transitional-care preparedness mediate the relationship between the cultural factors of patients and readmissions. Methods: A prospective cohort study of 599 internal medicine patients, Hebrew (general population) and Russian, or Arabic native speakers (minority groups), at a tertiary medical center in central Israel (2013 to 2014). The in-hospital baseline questionnaire included sociodemographic, cultural and linguistic characteristics (Internal Health Locus Control [IHLC], Powerful others Health Locus of Control [PHLC], Chance Health Locus of Control [CHLC], family collectivism and health literacy) and physical, mental, and functional health status (control variables). A follow-up telephone survey assessed the quality of the discharge process (parallel mediators): use of the teach-back method, providers' cultural competence, language concordance and caregiver presence, and the Care Transition Measure [CTM] (serial mediator). Information on chronic conditions, length of stay, prior hospitalization, and 30-day readmissions was retrieved from the healthcare organization's data warehouse. Testing multiple mediation models was conducted using Hayes PROCESS procedure, model 80. Results: A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors (IHLC, PHLC, CHLC, Family collectivism, Health literacy), except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Path analysis indicated significant indirect effects of the cultural factors on readmission through the quality of the discharge process (parallel mediators) and CTM (serial mediator). Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.949; p=0.021). Discussion: The results show that the association between patients' cultural factors and 30-day readmission is mediated by the quality of the discharge process and care transitions. Conclusions (comprising key findings): Providing high-quality discharge planning tailored to patients' cultural characteristics is related to better care-transition preparedness, which is related to reduced 30-day readmissions. Lessons learned: An understanding of the entire range of factors and their effects on the quality of care transitions may guide policy and practice in improving the quality of care by tailoring the discharge process to patients' personal and cultural needs. Limitations: Generalizability may be limited due to characteristics of the Israeli society. Nonetheless, transitions of minority patients are challenging in various healthcare systems worldwide. Suggestions for future research: future studies should test interventions aimed at improving transitions of minority patients through tailored discharge planning processes and examining the impact on the care transition experience and on readmissions. [ABSTRACT FROM AUTHOR]

Introduction: Patient centred care is often at odds with disease-focused evidence-based clinical practice, particularly for patients with multiple chronic conditions (CCs). To assess the extent to which care for patients with multimorbidity was not guideline-concordant and the reasons why not, examining reasons stratified by disease. Methods: Retrospective cohort study conducted within the context of a nurse-primary care physician team-based care management program, the Comprehensive Care for Multimorbid Adults Project (CC-MAP) across 12 primary care clinics in Israel. This study included CC-MAP patients aged 45+ years who had at least two of eight common CCs. Forty-four guideline-based care processes for these eight CCs and dyslipidemia ('focus conditions') were evaluated over one year prior to data collection, through EHR review, including: lifestyle modifications, diagnostic and follow-up tests, medications, non-medication treatments, and specialist referrals. When care was not guideline-concordant, reasons why not were examined by: biomedical, personal and care burden, and system related factors. Proportions of non-guideline-concordant care and related reasons were assessed overall and stratified by focus condition. Reasons were also stratified: provider-driven if the clinician didn't refer care, and patient-driven if care was referred but not followed by the patient. Results: 4515 care processes were evaluated among 204 multimorbid patients, on average aged 72.3 years (SD 9.7) and with 3.8 (SD 1.1) CCs. Overall, 20.8% of care was not guideline-concordant, and when examining disease-specific care for the focus conditions, ranged from 14.7% (for IHD) to 48.9% (for depression). Of 1071 reasons why care deviated from guidelines, 59.8% were provider-driven and 40.2% patientdriven. Thirty-five percent of all reasons given were biomedical-related, 28.5% personal and care burden-related, 13.3% system-related, 11.9% other and 11.9% unknown. A higher proportion of reasons were provider-driven than patient-driven for atrial fibrillation, congestive heart failure, diabetes, and hypertension specific care; whereas, a higher proportion of reasons were patientdriven than provider-driven for chronic kidney disease, chronic obstructive pulmonary disease, depression, and dyslipidemia. For ischemic heart disease, the provider- and patient-driven reasons were fairly evenly divided. Discussion: Patients with multimorbidity do not receive about a fifth of guideline recommended care overall, but this proportion varies substantially across diseases. More than a third of nonguideline- concordant care is driven by biomedical reasons, and about a third attributed to patientrelated reasons. Conclusions: Understanding the drivers to deviations from guidelines can inform improvements to guidelines and care delivery for patients with multimorbidity. Lessons learned: These findings show that many clinical, personal patient, and system-related reasons exist for deviation from guidelines. Quantifying these types of reasons may provide a basis for tailoring assessments of the appropriateness and compatibility in combining disease-specific guidelines for multimorbid patients. Limitations: An evaluation in a control group or in a usual care setting was not possible for this study and while the extent of guideline-concordance was measured, this was not linked to outcomes. Suggestions for future research: Future research could examine these patterns of care in a usual care practice setting, as well as aim to evaluate the relationship of guideline-concordant care with clinical outcomes among multimorbid patients. [ABSTRACT FROM AUTHOR]

Introduction: Most of readmission prediction models are implemented at the time of patient discharge. [1] However, interventions which include an early in-hospital component are critical for reducing readmissions and improving patient outcomes. [2] Thus, at-discharge high-risk identification may be too late for effective intervention. Nonetheless, the tradeoff between early versus at-discharge prediction and the optimal timing of the risk prediction model application remains to be determined. We examined a high-risk patient selection with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge. Methods: A retrospective cohort study of adults (=65 years) discharged alive from internal medicine units in Clalit's (the largest integrated payer-provider health fund in Israel) general hospitals in 2015.The outcome was all-cause 30-day emergency readmissions to any internal medicine ward at any hospital. We used the previously validated Preadmission Readmission Detection Model (PREADM) [3] and developed a new model incorporating PREADM with hospital data (PREADM-H). We compared the percentage of overlap between the models and calculated the positive predictive value (PPV) for the subgroups identified by each model separately and by both models. Results: The final cohort included 35,156 index hospital admissions. The PREADM-H model included 17 variables with a C-statistic of 0.68 (95% CI: 0.67-0.70) and PPV of 43.0% in the highestrisk categories. Of patients categorized by the PREADM-H in the highest-risk decile, 78% were classified similarly by the PREADM. The 22% classified by the PREADM-H at the highest decile, but not by the PREADM, had a PPV of 37%. Applying both the PREADM and PREADM-H allowed accurate detection of additional subsequently readmitted patients at the 10% highest-risk group. Discussions: Our results show that the timing of readmission risk prediction both at admission and discharge should be considered when making the decision regarding which population should be identified for inclusion in readmission prevention programs. Use of the PREADM model allowed early identification of high-risk patients, yet missed a portion whose readmission risk was almost as high. Alternatively, the PREADM-H enabled accounting for risk factors that accrued during the hospital stay, though missed some patients who had an a priori high-risk according to the PREADM and whose actual readmission rate was much higher than the general population. Conclusions: Readmission prediction models should be implemented twice, to allow for early intervention at-admission and to capture new at-risk patients at-discharge. Lessons learned: The timing of readmission risk prediction makes a difference in terms of the population identified at each prediction time point. Limitations: Our results may not be generalizable to other settings where clinic and hospital data are not linked. However, with the growing use of EHRs,[4] the data included in the final PREADM-H may be increasingly available to many healthcare organizations. Suggestions for future research: Our results provide an example of the potential complementary implementation of the predictive models to maximize their power in identifying various groups of high-risk patients for inclusion in within as well as post-discharge interventions. Further studies are needed to strengthen our findings. [ABSTRACT FROM AUTHOR]

Introduction: Informal caregiving during hospitalization of older adults is significantly related to hospital processes and patient outcomes. Studies in home settings demonstrate that ethno-cultural background is related to various aspects of informal caregiving; however, this association in the hospital setting is insufficiently researched. Objectives: Our study explore potential differences between ethno-cultural groups in the amount and kind of informal support they provide for older adults during hospitalization. Methods: This research is a secondary data analysis of two cohort studies conducted in Israeli hospitals. Hospitalized older adults are divided into three groups: Israeli-born and veteran immigrant Jews, Arabs, and Jewish immigrants from the Former Soviet Union (FSU). Duration of caregiver visit, presence in hospital during night hours, type of support (using the Informal Caregiving for Hospitalized Older Adults scale) are assessed during hospitalization. Results are controlled by background parameters including functional Modified Barthel Index (MBI) and cognitive Short Portable Mental Status Questionnaire (SPMSQ) status, chronic morbidity (Charlson), and demographic characteristics. Results: Informal caregivers of "FSU immigrants" stay fewer hours during the day in both cohorts, and provide less supervision of medical care in Study 2, than caregivers in the two other groups. Findings from Study 1 also suggest that informal caregivers of "Arab" older adults are more likely to stay during the night than caregivers in the two other groups. Conclusions: Ethno-cultural groups differ in their patterns of caregiving of older adults during hospitalization. Health care professionals should be aware of these patterns and the cultural norms that are related to caregiving practices for better cooperation between informal and formal caregivers of older adults. [ABSTRACT FROM AUTHOR]

Introduction: Primary care physician PCP post-discharge follow-up is increasingly advocated as part of readmissions-reduction efforts. Yet, previous studies mostly assessed whether a PCP visit occurred rather than examining the content of the visit and the quality of the PCP's review of the hospital discharge summary HoDS. We aimed to examine the association between the quality of PCPs' review of the HoDS recommendations during the post-discharge visit and 30-day readmissions. Methods: This Prospective cohort study included 594 internal medicine patients from 2013 to 2014. The in-hospital baseline questionnaire examined patients' sociodemographic characteristics, and physical, mental, and functional health status. patients were surveyed by phone about the discharge and post-discharge process. Information on participants' chronic conditions, length of stay, prior hospitalization, and 30-day readmissions were retrieved from the healthcare organizations' Clalit electronic health record data warehouse. Multivariate regressions were performed to model the relationship between in-hospital baseline characteristics, discharge briefing, primary care visit indicator, and the PCP HoDS review, and 30-day readmission. Results: Ratings of the quality of the PCP's HoDS review were higher than ratings of the inhospital discharge briefing 3.46 vs. 3.17, respectively, p=0.001. Multivariate Logistics Regression models show that the quality of the PCP HoDS review was significantly associated with lower odds of readmission OR=0.35, 95% CI 0.26-0.45. The c-statistic shows that the in-hospital baseline model provided fair discriminatory power C statistic 0.70; 95% CI: 0.64-0.75. Adding the discharge-briefing scale significantly improved the discriminatory power of the model C statistic 0.81; 95% CI: 0.76-0.84, but adding the PCP visit indicator within two weeks after discharge yes / no did not change the discriminatory power of the model C statistic 0.810; 95% CI: 0.77-0.85. Nonetheless, the final model that included the PCP HoDS review had a significantly improved discriminatory power relative to the in-hospital dischargebriefing model C statistic 0.872; 95% CI: 0.84-0.90. Discussions: our data show that the quality of the PCP's HoDS review is a strong protective factor associated with lower 30-day readmission. Adding the PCP HoDS review to the model significantly improved its discriminatory power relative to the in-hospital discharge-briefing model and the PCP visit indicator model. Conclusions: This study shows that the quality of the PCP's HoDS review is associated with reduced 30-Day readmission and thus should be considered as part of readmission prevention efforts. Lessons learned: Our findings point to a need for transitional care interventions and strategies to reduce 30-day readmission including earlier and meaningful PCP visit comprising review of the HoDS recommendations. The study findings have the potential to encourage hospitals and community-based clinicians to work together to improve post-discharge continuity. Limitations: This study was performed at only one tertiary medical center in Israel and its findings should be replicated in other healthcare systems with varying degree of postdischarge PCP involvement. Suggestions for future research: Further research should explore these findings for high-risk patients and foster information sharing between hospitals and primary care physician. [ABSTRACT FROM AUTHOR]

Introduction: Patients with low health literacy (HL) and minority patients encounter many challenges during transition from hospital to community care. We aimed to assess care transitions of patients from minority Arab and immigrant population groups and various HL levels and to test whether presence of caregivers and provision of language-concordant care are associated with better transitions. Methods: This prospective cohort study included 598 internal medicine patients, Hebrew, Russian, or Arabic native speakers, at a tertiary medical center in central Israel, from 2013 to 2014. Baseline measures included: HL (Brief Health Literacy Screen); mental and physical health status (SF-12v.2); daily functioning. A follow-up telephone survey assessed patients' care transitions (Care Transition Measure [CTM]). Additionally, patients reported on care provisions at discharge: caregiver presence (family members/close relations) and patientprovider language concordance. Results: Caregivers were present in 59% (351/598) of discharge briefings and patientprovider language concordance was available in 30% (123/408) of minority patients' discharge briefings. Patients with low HL and without language-concordance or caregiver presence had the lowest CTM scores (33.1). When language-concordance and caregivers were available, CTM scores did not differ between the medium-high and low HL groups (72.30 and 68.40, respectively, p=0.118). The adjusted analysis with tests of interaction, showed that language-concordance and caregiver presence during discharge moderate the relationship between HL and patients' care transition experience (p<0.001). Discussions: This study examined the relationship between HL and patients' transitional-care experience. Collectively, our data underscore two important points: (1) HL is inversely associated with patients' ratings of their care transitions, and (2) provisions of care during discharge moderate the relationship between HL and patients' care transition experience. These findings show that the negative impact of low HL is potentially mitigated when language-concordance and caregiver presence are available during discharge. Moreover, our findings on the independent effect of caregiver presence and language-concordance, at both low and medium-high HL levels, show that transitional care of all patients is better when these provisions are available. Nonetheless, for patients with low HL, absence of caregivers and lack of language-concordance is detrimental for their transitional care. Conclusions: This study shows that language-concordance care and caregiver presence are associated with better patients' transitional-care experience among patients with low HL levels and among minorities in general Lessons learned: Our findings point to a need to identify patients at risk for poor understanding and execution of hospital discharge instructions. This entails determining patients' HL levels and ensuring that discharge briefings are given by language-concordant providers and when caregivers are present. Limitations: The findings reflect cultural and healthcare characteristics of the Israeli society, which might not be applicable to other countries. However, studies from various developed countries show that deficits in communication at hospital discharge are a common problem that may adversely affect patient care. Suggestions for future research: Future studies should explore how these provisions may lead to improved health outcomes and reductions in hospital readmissions. [ABSTRACT FROM AUTHOR]

Introduction: Increasingly, big-data electronic health record (EHR) warehouses are used for targeted readmission prevention programs (RPPs). However, the ability of EHR tools to accurately detect the "appropriate" patients for RPP according to personal and clinical characteristics (termed "care-sensitivity") is not known. We aimed to examine the ability of a previously validated EHR 30-day readmission prediction risk tool (the Preadmission Readmission Prediction Model [PREADM](1) to detect care-sensitive patients for inclusion in RPPs. Methods: Physicians and nurses from internal medicine wards of 3 general hospitals in Israel's Clalit Health Services were asked to complete a questionnaire on the personal and clinical characteristics of discharged patients. We examined the degree of concordance between the PREADM (prediction score > 40, 60% of the sample) and the clinicians' classification of highrisk patients, and the likelihood for readmission according to each. Decision trees applying CART were used on PREADM high-risk patients, to classify the patients by whether they are likely to be readmitted, using the questionnaire responses. Results: A total of 817 questionnaires on 375 patients (discharged to their home) were completed by physicians and nurses. Ninety-one patients (24.3%) had a 30-day readmission. There was concordance between high-risk PREADM classification and the nurses' and physicians' assessments in about two-thirds of patients. Lack of concordance was found in: (a): 23% of patients with a high PREADM score and a low-risk assessment by the nurses, in which the actual readmission rate was 20% ; and (b) 12% of patients with a low PREADMscore and a high-risk assessment by the nurses, which had a 33% readmission rate. Conversely, physicians' classification had poorer detection than the PREADM. Decision tree models showed that the following questions were useful in identifying high-risk patients: does the patient receive a new drug that requires follow-up (risk for readmission 38% if yes vs 24% if no); and does the patient need special equipment at home (risk of readmission 61% if yes vs 23% if no). Discussions: Among about a third of patients, the nurses' assessment was more accurate than the PREADM model, when a high-risk score cutoff of >40 was used, while the physicians' assessment was worse than that of the model. The clinical data from nurses about new drugs and special equipment needed at home helped differentiate a higher-risk population from those at lower risk of readmissions. Conclusions: Combining EHR data with insight from hospital nurses regarding patients' clinical and personal characteristics provides more "care-sensitive" information, which can allow better adaptability and synchronization across different healthcare providers and better selection of patients for inclusion in RPPs. Lessons learned: While the EHR predictive algorithms can identify most patients at very high risk of readmissions, the nurses are able to target additional patients who are suitable for inclusion in RPPs with a few simple questions during the hospital stay. Limitations: A convenience sample of patients. Suggestions for future research: Whether a combined "care-sensitive' model is able to better classify readmission risk remains to be tested to improve the predictive tools. [ABSTRACT FROM AUTHOR]

To assess the validity and reliability of the Nijmegen Continuity Questionnaire in Hebrew (NCQ‐H) for measuring patients' perceived continuity of care in the multiprovider setting of oral anticancer therapy (OACT). Following forward–backward translation of the original instrument into Hebrew, the NCQ‐H was administered to adult cancer patients in five oncology centres in Israel, 2–3 months after initiation of OACT (either targeted, hormonal or chemotherapy). Confirmatory factor analysis and Cronbach's alpha were used to assess the validity and reliability of the NCQ‐H respectively. A total of 135 patients completed the questionnaire. The postanalysis models for measuring "personal continuity with care provider" (eight items for each provider: the oncology specialist and the primary care physician), and "team/cross‐boundary continuity" (four items for each setting: within the oncology team, and between the oncology specialist and the primary care physician) showed good fit for the observed data (root‐mean‐square error of approximation (RMSEA) = 0.02; RMSEA = 0.015; for each model respectively). Cronbach's alpha was 0.79–0.95 for all subscales. Conclusions. This study provides preliminary evidence for the reliability and validity of the NCQ‐H in assessing cancer patients' experience with continuity of care and for its usability in the context of OACT. [ABSTRACT FROM AUTHOR]

Introduction: Oncology patients often experience breakdowns in care when transitioning between care settings. Aims and objectives: To examine the experience of oncology patients at the transition between hospital and community care and identify factors which affect fragmentation. Methods: We used a complementary mixed method approach. Qualitative phase: semi-structured interviews and focus groups were conducted with patients and their caregivers, nurses, social workers, physicians and medical administrators. Quantitative phase: a survey was administered to 400 oncology patients of a large tertiary medical center in Northern Israel. Patients who were discharged from the hospital completed a validated questionnaire on their transition from the hospital to the community and on their perceptions of the quality of their primary care. The surveys were administered in Hebrew, Arabic, and Russian. Results: From the preliminary analysis of the qualitative data four broad themes emerged: (1) responsibility for care, (2) administrative and bureaucratic burden, (3) informal routes of communication, and (4) cultural barriers. The regression analyses examined the effect of patient characteristics (gender, age, education, income, health status, and language group) and showed that patients' language accounted for most of the variance in quality scores. Russian speaking patients reported poorer quality of care and Arabic speaking patients reported better quality of care, than Hebrew speakers, in all primary care domains. Both Arabic and Russian speakers scored significantly higher on the Care Transition Measure than Hebrew speakers. Conclusions: The differences between sub-groups found here suggest that avoidable variations in care exist. To enable a more streamlined process, cultural issues need to be addressed at the interface between care settings. Further research should examine the causes for such differences. [ABSTRACT FROM AUTHOR]

Performance of function-preserving hospitalization processes related to patient mobility, use of continence aids and food intake is significantly associated with outcomes in older adults. Nurses are the front-line personnel responsible for promoting performance of such processes. The degree to which nurse staffing is related to this performance is unclear. To identify nurse-staffing characteristics and nursing-related care needs associated with older patients' mobility, continence care and food intake during acute hospitalization. Cross-sectional study using survey data from the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR) cohort study combined with day-level administrative nurse staffing data and clinical day-level aggregated data for all patients hospitalized during the HoPE-FOR study period. Internal medicine units in two medical centers in Israel. Eight hundred seventy-three older adults. Mobility, continence care and food intake were assessed within 2 days of admission using validated questionnaires. Nurse-to-patient ratios and nursing-skill mix (i.e. registered nurses (RNs), nurse aides, nurses with advanced clinical training and RNs with an academic degree) were assessed using administrative data. Decision trees were developed for mobility, continence care and food intake, applying classification and regression-tree analysis. The mobility decision tree identified three characteristics subdividing patients into six nodes: pre-admission functioning, pre-admission activity level and percentage of nurses with advanced training. The percentage of nurses with advanced training classified low-functioning patients into those walking in corridors versus walking or sitting only inside the room. The continence-care classification decision tree identified two characteristics that subdivided the patients into four nodes: pre-admission functioning and bladder control. Nurse-to-patient-ratio variables and patients' nursing-related care needs did not contribute to this classification. The food-intake decision tree identified four characteristics—pre-admission functioning, gender, percentage of nurses with advanced training and percentage of nurse aides—subdividing patients into eight nodes. Low-functioning patients exposed to a higher percentage of nurses with advanced training had food-intake scores 14% higher than patients exposed to a lower percentage of nurses with advanced training. Independent men exposed to a higher percentage of nurse aides had a 14% higher habitual daily in-hospital food-intake score than independent men exposed to a lower percentage of nurse aides. A higher percentage of nurses with post-graduate education is associated with better performance of mobility and food intake of hospitalized older adults. To maintain the potential benefits of highly trained staff, education levels should be considered in scheduling and assignment decision-making processes in internal medicine units. Tweetable abstract : A higher percentage of nurses with post-graduate education is associated with better mobility and food intake of hospitalized older adults. [ABSTRACT FROM AUTHOR]

Objective: This study examined whether personal characteristics of consumers with serious mental illness (SMI), including being an immigrant, explained the lack of concordance in quality-of-life (QOL) ratings reported by consumers versus those reported by staff caring for consumers. Method: In a sample of consumers with SMI (n = 4,956), including nonimmigrants and immigrants from Ethiopia and countries comprising the former Soviet Union (FSU), we examined consumer-reported and staff-reported QOL ratings. Regression models measured the contributions of covariates to QOL ratings made by both groups. Results: Staff-reported QOL ratings were consistently lower than consumer-reported QOL ratings. Consumer-reported QOL ratings made by FSU immigrants were lower than consumer-reported QOL ratings made by Ethiopian immigrants or by nonimmigrants (p <.01). Conversely, staff-reported QOL ratings on Ethiopian immigrants were lower than staff-reported QOL ratings on FSU immigrants or nonimmigrants (p <.05). While consumer-reported QOL ratings were associated with the covariates of gender (p <.01), disability level (p <.001), and health status (p <.001), staff-reported QOL ratings were associated with the covariates of single marital status (p <.05), education (p <.001), and disability level (p <.001). Conclusions and Implications for Practice: Among consumers with SMI, FSU immigrants reported the lowest QOL ratings, yet staff rated the QOL of Ethiopian immigrants as the lowest. Bias is a potential explanation for this discrepancy. An educational program focusing on cultural awareness, sensitivity, and competency might help staff better understand consumers' needs, thereby contributing to better service and potentially improving staff's ability to make assessments of consumers' functioning and QOL. Impact and Implications: This study found that staff-reported quality of life (QOL) ratings on consumers with severe mental illness (SMI) were consistently lower than the consumer-reported QOL ratings, for both immigrant and non-immigrant consumers. Additionally, this study found that the lack of concordance between staff-reported and consumer-reported QOL ratings tended to differ by immigrant status as well as by immigrants' country of origin. [ABSTRACT FROM AUTHOR]

Objectives: The Necesidades Paliativas CCOMS-ICO© (NECPAL) screening tool was developed to identify patients in need of palliative care and has been used in Israel without formal translation, reliability testing, or validation. Because cultural norms significantly affect subscales such as social vulnerability and health-care delivery, research is needed to comprehensively assess the NECPAL's components, adapt it, and validate it for an Israeli health-care setting. This study linguistically and culturally translated the NECPAL into Hebrew to examine cultural and contextual acceptability for use in the Israeli geriatric health sector. The newly adapted tool was measured for itemized and scale-level content validity, inter-rater reliability (IRR), and construct validity., Methods: The NECPAL was back-translated and its content validated by a 5-member expert panel for clarity and relevance, forming the Israeli-NECPAL (I-NECPAL). Six health-care professionals used the I-NECPAL with 25 post-acute geriatric patients to measure IRR. For construct validity, the known-groups method was used, as there is no "gold standard" method for identifying palliative needs for comparison with the NECPAL. The known groups were 2 fictitious cases, predetermined of palliative need. Thirty health-care professionals, blinded to the predetermined palliative status, used the I-NECPAL to determine whether a patient needs a palliative-centered plan of care., Results: The findings point to acceptable content and construct validity as well as IRR of the I-NECPAL for potential inclusion as a tool for identifying geriatric patients in need of palliative care. Content-validity assessment brought linguistic changes and the exclusion of the frailty parameter from the annex of chronic diseases. The kappa-adjusted scale-level content-validity index indicated a high level of content validity (0.96). IRR indicated a high level of agreement (all parameters with an "excellent-good" agreement level). The sensitivity (0.93), specificity (0.17), positive predictive value (0.53), and negative predictive value (0.71) revealed how heavily the scale weighed upon the surprise question. These metrics are improved when removing the surprise question from the instrument., Significance of Results: Similar to other countries, the Israeli health-care system is regulated by policies that portray the local beliefs and culture as well as evidence-based practice. The decision about when to switch a patient to a palliative-centered plan of care is one such example. It is thus of utmost importance that only locally adapted and vigorously tested screening tools be offered to health-care providers to assist in this decision. The I-NECPAL is the first psychometrically tested palliative needs identification tool for use in the geriatric population in Israel, on both a scale and an itemized level. The results indicate that it can immediately replace the current unvalidated version in use. Further research is needed to determine whether all parts of the scale are relevant for this patient population.

Background: Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested., Methods: The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days., Results: Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample., Conclusions: Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches., (© 2023. The Author(s).)

Objectives: Patients with haematological malignancies receiving immunosuppressive therapy are at highest risk of invasive pneumococcal disease. Our goal was to investigate whether vaccination of haematological patients with pneumococcal 13-valent conjugated vaccine (PCV13) prior to therapy initiation is associated with decreased hospital admissions due to pneumonia or sepsis within 12 months., Design and Setting: A longitudinal retrospective cohort study was conducted at the haematology unit of Carmel Medical Center, Israel., Participants: Information on adult patients (>18 years) who were diagnosed between 1 January 2009 and 30 December 2019 with haematological malignancies and received immunosuppressive therapy was retrieved from the electronic health records. Patients with haematological malignancies who received the PCV13 vaccination during or after initiation of the immunosuppressive therapy were excluded from the study., Outcome Measures: A multivariate logistic regression model was performed to determine whether PCV13 vaccination is associated with fewer hospital admissions due to pneumonia or sepsis., Results: The cohort included 616 patients, of which 418 (67%) patients were not vaccinated and 198 (33%) were vaccinated. Within 12 months, 15.1% (n=63) of non-vaccinated patients compared with only 7.1% (n=14) of the vaccinated patients were hospitalised due to pneumonia or sepsis. The logistic regression analysis demonstrated that receiving PCV13 vaccination is associated with 45% (OR=0.45, 95% CI: 0.246 to 0.839, p=0.012) reduced odds of being hospitalised due to pneumonia or sepsis in patients with haematological malignancies receiving immunosuppressive therapy., Conclusion: This is the first observational study to demonstrate the association between PCV13 vaccination and hospital admissions in patients with haematological malignancies receiving immunosuppressive therapy. Patients receiving PCV13 vaccination before immunosuppressive therapy initiation had significantly reduced odds of hospitalisation due to pneumonia or sepsis compared with non-PCV13-vaccinated patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Poor food intake is a major concern among hospitalized older adults. This study investigated the frequency and optimal timing of in-hospital food intake assessment in terms of its ability to predict hospitalization functional outcomes., Methods: Secondary analysis of a cohort study of 699 older adults (age ≥70 years) admitted to internal medicine wards for non-disabling conditions was carried out. Daily food intake was assessed using self-reported estimation of portions consumed at each meal and calculated according to the caloric composition of the meals. Nutritional status on admission, baseline and discharge activities of daily living, and cognitive status were assessed using validated questionnaires. Repeated measures analysis of variance (n = 263) and multiple logistic regression models (n = 475) for predicting activities of daily living and cognitive decline were used to establish required frequency and optimal timing of food-intake monitoring., Results: Mean daily intake significantly increased from the first 48 h from admission (0.51 ± 0.30) to the second and third assessments (0.62 ± 0.30 and 0.63 ± 0.30, respectively). Eating half or less of the served meals both within the first 48 h of admission and after 48 h was associated with higher odds of cognitive decline (OR 1.93, 95% CI 1.27-2.94; OR 1.62, 95% CI 1.04-2.51, respectively). Low intake after 48 h of admission was associated with higher odds of activities of daily living decline (OR 1.66, 95% CI 1.03-2.67)., Conclusions: Food intake increases from the first 48 h of admission onwards and becomes more consistent 3 days after admission. The associations between low food intake at various time points and worse functional outcomes show the importance of routine food intake monitoring for at least 3 days. Geriatr Gerontol Int 2019; 19: 890-895., (© 2019 Japan Geriatrics Society.)

Objective: The objective of this study was to evaluate the incremental predictive power of electronic medical record (EMR) data, relative to the information available in more easily accessible and standardized insurance claims data., Data and Methods: Using both EMR and Claims data, we predicted outcomes for 118,510 patients with 144,966 hospitalizations in 8 hospitals, using widely used prediction models. We use cross-validation to prevent overfitting and tested predictive performance on separate data that were not used for model training., Main Outcomes: We predict 4 binary outcomes: length of stay (≥7 d), death during the index admission, 30-day readmission, and 1-year mortality., Results: We achieve nearly the same prediction accuracy using both EMR and claims data relative to using claims data alone in predicting 30-day readmissions [area under the receiver operating characteristic curve (AUC): 0.698 vs. 0.711; positive predictive value (PPV) at top 10% of predicted risk: 37.2% vs. 35.7%], and 1-year mortality (AUC: 0.902 vs. 0.912; PPV: 64.6% vs. 57.6%). EMR data, especially from the first 2 days of the index admission, substantially improved prediction of length of stay (AUC: 0.786 vs. 0.837; PPV: 58.9% vs. 55.5%) and inpatient mortality (AUC: 0.897 vs. 0.950; PPV: 24.3% vs. 14.0%). Results were similar for sensitivity, specificity, and negative predictive value across alternative cutoffs and for using alternative types of predictive models., Conclusion: EMR data are useful in predicting short-term outcomes. However, their incremental value for predicting longer-term outcomes is smaller. Therefore, for interventions that are based on long-term predictions, using more broadly available claims data is equally effective.

Background: Disparities between mental health patients and their professional caregivers in quality of life appraisals have been identified, however, the structure that such disparities assume is unknown., Aims: To examine the network structure of quality of life appraisals and disparities using network analysis., Methods: Participants were 1639 persons with schizophrenia using psychiatric rehabilitation services and their primary professional caregivers (N=582). Quality of life for persons with schizophrenia was measured based on an abbreviated version of the Manchester Short Assessment of Quality of Life. Appraisals were made self-reported and by professional caregivers. Disparities scores between the aforementioned were computed. Network analysis was performed on all quality of life appraisals. Sensitivity analyses were conducted., Results: The self-appraised network significantly (p<0.05) differed by network strength compared to the caregiver-appraised network. Self-appraised network communities (clusters of quality of life items) were health conditions and socioeconomic system, whereas caregiver-appraised network communities were social activities, and combined socioeconomic and health conditions. Strength centrality was highest for self-appraised social status and for caregiver-appraised residential status (Z=1.63, Z=1.12, respectively). The disparity scores network clustered into two communities: social relations and combined financial and health conditions. The most central appraisal disparities were in social status., Conclusions: Quality of life differed when self-appraised by persons with schizophrenia compared to when appraised by their professional caregivers, yet the salient role of social relations was shared. The latter may be an initial focus of discussion by persons with schizophrenia and their caregivers., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: This study examines the nature of disparities in cardiovascular risk by exploring chronic stressors and other cardiovascular risk factors on youth of African descent who are integrating into an industrialized society., Methods: Qualitative data on cardiovascular risk and acclimation to the dominant society were collected from three groups of key informants: (1) community leaders; (2) youth; and (3) a community advisory group., Results: Youth of Ethiopian descent engaged in the same western diets, computerized social networking, and habits in smoking and alcohol use as did youth from the dominant society. However, informants of Ethiopian descent encountered and witnessed racism, institutional discrimination and evidence of devaluing Ethiopian culture, influencing youths' ability to integrate into the society., Conclusion: Immigrant youth of Ethiopian descent face an accumulation of conflicting social support, psychosocial factors, and stressors, including: living in low-income, high-crime areas; encountering pervasive discrimination; acclimating to a new and industrialized culture; and navigating within an often unhospitable society. Contributing to these factors are changes in health behaviors such as adding processed foods and sugary drinks to the diet, increasing heavy alcohol use and substituting screen use for physical activity. The accumulative impact of these factors contributes to the marginalization of youth of Ethiopian descent in the dominant society and perpetuates a cycle of increasing cardiovascular risk.

Background: The functional changes that occur immediately before acute hospitalization and those that occur during hospitalization are pertinent to posthospitalization functional status in older adults. Our primary aim was to estimate the effects of membership in categories that take into account pre- and within-hospital functional changes on the likelihood of functional recovery (FR) 1 month after discharge., Methods: The sample included 691 older (≥70) adults admitted to general-medical inpatient units in two hospitals in Israel. FR was defined as a restoration of functioning 1 month postdischarge to levels reported 2 weeks prior to admission. Patients were classified according to functional decline or stability during the prehospital stage and decline, stability, or improvement between admission and discharge in terms of ability to perform self-care or mobility activities. We performed multivariate logistic regressions to test the association between categories of functional change and FR., Results: Patients who remained stable before and during hospitalization had the highest odds of maintaining their premorbid functional levels. Those who experienced functional improvement during hospitalization, despite previous functional loss, were 2.3-2.9 times more likely than persistent decliners to experience FR (p < .05 for all). Comparable patterns were found in the relationship between pre- and in-hospital functional trajectories and recovery, both in self-care and in mobility., Conclusions: Differentiating between pre- and in-hospital functional changes is important for promoting short-term posthospitalization FR. In-hospital function-focused care that takes into account preadmission functional history may help improve posthospitalization FR., (© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions., Objectives: To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission., Research Design: Retrospective cohort study of admissions between January 1 and March 31, 2010., Subjects: Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel., Measures: All-cause 30-day emergency readmissions. A prediction score based on before admission electronic health record and administrative data (the Preadmission Readmission Detection Model-PREADM) was developed using a preprocessing variable selection step with decision trees and neural network algorithms. Admissions with a recent prior hospitalization were excluded and automatically flagged as "high-risk." Selected variables were entered into multivariable logistic regression, with a derivation (two-thirds) and a validation cohort (one-third)., Results: The derivation dataset comprised 17,334 admissions, of which 2913 (16.8%) resulted in a 30-day readmission. The PREADM includes 11 variables: chronic conditions, prior health services use, body mass index, and geographical location. The c-statistic was 0.70 in the derivation set and of 0.69 in the validation set. Adding length of stay did not change the discriminatory power of the model., Conclusions: The PREADM is designed for use by health plans for early high-risk case identification, presenting discriminatory power better than or similar to that of previously reported models, most of which include data available only upon discharge.

Background: Patients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood., Purpose: This study sought to gain insight into the hospital-community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings., Methods and Sample: The sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used., Results: Two major concepts emerged: "ambivalence and confusion" and "overcoming healthcare system barriers." Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care., Conclusions: The heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital-community oncologic care., (Copyright © 2013 Elsevier Ltd. All rights reserved.)