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2. Lessons Learned in Developing a Patient-Centered Website to Support Stroke Patients and Caregivers During Transitions of Care

Author

Fritz, Michele C., Swierenga, Sarah J., Freddolino, Paul P., Coursaris, Constantinos K., Woodward, Amanda T., Reeves, Matthew J., Goos, Gerhard, Founding Editor, Hartmanis, Juris, Founding Editor, Bertino, Elisa, Editorial Board Member, Gao, Wen, Editorial Board Member, Steffen, Bernhard, Editorial Board Member, Woeginger, Gerhard, Editorial Board Member, Yung, Moti, Editorial Board Member, Soares, Marcelo M., editor, Rosenzweig, Elizabeth, editor, and Marcus, Aaron, editor

Published
2021
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6. Opening Pandora’s Box

Author

Reeves, Mathew J., Fritz, Michele C., Osunkwo, Ifeyinwa, Grudzen, Corita R., Hsu, Lewis L., Li, Jing, Lawrence, Raymona H., and Bettger, Janet Prvu

Subjects
outcomes research, Quality Assurance, Health Care, transitional care, patient-centered outcome, digestive, oral, and skin physiology, Humans, Original Articles, Patient Reported Outcome Measures, patient-reported outcome, Patient Readmission
Abstract

Background: Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. Methods and Results: This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. Conclusion: Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Published
2021

28. Improving stroke transitions: Development and implementation of a social work case management intervention.

Author

Hughes, Anne K., Woodward, Amanda T., Fritz, Michele C., and Reeves, Mathew J.

Subjects
FOCUS groups, MEDICAL care, QUALITY assurance, RESEARCH funding, THEMATIC analysis, EVALUATION of human services programs, PATIENTS' attitudes, STROKE patients, PSYCHOLOGY
Abstract

Strokes impact over 800,000 people every year. Stroke care typically begins with inpatient care and then continues across an array of healthcare settings. These transitions are difficult for patients and caregivers, with psychosocial needs going unmet. Our team developed a case management intervention for acute stroke patients and their caregivers aimed at improving stroke transitions. The intervention focusses on four aspects of a successful care transition: support, preparedness, identifying and addressing unmet needs, and stroke education. This paper describes the development and implementation of this program, and is an example of the synergy created between neuroscience and clinical practice. [ABSTRACT FROM AUTHOR]

Published
2018
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