
Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture
By: Justine Toscan, Katie Mairs, Stephanie Hinton and Paul Stolee
References
- Borrie MJ Stolee P Knoefel F Wells JL Seabrook JA Current best practices in geriatric rehabilitation in Canada Geriatrics Today: Canadian Journal of Geriatric Medicine and Geriatric Psychiatry 2005 8 148 53
- Naylor MD Stephen C Bowles KH Bixby MB Cognitively impaired older adults: from hospital to home The American Journal of Nursing 2005 105 2 52 61
- Coleman EA Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs Journal of the American Geriatrics Society 2003 51 4 549 55
- Coleman EA Boult C Improving the quality of transitional care for persons with complex care needs Journal of the American Geriatrics Society 2003 51 4 556 7
- Adair CE McDougall GM Beckie A Joyce A Mitton C Wild CT History and measurement of continuity of care in mental health services and evidence of its role in outcomes Psychiatric Services 2003 54 10 1351 56
- Kripalani S LeFevre F Phillips CO Williams MV Basaviah P Baker DW Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care Journal of Applied Hospital Medicine 2007 1 354 60
- McWilliam CL Sangster JF Managing patient discharge to home: the challenges of achieving quality care International Journal for Quality in Health Care 1994 6 147 61
- The Change Foundation Who is the puzzle maker? Patient/caregiver perspectives on navigating the health services in Ontario 2008 Toronto Ontario [cited 2011 Aug 28]. Available from: www.changefoundation.ca/docs/ChgFdn_Puzzle_Web.pdf
- Gandhi TK Fumbled handoffs: one dropped ball after another Annals of Internal Medicine 2005 142 5 352 8
- Naylor MD A decade of transitional care research with vulnerable care Journal of Cardiovascular Nursing 2000 14 3 1 14
- Naylor MD Transitional care of older adults Annual Review of Nursing Research 2002 20 127 47
- Picker Institute Continuity and transitions: preparing for discharge. New visions: ideas worth sharing 1999 Boston Massachusetts [cited 2011 Aug 22]. Available from: http://pickerinstitute.org/picker-institute-newsletters/
- Health Research for Action Transitional Care Leadership Summit. Summary proceedings 2006 Berkley California [cited 2011 Aug 22]. Available from: http://www.healthresearchforaction.org/sites/default/files/REPORT_PUBS_H2H%20SummitProc%20FNL_0.pdf
- Bodenheimer T Building teams in primary care: lessons from 15 case studies 2007 Oakland California [cited 2011 23 Aug]. Available from: http://www.chcf.org/∼/media/MEDIA%20LIBRARY%20Files/PDF/B/PDF%20BuildingTeamsInPrimaryCareCaseStudies.pdf
- Lichenstein R Alexander JA Jinnett K Ullaman E Embedded intergroup relations in interdisciplinary teams. Effects on perceptions of level of team integration Journal of Applied Behavioural Science 1997 33 4 413 34
- Helleso R Lorensen M Sorensen L Challenging the information gap—the patients transfer from hospital to home health care International Journal of Medical Informatics 2004 73 569 80
- Change Foundation Integration of care: the perspectives of home and community providers 2011 Toronto Change Foundation [cited 2012 4 Jan.]. Available from: www.changefoundation.ca/docs/integration_of_care_report.pdf
- Canadian Council on Health Services Accreditation CCHSA glossary (6th edition) 2007 Ottawa Canadian Council on Health Services Accreditation (CCHSA)
- Bowie JR The perceptions of continuity of care of rural Albertans following acute myocardial infarction 2006 Alberta M.N. University of Alberta
- Leith KH Phillips L Sample PL Exploring the service needs and experiences of persons with TBI and their families: the South Carolina experience Brain Injury 2004 18 1191 208
- Levine C Rough crossings: family caregivers' odysseys through the health care system 1998 New York United Hospital Fund of New York
- Woodward CE Abelson J Hutchison B My home is not my home anymore: improving continuity of care in homecare 2001 Ottawa Canadian Health Services Research Foundation
- Heller KS Solomon MZ Continuity of care and caring: what matters to parents of children with life-threatening conditions Journal of Pediatric Nursing 2005 20 335 46
- Laschinger SJ Van Manen L Stevenson T Fothergill-Bourbonnais F Health care providers' and patients' perspectives on care in HIV ambulatory clinics across Ontario Journal of the Association of Nurses in AIDS Care 2005 16 37 48
- Noël PH Frueh BC Larme AC Pugh JA Collaborative care needs and preferences of primary care patients with multimorbidity Health Expectations 2005 8 54 63
- Smith JE Experiences of caregivers in arranging services for survivors of traumatic brain injury 1998 Alberta M.N. University of Alberta
- Smith L Daughtrey H Weaving the seamless web of care: an analysis of parents' perceptions of their needs following discharge of their child from hospital Journal of Advanced Nursing 2000 31 812 20
- Gittell JH Fairfield KM Bierbaum B Head W Jackson R Kelly M Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients Medical Care 2000 38 807 19
- Ray LD The social and political conditions that shape special-needs parenting Journal of Family Nursing 2003 9 281 304
- Schoen C Osborn R Huynh PT Doty M Zapert K Peugh J Taking the pulse of health care systems: experiences of patients with health problems in six countries: patients' voices can provide policy leaders with a window onto what is happening at the front lines of care Health Affairs 2005 24 W5-509-25
- Coleman EA Berenson RA Lost in transition: challenges and opportunities for improving the quality of transitional care Annals of Internal Medicine 2004 141 533 6
- Pickett W Hartling L Brison RJ A population-based study of hospitalized injuries in Kingston, Ontario, identified via the Canadian hospitals injury reporting and prevention program Chronic Diseases in Canada 1997 18 2 61 9
- Hewitt M Rowland JH Yanick R Cancer survivors in the United States: age, health and disability The Journals of Gerontology, Series A, Biological Sciences and Medical Sciences 2003 58 1 82 91
- Roche JJW Wenn RT Sahota O Moran CG Effect of comorbidities and postoperative complications on morality after hip fracture in elderly people: prospective observational cohort study British Medical Journal 2005 10 331 1374
- Jaglal SB Sherry PG Schatzker J The impact and consequences of hip fracture in Ontario Canadian Journal of Surgery 1996 39 2 105 11
- Wells JL Seabrook JA Stolee P Borrie MJ Knoefel F State of the art in geriatric rehabilitation. Part II: clinical challenges Archives of Physical Medicine and Rehabilitation 2003 84 898 903
- Wiktorowicz ME Goree R Papaioannou A Adachi JD Papadimitropoulos E Economic implications of hip fracture: health service use, institutional care and cost in Canada Osteoporosis International 2001 12 4 271 8
- Nguyen-Oghalai TU Kuo Y Zhang DD Graham J Goodwin J Ottenbacher K Discharge setting for patients with hip fracture: trends from 2001 to 2005 Journal of the American Geriatrics Society 2008 56 6 1063 68
- McLeod J McMurray J Walker JD Heckman GA Stolee P Care transitions for older adults with musculoskeletal disorders: continuity from the providers’ perspective International Journal of Integrated Care [serial online] 2011 4 18 11 [cited 2011 Aug 23]. Available from: http://www.ijic.org. URN:NBN:NL:UI:10-1-101377
- Suter E Arndt J Arthur N Parboosingh J Taylor E Deutschlander S Role understanding and effective communication as core competencies for collaborative practice Journal of Interprofessional Care 2009 23 1 41 51
- Kodner D The quest for integrated systems of care for frail older people Aging Clinical and Experimental Research 2002 14 4 307 13
- Gulliford M Naithani S Morgan M What is ‘continuity of care’? Journal of Health Services and Policy 2006 11 248 50
- Hannum RJ Bowman KF O’Toole EE Abbott K Love TE Thomas C Dawson NV Caregiver objective burden and assessments of patient-centered, family-focused care for frail elderly veterans The Gerontologist 2007 47 1 21 33
- Quinn CC Port CL Zimmerman S Gruber-Baldini AL Kasper JD Fleshner Short-stay nursing home rehabilitation patients: transitional care problems pose research challenges Journal of the American Geriatrics Society 2008 56 1 1940 45
- Quinn K Methodological considerations in surveys of older adults: technology matters International Journal of Emerging Technologies and Society 2010 8 2 114 33
- Coleman EA Williams MV Executing high-quality care transitions: a call to do it right Journal of Hospital Medicine 2007 2 5 287 90
- LeCompte MD Schensul JJ Analyzing and interpreting ethnographic data, volume 5 1999 Walnuck Creek, CA AltaMira Press
- Knoblauch H Focused ethnography Forum: Qualitative Social Research [serial online] 2005 9 6 3 [cited 2011 Aug 22]. Available from: http://www.qualitative-research.net/index.php/fqs/article/viewArticle/20/43. URN:NBN:DE:0114-fqs0503440
- Cohen D Crabtree B Semi-structured interviews 1995 [webpage on the internet]. c2008 [cited 2011; updated 2008]. Available from: http://www.qualres.org/HomeSemi-3629.html
- Babbie E The practice of social research 7th edition 1995 Belmont, CA Wadsworth
- Kilian C Salmoni A Ward-Griffin C Kloseck M Perceiving falls within a family context: a focused ethnographic approach Canadian Journal on Aging 2008 27 4 331 45
- QSR International Pty Ltd NVivo qualitative data analysis software 2008;Version 8
- Throne S Data analysis in qualitative research Evidenced Based Nursing 2000 3 68 70
- Leggat SG Leat P A framework for assessing the performance of integrated health delivery systems Healthcare Management Forum 1997 10 1 11 8
- Shortell SM Casalino P Health care reform requires accountable care systems Journal of the American Medical Association 2008 300 1 95 7
- Bergman H Ferrucci L Guralnik J Hogan DB Hummel S Karunananthan S Frailty: an emerging research and clinical paradigm—issues and controversies The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 2007 62 7 731 7
- Hébert R Durand PJ Dubuc N Tourigny A Frail elderly patients: new model for integrated service delivery Canadian Family Physician 2003 49 992 7
- The Institute for Patient and Family Centred Care Applying patient- and family-centered concepts to beside rounds: a guidance document 2008 Bethesda, Maryland Institute for Patient and Family Center Care [cited 2011 26 Aug]. Available from: http://www.ipfcc.org/advance/topics/PH_RD_Applying_PFCC_Rounds_012009.pdf
- Boon H Verhoef M O’Hara D Findlay B From parallel practice to integrative health care: a conceptual framework BMC Health Services Research [serial online] 2004 7 1 4 15 [cited 2011 Aug 29]. Available from: http://www.biomedcentral.com/1472-6963/4/15. doi:10.1186/1472-6963-4-15
- Blanchette P Flynn B Geriatric medicine: an approaching crisis Generations 2001 25 1 80 4
- Cook RI Render ML Woods DD Gaps in the continuity of care and progress on patient safety British Medical Journal 2000 320 7237 791 4
- Levine C Kuerbis AN Gould DA Navaie-Walizer M Feldman PH Donelan K A survey of family caregivers in New York city: findings and implications for the health care system 2000 New York United Hospital Fund of New York [cited 2011 27 Aug]. Available from: www.uhfnyc.org/assets/806
- Van Walraven C Mamdani M Fang J Austin PC Continuity of care and patient outcomes after hospital discharge Journal of General Internal Medicine 2004 19 624 31
- Schmitt M Collaboration improves the quality of care: methodological challenges and evidence from US health care research Journal of Interprofessional Care 2001 15 1 47 66
- Gagliardi AR Dobrow MJ Wright FC How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management Surgical Oncology 2011 20 146 54
- Hudson B Pessimism and optimism in the inter-professional working: the Sedgefield Integrated Team Journal of Interprofessional Care 2007 21 1 3 15
- D’Amour D Oandasan I Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept Journal of Interprofessional Care 2005 19 1 8 20
- Freeth D Sustaining interprofessional collaboration Journal of Interprofessional Care 2001 15 1 37 46
- Vedel I Monette M Beland F Monette J Bergman H Ten years of integrated care: backwards and forwards. The case of the province of Quebec, Canada International Journal of Integrated Care [serial online] 2011 3 7 11 [cited 2011 Aug 29]. Available from: http://www.ijic.org. URN:NBN:NL:UI:10-1-101295
- MacAdam M Frameworks of integrated care for the elderly: a systematic review 2008 Ottawa Canadian Policy Research Networks Inc [cited 2011 28 Aug]. Available from: www.cprn.org/documents/49813_EN.pdf
- Shortell SM Gillies RR Anderson DA Moran KE Michell JB Remaking health care in America: the evolution of organized delivery systems 1996 San Francisco, CA Josey-Bass
- Shortell SM McCurdy RK Integrated health systems Studies in Health Technologies and Informatics 2010 153 369 82
- Doll R Barroetavena MC Ellwood AL Fillion L Habra ME Linden W The cancer care navigator: towards a conceptual framework for a new role in oncology Oncology Care 2007 6 4 28 35
- Manderson B McMurray J Piraino E Stolee P System navigation roles to support chronically ill older adults through health care transitions: a review of the literature Health and Social Care in the Community 2012 3 20 2 113 27 doi: 10.1111/j.1365-2524.2011.01032.x. Epub 2011 Oct 13
- Toscan J Silent partners in care: examining care transitions for caregivers of hip fracture and stroke patients 2011 Waterloo, ON University of Waterloo Thesis
- Uman GC Urman HN Elder care: the challenges of conducting clinical nursing research with elderly populations Association of Perioperative Registered Nurses Journal 1990 52 400 6
- Bowsher J Bramlett M Burnside IM Gueldner SH Methodological considerations in the study of frail elderly people Journal of Advanced Nursing 1993 18 873 9
- Gueldner SH Hanner MB Methodological issues related to gerontological nursing research Nursing Research 1989 38 3 183 5
- Carter WB Elward K Mamgren J Martin ML Larson E Participation of older adults in health programs and research: a critical review of the literature The Gerontologist 1991 31 584 92
- Ives DG Kuller LH Schulz R Traven ND Lave JR Comparison of recruitment strategies and associated disease prevalence for health promotion in rural elderly Preventative Medicine 1992 21 5 582 91
- McNeely EA Clements SD Recruitment and retention of the older adult into research studies Journal of Neuroscience Nursing 1994 26 57 61
- Mody L Miller DK McGloin JM Freeman M Marcantonio ER Magaziner J Recruitment and retention of older adults in aging research Journal of the American Geriatrics Society 2008 56 12 2340 8
- Kelsey JL O’Brien LA Grisso JA Hoffman S Issues in carrying out epidemiologic research in the elderly American Journal of Epidemiology 1989 130 5 857 66
- Polit DF Beck CT Nursing research: principles and methods, 7th edition 2004 Philadelphia, PA Lipincott, Williams & Wilkins
DOI: https://doi.org/10.5334/ijic.797 | Journal eISSN: 1568-4156
Language: English
Submitted on: Sep 9, 2011
Accepted on: Jan 25, 2012
Published on: Apr 13, 2012
Published by: Igitur, Utrecht Publishing & Archiving
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
© 2012 Justine Toscan, Katie Mairs, Stephanie Hinton, Paul Stolee, published by Igitur, Utrecht Publishing & Archiving
This work is licensed under the Creative Commons Attribution 4.0 License.