Programs and Communities

Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually, transitional care should be time-sensitive, patient-centered services intended to ensure continuity of care and an efficient transition between health care settings or home. A patient centered transitional care program was implemented at an outpatient primary care facility to reduce readmission rates. Institutional Review Board approval was obtained.

Twenty adult patients with chronic diseases discharged from an acute setting were identified. A follow up phone call and/or a home visit within 24-72 hours post discharge was employed. The Care Transitions Measure (CTM®) and Medication Discrepancy Tool (MDT®) were utilized to identify quality of care of transition and medication discrepancies. A chart audit collected data on the age of participant, diagnosis for initial hospitalization, CTM score, home visit, and ED visits or re-hospitalizations after 30 days of discharge. The outcome indicated that transitional care within primary care utilizing evidence-based practices is beneficial in reducing readmission rates. A logistic regression showed model significance, p = .002, suggesting that the CTM score was effective for both telephone support (TS) and home visit (HV).

A correlation analysis showed that as age of participants increased, the CTM score decreased, indicating that older adults required more support. A significance p <.001, of a proportional test indicated that readmission rates after the intervention was lower. It is evident that providing a timely and effective transitional care intervention in a primary care setting can reduce hospital readmissions, improve symptom management and quality of life of adult patients with chronic diseases.

Low back pain is a worldwide health problem. Preoperative education is essential to provide patients with information across the continuum of care. Gaps exist among healthcare organizations regarding deficiencies in properly educating patients about their surgical experience. The lack of proper preoperative education can negatively impact reimbursement for healthcare systems, providers, and patient outcomes. In a large metropolitan tertiary care center providing spine surgery, an evidence-based project was implemented. A self-developed pre and post intervention surveys was given assessing patients’ knowledge and surgical expectations after surgery. A tri-fold education pamphlet was given to the participants with information that included detailed information regarding expectations before and after surgery.

Descriptive statistics were used to describe the sample and outcome variable. An increase in knowledge in expectations after surgery was noted from pre-intervention (mean 1.83, SD .408) to post-intervention (mean 1.67, SD .816) with a Cohen’s D of 0.248 although this was not statistically significant. However, the change in average length of stay (LOS) was significant. The average LOS for the project participants dropped from 4.54 days to 2.833 days which is within the Centers for Medicare and Medicaid Services (CMS) guidelines of 2.92 days for this surgical population. In conclusion, an increased in patients’ knowledge regarding expectations following surgery and decreased LOS was seen for the project participants.

As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose.

King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages.

City governments are increasingly interested in the concept of urban resilience. While theoretical debates continue to develop and critique the value of ‘urban resilience,’ a growing number of cities are organizing policies and projects around the concept. Building urban resilience is viewed as a key concern for cities facing, in particular, climatic threats –although other urban challenges and equity concerns are increasingly prioritized. Support from city leadership and large funding opportunities, such as the Rockefeller Foundation’s 100 Resilient Cities program, have encouraged some leading cities to create and manage city-wide resilience strategies. Yet pioneering cities have few guideposts to institutionalize resilience. This research evolved out of conversations with city officials in Portland, OR who were interested to learn how other cities were organizing resilience work. We explore how urban resilience is being structured and coordinated in 19 North American cities, focusing on emerging definitions, organizational structures, internal and external coordination efforts, and practitioners’ insights. We situate our findings on emerging governance approaches and lessons learned within the current urban resilience literature on governance by reviewing 40 academic papers and identifying 6 recurrent factors for effective governance. Additionally, we conducted 19 semi-structured interviews with North American resilience practitioners to describe emerging organization trends and share lessons from practice. Based off our interviews, we propose 5 key findings for structuring resilience work in cities effectively. These include: establishing a clear, contextual definition and scope, bringing communities into the process, championing the agreed-upon vision, balancing a centralized and dispersed approach, and recognizing tradeoffs in organizational placement. This research provides practitioners with insights to help facilitate resilience work within their cities and contributed to the scholarly debate on moving resilience theory toward implementation.

Cities are restoring rivers to recapture the social, ecological, and economic benefits of rehabilitated rivers. But, traditional urban planning and flood management tools may not address the complex relationships between humans, the built environment, and natural elements in the social-ecological systems of which rivers are an important part. They also may not acknowledge and address the factors that led to channelization. The field of regenerative design and development—an eco-centric approach that aims to dismantle the underlying processes and viewpoints behind the most pressing environmental problems—offers tools to plan more effective and inclusive river restoration projects. To explore these issues and the potential of regenerative design and development, we reviewed 15 urban river restoration plans, followed by a comparative case study of the Los Angeles River, CA and the Kinnickinnic River, WI. We conducted a content analysis of plans and popular press articles, and interviewed key actors. Results indicate many participants exhibit regenerative thinking and participate in regenerative processes, but they are unable to fully implement regenerative projects due to several constraints at institutional, social, economic, physical levels. Study recommendations emphasize rooting restoration in the unique aspects of place, reframing projects as part of nested social-ecological systems, working from potential, addressing broader socioeconomic challenges, and leveraging strategic nodes. Changes to planning education and practice are needed to empower planners to think and act regeneratively.