Transition of Care

The researchers are investigating if using a risk-based prediction score or benefit-based prediction score to allocate transition of care (TOC) interventions is more effective in reducing the rate of unplanned hospital readmissions or death within 30 days of hospital discharge.

Moving from pediatric (children's) health care to adult health care can be challenging for youth and young adults with eating disorders. Many young people and families report feeling unprepared, unsure of what to expect, and worried about losing support during this time. Gaps in care during this transition can increase stress and make recovery more difficult. This study is testing a structured transition support program called the TransitionED framework. The goal is to see whether this program can be successfully used in real hospital settings and whether youth, caregivers, and clinicians find it helpful. The TransitionED framework is designed to help youth and families prepare for the move to adult care. It includes: 1. A transition planning package for youth 2. A separate planning package for caregivers 3. At least two guided transition meetings with a clinician 4. A short "Personal Transition Profile" written by the youth to help new adult providers understand them better 5. Optional virtual peer support sessions for youth and for caregivers 6. Tools to help pediatric and adult providers communicate more clearly Youth who are 16 years or older and currently receiving care in a participating pediatric eating disorder program may be invited to join, along with one caregiver. Clinicians and program leaders will also take part to help deliver and evaluate the program. Participants will complete surveys at the beginning of the study, about two months later, and six months after finishing the program. Some participants will also take part in interviews to share their experiences. This study is focused on feasibility. That means the main goal is to learn whether this transition program is practical, acceptable, and workable in everyday clinical care. What we learn will help improve transition support for youth and young adults with eating disorders in the future.

Cardiac rehabilitation (CR) is a secondary prevention program for patients with cardiovascular disease (CVD). It is especially valuable as CVD increasingly occurs in combination with comorbidity, frailty, and complexities of care that predispose patients to functional decline, disability, and high costs. Still, few Veterans participate in CR, in part because of the difficult logistics to attend. Promising Practice home-based CR (HBCR) was developed to increase CR participation, but many Veterans remain too limited by comorbidity and frailty for participation. A Transition to CR (T2CR) intervention is a face-to-face program that fosters vital skills, education, insights, motivation, and patient-provider relationships conducive to successful HBCR thereafter. This study compares Veterans eligible for CR who are randomized to T2CR intervention versus usual care. Differences in functional capacity, HBCR participation, and healthy days at home are compared over one year. Patients' experiences and providers' perspectives of barriers and facilitators to T2CR are also compared.

The PALMA project is part of a larger palliative research program COPAL in Capital Region of Denmark led by Professor Tom Møller. PALMA aims to improve palliative care for geriatric patients transitioning from emergency-hospital to primary care. The project addresses the lack of a systematic approach for assessing and managing palliative symptoms in geriatric patients to enhance communication between hospitals and municipal health care services. The PALMA cohort investigates the applicability of systematic palliative assessment (EORTC-C15 PAL) in the geriatric emergency setting combined with measures of frailty, socio-demographic risks, and cross-sectoral healthcare support.