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Improving Patient-Centered Transitional Care after Complex Abdominal Surgery.

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A pilot study found that an adapted Coordinated Transitional Care (C-TraC) program is a feasible phone-based intervention for surgical patients. High engagement and low refusal rates suggest potential for improving post-discharge care and reducing readmissions.

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Area of Science:

  • Surgery
  • Patient Care
  • Health Services Research

Background:

  • Poor hospital-to-home transitions increase readmissions after complex abdominal surgery.
  • Existing transitional care programs lack evidence for surgical populations.
  • This study piloted an adapted Coordinated Transitional Care (C-TraC) protocol for surgical patients.

Purpose of the Study:

  • To evaluate the feasibility of an adapted surgical C-TraC program.
  • To assess the preliminary effectiveness of the phone-based protocol.
  • To identify key areas for improvement in surgical transitional care.

Main Methods:

  • A phone-based intervention involving protocolized nurse calls post-discharge.
  • Enrollment criteria included complex abdominal surgeries and specific discharge needs.
  • Calls addressed medication management, appointments, concerns, and red-flag symptoms.

Main Results:

  • 212 patients enrolled with 95% engagement and 1% refusal.
  • A significant proportion (47%) had medication discrepancies at the first call.
  • Average of 3.2 calls per patient, indicating substantial follow-up.

Conclusions:

  • The adapted surgical C-TraC protocol is feasible and well-received by patients.
  • Medication management is a critical area needing attention in surgical transitions.
  • Further research is required to confirm the impact on healthcare utilization.