Early readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital. This is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term. Participants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26–0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16–0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07–12.9). In older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients’ social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study. NIH trials registry number ClinicalTrials.gov: NCT01221532 .

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula aim to promote effective communication between patients and clinicians and among members of health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically affiliated safety-net system to solicit feedback on content offered during RCC skills trainings. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings for application in interpreted interactions to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital. We randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge. Of 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen. An inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes.

BACKGROUND:Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success.OBJECTIVE:To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital.DESIGN:Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532).SETTING:Publicly funded urban hospital in Northern California.PATIENTS:Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese).INTERVENTION:Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner.MEASUREMENTS:Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals.RESULTS:There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days).LIMITATIONS:This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered.CONCLUSION:A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population.PRIMARY FUNDING SOURCE:Gordon and Betty Moore Foundation.

In America the diverse, language, literacy, and cultural and socioeconomic factors must drive the design of effective transitional care models.Ethnic minorities constitute the fastest growing segment of the elderly population, but the take-home literature provided during care transitions does not reflect this. Language, literacy, and cultural and socioeconomic factors will become increasingly important when designing transitional care models to meet the needs of a rapidly changing population.The number of minority group older adults is expected to increase more than 500 percent in the next fifty years, and accounts for more than one in four older persons. According to the Pew Research Center, 20 percent of the country's elderly people will be foreign born. In California, demographers predict that by 2050, the proportion of Hispanics and Asians will increase dramatically from 35 percent and 10 percent to around 50 percent and 15 percent, respectively.Projects to improve transitions in care have shown that as many as one-third of hospital re-admissions in the month after discharge can be avoided (Jack et al., 2009; Naylor et al., 2004; Coleman et al., 2004). However, most evaluations of transitional care models have lacked sufficient samples of minorities, recent immigrants, or limited English-proficient elders to determine effectiveness in these groups. Only one study to date has evaluated a program specifically targeting African American and Spanish-speaking older adults with heart failure, and it showed modest reductions in rehospitalizations and improved function (Sisk et al., 2006) with such cultural competency efforts.Immigration status, language barriers, and low health literacy were recently identified as major contributing factors to hospital re-admission in a survey of National Association of Public Hospital members (NAPH, 2011). Other studies have demonstrated that older adults who are recent immigrants and-or ethnic minorities are especially vulnerable during healthcare transitions (Graham, Ivey, and Neuhauser, 2009). Ethnic minorities have slower rates of recovery after hospitalization and increased incidence of potentially preventable re-hospitalizations, when compared with the general population (Davis, Liu, and Gibbons, 2003; Jiang et al., 2005; Lafata et al., 2004; Sands et al., 2005).In addition to known predictors of hospital re-admission, such as medical errors and inadequate follow-up care, other factors like low socioeconomic status (Weissman, Stern, and Epstein, 1994), poor social support (Rodriguez- Artalejo et al., 2006), and depression (Mitchell et al., 2010) are associated with re-admissions.Testing a Culturally Conscious Transitions InterventionA randomized controlled trial, Support from Hospital to Home for Elders (SHHE), is underway to assess the impact of interventions in ethnically and culturally diverse safety-net settings. The SHHE trial, generously funded by the Gordon and Betty Moore Foundation, is the first transitions intervention randomized controlled trial to target English-, Spanish-, and Chinese-speaking patients older than age 55. Through a hybrid of principles from Project RED (Jack et al., 2009) and the Care Transitions Intervention (Coleman et al., 2004), patients admitted to San Francisco General Hospital (SFGH) are assigned to work with a diverse team of registered nurses that reflects the cultural and language diversity of the target population. A single nurse from this team shepherds a patient and their family members through the process of preparing for a successful transition home.The transitionalist nurse has three primary roles. The first is to be a patient and caregiver coach who engages patients and caregivers through motivational interviewing techniques and goal-setting to help prepare them for self-care and care-navigation challenges after discharge. The second role is to be an educator who uses a combination of teach-back (where patients explain back to the provider the steps they need to follow) and traditional bedside teaching techniques to help patients understand their diagnoses, medications, and posttransition care plan. …