Care Transitions – Critical to
Quality and Patient Safety
Society of Hospital Medicine
Lakshmi K. Halasyamani, MD
Society of Hospital Medicine
• Professional Society for Hospitalists and
other hospital-based healthcare
professionals (nurses, pharmacists, AHP,
etc….)
• Total number of members > 6000
Areas of Interest/Focus
• Management of patient populations in
hospital
• Teamwork
• Hand offs
• Care Transitions
Overview of Care Transitions
• Admission to Hospital (From ED or Direct
admission)
• Transitions within hospitalization
(shift/service change transitions/handoffs)
• Transition from hospital to post-acute setting
(home, subacute facility/nursing home,
hospice, other acute care setting)
• Transitions within outpatient care delivery
settings
SHM and Care Transitions
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Defining Standards
Developing Team-based Interventions
Evaluating Interventions
Influencing Policy
Defining Standards
• Participation in consortiums regarding care
transitions:
– SUTTP – Stepping Up to the Plate
– TOCCC – Transitions of Care Consensus Conference
– NTOCC – National Transitions of Care Coalition
• Development of Hospitalist Standards for
Discharge and Shift/Service change transition
Key Messages
• Patient-Centered
• Transitions involve two-way
communication of information
• Timely
• Clinician accountability
• Development of standardized care
transition data set
• Need for communication infrastructure
Developing Interventions
• SafeSteps – pilot initiative to improve
medication safety
• Hartford BOOST initiative -- Better
Outcomes for Older Adults through
Safe Transitions
• Common Theme: Focus on
Implementation and real-world
sustainability of initiatives
SHM/Hartford Partnership
• BOOST Advisory Board:
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American Geriatrics Society
American Society of Health-System Pharmacists
Case Management Society of America
Blue Cross Blue Shield Association
Centers for Medicare and Medicaid Services
The Families and Healthcare Project
Society of General Internal Medicine
Institute for Healthcare Improvement
John A Hartford Foundation
Joint Commission
Agency for Health Research and Quality
National Quality Forum
Philosophy of Initiative
• Patient/Family/Caregiver –centered
• Multi-disciplinary Team-based
• Embedded in care delivery to promote
sustainability
• Includes both academic and community
settings
• Includes rigorous evaluation
Components of Initiative
• Develop Interventions to Improve
Discharge Care Transition
– Patient-centered risk assessment
– Identification of Gaps
– Engagement of patient/family/caregiver
through teach back strategy
Components of Initiative
• Develop Implementation Guide
• Develop Network of Institutions to
implement discharge interventions
• Identify Facilitating Factors
• Identify Barriers
Influencing Policy
• Work with organizations developing care
transition measures
• Focus on discharge and shift/service
change as a standardized team process
• Work collaboratively with other
organizations to develop a multidisciplinary strategy to improve care
transitions
Future Directions
• Alignment of payers and systems around
safe care transitions
• Work with major HIT vendors regarding
standardization of pathways to improve
care transitions
• Partner with home and community
services to facilitate seamless care
transitions across the continuum