Effective and Supportive Transitions of Care:
The Care Teams Role in Reducing Admissions
Jim Kinsey, Planetree
Presented to Texas Center for Quality and Safety
January 2013
Setting the Stage
The term "transitions of care" refers to a patient leaving one
care setting and moving to another as their condition or
healthcare needs change. The care transition often involves
multiple persons including the patient, family or other
caregivers...
An optimal transition should be well planned with the
involvement of the patient and family, and adequately timed.
More often, however, the communication between settings
and the coordination among caregivers, patients and
healthcare professionals fail to provide all the information
needed for optimum quality of care
Just the Facts
Just the Facts
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Cost $25 billion dollars annually
Most patients are on 6+ medications at time of discharge
Limited access to post-hospitalization follow-up care
Preventable transition errors (mostly medication related)
 Penalties:
 $280,000,000 in 2012
 Including over 2, 000 hospitals
 1,910 of those hospitals receiving less than
1% penalty
 Penalties increase to 2% in 2013 and 3% 2014
NQF 2010-2012
It is not just about reimbursement…
So where do we begin…
Communication
Collaboration
Communicate: Patient and Family Activation
• Care Partner Programs
• Clear concise advance directives
• Diagnosing patient preferences
Preference Diagnosis: First Step to Effective Transitions
TEAM TALK
• Inform the patient that choice exists.
• Differentiate between the doctor’s medical expertise and the patient’s expertise on what
matters most to him/her.
• Invite the patient to form a team to explore options.
OPTION TALK
• List options and risks, benefits and side effects.
• Engage patient in deliberations.
• Observe patient’s reactions.
• Follow patient’s lead as guide for continuing option talk or moving to decision talk.
DECISION TALK
• Ask: Do you feel ready to make a decision or receive a recommendation?
• Assess whether patient’s decision is consistent with stated priorities. If yes, offer support;
if no, propose additional option talk
• If asked to make a recommendation, doctor should confirm understanding of patient’s
priorities
Drawn from Mulley, A.G., Trimble, C. and Elwyn, G. “Stop the silent misdiagnosis: patients’ preferences matter.” BMJ, 2012, 345.
Collaborating for Positive Patient Outcomes
Medication
Reconciliation
Discharge
Instructions
Consistent Care
Philosophy
Coordinated
Discharge Plan
Patient Care
Narrative or
Personal EMR
Physician
Follow-Up
Scheduled for
24 hours or less
Social Support
Evaluation
Verbal Report
Shared
Electronic
Record
Care Team Activities
Acute Care
Preference Diagnosis/Social Support
Care Partner Program
Discharge Planning
Comprehensive Medication Review
Personal MR Narrative
Verbal report to next provider
Skilled Care
Standing orders collaboration
Doctor Visit within 24 hours
Evaluate Social Support
Medication Availability
Consistent treatment plan
Prepare for discharge
Home Care
Receive verbal report, preferably in person with
patient
Equipment delivered in advance
Medication reconciliation
Creating a Collaborative
Patients Voice
• Tell me about your recent transition of care?
• Tell me how we may have done that better?
Provider Voice: Who are the players in your community?
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What is working?
What isn't working?
How to we create standard work and processes between our service lines?
How can we standardize treatment philosophies while maintain focus on patient preferences?
Most importantly put down the history and focus on providing exceptional patient experiences
“…the thought is that we are here to provide service to
patients and their families, understanding that patients are
not isolated individual units, but they function as part of a
social system, so involving family also in access to
information, education and care is very important.”
Susan Frampton, President Planetree
Jim Kinsey, Planetree
610.733.5140
jkinsey@planetree.org
www.planetree.org