Transitions of Care
Coordination of Care Across Settings
Mark Hawk, MSN, ACNP
Carla Graf, MS, CNS
Bree Johnston, MD
Objectives
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Identify all potential acute care setting
disciplines/departments that are involved in the care
of this population.
Explain current evidence-based research regarding
“models of care” for transitions across acute
settings/units.
Identify all potential disposition avenues (SNF, rehab,
home, etc.) for acutely hospitalized elders.
Recognize common obstacles in providing seamless
transitions between acute care settings/providers.
Transitions of Care
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Insurance
Placement needs
Need for SNF with on-site dialysis
Support System
Occupying inpatient med-surg bed
Unable to schedule elective surgery
Patient outcome
Discontinuity Errors
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3 types of errors:
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Medication continuity
Test result follow up
Workup
49% had at least one error
(Moore JGIM 2003; 18: 646-51)
Transition
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Passage from one place, state, stage of
development to another; also the period or
place where such a change is effected
(Fletcher 2005)
What is “Transitional Care”?
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…a set of actions designed to ensure the
coordination and continuity of health care as
patients transfer between different locations or
different levels of care within the same
location.
(Coleman, 2003)
Transitional Care
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Encompasses both sending and receiving
aspects of transfer
Appropriate information sharing
Logistical arrangements
Education of patient and caregivers
Coordination among varied HCP
Absolutely NECESSARY for those with
comp,ex care needs (Fletcher, 2005)
An 82 yr old with a hip fracture in
an acute hospital setting sees…
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Paramedics
Emergency Physician
Nursing
Orthopedic Surgeon
Hospitalist/Intensivist
PT/OT
Social Services
Nutrition
This 82 yr old with a hip fracture then is
“transitioned” to a Skilled Nursing
Facility where he/she sees…
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SNF Physician
SNF Nursing
SNF PT/OT
Then they are “transitioned” home where
they see…
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Home Care Nurses
Home Care PT/OT
PCP
PCP Nurse
PC Pharmacist
What is the common thread?
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The patient
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And the caregivers
What breaks the common thread?
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From the patients’ perspective:
Deficiencies in preparing caregivers and the
patient themselves for the transition
 Transferring of information across settings
 Supporting self-management of chronic conditions
 No encouragement to express own preferences of
the patient or caregiver
(Coleman, 2003)
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Patient Perspective
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According to a California Health Care
Foundation survey, patients rated transition to
home lower than ANY other health care
experience
Qualitative studies suggest that patients often
don’t understand medication SEs, whom they
should direct questions to, what warning signs
to look for, or when to resume normal
activities
What breaks the common thread?
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From the caregivers’ perspective:
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Lack of preparation in “what to expect” and how
to respond to the changing needs of their loved
ones moving between settings
(Coleman, 2003)
Often, all that is needed is 1
or 2 more days of acute care!
Transitional Care for Learners
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Helps address the systems based practice (and
possible practice based learning) competency
May help move learners beyond the culture of
rewarding all discharges
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“You’re awesome - you diuresed the service!
(but with what patient outcomes?)
May help learners see patients in the context of
their own lives
Prevalence
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In 2000 for every 1000 people aged 65 and
over they averaged:
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400 ambulatory care visits
300 emergency department visits
200 hospital admissions
46 SNF admissions
106 home care admissions
(Coleman, 2003)
Prevalence
2001 Harris Poll commissioned by Robert
Wood Johnson Foundation
 On average, older people with one or more
chronic conditions sees how many different
physicians over the course of one year?
 Eight!
(Coleman, 2003)
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Prevalence
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23% of hospital patients aged 65 and over are
discharged to another institution.
11.6% are discharged with home care.
19% of SNF patients are transferred back to an acute
care hospital within 30 days, 42% within 24 months.
Ma, et al (2002) studied 920 community dwelling
elders DCed from hospital to SNF/Rehab…
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Nearly 50% had four or more additional institutional
transitions over a 12 month period.
(Coleman, 2003)
Why do poor transitions happen?
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Fragmented Care
Institutional isolation from one another
Lack of financial incentives
Regulatory
Medicare directed towards each “setting”
rather than each “episode” of care
Few quality indicators to measure performance
Professional barriers
Why do poor transitions happen?
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Multiple providers unfamiliar with “scope of
care/services” at receiving facility
PCP doesn’t have privileges at receiving facility
Conflicting recommendations about chronic condition
management
Confusing medication regimens-error and duplicity
Lack of follow-up care
Inadequate preparation of patient and caregiver for
receiving care at next facility
Passive Role of the patient/caregiver
Transitions often urgent and unplanned
Care Transitions Intervention-Four
“Pillars”
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Medication self-management
A patient-centered record
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Personal Health Record
Use of a Transition Coach
Primary care and specialist follow-up
 Knowledge of “red flag” warning symptoms or
signs indicative of a worsening condition
(Coleman et al, 2004)
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Medication Reconciliation
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2001 Harris Poll for RWJ Foundation…
16 million adult Americans with chronic
illness revealed that their pharmacist told them
that medications prescribed by one or more of
their physicians had potentially harmful
interactions.
(Coleman, 2003)
Medication Reconciliation
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Forster et al, 2003-19% of patients discharged
from a hospital experienced an associated
adverse event within 3 weeks.
66% of those were adverse drug events
2006 JCAHO National patient
Safety Goals
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Goal 8A:
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Implement a process for obtaining and
documenting a complete list of the patient’s
current medications upon the patient’s admission
to the organization and with the involvement of the
patient. This process includes a comparison of the
medication the organization provides to those on
the list.
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Goal 8B:
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A complete list of the patient’s medications is
communicated to the next provider of service
when a patient is referred or transferred to another
setting, service, practitioner or level of care within
or outside the organization.
Anatomy of a “good transition”
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Communication of vital elements of the care plan
A Common Plan of Care
The patient’s goals and preferences
An “updated” list of problems, baseline physical and
cognitive functional status, current medications and
allergies
Contact information for the patient’s caregiver and
PCP
Preparation of the patient and caregiver
Anatomy of a “good transition”
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Reconciliation of medication list “pre” and
“post” transfer
Transportation of the patient
Completion of Follow-up care with a
practitioner and/or diagnostic studies
Availability of diagnostic results
Availability of advance care directives
“warning signs” and contact information
Why Coordinate Care?
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Advance “patient-centered” care
Support for shared decision-making
Promote patient safety
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Medication use/errors
Control Medicare costs
Reduce unnecessary utilization/redundancy of
care
JCAHO
What needs to be done?
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System level performance measurement
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Process measures
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Is the patient prepared for transfer?
Is the appropriate information promptly transmitted?
Reconciliation of “pre-” and “post”- transition care
regimens
Information technologies
What needs to be done?
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Intervention from “oversight” level
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Medicare
JCAHO
Change payment policies
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Financial incentives for institutions/providers
Coding and Billing Changes
Research
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How to best integrate patient and caregiver
into interdisciplinary care team
How to foster collaboration
How to identify those patients at high risk for
poor transition-related outcomes
Development of performance indicators to
track quality of transitions
What does work?-A “Bridging”
Model
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Use of APNs to identify those at high risk for
re-admission, follow them through
hospitalization and then after discharge to
home.
APNs assume responsibility for
comprehensive care in collaboration with the
PCP for 4 weeks post discharge
Transition Coach
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Usually Nurse or NP
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Follows patient to home or nursing facility
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Prepares patient for what to expect
Provides tools
Reconciles pre- and post- discharge medication
Practices role play of next MD visit
Phone calls after discharge
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Reinforce plan, ensure follow up
Tools for transitional care
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Medication Discrepancy Tool
Personal Health Record
Care Transitions Measure
CARE TRANSITIONS MEASURE (CTM-3)
1. The hospital staff took my preferences and those of my family or
caregiver into account in deciding what my health care needs would
be when I left the hospital.
Strongly Disagree
Disagree
Agree
Strongly Agree N/A/dont’ know
2. When I left the hospital, I had a good understanding of the things I
was responsible for in managing my health.
Strongly Disagree
Disagree
Agree
Strongly Agree N/A/dont’ know
3. When I left the hospital, I clearly understood the purpose for taking
each of my medications.
Strongly Disagree
Disagree
Agree
Strongly Agree N/A/dont’ know
What does work?-Other Models
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APNs enhancing and encouraging the patient’s &
caregiver’s participation in their care management
Staff from “receiving” facility visits the patient in
hospital and initiates the transition
Extended Care Pathways
Program for All-Inclusive Care of the Elderly (PACE)
www.SFGetCare.com
www.sfgov.org/daas (Dept of Aging and Adult
Services)
In Summary
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Problems related to transitional care are
common
There is evidence that enhanced focus on
transitional care improves outcomes
Multiple tools are available that can help us
improve our transitional care
In Summary:
High Quality Transitional Care
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Reliable information on transfer
Clear instructions about pending tests, follow
up visits, follow up tasks, and medications
Preparation of patient, family, and caregiver
Empowerment of patient to assert preferences
References
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Coleman EA. (2003). Falling through the cracks:
challenges and opportunities for improving
transitional care for persons with continuous
complex care needs. Journal of the American
Geriatrics Society. 51: 549-555
Coleman et al. (2004). Preparing patients and
caregivers to participate in care delivered across
settings: the care transitions intervention.
Journal of the American Geriatrics Society. 52:
1817-1825