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  1. Transitions of Care

  2. What is “Transition of Care” • The movement of patients from one health care practitioner or setting to another as their condition and care needs change • Occurs at multiple levels • Within Settings • Primary care  Specialty care • ICU  Ward • Between Settings • Hospital  Sub-acute facility • Ambulatory clinic  Senior center • Hospital  Home • Across health states • Curative care  Palliative care/Hospice • Personal residence  Assisted living (c) Eric A. Coleman, MD, MPH

  3. What is “Transitional Care?” • 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 • Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the patient's goals, preferences, and clinical status. • Includes: • Logistical arrangements • Education of the patient and family • Coordination among the health professionals involved in the transition Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.

  4. Ineffective Transitions Lead to Poor Outcomes • Wrong treatment • Delay in diagnosis • Severe adverse events • Patient complaints • Increased healthcare costs • Increased length of stay Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

  5. Problems That Illustrate Inadequacies of Care Transitions • Medication errors • Increased health care utilization • Inefficient/duplicative care • Inadequate patient/caregiver preparation • Inadequate follow-up care • Dissatisfaction • Litigation/Bad publicity (c) Eric A. Coleman, MD, MPH

  6. Barriers to Improving Transitions of Care

  7. Barriers to Care Coordination • System level barriers • Practitioner level barriers • Patient level barriers (c) Eric A. Coleman, MD, MPH

  8. System Level Barriers (c) Eric A. Coleman, MD, MPH

  9. Practitioner Level Barriers • Practitioners often have not practiced in settings where they transfer patients • Sending practitioners may not communicate critical information to receiving practitioners • Practitioners may not know the patient and his or her preferences for care • Practitioners have no accountability (c) Eric A. Coleman, MD, MPH

  10. Patient Level Barriers • Patients assume that someone is in charge of coordinating care • Patients (and caregivers) are often the only common thread weaving between care sites • Yet they navigate the system with few tools or training to manage in this role (c) Eric A. Coleman, MD, MPH

  11. AGS Position Statement Position 1: Clinical professionals must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7. (c) Eric A. Coleman, MD, MPH

  12. AGS Position Statement Position 2: Bidirectional communication between clinical professionals is essential to ensuring high quality transition care Position 3: Develop policies that promote high quality transitional care Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7. (c) Eric A. Coleman, MD, MPH

  13. AGS Position Statement Position 4: Education in transitional care should be provided to all health professionals involved in the transfer of patients across settings Position 5: Research should be conducted to improve the process of transitional care Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7. (c) Eric A. Coleman, MD, MPH

  14. Expectations for Both Sending and Receiving Teams • Shift from the concept of “discharge” to “transfer with continuous management” • Begin transfer planning upon or before admission • Incorporate patient/caregivers’ preferences into plan • Identify a patient’s social support and function (how will this patient care for herself after transfer?) • Collaborate with practitioners across settings to formulate and execute a common care plan. (c) Eric A. Coleman, MD, MPH

  15. Expectations for the Sending Team • The patient is stable for transfer • The patient and caregiver understand the purpose of the transfer • The patient and family understand their coverage • The receiving institution is capable and prepared • The care plan, orders, and a clinical summary precede the patient’s arrival • The patient has a timely follow-up appointment (c) Eric A. Coleman, MD, MPH

  16. Expectations for the Receiving Team • Review the transfer forms, clinical summary, and orders prior to or upon the patient’s arrival. • Incorporate the patient/caregiver’s goals and preferences into the care plan. • Clarify discrepancies regarding the care plan, the patient’s status, or the patient’s medications (c) Eric A. Coleman, MD, MPH

  17. What is the National Transitions of Care Coalition? • The National Transitions of Care Coalition was formed to bring together stakeholders from various care settings to address improving care coordination and communication when patients, especially older adults, leave one health care setting and move to another.

  18. Goals • Identify issues and barriers to transitions across the continuum of care • Evaluate appropriate referral criteria between levels of care • Assess available technology, evidence based guidelines, medication reconciliation, and adherence gaps • Establish disease state priorities for coalition focus, e.g., venous thromboembolism, diabetes/glycemic control, acute coronary syndrome, and stroke • Develop tools, guidelines, and pathways for communication between patients, providers, and payers • Develop awareness and resource implementation plans for coalition members to disseminate

  19. Academy of Managed Care Pharmacy American Association of Homes and Services for the Aging American College of Healthcare Executives American Geriatrics Society American Medical Directors Association American Medical Group Association American Society of Consultant Pharmacists American Society of Health-System Pharmacists American Society on Aging AXA Assistance, USA Case Management Society of America Consumers Advancing Patient Safety Health Services Advisory Group Institute of Healthcare Improvement Joint Commission Intl Center for Patient Safety The Joint Commission Liptiz Center for Integrated Health Care Mid-America Coalition on Health Care National Association of Directors of Nursing Administration – Long Term Care National Association of Social Workers National Business Coalition on Health National Quality Forum National Case Management Network Predictive Health, LLC Society of Hospital Medicine The Joint Commission Disease-specific Care Certification URAC Advisory Task Force

  20. Raise NTOCC Awareness Information and tools available by stakeholder Consumer Policy Maker Professional Media

  21. Working Groups Education & Awareness Policy & Advocacy Tools & Resources NTOCC Metrics & Outcomes

  22. Education & Awareness • Working to address awareness and general knowledge about the problems associated with transitions of care and provide the necessary information to various stakeholders – patients, caregivers, health care professionals, and government officials.

  23. Policy & Advocacy • Assessing ways to improve care through enhanced communication tools, collaborative partnership and evaluating the possibility of enhanced reimbursement for transitional care support and technical medical information shared between care settings.

  24. Tools & Resources • Identifying practical tools and resources that can be used by health care professionals, care givers and patients to improve communication in a consistent manner between care settings and reduce risk associated with care transitions.

  25. Metrics & Outcomes • To develop and adopt a framework for measuring transitional care. • To recommend metrics or standards to demonstrate the impact of interventions on reducing risk associated with transitional care

  26. Case Studies for Discussion

  27. Case 1 • During a patient’s monthly follow-up appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.

  28. Case 2 • An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was rehospitalized with uncontrollable bleeding.