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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….)

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care transitions critical to quality and patient safety

Care Transitions – Critical to Quality and Patient Safety

Society of Hospital Medicine

Lakshmi K. Halasyamani, MD

society of hospital medicine
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
Areas of Interest/Focus
  • Management of patient populations in hospital
  • Teamwork
  • Hand offs
  • Care Transitions
overview of 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
SHM and Care Transitions
  • Defining Standards
  • Developing Team-based Interventions
  • Evaluating Interventions
  • Influencing Policy
defining standards
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
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
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
SHM/Hartford Partnership
  • BOOST Advisory Board:
    • 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
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
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 initiative12
Components of Initiative
  • Develop Implementation Guide
  • Develop Network of Institutions to implement discharge interventions
  • Identify Facilitating Factors
  • Identify Barriers
influencing policy
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 multi-disciplinary strategy to improve care transitions
future directions
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