Summer 2008

Coordinated Care Transitions Improve Outcomes
By Naomi Hauser, RN, MPA, CLNC
Aging Well
Vol. 1 No. 3

Once an area that received little attention, transitional care planning is currently identified as a national priority requiring both research and action. The Joint Commission, the Centers for Medicare & Medicaid Services (CMS), and quality improvement organizations have all focused their attention on the issue.

Additionally, healthcare organizations such as the Institute for Healthcare Improvement, the Institute of Medicine, the National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition (NTOCC), the American College of Physicians, the Society of General Medicine, and the Society of Hospital Medicine are expending concerted efforts toward optimizing transitions.

Eric Coleman, MD, MPH, of the University of Colorado Health Sciences Center in Denver, completed research demonstrating that developing better approaches and implementing strategies focused upon improving the transition of patients from setting to setting improve outcomes and lower hospital readmission through better communication and increasing self-care management.

The NTOCC carries out its mission, raising awareness among healthcare professionals and government leaders with respect to these issues. It focuses on assembling thought leaders and healthcare experts from various settings to address the gaps impacting patient care, including coordinating healthcare across settings, maximizing quality of care, reducing medication errors, enhancing clinical outcomes by identifying critical issues, defining solutions, and developing essential tools. Some of the tools, such as “My Medication List” and “Transitions of Care Checklist,” can be found on the NTOCC Web site at www.ntocc.org.

The term transitions of care refers to the movements patients make between healthcare practitioners and various settings as their conditions and care needs change during the course of acute or chronic illness episodes. Older adults with complex care needs frequently require care in multiple settings. Transitions occur at many levels, such as the following:

• within settings (e.g., from intensive care unit to a ward);

• between settings (e.g., a hospital and a skilled nursing facility); or

• between health states (e.g., curative and palliative or acute care, long-term care, and chronic care).

Patient-Centered Coordination
As Medicare recipients move between care settings, the quality of services and level of safety may be compromised, leading to an increased fragmentation of care delivery for this vulnerable patient population. Healthcare professionals often function independently from each other. Much of the care delivered exists in silos with minimal communication between entities and no common care plan. Transitional care encompasses coordination among the multitude of healthcare professionals involved in the transition, including the sending and receiving of transfer forms, logistical arrangements, and education of patients and caregivers.

The CMS’ Office of Clinical Standards and Quality Ninth Scope of Work for the Quality Improvement Organization Program from August 2008 through July 2011 includes multiple components formulated for implementation in a cross-setting, collaborative process. This approach addresses care transitions, prevention, and patient safety, with an emphasis on breaking down “silos of care” into more seamless care delivery with improved outcomes for Medicare recipients.

The challenges that occur during care transitions affect the patient, practitioners, institution, and performance measurement. A sequence of transfers from high-intensity to lower intensity environments without recidivism constitutes an uncomplicated care transition. Care patterns with one or more transitions occurring in reverse order characterize complicated care transition. Such care transitions result in poor care management and directly impact the bottom line.

On the patient level, dependency fostered by the institution frequently contributes to the patients’ uncertainty about their roles. Transferring patients to a level of care in which they are expected to assume major roles in self-care management can alter patients’ status from dependency to empowerment. However, patients are often inadequately prepared for the transition to a new care setting and receive conflicting advice on illness management. The prevalence of impaired cognition among patients aged 65 and older only adds to the challenge.

Training patients and their caregivers in self-management skills allows them to take a more active role in care transitions, in turn, leading to improved quality of care in the next setting. Because caregivers make important contributions to quality, adherence, and safety, their roles need to be formally recognized and supported.

Third party reimbursement policies dictate quicker discharges and shorter lengths of stay, allowing little time to make arrangements for the transition to the next care setting. Nursing homes, home health agencies, and primary care physicians allege that they receive inadequate information, which can cause a kink in the seamless delivery of care. The American Medical Directors Association, along with the CMS, recommends and is developing the use of the universal transfer form to facilitate the transfer of necessary patient information and minimize the potential for errors when a patient moves from one care setting to another.

Coaching the Team to Success
On the practitioner level, the addition of a care transition coach to the multidisciplinary team, strongly recommended by Coleman, has become a highly successful intervention. The care transition coach functions as a facilitator from the outset to the final stages of the transition. The coach oversees the involvement of interdisciplinary expertise, ensuring that critical issues are addressed and discussed and treatment goals are explained, understood, and executed correctly.

Usually an advanced practice nurse, the transition coach encourages patients and caregivers to actively participate in the transition from hospital to home or the next care setting following acute hospitalization. The coach prepares patients for what to expect, enabling them to achieve their goals for symptom control and functional status.

For the institution, poorly planned care transitions ultimately result in higher healthcare costs, inefficiencies, duplication of services, and higher rates of rehospitalization within a 30-day period, often for the same condition. Ineffective care transitions result in other adverse outcomes, such as more frequent use of emergency departments, medication errors, and increased malpractice litigation.

The lack of quality measures for transitional care remains a significant barrier with respect to performance measurement. The care plan in one setting may completely unravel when received by the new setting, with valuable information going unused or unheeded. This results in unnecessary duplication and waste of resources, as well as lost time in care delivery.

Care transition programs improve care delivery and reduce fragmentation through the development of patient education and self-management programs. This model encourages collaboration between interdisciplinary care teams across and between settings, enhances communication through utilization of a patient-centered record and universal transfer form, and reduces rates of medication errors and rehospitalization. To maximize patient-centered activity for improved outcomes and reduced costs, the care transition coach provides the ideal solution.

— Naomi Hauser, RN, MPA, CLNC, is director of the healthcare quality information program for Quality Insights of Pennsylvania in King of Prussia, PA.