Physician's Weekly Article - A Recipe to Improve Transitional Care

       New tools are being created to help healthcare facilities integrate a framework for transitioning patients across different settings in an effort to reduce readmission rates after hospital discharge.

      Older patients with chronic illness frequently require care from a variety of practitioners in multiple settings, including hospitals, nursing homes, homecare services, and physician offices. Despite recent efforts focusing on processes of quality and measurable improvements, each setting remains relatively isolated from each other, creating a unique quality gap. A tremendous cost to patients and society results from this gap as it frequently leads to poor health outcomes and significant monetary expenses.

      Elimination of the gap in quality care is likely to require standardized approaches to coordinate services, according to Jane Brock, MD, MSPH. “Effective recruitment of patients in their own care, and ensuring reliable and traceable information transfer across settings is critical. The current state of transitional care is one of the biggest money wasters in medicine today.”

      Defining the Problem

      Professional and academic organizations have defined transitional care as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between locations or different levels of care in the same location. Dr. Brock says that transitions of care are associated with adverse events, medication errors, poor patient compliance, and patients returning to a higher-intensity care setting. “Despite most practitioners acknowledging that poorly executed care transitions are dangerous to patients and contribute to increased healthcare costs, few models of successful quality improvement interventions for transitional care currently exist.”

      Continuity and coordination of care are important components in transitions of care, according to Dr. Brock. “Continuity of care refers to ensuring that patients see the same physician or healthcare team throughout their course of treatment while coordination of care means that patients have a care plan that aggregates the available information and is reliably shared and followed by all involved providers at the time the patient transitions among silos.”

      The Care Transitions Intervention

      The Colorado Foundation for Medical Care (CFMC), as a special study funded by CMS, has created a framework for improving transitional care processes. The Transitions of Care Pilot Program includes implementation of the Care Transitions Intervention (developed by Eric Coleman, MD, MPH at the University of Colorado) and standardization of handoff management activities to ensure reliable coordination of care. The CFMC collaboration has resulted in an evidence-based interdisciplinary team approach to enhance transitional care. Data on the Care Transitions Intervention (CTI) is available at www.caretransitions.org.

      “The CTI prepares patients and caregivers for successful incorporation of key self-management skills at the time of a care transition as opposed to assuming that patients can execute their care plan flawlessly on arrival to the next care setting through the receipt of written discharge instructions,” says Dr. Brock. Research has demonstrated that the CTI has reduced the risk of patients returning to hospitals for care.

      Identifying Key Interventional Strategies

      The CTI outlines several important interventions that can have a profound impact on transitional care improvement efforts (Table 1). “Basically, the CTI consists of four key components: medication self-management, a patient-centered record (eg, personal health record), primary care and specialist follow-up, and knowledge of ‘red flag’ warning symptoms or signs indicative of a worsening condition,” Dr. Brock explains. “Using patient-centered records and transition coaching, the CTI requires five coach-patient encounters. These occur during a visit in the hospital, a visit in the home within 72 hours of discharge, and three follow-up phone calls.”

      The mission of CFMC’s pilot program is to facilitate organizations coming together to improve transitions of care through collaborative development of new processes for cooperation that include delivering the CTI. “There is much variation in how providers are and are not coordinating care,” says Dr. Brock. “The idea behind our program is to establish several variations of ‘recipes’ across different healthcare settings so that all stakeholders can benefit.” Dr. Brock notes that the added responsibilities of each provider in the CTI can be a challenging hurdle to overcome. “However,” she adds, “studies estimate that 30% to 60% of healthcare activity is wasteful. Developing and standardizing a new approach can enable each care team to waste less time and effort through knowledge of and reliance on its partners’ processes. In turn, these potential barriers can be broken.”

      Strive for Long-Term Improvements

      The history of quality improvement efforts is filled with projects that enhance results for the short term, but fail to last for the long haul. “Building a test model within the community that hinges on workflow efficiencies can help sustain results,” Dr, Brock says (Table 2). “A test model can help detect where efficiencies might lie and aid providers in finding the appropriate ‘recipe’ for their unique setting. Our hope is that multi-setting communities of healthcare providers can work together to incorporate the CTI and provide quality transitional care without adding resources by establishing predictable and reliable ‘standard operating procedures’ for transferring patients among themselves.”



      Jane Brock, MD, MSPH has indicated to Physician’s Weekly that she has or has had no financial interests to report.