Transitions of Care: What We Need to Know

1. Transitions of Care: What We Need to Know Why are we involved? www.ntocc.org

2. Current State of Healthcare • Care is complex • Care is uncoordinated • Information is often not available to those who need it when they need it • As a result patients often do not get care they need or do get care they don’t need IOM, Crossing the Quality Chasm

3. 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

4. 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. J Am Geriatr Soc 2003;51:556-7.

5. 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 www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

6. Transition Issues Dramatically Impact Patient Care • OUTPATIENT: • Home • PCP • Specialty • Pharmacy • Case Mgr. • Care Giver Patient ER ICU In-Patient SNF ALF Patient

7. NODischargeCare Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NOMedication Reconciliation NOPersonal Medicine List NO Coordinated Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List Transition Issues Dramatically Impact Patient Care • OUTPATIENT: • Home • PCP • Specialty • Pharmacy • Case Mgr. • Care Giver Patient ER ICU In-Patient SNF ALF Patient

8. What Can We Do …

9. Keep A Medication List • Develop your “My Medicine List” • You can get started with a simple tool by NTOCC • Download the tool from the website • Complete the tool with your personal medications • Share that information with each clinician you see whether in the ER, hospital, doctor’s office, clinic or pharmacy

12. The NTOCC Tools Make it Possibleto Address the Transition Issues Medication ReconciliationData Elements + Care / CaseTransition Process My Med List • OUTPATIENT: • Home • PCP • Specialty • Pharmacy • Case Mgr. • Care Giver ER ICU In-Patient Patient SNF ALF

13. Watch for New Patient Tools Over the Next Few Months www.ntocc.org