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Transitional Care: Strategies for Seamless Patient Transitions

Explore challenges, best practices, and outcomes in transitional care to enhance patient safety and quality of care across healthcare settings.

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Transitional Care: Strategies for Seamless Patient Transitions

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  1. TRANSITIONAL CAREmodule one Bill Lyons, M.D. UNMC Geriatrics Asst. Professor wlyons@unmc.edu

  2. objectives Upon completion learner will be able to; 1. List the current problems in transitional care 2. Describe adverse outcomes from inappropriately performed transitional care 3. Describe best practices in performance of transitional care

  3. TRANSITIONAL CARE • Actions designed to ensure coordination and continuity of care as patients transfer between different venues • IOM has called for greater integration of care delivery across settings • Why the challenge is greater: • Aging population – greater complexity • Proliferation of care venues • Providers increasingly define practice by location

  4. CASE 1 • Mrs. G, a 96 yo woman is seen by her physician at a home visit. • For 2-3 day period has been feeling progressively short of breath • No fever, chills, cough, chest pain • Had been discharged from hospital about one week before

  5. CASE 2 • 68 yo man transferred from acute hospital to distant suburban SNF following uneventful aortic valve replacement • On warfarin, plus enoxaparin until INR 2.5-3.5 • Progressively less ambulatory • INR rises to 17, even after warfarin held and vitamin K administered • Cardiac arrest

  6. PATTERNS OF TRANSFER, LAPSES IN QUALITY • In 2001 older (65+ yo) patients discharged from acute settings were discharged… • to another institution ¼ of the time • to home with home health 11% of the time Agency for Health Care Quality Research HCUPnet

  7. PATTERNS AND LAPSES, cont’d • Study of posthospital transfers of Medicare beneficiaries in 30-day period after discharge • Single transfer 60% • Two transfers 18% • Three transfers 9% • Four or more transfers 4% Coleman et al. Health Services Research 2004

  8. PATTERNS AND LAPSES, cont’d • Study of 300 consecutive admissions to 10 New York City nursing homes from 25 area hospitals • Legible transfer summaries in only 72% • Clinical data often missing (ECG, CXR, etc.) • Contact info for hospital professionals who completed summaries present in less than half Henkel G. Caring for the Ages 2003

  9. QUALITATIVE STUDIES • Patients don’t understand medication side effects • …or when to resume normal activities • …and don’t know what questions to ask, or whom to ask • …or what warning signs to watch for • They also lack confidence in their ability to assure care plan reflects their needs and values

  10. Post-test question 1 All of the following statements regarding care transitions in the United States are correct EXCEPT: • Federal statistics show that, in 2001, about a quarter of patients aged 65 and older who were discharged from acute hospitals were transferred to another institution for further care. • The increased tendency for health care providers to define their practice by location increases the challenge of providing high-quality care transitions. • Qualitative studies suggest that many patients undergoing care transitions do not understand the potential side effects of their medications, nor what warning signs to watch for after discharge. • Significant improvements in transitional care must await study by and recommendations from the Institute of Medicine

  11. Correct Answer:    D. Significant improvements in transitional care must await study by and recommendations from the Institute of Medicine • Feedback:Statements (1) through (3) are all true. Statement (4) is not true, as the Institute of Medicine has already called for greater integration of health care delivery across care settings, in their report, Crossing the Quality Chasm.

  12. Post-test question 2 In the study by Coleman et al of post-hospital transfers of Medicare beneficiaries in the 30-day period from hospital discharge, some 80% of patients made a single transfer. • True • False

  13. Correct Answer: B. False Feedback:Incorrect. Only 60% of the patients in this study made a single transfer. This reflects the fact that a large number of elders change care venues repeatedly in the one-month period following discharge from the hospital. And, to use a football analogy, more patient handoffs means greater opportunities for fumbles. End

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