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 • Professional Society for Hospitalists and other hospital-based healthcare professionals (nurses, pharmacists, AHP, etc….) • Total number of members > 6000

Areas of Interest/Focus • Management of patient populations in hospital • Teamwork • Hand offs • 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 • Defining Standards • Developing Team-based Interventions • Evaluating Interventions • Influencing Policy

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 • 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 • 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 • 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 • 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 • 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 Initiative • Develop Implementation Guide • Develop Network of Institutions to implement discharge interventions • Identify Facilitating Factors • Identify Barriers

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 • 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

Care Transitions – Critical to Quality and Patient Safety