What are Care Transitions?

What does the term “care transitions” mean?

“The term “care transitions” refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, in the course of an acute exacerbation of an illness, a patient might receive care from a Primary Care Provider (PCP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition.”[i]

Why are hospitals interested in care transitions programs?

Through healthcare reform and new initiatives, the federal government aspires to save $26 billion dollars in the coming years by leaning on hospitals to lower their preventable readmission rates.   According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[ii] The Medicare Payment Advisory Commission estimates that up to 76% of these readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200. With impending cuts to Medicare spending, hospitals will be motivated to develop solutions within their community as their performance (of reducing readmission rates) will start to impact how much they will be paid by Medicare.

Care transitions programs allow hospitals to focus on reducing those numbers by improving the care coordination for patients between settings, which in turn lessens the likelihood that they will return for a related readmission.  The core benefit of these programs for hospitals is that they are relatively low cost to implement and if successful, they have the potential to produce a good return on investment (ROI) in terms of clinical and financial results.  For example, various Colorado communities have successfully utilized care transitions programs.  Through the Care Transitions Intervention Model developed by Dr. Eric Coleman, Colorado area hospitals have been able to reduce readmission rates by 35-50%. [iii] According to the executive summary of the Care Transitions Interventions Model, annual costs to administer a Care Transitions Intervention program total $74,310 while the annual cost savings for a year is projected to be $289,594.[iv]

What are some of the problems with the care continuum between healthcare settings?

Due to the infrastructure of our health care system, patients often encounter fragmented care when moving between health care settings.  Many elderly patients with chronic illnesses or conditions require care from more than one provider.  The following are some of the contributing outcomes of poor transition management:

How are care transitions initiatives addressing these issues?

1. Information silos and poor communication between settings – A common misconception that many patients have is that information about their medical conditions is shared between settings; however, this is typically not the case.  Many care transitions models have suggested automating the exchange process with electronic medical records (to be shared between providers). This objective has been controversial as there are still concerns about how secure the exchange of that information would be, and thus made the adoption of the idea very slow.

To overcome this barrier, many care transitions models have implemented the use of Personal Health Records, forms that patients use to track information about the care they receive across settings. Patients are encouraged to record information about any chronic health problems, visits to each healthcare setting, dates they were treated, what they were treated for, what type of medications they take, the dosages associated with those medications, etc. Care transitions programs also employ transition coaches (explained in greater detail later on) who conduct home visits and/or place follow up calls to encourage patients to complete the Personal Health Record before and after each transition.

2. Confusion about care management– Patients are often confused about the discharge instructions set out by their care providers. Most elderly patients are contending with multiple chronic diseases/conditions and medications. They are often readmitted for an adverse event within 30 days of discharge because they do not understand or did not follow instructions given to them.  If there is no care coordination across settings, there is often conflicting and confusing information in the Care Plan or discharge instructions from different provider settings.

In order to contend with these challenges, care transitions programs are empowering patients and their caregivers to advocate for themselves, since they are the constant thread through the care continuum.  These programs are doing this by educating patients and equipping them with tools to manage their own care and prepare them for transfer to and from each setting.

3. Medication Errors – Care fragmentation impacts many aspects of the care continuum including patient safety. Medication errors account for many unnecessary readmissions to the hospital. In fact, an estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, or discharge of a patient.”[v]

To help ward off readmissions due to these types of errors, care transitions initiatives take a few approaches. During home visits, the transitions coach will typically review all prescribed medications, over the counter (OTC) medications and dietary supplements as well as prescribed dosages with clients. They will consult the patient’s Personal Health record and ask them questions about medication adherence.  The coach will also make recommendations regarding questions they should ask their physician at the next follow up visit. (These duties are not assumed by Right at Home caregivers, rather by a Care Transitions Coach that is either a certified Nurse or Social Worker.)

4. Poor follow up with PCP – Another main cause for patients to be readmitted to hospitals is poor follow up with their PCP. Frequently patients are scheduled for a follow up visit after being discharged for a major procedure, such as heart surgery; however, they fail to make their appointment because they either forget about it, can’t drive themselves and/or do not have anyone that can take them.

Care Transition programs are trying to account for issues like this by beginning the care coordination process much sooner than traditionally done in the past. Many care transition models promote that care coordination (for the next setting) should begin when the patient is first admitted to the hospital. One key element that care coordinators are looking at is the patient's support structure following discharge. If it doesn't appear that the patient will be able to fully function on their own and they do not have a caregiver they can rely on, then alternative plans need to be arranged so that the patient will have a successful transition.

5. Alternate Solutions – While hospitals and healthcare professionals are beginning to understand and embrace the idea of better care coordination, they may not see the connection or need for alternative (non-medical) care providers. Hospitals have long seen the connection between discharge and home health settings but there is a void between those services and companion care.

Many hospitals that are interested in improving care transitions are taking a community based approach at care coordination. Jane Brock, Care Transitions Medical Officer for the Quality Improvement Services says that "there is an under utilization of non-medical resources with care transitions. Hospitals need to be including these resources and introducing them earlier to patients to help assist with the care transitions initiative."[vi]

Are there any care transitions pilot projects currently being conducted?

Hospital to Home (H2H) – The American College of Cardiology (ACC) and the Institute for Healthcare Improvement (IHI) have collaborated on a new care transitions initiative Hospital to Home (H2H). "This national initiative aims to reduce unnecessary readmissions for cardiovascular patients. The goal is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction (AMI) by 20 percent by December 2012."[x]

Example of how Right at Home is involved - Right at Home Franchisees, Greg and Jackie Brewer are currently participating in a Hospital to Home initiative in the Winston-Salem, NC area. This program was modeled after a similar Hospital to Home program in San Francisco and was funded through a grant by the Duke Endowment. Through a relationship they established with the Director of Case Management at Forsyth hospital, Greg and Jackie have been able to position themselves as the direct referral for eligible patients needing care post discharge. They offer assistance with grocery shopping, housecleaning, meal preparation, and transportation to and from doctor's appointments for four months after the patient is discharged from the hospital. When it is deemed that Right at Home services are necessary post discharge, the patient navigator (the care transition coach provided by the hospital) contacts Jackie, who in turn meets the client upon their return home to do the initial assessment and have them sign the service agreement. According to the Duke Endowment Annual Grant Report, (which summarizes the findings for the first 9 months of the three year program), the program has resulted in a 53.5% reduction in hospital readmissions and an estimated $400,000 reduction in hospital costs for year one.[xi]

To learn more about H2H initiatives please visit the following site: http://www.h2hquality.org

Who are the key players in community based transitions programs?

To ensure a smooth transition across the care continuum, transitions of care typically involve multiple individuals across many settings. These individuals will include: patients, family, health care professionals as well as non-medical community based providers. While titles and responsibilities may vary from program to program there are three integral roles (in the hospital setting) that will be increasingly important in the development and execution of care transitions programs:

Case Manager – Licensed health care professionals responsible for providing patient assessment, treatment planning, health planning, health facilitation, and patient advocacy.

Transition Coach –Typically a nurse or a social worker who works for the hospital or Long-Term Care Facility and designated by the program to prepare patients for what to expect in each setting and equips patients with the knowledge and tools required for successful self-management. In addition to transitions coach (most commonly referred to in this paper) they may be referred to as; patient or care navigator, care intervention specialists, transitions care coordinator, etc.

Hospitalist – Physicians, often internists or family physicians, who spend the bulk of their time caring for hospital patients. "The percentage of inpatients cared for by hospitalists varies, with some hospitals having up to 100 percent hospitalist coverage."[xii] Since seniors being readmitted to the hospitals are encountering hospitalists (vs. other provider) more often they will play a pivotal role in the care continuum.

There are also a variety of non-medical community based organizations involved with some hospital programs. Transition programs seeking a community based support structure have begun to reach out to local senior centers to help provide support and education to patients. Some of these organizations have even become part of the programs themselves. In Pennsylvania, the QIO pilot program has implemented social workers from several local Area Agencies on Aging into their program as transition coaches. Ultimately, each of these programs is unique and will embrace their community and organize their efforts in ways specific to their needs.

[i] The Care Transition Program: http://www.caretransitions.org/definitions.asp

[ii] Department of Health and Human Services Press Release

[iii]Bennet Bill Works to Reduce Hospital Readmission Rates Using Proven "Care Transitions" Model, (2010)

[iv] The Care Transition Program

[v] JD Rozich & RK Resar, Medication Safety: One Organization's Approach to the Challenges, J. Clin OutcomesManag. 8:27-34 (2001)

[vi] Jane Brock, Care Transitions Medical Officer, Quality Improvement Services: Webinar – 339 Days in the life of Mrs. B, A Medicare Beneficiary (2010)

[x] The Institute for Healthcare Improvement

[xi] The Annual Grant Report: The Duke Endowment: Forsyth Medical Center Foundation, (2009)

[xii] National Transitions Of Care Coalition (NTOCC): Improving Transitions of Care, (2008)

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