1. Patient Safety in Transitions of Care
Whose responsibility? Yours, Mine ,Whose?
Patient Safety in Transitions of Care

2. Learning Objectives Describe the care transitions process
Identify potential lapses in the care transitions process
Describe the effects of unsafe transitions
Describe the role providers play in patient transitions
Discuss effective team based collaboration that promotes safety in transitions of care

3. A Patient’s Story
Video Clip

4. Ms Brown
84 yr old female with a history of diabetes, hypertension, atrial fibrillation and hyperthyroidism recently admitted for pneumonia
Hospital course complicated by several hazards of hospitalization including delirium, restraints, deconditioning resulting in a fall
Ms Brown improved and was discharged home. At the time of discharge, she was oriented to place and person but not to time

5. Ms Brown
She was sent home without instructions on how to care for herself
She lives alone and had great difficulty getting out of bed to use the toilet, and she could not prepare meals for herself
She was confused about her medications and had great difficulty managing them
She had to be readmitted for blood sugars running above 600mg/dl

6. Scope of Problem
Patients experience heightened vulnerability during transitions between settings
Quality and patient safety are compromised during this vulnerable period

7. Scope of Problem Hazards of Poorly Executed Transitions
High rates of medication errors
Inappropriate discharge and discharge setting
Inaccurate care plan information transfer
Lack of appropriate follow-up care
The multitude of adverse effects that can be attributed to poorly executed care transitions is often underappreciated

8. Scope of Problem Outcomes of Poorly Executed Transitions
Re-hospitalization
Greater use of hospital emergency, post-acute, and ambulatory services
Further functional dependency
Permanent institutionalization

9. Care Transitions Process
Patient Admitted
Assessment
Define Problem
Treatment Plan
Patient Treated
Investigations
Procedures
Consultations
Patient improved and discharged
Readiness for Discharge
Discharge Setting
Discharge Education
Care Coordination
Provider Communication
Post Discharge Follow-up
DC Summary
Medication Reconciliation
Follow-up appointments
Follow-up Consultations
Follow-up tests
The usual process of care of a patient from admission to discharge is shown – describe process

10. Provider Role in Care Transitions
Patient Admitted
Assessment
Define Problem
Treatment Plan
Patient Treated
Investigations
Procedures
Consultations
Supportive Care
Treatment of illness
Patient improved and discharged
Readiness for Discharge
Discharge Setting
Discharge Education
Care Coordination
Provider Communication
Post Discharge Follow-up
DC Summary
Medication Reconciliation
Follow-up appointments
Follow-up Consultations
Follow-up tests
Have participants discuss the role of various healthcare providers in the care transitions process shown above

11. Provider Role in Care Transitions
Clinician – Physician, Nurse Practitioner, Physician Assistant
Pharmacist
Nurse
Case Manager
Social Worker
Have participants discuss the role of various healthcare providers in the care transitions process shown above

12. Potential Lapses in Care Transitions Process
Patient improved and ready for discharge
Readiness for Discharge
Discharge Setting
Discharge Education
Medication Reconciliation
Care Coordination
Provider Communication
PCP communication
DC Summary
Discharged to the next care setting
Medication Compliance
Dietary Compliance
Keep follow-up appointments
Transportation
Caregiver support
Home Health/ Community Resources
Post Discharge Follow-up
DC Summary review
Medication Reconciliation
Follow-up appointments
Follow-up Consultations
Follow-up tests
Potential areas for lapses during the care transitions process are shown above – discuss with participants these potential areas for lapses.

13. Factors Contributing to Failure in Transitions of Care
Failed Transitions
System- Related Factors
Provider - Related Factors
Patient - Related Factors
Summarize factors that can contribute to failure in transitions of care.

14. Discharge Planning
How can we improve the patient’s experience at discharge?
Do we understand our roles and how crucial they are in ensuring that our patients are safe at discharge?
How best can we collaborate to implement a discharge plan that ensures patient safety?
Interactive discussion, get participants to answer each question and facilitate discussion; summarize answers at the end of side presentation

15. Discharge Planning
Do we understand that we should work as a team with one focus – to promote patient safety?
Do we understand that promoting safety may entail identifying potential errors by team members and resolving these?
Do we feel safe communicating potential errors to team members?
How best can we communicate with each other?
Interactive discussion, get participants to answer each question and facilitate discussion; summarize answers at the end of side presentation

16. Competencies for Interprofessional Collaborative Practice
Values/Ethics for Interprofessional Practice
Competency Domain 1
Roles/Responsibilities
Competency Domain 2:
Interprofessional Communication
Competency Domain 3
Teams and Teamwork
Competency Domain 4:
Important attributes of interprofessional collaborative practice include:

17. Ms Brown Let’s review Ms Brown’s discharge planning process………..
Review case discussion worksheet