1. Transitions of Care

2. 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
Transition of care is the movement of patients from one health care practitioner or setting to another as their condition and care needs change and it necessarily occurs at multiple levels. It occurs 1) within settings, such as primary care and specialty care in the context of care in the community, 2) between settings, such as someone who moves from the hospital to the rehabilitation facility, and it occurs 3) across health states, such as from receiving care in the home to needing care in assisted living.
(c) Eric A. Coleman, MD, MPH

3. 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
Persons whose conditions require complex, continuous care frequently require services from different practitioners in multiple settings, but practitioners in each setting often operate independently, without knowledge of the problems addressed, services provided, information obtained, medications prescribed, or preferences expressed in previous settings. The growing national trend for physicians and other clinicians to restrict their practices to single settings (e.g., hospitals, skilled nursing facilities, or ambulatory clinics) and not to follow complex patients as they move between settings heightens this potential for fragmentation of care. During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan “falling through the cracks.”
Ultimately, poorly executed care transitions may lead to poor clinical outcomes; dissatisfaction among patients; and inappropriate use of hospital, emergency, postacute, and ambulatory services.
Coleman EA, Boult C. Improving the quality of care for persons with complex care needs. J Am Geriatr Soc 2003;51:556-7.
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.

4. Ineffective Transitions Lead to Poor Outcomes
Wrong treatment
Delay in diagnosis
Severe adverse events
Patient complaints
Increased healthcare costs
Increased length of stay
The Australian Resource Centre for Healthcare Innovations (ARCHI) was contracted by the Australian Council for Quality and Safety in Health Care (the Council) to undertake a comprehensive review of published and unpublished literature on clinical handover and patient safety. The literature review was designed to identify:
• factors relating to clinical handover associated with patient safety;
• the effectiveness of safety cultures within non-health industries; and
• the quality of evidence and gaps in research.
For the purpose of the report, clinical handover includes communication between the change of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care. Patient safety includes the variables that limit or affect preventable adverse patient outcomes and errors. Information that transfers between practitioners about patient care is becoming recognized as
an important consideration in improving patient safety, work flow and quality care. Ineffective handover can lead to wrong treatment, delays in medical diagnosis, life threatening adverse events, patient complaints, increased health care expenditure, increased hospital length of stay, and a range of other effects that impact on the health system.
A number of industries, unrelated to the health system, can provide new insights into improving handover and workers’ safety. For this reason there are sections relating to nonhealth related industries in this report. These industry areas are most commonly mining, heavy industries, and aviation. It is anticipated that the practices adopted and evaluated in non-health industries could be applied to the health sector. This review was undertaken over a 3-month period and used published and unpublished literature that describes the handover process and the impact on safety. Literature was drawn from the ARCHI extensive network of practitioners and researchers internationally contributing particularly to the collection of “grey literature” or unpublished material. Extensive searching was undertaken using electronic databases including websites.
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March Available AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

5. Problems That Illustrate Inadequacies of Care Transitions
Medication errors
Increased health care utilization
Inefficient/duplicative care
Inadequate patient/caregiver preparation
Inadequate follow-up care
Dissatisfaction
Litigation/Bad publicity
There are a number a factors we can identify that highlight care transition inadequacies. Some of these we see daily in our practices, some of them we may only hear about by chance (e.g., patient satisfaction survey, newly published primary literature about these problems), and some we see in the press (e.g., nursing facility sued due to poor transition from hospital that possibly resulted in death).
(c) Eric A. Coleman, MD, MPH

6. Barriers to Improving Transitions of Care

7. Barriers to Care Coordination
System level barriers
Practitioner level barriers
Patient level barriers
(c) Eric A. Coleman, MD, MPH

8. System Level Barriers (c) Eric A. Coleman, MD, MPH
The healthcare system is often kept in information silos. An information silo is a management system incapable of reciprocal operation with other, related management systems. This expression is often used to describe management systems that focus inward with vertical information communication, making it difficult if not impossible for different departments to share information.
Information silos within healthcare systems can cause problems at the patient care level such as prescribing a medication when a patient has known allergies or intolerance, discrepancies from different information sources, incomplete or inaccurate discharge instructions, and therapy duplication, as well as numerous other examples.
(c) Eric A. Coleman, MD, MPH

9. Practitioner Level Barriers
Practitioners often have not practiced in settings where they transfer patients
Sending practitioners may not communicate critical information to receiving practitioners
Practitioners may not know the patient and his or her preferences for care
Practitioners have no accountability
(c) Eric A. Coleman, MD, MPH

10. Patient Level Barriers
Patients assume that someone is in charge of coordinating care
Patients (and caregivers) are often the only common thread weaving between care sites
Yet they navigate the system with few tools or training to manage in this role
(c) Eric A. Coleman, MD, MPH

11. AGS Position Statement
Clinical professionals must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan
The rationale for this position is that during a care transition, patients with complex care needs and their caregivers require preparation for what to expect at the next care site and the opportunity to provide input into the plan of care regarding their values and preferences. An important component of this preparation is to ensure that these patients and their caregivers have clear advice on how to manage their conditions, how to recognize warning symptoms that may indicate that their condition has worsened, how to contact a health professional who is familiar with their plan of care, and how to seek care in the setting to which they have moved.
Coleman EA, Boult C. Improving the quality of care for persons with complex care needs. J Am Geriatr Soc 2003;51:556-7.
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH

12. AGS Position Statement
Bidirectional communication between clinical professionals is essential to ensuring high quality transition care
Position 3:
Develop policies that promote high quality transitional care
The rationale for position 2 is that during a care transition, the “sending” and “receiving” healthcare professionals require a uniform plan of care to facilitate communication and continuity across settings and an accessible record that contains a current problem list, medication regimen, allergies, advance directives, baseline physical and cognitive function, and contact information for caregivers and healthcare professionals. This communication can be telephonic, electronic, or through a paper medical record. The opportunity to collaborate with a “coordinating” health professional functioning across healthcare settings to reduce care fragmentation may enhance the care that professionals deliver. This professional should be skilled in the identification of changes in health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with interdisciplinary healthcare professionals and caregivers.
For position 3, the rationale is that policymakers need to recognize the critical role of transitional care in the quality and outcomes of care experienced by persons with complex care needs and commit to implementing new quality-improvement strategies. Performance indicators designed to measure the effectiveness of transitional care across different delivery settings are needed to ensure that both the “sending” and “receiving” providers are held accountable for the success or failure of a patient’s transition. Whenever possible, quality improvement entities such as the National Committee for Quality Assurance, Quality Improvement Organizations (formerly known as Peer Review Organizations), the Joint Commission, state health departments, or a new quality improvement entity should monitor transitional care performance in fee-for-service and capitated practice environments. Finally, greater financial incentives are needed to improve transitional care. Essential elements of transitional care should become Medicare benefits (e.g., interinstitutional and interprofessional communication to coordinate their execution of each patient’s care plan).
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH

13. AGS Position Statement
Education in transitional care should be provided to all health professionals involved in the transfer of patients across settings
Position 5:
Research should be conducted to improve the process of transitional care
Professional educational institutions, specialty certification boards, licensing boards, and quality improvement programs should seek to improve, evaluate, and monitor health professionals’ ability to collaborate across settings to execute a common plan of care. Core competencies include the incorporation of patients’ and caregivers’ preferences into a plan of care, active communication (telephonic, electronic, or printed paper) with health professionals across settings, attention to and coordination of individual elements of the plan of care, and ensuring timely transfer to the next level of care or follow-up in the ambulatory setting.
To advance the understanding and practice of high-quality transitional care, research is needed to better understand how to empower persons with complex care needs and their caregivers to express their preferences and manage their care needs across healthcare settings. This line of inquiry further necessitates attention to the needs of persons from various ethnic and racial groups.
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.
(c) Eric A. Coleman, MD, MPH

14. Expectations for Both Sending and Receiving Teams
Shift from the concept of “discharge” to “transfer with continuous management”
Begin transfer planning upon or before admission
Incorporate patient/caregivers’ preferences into plan
Identify a patient’s social support and function (how will this patient care for herself after transfer?)
Collaborate with practitioners across settings to formulate and execute a common care plan.
To improve the process, change the expectations for both sending and receiving teams.
Shift from the concept of “discharge” to “transfer with continuous management.” The transfer planning process should begin upon or before admission. The patient and caregiver preferences should be incorporated into the plan. The patient’s social support and function (how will this patient care for herself after transfer?) should be identified. Practitioners across settings should collaborate to formulate and execute a common care plan.
(c) Eric A. Coleman, MD, MPH

15. Expectations for the Sending Team
The patient is stable for transfer
The patient and caregiver understand the purpose of the transfer
The patient and family understand their coverage
The receiving institution is capable and prepared
The care plan, orders, and a clinical summary precede the patient’s arrival
The patient has a timely follow-up appointment
The expectations should be understood by all members of the sending team. These criteria should be met before the patient transitions to another setting.
The patient is stable for transfer.
The patient and caregiver understand the purpose of the transfer.
The patient and family understand their coverage.
The receiving institution is capable and prepared.
The care plan, orders, and a clinical summary precede the patient’s arrival.
The patient has a timely follow-up appointment.
(c) Eric A. Coleman, MD, MPH

16. Expectations for the Receiving Team
Review the transfer forms, clinical summary, and orders prior to or upon the patient’s arrival.
Incorporate the patient/caregiver’s goals and preferences into the care plan.
Clarify discrepancies regarding the care plan, the patient’s status, or the patient’s medications
The receiving team should also be clear in what is expected.
The transfer forms, clinical summary, and orders should be reviewed prior to or upon the patient’s arrival. Incorporate the patient/caregiver’s goals and preferences into the care plan. Clarify discrepancies regarding the care plan, the patient’s status, or the patient’s medications with the sending team.
(c) Eric A. Coleman, MD, MPH

17. What is the National Transitions of Care Coalition?
The National Transitions of Care Coalition was formed to bring together stakeholders from various care settings to address improving care coordination and communication when patients, especially older adults, leave one health care setting and move to another.
The coalition is working to be an influential stakeholder in public awareness, education, and health policy so that our health care system will focus efforts on improving the coordination of care among the various health care settings impacting quality of care, reduction of medication errors, and enhancing clinical outcomes.

18. Goals
Identify issues and barriers to transitions across the continuum of care
Evaluate appropriate referral criteria between levels of care
Assess available technology, evidence based guidelines, medication reconciliation, and adherence gaps
Establish disease state priorities for coalition focus, e.g., venous thromboembolism, diabetes/glycemic control, acute coronary syndrome, and stroke
Develop tools, guidelines, and pathways for communication between patients, providers, and payers
Develop awareness and resource implementation plans for coalition members to disseminate

19. Advisory Task Force Academy of Managed Care Pharmacy
American Association of Homes and Services for the Aging
American College of Healthcare Executives
American Geriatrics Society
American Medical Directors Association
American Medical Group Association
American Society of Consultant Pharmacists
American Society of Health-System Pharmacists
American Society on Aging
AXA Assistance, USA
Case Management Society of America
Consumers Advancing Patient Safety
Health Services Advisory Group
Institute of Healthcare Improvement
Joint Commission Intl Center for Patient Safety
The Joint Commission
Liptiz Center for Integrated Health Care
Mid-America Coalition on Health Care
National Association of Directors of Nursing Administration – Long Term Care
National Association of Social Workers
National Business Coalition on Health
National Quality Forum
National Case Management Network
Predictive Health, LLC
Society of Hospital Medicine
The Joint Commission Disease-specific Care Certification
URAC

20. Information and tools available by stakeholder
Raise NTOCC Awareness
Information and tools available by stakeholder
Consumer
Professional
Policy Maker
Media

21. Working Groups NTOCC Education & Awareness Tools & Resources Policy &
Advocacy
NTOCC
Metrics &
Outcomes

22. Education & Awareness
Working to address awareness and general knowledge about the problems associated with transitions of care and provide the necessary information to various stakeholders – patients, caregivers, health care professionals, and government officials.
Public Website – Updates, FAQ, Awareness
Case Statement about NTOCC
Survey of members Ask Me Three – Provide a Case Scenario
Educate Patients, Providers, Payors & Regulatory Policy
Articles about NTOCC in Association Journals
Send a consistent message from all NTOCC Partners
Highlight NTOCC web search priority

23. Policy & Advocacy
Assessing ways to improve care through enhanced communication tools, collaborative partnership and evaluating the possibility of enhanced reimbursement for transitional care support and technical medical information shared between care settings.
Create a concept paper with supporting data and impact from poor TOC coordination to show “Why I Should Care” for various stakeholders
Work with members for grass root campaign
Mission thought statement
Identify the key areas of commitment for NTOCC members to support
Align incentives for implementing and using the NTOCC tools

24. Tools & Resources
Identifying practical tools and resources that can be used by health care professionals, care givers and patients to improve communication in a consistent manner between care settings and reduce risk associated with care transitions.
NTOCC has a variety of tools and resources available for public use on their website. These items can be customized for your setting.
Review the current tools for medication reconciliation and other coordination resources
Identify the gaps and issues – poor to no hand off, inconsistent tools, non-trust of others data
Provide a guideline for common, consistent information that should be included for medication reconciliation
Create a TOC guideline for case/care management coordination
Create Patient Resources, Tools and Things to Ask when moving through the continuum of care – Patient Engagement

25. Metrics & Outcomes
To develop and adopt a framework for measuring transitional care.
To recommend metrics or standards to demonstrate the impact of interventions on reducing risk associated with transitional care

26. Case Studies for Discussion

27. Case 1
During a patient’s monthly follow-up appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.
The instructions now include removal of the old patch before applying a new one.
Think about the patient!

28. Case 2
An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was rehospitalized with uncontrollable bleeding.
Adapted from