Continuity Throughout Transition of Patient Care 2017

High-Quality Care Transitions Promote Continuity of Care and Safer Discharges

Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM

n Abstract The care transition process is an essential part of healthcare delivery affecting patients and families, healthcare providers, and healthcare systems. The care transition, when instituted at the right time and in the right setting, has the powerful effect of smoothing a patient's journey across the care continuum in a safe and effective manner, as well as informing the development of best practice guidelines (Dusek, Pearce, & Harripaul, 2015). Interdisciplinary collaboration, communication, and care coordination are among the vital components that support the care transition process. As such, these components are indispensable in assisting nurses and other healthcare professionals in understanding their roles and responsibilities as they work toward promoting a safe and positive care transition outcome. Today, healthcare systems across the country are carefully evaluating many care transition initiatives in order to adopt and/or develop their own best practices. When implemented at the right time and in the right way, care transitions enhance care delivery, improve patient outcomes, and move organizations toward successful attainment of the triple aim: better health, better care, and lower cost through improvement. This article defines and describes the care transition process and its potential to influence continuity of care and patient safety. When actively incorporated into patient care delivery, both during and post hospitalization, this process builds collaborative patient-centered relationships, which in the long term may have the positive effect of troubleshooting post-discharge problems, thus mitigating potentially avoidable readmissions.

What Are Care Transitions?

The concept of care transitions has been on the healthcare radar since the early 2000s. Dr. Eric Coleman (2004) defined care transitions as a set of actions designed to ensure care coordination and continuity as patients transfer between different locations or different levels of care within the same location. Over time, this definition remains essentially unchanged. Accordingly, Clark, Doyle, Duco, and Lattimer (2016, p. 3) in their Joint Commission publication, "Transitions of Care: The need for a more effective approach to continuing patient care," similarly noted that a care transition refers to the movement of patients between healthcare practitioners, care settings, and home. Although one episode of care might entail many transitions, much of the literature describing these transitions shows they are coordinated pathway(s) through and across healthcare systems. Such transitions can be manifold—from department to department, institution to institution, and/or from facility to home (Cobler, Wang, Stout, Piejak, & Rodts, 2017; Deravin Carr, 2008; Coleman, 2004). Among most commonly seen patient care transitions are those occurring during the hospital admission process— between the emergency department (ED) and inpatient units—and again at discharge to the community. Figure 1 provides an example of the multiple transitions of care that can occur within healthcare systems.

Figure 1. Patient transition points for individuals living with dementia.Reprinted from "Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia," by K. B. Hirschman & N. A. Hogson, 2018, retrieved from doi:10.1093/geront/gnx152. Copyright 2018, The Gerontologist. 58(suppl_1):S129-S140

Over the past decade, healthcare executives and healthcare providers have gained an increased understanding of how the care transitions process can enhance patient care and patient safety. Targeted interventions employed throughout the hospital stay and continued post discharge help ensure a patient's continued connectivity to the healthcare team. Interestingly, research conducted by health policy experts has shown poor transitions to be a major contributor to poor quality and waste. Lack of integrated processes siloed care delivery and layers of processes often bewilder and frustrate patients, families, and providers (Burton, 2012).

Recognizing the negative effect of poor care transitions, in 2013 the federal government established the Hospital Readmissions Reduction Program (HRRP) through Section 3025 of the Affordable Care Act (ACA) (Centers for Medicare & Medicaid Services [CMS], 2012). This program requires Medicare to reduce payments to hospitals with relatively high readmission rates for patients in the traditional Medicare program. The HHRP is a permanent component of Medicare's inpatient hospital payment system and applies to most acute care hospitals (Boccuti & Casillas, 2017). Although many healthcare providers have felt the financial sting associated with these penalties, others view them as an opportunity for strategic change, hence the move toward care transitions programs. As a result of HRRP and support from other Medicare-inspired projects such as the Community-based Care Transitions Program (CCTP) (CMS, 2011), many healthcare organizations developed a new mindset by initiated programs that would not only provide tailored interventions for patients post discharge, but also potentially improve both clinical and financial outcomes as well as patient satisfaction.

The processes associated with care transitions are designed to ensure safe and effective continuity of care as clients experience a change in health status, care needs, healthcare providers, and/or location of care. Although all transitions are important to exacting patient-centered quality when it comes to readmissions, the facility-to-home transition appears to be a time frame of increased vulnerability for high-risk patients (Dharmarajan et al., 2013; Deravin Carr, 2008). As a result, many hospitals have implemented care transition interventions that are consistently employed throughout each transfer point of hospitalization and post discharge.

A recent 3-year, grant-funded study conducted across the six busiest EDs in the public hospital facilities of the New York City Health and Hospitals Corporation (NYCHHC) demonstrated the benefits and lessons learned from ED care management staffing. The principal aim of the ED Care Management Program was to reduce subsequent acute care utilization after an initial ED visit. Additional goals were to successfully embed care management teams within the ED setting, leverage the ED visit as an opportunity to engage otherwise hard-to-reach patients, and increase linkages to primary care and community resources to address ongoing non-emergent care needs longitudinally. When patients were admitted to acute care, ED care managers effectively transitioned patients to inpatient care managers, who in turn enabled team-based transition interventions that included postdischarge follow-up support (Roy, Reyes, Himmelrich, Johnston, & Chokshi, 2018). Patients who were not admitted were transitioned to primary care and/or skilled home care services accordingly.

The NYCHHC study followed an earlier study conducted by the RAND Corporation (Morganti et al., 2013) that also demonstrated interesting outcomes when EDs in hospitals across the country added an RN case manager or discharge planner to the interdisciplinary care team. Outcomes from the RAND study reflect improved communication, improved patient flow, and decreased inappropriate admissions. Emergency department case managers focus on patients' medical needs and collaborate with social workers also assigned to the ED on psychosocial issues, including domestic violence, child abuse or elder abuse, and neglect. Often, staff members intercede and arrange home services when a physician wants to admit a patient who truly does not require inpatient care.

At the other end of the care spectrum, outcomes from the literature describe patients as having greater vulnerability during the post-discharge, 30-day period (Dharmarajan et al., 2013; Nelson & Pulley, 2015). In their review of more than 3 million discharges of Medicare patients, Yale University researchers found readmissions remained frequent throughout the first month after a hospitalization. Although a high percentage of 30-day readmissions occurred relatively soon after hospitalization, readmissions remained frequent during days 16 through 30 post discharge, and included a wide range of medical conditions regardless of patient age, sex, or race (Dharmarajan et al., 2013). Furthermore, Nelson and Pulley (2015) also noted one in five Medicare enrollees is readmitted to the hospital within 30 days and the readmission rate for patients discharged to skilled nursing homes is even higher—25% are readmitted within 30 days. Such readmissions cost the U.S. healthcare system approximately $17 billion annually, not including post discharge visits to EDs or urgent care settings (Burton, 2012).

Such findings likely reflect the experiences of many hospitals, and, as a result, healthcare systems nationwide have implemented some type of care transition initiative including, but not limited to, telephonic support as well as skilled home care services. Successful initiatives are comprehensive, extend beyond the hospital stay, and have the flexibility to respond to individual patient needs (Kansagara et al., 2016). Having a framework for patient-centered care delivery is essential to developing a flexible program that addresses the essential needs of patients; this added support may help patients through the first 30-day post-discharge period.

Increasingly, as care transition initiatives gain in popularity, researchers have conducted systematic reviews that document the effectiveness of various care transition platforms (Hirschman & Hodgson, 2018; Kansagara et al., 2016; Dusek, Harripaul, & Lloyd, 2015). Consistent findings demonstrate that generally and across different intervention types, patient populations, and settings, successful programs tend to be more comprehensive and involve more aspects of the care transition, including actions that transpire before and after the hospital discharge.

Team collaboration, communication, and coordination are recurrent themes throughout the interdisciplinary process, and as such, are essential components of the care transition process; all participants, including the patient, are process owners. Incorporating patients and caregivers into the interdisciplinary team process throughout a hospitalization helps establish a network of support for the post-discharge period. Patient and caregiver engagement may begin in the ED (depending on the patient's status), but undoubtedly should take place once the patient is admitted. No single specific transitional care activity has been shown to decrease hospital admissions effectively, but an array of activities linked to transitional care principles can reduce short- and long-term readmission risk (Nadzam, 2017). High-quality transitional care programs have been shown to enhance patient safety and reduce hospital readmissions for high-risk patients.

Whichever care transition intervention a healthcare organization employs, the role of nurses is a powerful one in ensuring that patients receive the most appropriate care and follow-up. In most instances, the Having a framework for patient-centered care delivery is essential to developing a flexible program that addresses the essential needs of patients; this added support may help patients through the first 30- day post-discharge period.

nurse is both the first (through the triage process) and the last (providing discharge education) healthcare professional to touch a patient. The nurse's role is integral in many of the well-established transitional care programs, and these have shown consistent benefit in reducing hospital readmissions. Such programs provide tools and best practices on which new programs can be modeled. Moreover, provisions in the ACA offer a carrot-and-stick approach to transitional care by offering reimbursement opportunities for programs that reduce readmissions (the carrot) and imposing penalties on hospitals with high readmission rates (the stick) (Guterman, 2013; Burton, 2012). In addition, the Joint Commission's Hospital National Patient Safety Goals, survey activities, and educational services also address care transitions (Nazdam, 2017). These processes serve as important guides that can supplement an organization's already established initiatives and enhance current transition processes.

Specific Care Transition Models While the ideas and initiatives around care transitions are manifold, this article speaks to proven models that have demonstrated positive outcomes in reducing both healthcare costs and readmissions. These include the Care Transitions Intervention Model (Coleman model), the Transitional Care Model (Naylor model), and the Better Outcomes for Older Adults through Safe Transitions (BOOST) model, all described by Deborah Nazdam (2017) as follows:

Care Transitions Intervention Model

Eric Coleman's Care Transitions Intervention Model is a 4-week program designed to foster patient engagement and promote a smooth transition from the hospital or skilled nursing facility to the home. It has been shown to decrease re-hospitalizations. The Coleman model rests on four pillars: medication self-management, maintenance of a personal health record, primary care physician follow-up, and alertness to red flags as described in Table 1.

Table 1 The Four Pillars of Care Transition Intervention

The "Four Pillars" of Care Transition Intervention

 Medication self-management

 Use of a dynamic patient-centered record (Personal Health Record – PHR)

 Primary care provider (PCP) or specialist follow-up

 Patient is knowledgeable about medications and has a medication management system.

 Patient understands and utilizes a PHR to facilitate communication and ensure continuity of the care plan across providers and settings.

 Patient schedules and completes follow-up visit with the PCP or specialist and is empowered toward self-advocacy.

 Knowledge of red flags

 Patient is knowledgeable about indications that their condition is worsening and how to respond.

Note. Reprinted from "The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care," by C. Parry, E. A. Coleman, J. D. Smith, J. Frank, & A. M. Kramer, retrieved from https://caretransitions. org/four-pillars/, copyright 2013, Home Health Services Quarterly, 22(3):1-18

In practice, a transition coach focuses on the patient's self-identified goals and helps the patient develop self-management skills. The relationship is relatively short, spanning only the 4-week intervention period, and the coach doesn't assume home care or case management responsibilities. Coaching starts in the hospital, where the coach describes the transitional care program, obtains the patient's consent to participate, and introduces the Coleman personal health record (PHR). This record guides the patient in documenting medication and other medical information and generates a list of questions for the healthcare provider. A home visit is scheduled within 72 hours of discharge.

During the home visit, the coach assists the patient with a pre-/posthospitalization medication review and addresses any discrepancies. The patient develops his or her own list of questions for the primary care provider (PCP). The coach and patient review the discharge plan and update the PHR. Finally, the coach discusses symptoms and drug side effects and establishes an alert-and-response system.

After the home visit, three follow-up calls take place to address the patient's remaining medication questions, discuss the outcomes of follow-up PCP visits, describe available support services, and assist with scheduling additional follow-up appointments (as needed).

Transitional Care Model

Dr. Mary Naylor is the architect of the Transitional Care Model, which was developed after many years of clinical research (Naylor et al., 1994, 1999, 2004). This intervention involves a 1- to 3-month period of interventions with high-risk, older adults to prevent hospital readmissions. An advanced practice registered nurse (APRN) performs a pre-discharge patient assessment, and then collaborates with a hospital team to develop a transitional care plan. Post discharge, the APRN makes multiple home visits, uses telephone outreach throughout the transitional care period, and promotes information transfer between the acute care and primary care settings by accompanying the patient to the first primary care follow-up visit.

The cornerstones of this model are patient engagement, goal setting, and communication with patients, families, and healthcare team members. The APRN helps the patient identify early signs and symptoms of a worsening condition to expedite prompt intervention and avoid future hospitalization. Patients with specific risk factors are good candidates for this care model.

Better Outcomes for Older Adults Through Safe Transitions (BOOST)

Project BOOST was developed by a team of payers, regulators, and leaders in healthcare transitions and hospital medicine (the Society of Hospital Medicine) to improve the quality of care transitions (Hansen et al., 2013). This model focuses on discharge processes and communication with patients and receiving providers. Project BOOST involves discharge planning, medication reconciliation, patient and family communication, and PCP communication before discharge. It includes post-discharge telephone follow-up (including facilitating appointment scheduling). Patient-centered discharge instructions actively involve the patient in his or her own care. Project BOOST aligns evidence-based interventions with specific problems identified by the 8Ps tool, which identifies problems with medication, psychological concerns, principal diagnosis, physical limitations, poor health literacy, poor social support, prior hospitalization and palliative care, and then maximizes patient involvement in the plan of care through concise, patient-centered discharge instructions tailored to the patient's literacy level. The instructions include the reason for hospitalization, red flags signaling complications, follow-up appointments, post-discharge care,

key contact information, and space for the patient to list questions for the PCP. Before discharge, nurses use the teach-back method to review this information with the patient. Patient and caregiver engagement through use of communication strategies such as motivational interviewing, collaboration, care coordination, and validation are essential to maintaining the patient's active participation in the treatment plan and care process (Deravin Carr, 2016). For more information about these and other care transition models, the following websites as shown in Table 2 are of value.

Table 2 Care Transitions Model Information Websites

Transitional Care Model: www.transitionalcare.info Care Transitions Program: www.caretransitions.org Project BOOST: www.hospitalmedicine.org/BOOST Project RED: www.bu.edu/fammed/projectred/index.html National Transitions of Care Coalition (NTOCC): www.ntocc.org United Hospital Fund of NYC: www.nextstepincare.org

Note. Website information and associated articles are further noted in the References section.

While no one program is a panacea, perhaps the better programs are a compilation of the best components care transition models. It should be said that transitional care programs are resource-intensive and are most likely to be effective when targeting individuals with the highest readmission risk. Patient factors that pose a higher risk for readmission include active comorbid medical conditions, previous acute care hospitalizations and ED visits, older age, lack of family/social support, poor access to healthcare services, substance abuse, poor health literacy, and functional limitations (Nazdem, 2017). Too often, a patient is the only one to receive selfmanagement education, even though family caregivers are primary in providing the actual care. It is important that, whenever possible, family members are included in the care transition and education process. Of note, unplanned weekend discharges also create high-risk situations for some patients due to a lack of available support services, such as skilled nursing and/or aide services, durable medical supplies and equipment, and/ or special pharmaceuticals. Many of these issues are detailed in Table 3.

Table 3 Challenges to Effective Care Transitions Patient Hospital Medical Team

Lack of a primary care provider Limited or no insurance coverage Inability to pay for medication/ copays Language barriers Poor health literacy/inability to read Long wait times while calling health centers Late discharge; less effective teaching to patients who are anxious to leave Lack of resources and financial incentives to sustain discharge programs Standardized discharge papers not personalized or in language of patient Resistance to change by clinicians Financial pressure to fill beds as soon as they are empty Homeless patients with nowhere to go Inadequate shelter systems Busy medical team; discharge receives low priority in the work schedule of inpatient clinicians Discharge is relegated to the least experienced team member Last-minute test and/ or consultations resulting in delay of final discharge plan and medication list Inaccurate medication reconciliation Discharge medication reconciliation started on the day of discharge

Sustaining care continuity can be a formidable task for safety-net hospitals in large urban centers where subpopulations are often culturally diverse and socioeconomically challenged. Issues such as poor access to healthcare, inadequate housing, and poor food resources present challenges for patients and the healthcare professionals caring for them. Recently, the transitioning of uninsured/underinsured and undocumented populations has become a growing and equally concerning matter. Large urban areas tend to draw undocumented and homeless populations. It is not uncommon to find urban hospitals unable to transition very ill homeless, uninsured, and undocumented persons that, for a variety of reasons—such as the need for ongoing hemodialysis or the requirement of life saving care—impede the discharge process, thereby placing undue pressure on our healthcare systems (Butcher, 2017; Roberts, 2012). Effective teamwork and creativity are essential in planning for these types of care challenges.

At its best, communication before, during, and after the care transitions process creates opportunities that answer important questions while ensuring and confirming the timely delivery of essential patientrelated information. This requires that healthcare providers use proactive

communication skills, which are foundational to building influence and trust throughout a patient's hospitalization and beyond. Communication, a core competency for all healthcare professionals, supports collaborative practice and ensures patient-centered care and patient safety (Suter et al., 2009). As patients are being discharged "quicker and sicker" than ever before, proactive communication should occur in such a manner that the transferring and receiving parties have an opportunity to clarify the patient's care needs by asking and responding to relevant questions (Qian, Russell, Valiyeva, & Miller, 2011). This exchange of information can be face-to-face or, in the case of patients transferring from unit to unit, to outside facilities or home with home care services, information flow can be best managed via transfer summaries, discharge summaries, fax and/or telephone (Jackson et al., 2016). It is important to note, however, that although discharge summaries are a common means of communication between inpatient and outpatient providers, numerous studies have shown they may lack relevant information, e.g., lab and test results, relevant medical information, and/or incomplete medication profiles, which are important for planning continued care (Krialani, Jackson, Schnipper, & Coleman, 2007). Therefore, the continued availability of certain team point person(s)—nurse, social worker and/or case manager—can ensure communication clarity, thoroughness of clinical information, and follow up as needed.

Conclusion

Transitions across the care continuum can increase a patient's vulnerability and exposure to adverse events. Keen attention to care transitions is essential to ensuring continuity of care and patient safety. The ability of caring healthcare professionals to effectuate a smooth, patientcentered journey across many levels of care is grounded in their powerful role as facilitators of the care transition process and their understanding of how effective transitions add value to the patient care experience. Team and patient-centered communication, collaboration, and care coordination are among the most effective methods utilized in ensuring a patient's safe passage across the care continuum. Building trust in our healthcare delivery system and our healthcare professionals helps ensure best practices and best outcomes.

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