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Defining Results-Based Care Transition Processes March 2015

Transitions of Care

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Page 1: Transitions of Care

Defining Results-Based Care Transition

ProcessesMarch 2015

Page 2: Transitions of Care


• Objectives

• Background

• Root causes of ineffective transitions of care

• Structured approaches to improve Care Transitions

• 8 Care Transition areas to review

• Recommended approach improve Care Transitions

• Question & Answers

Copyright 2015 Digital Collaboration Solutions, LLC 24/10/2015

Page 3: Transitions of Care

A consulting and services company that

provides care coordination, collaboration,

and patient/provider engagement solutions.

Care Coordination Collaboration Communications





DCS helps healthcare organizations improve care coordination and care team

engagement through process optimization, better collaboration, digital

communications, and use of innovative technology.

DCS combines in-depth experience

in healthcare, healthcare information

technology and patient/provider

engagement to deliver measurable

results and improved outcomes.

Copyright 2015 Digital Collaboration Solutions, LLC 3


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DCS approach to improving care transitions

1. Quick survey of your existing processes

2. Quantify the risk (impact & cost) today

3. Estimate the revenue impact/costs savings from

implementing the strategy

4. Estimate the costs to implement the process improvement

5. Compute projected return on investment (ROI)

6. Is the return worth it?

Copyright 2015 Digital Collaboration Solutions, LLC 4


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Care transitions processes - increasingly complex as patients receive care

from multiple providers in multiple settings.

• Lower care quality

• waste

• delays

• longer length of stays

• poor transitions of care

• Optimizing care transitions takes the careful integration

of people, process and technology.

Must work for the patient, care teams, and families.

Which are effective and how to get started?

Copyright 2015 Digital Collaboration Solutions, LLC 54/10/2015




Impact Medicare reimbursement through

readmissions penalties, Value Based

Purchasing (VBP) and subjective patient

quality scores (HCHAP)

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Define care transitions processes that reduce readmissions

and improve overall quality and patient satisfaction

• Real-world processes working for today's hospitals

• Small workflow changes that have big impact

• Technology's role

• How do you get there

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Benefits of Good Care Transition

• Reduction in readmission rates and penalties

• Reduction in bounce backs

• Reduction in length of stay

• Improved patient satisfaction

• Higher value based purchasing scores

• Improved family satisfaction

• Improved staff satisfaction

Copyright 2015 Digital Collaboration Solutions, LLC 74/10/2015

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Transitions of care today

• Approximately 75% of hospitalized patients are able to

return home following discharge 3

• 25% go elsewhere

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Inpatient Rehab Facilities (IRFs)

Long Term Acute Care Hospitals (LTACs)

Skilled Nursing Facilities (SNFs)

Extended Care Facilities (ECFs)

Home Based Services




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Transition of Care – Two definitions

The movement of a patient from one setting of care (hospital,

ambulatory primary care facility, long-term care, home health,

rehabilitation facility) to another. 1

The movement of patients between health care practitioners, settings,

and home as their condition and care needs change. 2

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Page 10: Transitions of Care

Root Causes of Ineffective Transitions of Care

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Root causes of ineffective transitions of care

The Joint Commission defines

three main areas of breakdowns

that are the root causes of

ineffective transitions of care

– Communication breakdowns

– Patient education breakdowns

– Accountability breakdowns

Copyright 2015 Digital Collaboration Solutions, LLC 114/10/2015

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Root causes of ineffective transitions of care

• Communication breakdowns

– Handoffs - Care providers do not communicate important information effectively, completely or in a timely fashion:

• Among themselves,

• To the patient, or

• To those taking care of the patient.

– Communication methods – whether verbal, recorded, or written – are ineffective.

– Differing expectations of senders and receivers of handoffs


Copyright 2015 Digital Collaboration Solutions, LLC 124/10/2015


during handoffs is an

important contributing

cause in 80% of

adverse events. 7

The Joint Commission

Discharge Summaries

Reach the primary care

provider by the time of

the first follow-up visit in

only 12 to 34 percent of

such visits, and even

then often lacks key

information 5

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Root causes of ineffective transitions of care

• Patient education breakdowns

– Patients or family/friend caregivers sometimes


• Conflicting recommendations,

• Confusing medication regimens, and

• Unclear instructions about follow-up care.

– Patients and caregivers are sometimes excluded

from the planning related to the transition


– Patients may lack understanding of the medical

condition or care plan. As a result, they do not

buy into the importance of following the care plan

or lack the knowledge or skills to do so.

Copyright 2015 Digital Collaboration Solutions, LLC 134/10/2015

In one interview study of

patient perception and

understanding of

discharge instructions,

among discharged

patients aged >65 years

who felt that they had

good understanding of

their discharge


• 40% were unable to

accurately describe

the reason for their


• 54% did not

accurately recall

instructions about

their follow-up

appointment 6

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Root causes of ineffective transitions of care

• Accountability breakdowns

– No physician or clinical entity takes responsibility to assure

that care is coordinated across various settings and


– Providers – especially when multiple specialists are involved

– often fail to coordinate care or communicate effectively,

which creates confusion for the patient and those

responsible for transitioning the care of the patient.

– Primary care providers are sometimes not identified by

name, and there is limited discharge planning and risk


– Steps are not taken to assure that sufficient knowledge and

resources will be available – either at home or at the next

setting to the patient upon discharge.

Copyright 2015 Digital Collaboration Solutions, LLC 144/10/2015

9% of physicians have

“Turfed” patients.

A survey at 101 Hospitals

revealed that 9% of

physicians have admitted

to “Turfing” patients. The

term refers to refusing to

accept a patient into their

unit by claiming the

patient should be cared

for in another part of the

hospital, transferring a

patient that a physician

was capable of taking

care of, but switching

them to another doctor’s

care to reduce their

patient load. 8

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Structured approaches to Care Transition improvement

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Current Transition of Care Models

• Care Transitions Intervention (CTI)

• Transitional Care Model (TCM)

• Better Outcomes for Older Adults through Safe

Transitions (BOOST)

• The Bridge Model

• Guided Care

• Geriatric Resources for Assessment and Care of Elders


• Project RED (Re-Engineered Discharge).

Copyright 2015 Digital Collaboration Solutions, LLC 164/10/2015

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3 basic types of common transition of care interventions

Copyright 2015 Digital Collaboration Solutions, LLC

1. Pre discharge interventions

Patient education, discharge planning, medication

reconciliation, scheduling a follow-up appointment

2. Post discharge interventions

Follow-up phone call, communication with ambulatory provider,

home visits

3. Bridging interventions

Transition coaches, patient-centered discharge instructions,

physician continuity between inpatient and outpatient settings


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The Joint Commission - seven foundations of safe and

effective transitions of care to home

Leadership support

Multidisciplinary collaboration

Early identification of patients/clients at risk

Transitional planning

Medication management

Patient and family action/engagement

Transfer of information

Multi-Component Intervention

Comprehensive Care Coordination Program

4/10/2015 Copyright 2015 Digital Collaboration Solutions, LLC 18

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8 Care Transition Processes Areas to Review

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1. Multidisciplinary communication, collaboration and

coordination - from admission through transition.

– Care team – including physician, nurse, pharmacist,

social worker, and others – communicates,

collaborates and coordinates effectively.

– Team starts at admission and throughout patient’s

hospital stay to assure a successful transition.

– In addition to daily rounding/meetings, actively teach

• patient and family/friend caregivers to learn and

practice self-care and

• to follow the care plan, including how to self-

manage medications.

Copyright 2015 Digital Collaboration Solutions, LLC 204/10/2015

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2. Clinician involvement and clear accountability during all

points of transition.

• Both sending and receiving clinicians are involved in and

accountable for a successful transition.

• They are identified by name and exchange information

electronically or by fax or telephone during the time of


• At every point during the transition, the responsible

coordinating clinician (such as a primary care physician

or nurse practitioner) is identified for the patient.

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3. Comprehensive planning and risk assessment

throughout hospital stay.

• Each patient and family/friend caregiver has a discharge risk assessment completed during the hospital stay, usually within the first 24-48 hours of admission.

• Discharge planning begins immediately after admission.

• During the hospital stay, patients are assessed for risk factors that may limit their ability to perform necessary aspects of self-care.– Low literacy, recent hospital admissions, multiple chronic conditions or

medications, and poor self-health ratings.

• Clinicians begin to assess risks that may be present at the receiving setting. – For example, the clinician should confirm that the patient will have access to

medications he or she needs at the next setting, as the pharmacy formulary there may not have the medications, or the ability to compound medications as ordered.

Copyright 2015 Digital Collaboration Solutions, LLC 224/10/2015

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4. Standardized transition plans, procedures and


• Written transition plan or discharge summary includes:

– Active issues,

– Diagnosis,

– Medications,

– Required services,

– Warning signs of a worsening condition, and

– Whom to contact 24/7 in case of emergency.

• Plans are provided in the patient’s preferred language

and use pictures for patients having low literacy.

Copyright 2015 Digital Collaboration Solutions, LLC 234/10/2015

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5. Standardized training

• Begin by defining what constitutes a successful transition.

• Staff are taught the necessary steps to complete a successful

transition and are engaged in real-time performance


• Successful transitions are an organizational priority and

performance expectation.

• Medical schools - incorporate risk assessment, collaboration,

care planning, and medication management relating to

transitions of patient care into curricula.

• Nursing schools - include training on transitions elements and

risks and how they can contribute to safe care transition.

Copyright 2015 Digital Collaboration Solutions, LLC 244/10/2015

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6. Timely follow-up, support and coordination after the

patient leaves a care setting.

• Develop processes that provide for timely post-discharge follow-up

and successful recoveries

– Telephone or in-person follow-up, support, and coordination

– By a case manager, social worker, nurse, or another health care


– 24-48 hours after discharge

• A 24/7 call center provides a recently transitioned patient or family

member with information or reassurance

• Have a transitional care nurse accompany the patient to the first

follow-up outpatient visit

• Schedule home care visits for the patient.

Copyright 2015 Digital Collaboration Solutions, LLC 254/10/2015

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7. If a patient is readmitted within 30 days, gain an

understanding of why.

• 30 day readmissions can often be prevented by providing a

safe and effective transition of care.

• Convene care team meeting including attending physician,

other staff, patient and family members.

• Ask patient questions about what happened after discharge.

• Find out if there were financial or transportation barriers,

and whether or not home caregivers were unavailable.

– This important information can be used by organizations to improve

care transitions for patients and family/friend caregivers

Copyright 2015 Digital Collaboration Solutions, LLC 264/10/2015

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8. Clear measurements throughout transitions of care

• Monitor compliance with standardized forms, tools, and

methods for transitions of care.

• Use surveys and data collection

– Find root causes of ineffective transitions and

– Identify patient and caregiver satisfaction with transitions and

their understanding of the care plan.

• Measure important results

– Readmission rates

– Time between discharge order creation and discharge

– Bed wait time

– Intervals between blank electronic discharge summaries

Copyright 2015 Digital Collaboration Solutions, LLC 274/10/2015

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Recommended Approach to Improve Care Transitions

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Copyright 2015 Digital Collaboration Solutions, LLC 294/10/2015

Best Practices vs. Good AnalysisRoot causes of bad handoffs

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Copyright 2015 Digital Collaboration Solutions, LLC 304/10/2015

Best Practices vs. Good AnalysisRoot causes of bad handoffs

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Recommendations and take a ways

Copyright 2015 Digital Collaboration Solutions, LLC 314/10/2015

• To improve Transitions of Care, you have to confront and improve:

– Communication breakdowns

• Align the expectations of the senders and receivers of handoffs!

– Patient Education breakdowns

– Accountability breakdowns

• 8 Care Transition processes areas to review

• Best practices alone may not be best for you

• Define and measure your existing processes

– Understand where your issues are and their impact

• Financial

• Care delivery success

• Care team effectiveness

• Each transition of care is complex and will fight you.

• Be deliberate, incorporate the stakeholders and show results


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Michael Levinger

President & CEO

Digital Collaboration Solutions

[email protected]

V: 781.307.7898

Skype: mlevinger

Twitter: @mlevinger

Questions & Answers

Timothy Perkins

Vice President

Digital Collaboration Solutions

[email protected]

V: 781.424.3698

Skype: timperkins80

Twitter: @timperkins

Page 33: Transitions of Care


1. Eligible Professional Meaningful Use Menu Set Measures 7 of 9 Stage 1 (2014 Definition) Last Updated: May 2014


Guidance/Legislation/EHRIncentivePrograms/downloads/8_Transition_of_Care_Summary.pdf (accessed March


2. Hot topics in Healthcare - Transitions of Care: The need for a more effective approach to continuing patient Care,

The Joint Commission, 06/2012

3. Hospital Discharge and Readmission, UptoDatehttp://www.uptodate.com/contents/hospital-discharge-and-

readmission (accessed March 2015)

4. Discharge planning: issues and challenges for gerontological nursing. A critique of the literature, Journal of

Advanced Nursing, 1994;Mar;19(3):492-502

5. Deficits in communication and information transfer between hospital-based and primary care physicians:

implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW, JAMA. JAMA 2007;297(8):831

6. Quality of discharge practices and patient understanding at an academic medical center.

Horwitz LI, Moriarty JP, Chen C, Fogerty RL, Brewster UC, Kanade S, Ziaeian B, Jenq GY, Krumholz HM

JAMA Intern Med. 2013;173(18):1715.

7. Targeted Solutions Tool Webinar, http://www.centerfortransforminghealthcare.org/multimedia/tst-for-hand-off-

communications-webinar-playback_july-26-2012/ (accessed March 2015)

8. Participation in unprofessional behaviors among hospitalists: A multicenter study, Shalini T. Reddy MD1, James A.

Iwaz BS2,Aashish K. Didwania MD3, Kevin J. O'Leary MD, MS3, R. Andy Anderson MD4, Holly J. Humphrey

MD1, Jeanne M. Farnan MD, MHPE1, Diane B. Wayne MD3 andVineet M. Arora MD, MAPP, Journal of Hospital

Medicine, 543-550, September 2012

Copyright 2015 Digital Collaboration Solutions, LLC 334/10/2015