physician continuity between inpatient and outpatient settings
The Joint Commission - seven foundations of safe and
effective transitions of care to home
Early identification of patients/clients at risk
Patient and family action/engagement
Transfer of information
Comprehensive Care Coordination Program
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8 Care Transition Processes Areas to Review
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-
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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.
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4. Standardized transition plans, procedures and
• Written transition plan or discharge summary includes:
– Active issues,
– 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.
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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
• 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.
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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.
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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
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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
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Recommended Approach to Improve Care Transitions
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Best Practices vs. Good AnalysisRoot causes of bad handoffs
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Best Practices vs. Good AnalysisRoot causes of bad handoffs
Recommendations and take a ways
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• 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
• Care delivery success
• Care team effectiveness
• Each transition of care is complex and will fight you.
• Be deliberate, incorporate the stakeholders and show results