Pat Stricker, RN, MEd

Senior Vice President

Last month’s newsletter article, Reducing Adverse Events in Post-discharge Transitions of Care Programs, explained the frequency and significance of post-discharge adverse events, the role that transition of care programs play in reducing those events, and suggested transition strategies that should be incorporated in all transition programs.  This article will explore the goals, strategies, and essential components of transition of care programs and how health information technology (HIT) can help improve those programs. A list of resources, position papers, references, technology tools, and other helpful information will also be provided for those who may be developing or revising a transition of care program.

Aims for Improving Healthcare

In 2001 a detailed report, Crossing the Quality Chasm: A New Health System for the 21st Century, released by the Institute of Medicine (IOM) defined six Aims for Improvement that the U.S. healthcare system must have in order to achieve significant improvements.

  • Safety: This must be a main focus and goal of the entire healthcare system. It is more than “do no harm”. It means no one should ever be harmed by healthcare.
  • Effectiveness: Medical science should be used to assure the best available treatment techniques are used and to prevent the overuse/underuse of these techniques.
  • Patient-Centeredness: The patient’s culture, social background, and needs must be respected. Patients must be encouraged to actively participate in making healthcare decisions.
  • Timeliness: Care should be prompt. Delays that do not provide information or time to heal should not be tolerated.
  • Efficiency: Continuous effort should be focused on reducing all types of waste (equipment, supplies, space, utilization, and time) in order to ultimately reduce costs.
  • Equitableness: High-quality care should be available to everyone regardless of race, ethnicity, gender, or income.

The Institute for Healthcare Improvement (IHI), one of the authors of the Chasm report, continued to work on defining these aims. This led to the development, in 2007, of a more simplistic, yet still far-reaching goal called the Triple Aim.  The IHI actually describes this as a single aim (improving the U.S. healthcare system) focused on three separate dimensions:

  • To improve the entire patient care experience, as defined by the six improvement aims noted above. It should not be focused on only improving patient satisfaction.
  • To improve the health of populations, which is a wide-spread approach that requires the engagement of partners across the community, not just within the healthcare systems.
  • To reduce per capita (per person) health care costs, allowing organizations to use the resources in other ways. It should not focus entirely on cost reduction, but rather the value received from the money invested.

Transition of Care (TOC) Programs

Care transitions have been identified as a key area of concern and an area to focus on to improve the quality of care. These hand-offs are particularly important junctures of care for patients, yet transitions are known to have issues with lack of adequate care coordination, system segmentation and fragmentation (“creating silos”), and lack of communication among care team members.

When thinking of transitions of care most of us think about hospital-to-home transitions, yet there are actually numerous other transitions that occur: from the hospital to long-term care (LTC), post-acute care (PAC), assisted living facilities, or other hospitals; from emergency department to intensive care or surgery; from PAC to LTC, home or a hospital; from LTC to home or a hospital; and from a medical home or provider to a specialist. However the most critical transition is from the hospital-to-home, due to the lack of close oversight from a trained healthcare professional once the patient is in the home. It is also the transition that is most analyzed and focused on, in regards to program development.

It is imperative to keep the nine aims previously mentioned above in mind, when developing any healthcare program or initiative. In addition, a successful Transition of Care Program should also include the following goals and strategies:

  • Increase the quality of care and patient outcomes
  • Decrease overall costs, especially avoidable hospital readmissions
  • Develop and follow evidence-based best practices
  • Review, revise, and include discharge summaries, medication reconciliation, risk assessments, care plans, patient-specific interventions, transition records, and patient/caregiver education
  • Monitor patients to promote health and safety
  • Identify, manage, and reduce risks and gaps in care
  • Standardize processes and provide consistency of practice
  • Use technology applications and tools, whenever possible
  • Develop and track performance measures
  • Implement payment systems that align with incentives
  • Establish and expect accountability from all members of the care team
  • The care team should consist of physicians, nurses, social workers, pharmacists, behavioral health professionals, patient and caregivers, and other community resources
  • Provide real-time patient updates to all members of the healthcare team, regardless of where they are located
  • Increase communication among all members of the care team

NoteSee last month’s article for further detailed transition strategies and recommendations.

In 2006, the Case Management Society of America (CMSA) and Sanofi U.S. developed the National Transition of Care Coalition (NTOCC) to identify solutions to address the safety and quality of care gaps that occur in patient transitions. Through the years, NTOCC has developed into a large, independent entity comprised of an Advisors Council with over 30 organizations, 450 associate member organizations, and over 3,000 individual professional subscribers devoted to its mission to “raise awareness about transitions of care among healthcare professionals, government leaders, patients and caregivers to increase the quality of care, reduce medication errors and enhance clinical outcomes”. In addition, NTOCC develops, implements and evaluates innovative, high quality learning resources for all healthcare professionals and consumers of healthcare services.

TOC Resources, Tools, and White Papers by Organization

The following are organizations involved in transitions of care that provide information, program design, toolkits, research papers, white papers, educational material, and other tools to help organizations who are developing or revising their care programs.

·         The Agency for Healthcare Research and Quality (AHRQ) provides a Transition of Care Toolkit and a package of tools and strategies, Designing and Delivering Whole-Person Transitional Care, designed to reduce Medicaid readmissions.

  • The Alliance for Home Health Quality and Innovation offers a model for Improving Care Transitions Between Hospital and Home Health. It includes checklists, tools, assessments, advanced care directives, and other helpful tools.
  • The American Academy of Ambulatory Care Nursing (AAACN) offers a Care Transition Hand-Off Toolkit and a chart showing a comparison of 6 Care Transition Models including tools, components and key findings.
  • Boston University Medical Center’s Project RED (Re-Engineered Discharge) contains complete implementation guidance and a toolkit with multiple tools to re-engineer an organization’s discharge processes. Evidence of RED’s impact is also discussed.
  • The Care Transitions Program offers training, tools and resources that include: Interventions, Measures, Family Caregiver Activation Tool (FCAT©), a Medication Discrepancy Tool, and a Patient Activation Assessment Tool (PAA©).

·         The Center for Health and Research Transformation (CHRT) provides a white paper, Care Transitions: Best Practices and Evidence-based Programs that summarizes 6 Best Practices in care transitions and describes 3 successful programs.

Health Information Technology (HIT)

As the healthcare industry was beginning its major re-design after the Chasm report was released in 2001, the world of healthcare technology was also increasing rapidly. Changes to the new healthcare system would require the use of more sophisticated and integrated technology to assure the re-design goals could be met. The disproportionate increase in the number of “aging” baby boomers who would soon require medical care also significantly impacted the need for new and targeted healthcare technologies.

Government legislation began to encourage and mandate the use of healthcare technology in the earl part of the 21st century. In 2009 the American Reinvestment & Recovery Act (ARRA) was enacted to modernize our nation’s technological infrastructure. This legislation included the Health Information Technology for Economic and Clinical Health (HITECH) Act that established programs to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records (EHRs) and private and secure electronic health information exchanges. It was known as the “meaningful use act”. It defined minimum standards for using electronic health records (EHRs) and how patient data would be exchanged between healthcare providers and patients. The Act also provided financial incentives to encourage eligible professionals to adopt and use EHR technology. The healthcare industry struggled with this implementation initially, but it definitely helped spearhead a definite move forward for HIT.

This Affordable Care Act, also known as ObamaCare that followed in 2010, relied heavily on new technology to integrate disparate systems. All of these legislative requirements increased the technology needs in healthcare and allowed HIT to grow exponentially.

Technology was identified as a critical component in healthcare’s re-design. HIT devices and applications had already proven that they were a valuable asset to the care process – helping to improve care coordination and reduce errors. Computerized systems and electronic health records (EHRs) were essential and technologies were being used more and more to educate patients and caregivers, and in helping them become more personally involved in monitoring and managing their own health.

NTOCC analyzed the value and effect of HIT in care transitions and identified critical functionality that was considered essential in HIT applications. These included the ability to: standardize processes, increase communication, track performance measures, establish accountability, and improve strong care coordination.

Care management software meets all of those requirements and is an essential component for any care management organization. With so many aspects of care coordination to think about, case managers need to have a system that helps them assess, plan, implement, track, facilitate, and document key aspects of a patient’s care. The system needs to be flexible enough to allow each organization to configure it to meet their unique business needs, so it can drive “best practices” and achieve the expected improved patient outcomes. Assessments can capture the care needs, medication lists, gaps  in care, etc. that need to be addressed and automatically present a suggested care plan to the case manager. It also  needs to be able to be seamlessly integrated with other systems used within the care management programs in order to share information to all members of the care team in real-time.

HIT Resources, Tools, and White Papers by Organization

The following resources provide numerous free tools, tips, educational material, best practices, evidence-based practices, recommendations, white papers, studies, literature, journal articles, policies, and program development ideas

  • The Center for Technology and Aging’s position paper, Technologies for Improving Post-Acute Care Transitions, illustrates technology applications used in their Tech4Impact Diffusion Grants Program. The aim of the program is to expand the use of TECHnologies FOR IMproving Post-Acute Care Transitions and reduce avoidable hospital readmissions. It provides examples of how technology is used for transition models, medication adherence and reconciliation, patient monitoring devices, risk assessments, care team communications, and patient and staff educational and managerial training.
  • IMPACT (Improving Massachusetts Post-Acute Care Transfers) is a multi-focused grant funded project to improve care transitions. It included analyzing and re-designing workflow processes, developing technological forms for data transfer, designing care transition tools, and the development of user-friendly consumer tools.
  • The National Learning Consortium’s Care Coordination Tool for Transition to Long-Term Care and Post-Acute Care is a white paper that helps determine pertinent content for summary of care records when transitioning patients. Additional toolkits are also available for Summaries of Care and Medication Reconciliation.
  • NTOCC’s position paper, Improving Transitions of Care with Health Information Technology, is thought-provoking and anyone who is developing or revising a care transition program should take the time to read this white paper.
  • NTOCC also has a web-based TOC Evaluation Software that allows users to input, visualize, and analyze their TOC quality improvement efforts. It is free to use, so check it out.
  • Telehealth and Telemedicine programs, such as remote patient monitoring devices, tele-medicine visits for patients in rural areas and tele-pharmacy programs are examples of HIT programs that are growing rapidly.
  • The use of email, text messages, cell phones, and mobile applications have also increased over the past few years. That would have been unthinkable 20 years ago.
  • Numerous healthcare technology programs, applications, and tools have been developed in the past few years. Some of them were included above in the TOC resource list.

As pressure to reduce readmissions and improve patient outcomes continues to escalate, the use of transitions of care and readmission prevention programs will also steadily increase and new, innovative  technologies will emerge to meet the needs. Trying to define the “perfect” process for transitioning a patient from one care setting to another is difficult, but we can’t give up. Promoting better transitions of care is like promoting higher quality improvement — both are never-ending journeys towards something better.