Transitions of Care: How teamwork and communication smooth the journey

Posted: October 1, 2023 | Category: News

By Mark Wendling, MD, Primary Care Physician and Executive Director, Valley Preferred

“$26 billion is spent on poor transitions of acute care Medicare patients per year.” (1)

The delivery of health care continues to evolve. Unless critically ill, today’s patients usually do not experience extended hospital stays and there are often multiple providers taking care of them. Both of these trends have given rise to an increased focus on transitions of care (TOCs): movement from one level of care to another, among multiple health care team members, and across settings, such as hospitals to homes.

“In much of the nation, the model of one primary care physician tending to his or her patients throughout their entire stay in the hospital as well as managing all of their outpatient medical needs has evolved,” says Joseph Habig II, MD, Medical Director at Valley Preferred, the provider organization associated with Lehigh Valley Health Network. “Medicine today is complex and specialized. Admitted patients are seen and cared for by hospitalists. Patients are discharged, often while still in the recovery phase of their illness and are cared for in the ambulatory setting. The concept of ‘shared’ or ‘collaborative care’ and a team-based approach with other providers requires efficient, effective  communication and reliable transitions of care.”

Systemic change creates new challenges

A few illustrative examples of potentially complex transitions include going from the operating room to the ICU, the emergency department to a specialist, or hospital to their home. Patients and their caregivers may be anxious or overwhelmed, they may not understand what they need to do or to expect, they may be confused about their medications, or not know how to address their needs. Poorly executed care transitions can lead to adverse events, reduced quality of life, unneeded use of resources, and unnecessary or necessary readmissions.

In fact, on average, TOCs harbor a 1 in 5 chance of readmission to the hospital or a visit to the emergency department. (2) Readmissions are potentially drivers of cost and inefficiency and can affect clinical outcomes positively or negatively depending on how they are managed. Therefore, readmissions are used by insurers and health care institutions to measure transitions of care. Most use 7 or 30 days and many insurers, including Medicare, charge penalties for patient readmissions of 30 days or under. For those occurring under 30 days, there can be incentives.

It means that TOCs impact everything from patient well-being to insurance reimbursement and health care organization reputation. These factors have put the spotlight on TOCs as areas that need attention and improvement.

Starting off on the right foot

One of the most logical and valuable ways to reduce readmissions – and therefore improve transitions – has been found in the role of the primary care physician (PCP). Readmission reduction associated with in‐person physician visits (compared to none) was seen early after discharge, with 67.8 fewer readmissions per 1,000 discharges if physician visit occurred within 7 days, and 110.0 fewer readmissions for those seen within 21 days. (3) It’s just a fact: The PCP knows the patient and their family better than anyone and can notice if something is awry.

“For patients on Medicare, PCPs must wait to bill for their follow-up services until 30 days after discharge with the goal of reducing the chance of readmission,” says Dr. Habig. “PCPs are also encouraged to follow up after a patient visits the emergency department (ED) to assist with resolution of the medical problem and reduce the need for repeat ED visits and possible admission. There is also emphasis on reducing unnecessary ED visits. Many problems can be safely handled in the PCP office, which can be better for the patient and less expensive than an ED visit.

To make sure this timeframe is met, some hospitals have instituted “discharge teams,” to assist in the discharge and transition process. The staff on these teams will make an appointment with a patient’s PCP for them, having direct access to physicians’ schedules. They’ll also help navigate the transition. “Bridge” or transition clinics are ready so that if a patient doesn’t have a PCP or the PCP is not available, the patient will be able to see a doctor within that 7-day window.

Teamwork is the norm

Even when patients can see a PCP, there are additional considerations that have an impact on TOCs. Organizations have had to rethink their workflows, their personnel, and their very structures. Much of this transition management is covered by care coordination teams when providers or health systems have them in place. These teams assist in a wide variety of areas including behavioral health referrals, pharmacy consultation, and social work. Once patients are back home, care coordination assists with home care and visiting nurses or whatever else the patient needs to continue following their doctor’s care plan.

The importance of this coordination is illustrated in, “Effects of Different Transitional Care Strategies on Outcomes after Hospital Discharge—Trust Matters, Too,” from the January 2022 issue of The Joint Commission Journal on Quality and Patient Safety. (4) Researchers collected data on nearly 8,000 patients across 42 participating hospitals to evaluate the association of different combinations of TOC strategies with patient-reported and post-discharge outcomes.

The group, “hospital-based trust, plain language, and coordination” was the only group associated with lower 30-day rehospitalizations and emergency department visits within 7 days, among all the patients studied. This group encompassed the following TOC strategies:

  • Communicating in plain language that patients can understand.
  • Treating patients compassionately, as people, and building trust with the patient.
  • Having a designated person responsible for conducting medication reconciliation and clarifying the medication list with outside sources when needed.
  • Ensuring clinician access and conducting a post-discharge follow-up to reinforce education.
  • Identifying high-risk patients (medical, behavioral, and social) and initiating intervention if appropriate.
  • Creating a transition summary document containing key information for family caregivers.

Regarding communication, the information caregivers need for TOCs has to be specific and up to date. They need everything from descriptions of remarkable hospital events; written orders for medications, treatments, activity level and diet; recent and pending laboratory test results; and accurate descriptions of functional and cognitive status to pertinent social information such as preferences and unique needs

Making certain patients and their families (i.e., multiple listeners) were engaged in the transition was an important key to success in the study. That’s why clear communication from patients and caregivers as well as from providers is the first strategy listed above and the one that most helps to optimize any transition.  

“Hospital care is very expensive for the patient and patients do better when they can finish recovery at home while working with their PCP,” says Dr. Habig. “The framework for value-based care – looking at health outcomes rather than how many times a patient visits the doctor – is seated in more ambulatory care when patients can be effectively and safely discharged. To make the entire process successful, you need excellent communication and attentive teams to facilitate a safe and satisfactory TOC.”





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