Why are we involved?

Transitions of Care: Transitions of Care: What We Need to What We Need to

KnowKnow

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Current State of HealthcareCurrent State of Healthcare

Care is complexCare is complex Care is uncoordinatedCare is uncoordinated Information is often not available to those who Information is often not available to those who

need it when they need itneed it when they need it As a result patients often do not get care they As a result patients often do not get care they

need or do get care they don’t needneed or do get care they don’t need

IOM, Crossing the Quality Chasm

What is “Transition of Care”What is “Transition of Care”

The The movement of patientsmovement of patients from one health care from one health care practitioner or setting to another as their condition and practitioner or setting to another as their condition and care needs changecare needs change

Occurs at multiple levelsOccurs at multiple levels– Within SettingsWithin Settings

Primary care Primary care Specialty care Specialty care ICU ICU Ward Ward

– Between SettingsBetween Settings Hospital Hospital Sub-acute facility Sub-acute facility Ambulatory clinic Ambulatory clinic Senior center Senior center Hospital Hospital Home Home

– Across health statesAcross health states Curative care Curative care Palliative care/Hospice Palliative care/Hospice Personal residence Personal residence Assisted living Assisted living

(c) Eric A. Coleman, MD, MPH

What is “Transitional Care?”What is “Transitional Care?”

A set of actions designed to ensure the coordination and A set of actions designed to ensure the coordination and continuity of health care as patients transfer between continuity of health care as patients transfer between different locations or different levels of care within the same different locations or different levels of care within the same locationlocation

Based on a comprehensive care plan and availability of well-Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the trained practitioners that have current information about the patient's goals, preferences, and clinical status.patient's goals, preferences, and clinical status.

Includes:Includes:– Logistical arrangementsLogistical arrangements– Education of the patient and familyEducation of the patient and family– Coordination among the health professionals involved in Coordination among the health professionals involved in

the transitionthe transition

Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

Ineffective Transitions Ineffective Transitions Lead to Poor OutcomesLead to Poor Outcomes

Wrong treatmentWrong treatment Delay in diagnosisDelay in diagnosis Severe adverse eventsSevere adverse events Patient complaintsPatient complaints Increased healthcare costsIncreased healthcare costs Increased length of stayIncreased length of stay

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

PatientPatientPatientPatient

ERERERER ICUICUICUICU

In-PatientIn-PatientIn-PatientIn-Patient

PatientPatientPatientPatient

OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver

OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver

SNFSNFSNFSNF ALFALFALFALF

Transition Issues Dramatically Transition Issues Dramatically Impact Patient CareImpact Patient Care

Transition Issues Dramatically Impact Transition Issues Dramatically Impact Patient CarePatient Care

Patient

ER ICU

In-Patient

Patient

OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver

SNF ALF

NOMedication

Reconciliation

NOPersonal

Medicine List

NO Coordinated

Care Plan

NODischargeCare Plan

NO Care Plan

NO Medication Reconciliation

NO Personal Medicine List

NO Care Plan

NO Medication Reconciliation

NO Personal Medicine List

What Can We Do …What Can We Do …

Keep A Medication List Keep A Medication List

Develop your “My Medicine List”Develop your “My Medicine List” You can get started with a simple tool by You can get started with a simple tool by

NTOCCNTOCC Download the tool from the websiteDownload the tool from the website Complete the tool with your personal Complete the tool with your personal

medicationsmedications Share that information with each clinician you Share that information with each clinician you

see whether in the ER, hospital, doctor’s office, see whether in the ER, hospital, doctor’s office, clinic or pharmacyclinic or pharmacy

SNFSNFSNFSNF ALFALFALFALF

ERERERER ICUICUICUICU In-PatientIn-PatientIn-PatientIn-Patient

The NTOCC Tools Make it PossibleThe NTOCC Tools Make it Possibleto Address the Transition Issuesto Address the Transition Issues

OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver

OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver

PatientPatientPatientPatient

My

Med List

Medication ReconciliationData Elements

+Care / Case

Transition Process

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Watch for New Patient Watch for New Patient Tools Over the Next Few Tools Over the Next Few

MonthsMonths