If ever there was a conundrum, the post-hospitalization discharge — with its often intricate and difficult problems — is surely one.
So many stakeholders, so much information, so many opportunities for ineffective communication — all can promote and multiply the threats to patient safety and physician liability during the patient’s transition from one setting to another.
At any age and in any group — but especially among the elderly and the very young — chronic illness with multiple comorbidities, critical illness, cognitive impairment, a lack of health literacy, a first language other than English, can all increase the risks to patient, physician, and staff.
The Affordable Care Act, the implementation of CPT codes for managing transition of care, and the penalty for hospital readmissions within 30 days of discharge, have increased the pressure for finding workable solutions to the post- hospitalization conundrum. Responsibility, accountability, liability, and defensibility are warning flags along the track to patient, physician, and staff safety. The recent history of research, analysis, and program development to achieve effective care transitions confirms what we know anecdotally: we need to have a system and use it relentlessly.
If we are to “promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” as described by Naylor in her presentation, “Avoid Readmissions Through Collaboration,” we must broaden our view of the who, what, and how involved in achieving effective transitions of care.
There are multiple descriptions and definitions of transition of care, and a wide variety of models designed to improve the process. These models may include, unless limited by their state code of practice, non-physician practitioners such as nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives who are eligible to bill the CPT Transitional Care Management codes. Naylor, et al. define transition of care as “…a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.”
The Agency for Healthcare Research and Quality’s patient safety culture survey assesses staff perceptions of patient safety in more than 1,000 hospitals nationwide. In 2012, handoffs and transitions formed the second-lowest scoring area — non-punitive response to error was one percent lower.
More than 50 percent of staff responding agreed that:
- “Things ‘fall between the cracks’ when transferring patients from one unit to another.”
- “Important patient care information is often lost during shift change.”
- “Problems often occur in the exchange of information across hospital units.”
- “Shift changes are problematic for patients in this hospital.”
Accepting that these perceptions are accurate when the patient stays within the same organization and physical setting, we have to consider how much more likely is it that important patient information will be lost upon discharge.
The National Transitions of Care Coalition (NTOCC) was founded in 2006 to define solutions by addressing the gaps that impact safety and quality of care for transitioning patients. The NTOCC has seven recommendations for improving transitions of care:
- Improve communication
- Establish accountability
- Integrate information technology
- Expand pharmacists’ roles
- Develop quality measures
- Increase use of case management
- Align payment systems and incentives
Balaban, Weissman, Samuel, and Woolhandler, in their 2008 study, measured four undesirable outcomes after hospital discharge:
- No outpatient follow-up within 21 days
- Readmission within 31 days
- Emergency department visit within 30 days
- Failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors
In light of the concerns confirmed by the research noted above, and in view of the recommendations from NTOCC among others, how have organizations and providers responded to the demands for effective transition of care from one provider or entity to another?
The hospital instituted an intervention designed to promptly reconnect patients to their homes after hospital discharge. The intervention patients received a standardized, user-friendly, patient discharge form and upon arrival at home, a phone call outreach from a nurse at their primary care site. The study found:
- 25.5 percent of intervention patients had one or more undesirable outcomes, compared to 55 percent of the concurrent and historic controls
- About 15 percent of the intervention patients failed to follow up within 21 days compared to 41percent of the concurrent and 35 percent of the historic controls
- 12 percent of recommended outpatient workups were incomplete, versus 1 percent in the concurrent and historical controls
In 2009, the Picker Institute launched an initiative to impact the patient experience by identifying those things that are so important to patients and families that they should occur in every health care interaction for every patient, every time. The Institute moved from “never events” to “Always events,” a significant change in how to think about not just the patient experience, but the physician and staff experience as well. (In 2013, the Picker Institute’s Always events initiative was moved to the Institute for Healthcare Improvement, where the initiative’s materials and references can now be found.) The Always events® Healthcare Solutions Book offers information and tools to improve coordination and integration of care, and to help avoid the frustrating, expensive, and even life-threatening consequences of poor transitions of care.
Anne Arundel Medical Center (AAMC) in Annapolis, MD, received a grant from the Picker Institute and put it to work to develop the SMART Discharge Protocol. The SMART discharge process helps to insure that key information is consistently discussed and understood. A SMART discharge includes communication about:
- S – Symptoms
- M – Medications
- A – Appointments
- R – Results
- T – Talk with me
Available materials for reference include the SMART Discharge Worksheet, FAQs, the SMART Discharge Self-Learning Packet for staff, and the SMART Discharge Training Presentation. AAMC reported decreased emergency department and inpatient hospital utilization, and an increased percentage of patients seeing the correct physician after the transition.
The Lahey Clinic Palliative Care Services and the Middlesex East VNA/Hospital in Massachusetts also received a grant and developed Partnering with Patients and Families to Reduce Readmissions. The commitment is to always actively partner with patients and families through use of transitions liaisons and personalized educational tools. Available tools include:
- Transitions of Care Partnership Project Overview
- Transitions of Care Management Call and Questionnaire
- Case Management Initial Assessment and Readmission 30 Day Assessment
- Patient Medical Journal Templates
The Patient Medical Journal enables patients and families to record and organize health care information. The Lahey Clinic reported a decreased readmission rate; an increase in patients reporting they felt ready to go home; an increase in patients reporting they understood their medications at time of discharge; and caregivers report that the medical journal is an effective family communication tool.
Literature reviews identify 46 articles describing 24 handoff mnemonics published since 1987, most since 2006. Our job is to identify the at-risk populations we encounter, and the information, tools, and behaviors we need to mobilize to seal the cracks and effectively transfer patient information among the members of the patient’s health care team.
In practical terms, at every step in the patient’s and family’s experience, there is the opportunity to get everyone on the same page. At every step there is the opportunity to build trust and alleviate anxiety.
Author Carole A Lambert is Assistant Vice President of Membership Review and Education, as well as its Residents Program director at Cooperative of American Physicians, Inc. (CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.