If ever there was a conundrum, the post-hospitalization discharge, with its often intricate and difficult problems, is 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.
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. 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, 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.
The National Transitions of Care Coalition (NTOCC) was founded 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
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 Lambert, MPA, RN, is an Assistant Vice President, Membership Review and Education and Residents Program Director at the 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.