BACKGROUND AND STATEMENT OF PROBLEM

A.  Definition

Transitional care: The American Geriatrics Society defines transitional care as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, subacute and postacute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is based on a comprehensive plan of care and includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition” (Coleman & Boult, 2003, p. 549).

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of healthcare and across care settings (Naylor & Keating, 2008).

B.  Etiology and/or epidemiology

1. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients’ cognitive limitations (Cumbler, Carter, & Kutner, 2008).
2. Medication errors related to medication reconciliation typically occur at the “interfaces of care”—when a patient is admitted to, transferred within, or discharged from a healthcare facility (TJC, 2012).
3. Hospital discharge practices are placing an increasing burden of care on the family caregiver (Bauer, Fitzgerald, Haesler, & Manfrin, 2009).
4. RCTs of transitional care interventions have been shown to reduce hospital readmissions and healthcare costs (Arbaje et al., 2010; Coleman et al., 2006; Naylor et al., 2004).
5. APN interventions in transition care have consistently resulted in improved patient outcomes and reduced healthcare costs (Naylor, 2002).

PARAMETERS OF ASSESSMENT

A.  The patient population that is most likely to benefit from transitional care interventions includes those who are diagnosed with one or more of the following diseases: CHF, cognitive impairment (dementia), chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, medical and surgical back conditions (spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrhythmias, DVT, and pulmonary embolism (Coleman, Smith, et al., 2004).

B.  On admission to an acute care setting, starting at the ED, patient evaluation must include referral of vulnerable older adults for transitional care services.

C.  Compliance with TJC standards in medication reconciliation will be used as one of the quality indicators and predictors in overall patient safety.

NURSING CARE STRATEGIES

A.  A synthesis of best practice guidelines based on existing transitional care models recommends the following key features of a fully developed transition of care (TJC, 2012):

1. Multidisciplinary communication, collaboration, and coordination, including patient/caregiver education, from admission through transition
2. Clinician involvement and shared accountability during all points of transition
3. Comprehensive planning and risk assessment throughout the hospital stay
4. Standardized transition plans, procedures, and forms
5. Standardized training of every care provider involved
6. If a patient is readmitted within 30 days, gain an understanding of the factors associated with the admission
7. Evaluation of transitions of care measures

B.  Successful and safe transitions demand active patient and informal caregiver involvement. To improve patient advocacy and safety, the nurse can:

1. Use the teach-back method in all patient education encounters (AHRQ, 2015).
2. Promote the “Speak Up” initiative by the TJC (2018). The brochure “Planning Your Follow-Up Care” lists patient-centered and safety-focused questions to be asked by the patients of their healthcare provider before they are discharged from the hospital.
3. Encourage family involvement and direct them to the “Next Steps in Care” website (see “Resources” section).
4. Provide the patient with a complete and updated medication reconciliation record. The record should include medications the patient was taking before admission, medications prescribed during hospitalization, and medications to be continued on discharge (TJC, 2019).
5. Implement evidence-based interventions to reduce transition-related medication discrepancies (Corbett et al., 2010).
6. Encourage the patients to carry a medication list (i.e., a copy of recent medication reconciliation from a recent hospital admission) and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists, and so forth (TJC, 2019).

C.  Critical elements of successful transitions

1. The Society of Hospital Medicine (n.d.), recommends the 8P Screening Tool to identify patients at risk for adverse events post hospital discharge (www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/8ps_riskassess-1.pdf).
2. Team approach and preferably nurse led (APN or specialized nurse; Coleman et al., 2006; Naylor & Keating, 2008)
3. Active and early family involvement across transitions (Almborg, Ulander, Thulin, & Berg, 2009; Bauer et al., 2009; Naylor & Keating, 2008)
4. Proactive patient roles and self-advocacy (Coleman et al., 2006)
5. High-quality and individualized patient and family discharge instructions (Clark et al., 2005)
6. Apply interventions for improving comprehension among patients with low health literacy and impaired cognitive function (Chugh, Williams, Grigsby, & Coleman, 2009), such as the National Patient Safety Foundation’s “Ask Me 3” campaign. Retrieved from http://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx
7. Patient and informal caregiver empowerment through education
8. Commence interventions well before discharge (Bauer et al., 2009)
9. Elements identified for effective and successful transitions (Coleman, 2003):
   • Communication between the sending and receiving clinicians regarding a common plan of care
   • A summary of care provided by the sending institution (to the next care interface providers)
   • The patient’s goals and preferences (including advance directives)
   • An updated list of problems, baseline physical and cognitive functional status, medications, and allergies
   • Contact information for the patient’s caregiver(s) and primary care practitioner
   • Preparation of the patient and caregiver for what to expect at the next site of care
   • Reconciliation of the patient’s prescribed medications before the initial transfer with the current regimen and communication of changes to the patient and family
   • A follow-up plan for how outstanding tests and follow-up appointments will be completed
   • An explicit discussion with the patient and caregiver regarding warning symptoms or signs to monitor that may indicate that the condition has worsened and the name and phone number of whom to contact if this occurs

D.  Barriers to successful transitions (barriers to effective care transitions have been identified at three levels: the delivery system, the clinician, and the patient; Coleman, 2003).

1. The delivery system barriers
   • The lack of formal relationships between care settings represents a barrier to cross-site communication and collaboration.
   • Lack of financial incentives promoting transitional care and accountability in fee-for-service Medicare; although such incentives exist in Medicare-managed care, most plans do not fully address care integration.
   • The different financing and contractual relationships that facilities have with various pharmaceutical companies impede effective transitions. As patients are transferred across settings, each facility has incentives to prescribe or substitute medications according to its own medication formulary. This constant changing of medications creates confusion for the patient, caregiver, and receiving clinicians.
   • Neither fee-for-service nor Medicare-managed care has implemented quality or performance indicators designed to assess the effectiveness of transitional care.
   • There is a lack of information systems designed to facilitate the timely transfer of essential information.
   • There is a lack of interoperability of electronic health information.
2. The clinician barriers
   • The growing reliance on designated institution-based physicians (i.e., hospitalists) and productivity pressures have made it difficult for primary care physicians to follow their patients when they require hospitalization or short-term rehabilitation.
   • Nursing staff shortages have forced an increasing number of acute care hospitals to divert patients to other facilities, where a completely new set of clinicians, who often do not have timely access to the patients’ prior medical records, manages them. SNF staff are also overwhelmed and do not have the time or initiative to request necessary information.
   • Clinicians do not verbally communicate patient information to one another across care settings.
   • Clinicians are not familiar with other clinical sites (e.g., sending or receiving).
3. The patient barriers
   • There is a lack of advocacy or outcry from patients for improving transitional care until they or a family member are confronted with the problem firsthand.
   • Older patients and their caregivers often are not well prepared or equipped to optimize the care they will receive in the next setting.
   • Patients may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences or provide input for their care plan.
   • Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed.

E.  Evaluation/Expected outcomes

1. Clinician outcomes
   • Increase nurse involvement in leading transition-care teams.
   • Enhance staff training of transitional care by a multidisciplinary team.
   • Include patient’s transitional care needs during in-hospital handoff.
   • Improve medication reconciliation throughout all transition interfaces.
2. Patient outcomes
   • Improve patient satisfaction, and increase involvement in their care during hospitalization and transitions across healthcare settings.
   • Increase feeling of empowerment in making healthcare decisions.
   • Reduce rehospitalization and ED visits because of primary disease and comorbidities.
   • Increase timeliness of making follow-up appointments after hospital discharge.
3. Informal caregiver outcomes
   • Improve informal caregiver satisfaction and exercise proactive roles during transitions across healthcare settings.
   • Increase informal caregiver participation in all transition interfaces.
4. Institutional outcomes
   • Adopt evidence-based TCMs and provide logistic support.
   • Provide orientation and ongoing education on transitional care strategies.
   • Introduce transitional care content into nursing core curriculum, at both baccalaureate and graduate levels.
   • Assess transition-care interventions as part of hospital accreditation by TJC and CMS.

FOLLOW-UP MONITORING

A.  Institute comprehensive and multidisciplinary transition-care planning as soon as the patient is admitted, and sustain throughout hospitalization.

B.  Identify transition-care team members and perform periodic role reassessment, including roles of informal caregivers.

C.  Incorporate continuous quality-improvement criteria into transition-care programs such as monitoring for rehospitalization of targeted older adults, quality of discharge instruction, and medication reconciliation.

D.  Develop ongoing transitional care educational programs for both formal and informal caregivers, using high-tech and traditional media.

E.  Provide orientation and ongoing education on procedures for reconciling medications to all healthcare providers, including ongoing monitoring (TJC, 2019).

F.   Perform periodic debriefing of high-risk discharges as a quality-improvement strategy.

G.  Improve recognition of condition changes or adverse events caused by medications.

H.  Increase patients’ and caregivers’ knowledge concerning actions to take if condition worsens, including contact information.

I.   Consistently transmit hospital discharge summary with all the relevant information to primary care providers (Burton, 2012).

J.   Use the Assessing Care of Vulnerable Elders-3 Quality Indicators as a guide in assessing, monitoring, and evaluating care of specific conditions (American Geriatrics Society, 2007).

K.  Use a decision support algorithm for referrals to post-acute care (Bowles et al., 2018).

L.  Gauge hospital performance in the HRRP. Measure the hospital’s relative performance and the ratio of predicted-to-expected readmissions (CMS, 2019a).

RELEVANT PRACTICE GUIDELINES

A.  Ongoing chart and medical records review of patients being considered for discharge or awaiting transition should reflect the QI outlined in the ACOVE under the Continuity and Coordination of Care QI heading (Askari et al., 2011).

B.  Adopt NPSGs most relevant to transitions of care such as the domains of improving staff communication and using medicines safely (TJC, 2019). The elements of performance include:

1. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.
   • Current medications include those taken at scheduled times and those taken on an as-needed basis.
   • It is often difficult to obtain complete information on current medication from a patient. A good-faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.
2. Define the types of medication information to be collected in non–24-hour settings and different patient circumstances.
   • Examples of non-24-hour settings include the ED, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings.
   • Examples of medication information that may be collected include name, dose, route, frequency, and purpose.
3. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital to identify and resolve discrepancies.
   • Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the hospital, does the comparison.
4. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (i.e., name, dose, route, frequency, and purpose).
   • When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications.
5. Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.
   • Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations.

C.  The Position Statement of the American Geriatrics Society Health Care Systems Committee on Improving the Quality of Transitional Care for Persons With Complex Care Needs must be considered in developing practice guidelines (Coleman, 2003).

D.  Implement policies and procedures related to the Caregiver Advise, Record, Enable (CARE) Act such as educating the caregiver with education and instruction of the medical tasks he or she will need to perform for the patient at home (American Association of Retired Persons, n.d.).

ABBREVIATIONS

ACOVE      Assessing Care of Vulnerable Elders

APN            Advanced practice nurse

BOOST       Better Outcomes for Older Adults through Safe Transitions

CARE         Act Caregiver Advise, Record and Enable (CARE) act

CBO            Community-based organization

CHF            Congestive heart failure

CMS            Centers for Medicare & Medicaid Services

DVT            Deep venous thrombosis

ED               Emergency department

EP                Elements of performance

HRRP          Hospital Readmissions Reduction Program

NPSG          National Patient Safety Goals

NTOCC       National Transitions of Care Coalition

QI                Quality indicator

SNF             Skilled nursing facility

TCM            Transitional care model

TJC              The Joint Commission

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 42:  Lim, F., & Foust, J., (2021) Transitional Care.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 807-824).   New York: Springer.