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transition of care; health care transition

A process involving a shift in patient care from one setting to another. The process may involve an increase or decrease in intensity of care, or a change in healthcare personal. Examples include: - hospitalization - hospitalization from the emergency department - emergency department to ICU - hospitalization from skilled nursing facility - hospital to discharge home - ICU to transitional care unit - hospital to skilled nursing facility - skilled nursing facility to home - changes in hospital shifts, i.e. doctors, nurses Complications: - poorly managed transitions can diminish health & increase costs - an estimates $25-$45 billion was wasted in 2011 through avoidable complications & unnecessary hospital readmissions [2] - risk factors for suboptimal care transitions [4] - limited education (not high school graduate) - functional impairment due to physical or cognitive deficits [4,14,15] - unmet need for assistance with at least 1 ADL - limited self-management ability - delirium, dementia - worse self-rating of health - poor healthcare literacy [4] - living alone - transition to home with home-care services - prior hospitalization - low income or Medicaid eligible - older age - 5 or more comorbidities - specific diagnoses: - depression - heart disease - diabetes mellitus - cancer - transitions mid-surgery - anesthesia transition of care mid-surgery associated with poor outcomes (combined mortality, hospital readmission, & major complications within 30 days) 44% vs 29% with continuity of care [4] - poor communication may play a role [12] - treatment at a teaching hospital does not increase 30-day readmissions or mortality [4] Management: - most widely used method for handoff communication during transition of care is the SBAR technique [18] - successful hospital-to-home transitional care programs all center around interprofessional care coordination teams [4] - a dedicated transition care provider who contacts inpatients before & after discharge is the most effective means of reducing hospital readmission (GRS9) [4] - explicit communication with the primary care physician is fundamental to a successful transition of care after hospitalization [18] - effective communication between different care settings - often difficult - support for self-management - ensure patient & caregiver understand the purpose of the transfer & what to expect at the next site of care - medication reconciliation at the time of transfer - transfer summaries should include documentation of cognitive & functional status [4] - structured handoff tool for transition from hospital to skilled nursing facility can decrease wait time for receipt of controlled medications & intravenous antibiotics & time to medication administration [20] - advance directives can diminish burdensome care transitions from skilled nursing facility to hospital in the last 3 days of life [3] - care transitions may be opportunities to correct the differential diagnosis [21] Notes: - transitional care activities are largely unbillable in the current American reimbursement system [4] - a resident hand-off program, including written handoffs incorporated into electronic health records, diminished medical errors & adverse events (24-30%) [7] - billing codes to support Medicare's Transitional Care Manangement infrequently used [13] - occupational therapists & physical therapists can predict which patients can have successful skilled nursing facility (SNF) to home discharges - medical providers & social workers can not [4,16,17] - most patients receive postdischarge follow-up telephone calls ~90% found them to be valuable [17]

Related

transitional care unit (TCU)

Specific

admission to service complicated transition; hospital readmission; bounce back discharge from service hospitalization inpatient discharge (includes hospital discharge) skilled nursing facility discharge

General

patient care

References

  1. Hesselink G et al Improving patient handovers from hospital to primary care: A systematic review. Ann Intern Med 2012 Sep 18; 157:417. PMID: 22986379 - Prvu Bettger J et al. Transitional care after hospitalization for acute stroke or myocardial infarction. Ann Intern Med 2012 Sep 18; 157:407. PMID: 22986378 - Bray-Hall ST. Transitional care: Focusing on patient-centered outcomes and simplicity. Ann Intern Med 2012 Sep 18; 157:448. PMID: 22986380
  2. Health Affairs: Health Policy Brief Improving Care Transitions http://healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76
  3. Gozalo P, Teno JM, Mitchell SL, et al End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011; 365:1212-1221 PMID: 21991894
  4. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  5. Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011 Apr;30(4):746-54 PMID: 21471497
  6. Sato M, Shaffer T, Arbaje AI, Zuckerman IH. Residential and health care transition patterns among older medicare beneficiaries over time. Gerontologist. 2011 Apr;51(2):170-8 PMID: 21177399
  7. Starmer AJ et al Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014; 371:1803-1812. November 6, 2014. PMID: 25372088 http://www.nejm.org/doi/full/10.1056/NEJMsa1405556
  8. Goossens E, Bovijn L, Gewillig M et al. Predictors of care gaps in adolescents with complex chronic condition transitioning to adulthood. Pediatrics 2016 Mar 3 http://pediatrics.aappublications.org/content/early/2016/03/01/peds.2015-2413
  9. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):556-7. PMID: 12657079
  10. Rennke S, Nguyen OK, Shoeb MH et al Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):433-40. Review. PMID: 23460101
  11. Di Anni B, Eng L, Islam I. An Operational Standard for Transitioning Pediatric Patients to Adult Medicine. NEJM Catalyst. Oct 26, 2016 http://catalyst.nejm.org/operational-standard-pediatric-transition-adult/
  12. Lou N. Anesthesia Care Hand Off Mid-Surgery Associated With Substantial Risk - Poor communication the presumed reason. MedPage Today. January 09, 2018 https://www.medpagetoday.com/surgery/generalsurgery/70379
  13. Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Intern Med 2018 Jul 30 PMID: 30073240 - Huckfeldt P, Neprash H, Nuckols T. Transitional care management services for Medicare beneficiaries - Better quality and lower cost but rarely used. JAMA Intern Med 2018 Jul 30; PMID: 30073322
  14. Aubert CE, Folly A, Mancinetti M et al. Performance-based functional impairment and readmission and death: a prospective study. BMJ Open. 2017;7:e016207 PMID: 28600376 PMCID: PMC5726050 Free PMC article https://bmjopen.bmj.com/content/7/6/e016207
  15. Greysen SR, Stijacic Cenzer I, Auerbach AD et al. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565 PMID: 25642907 PMCID: PMC4388787 Free PMC article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388787/
  16. Simning A, Caprio T, Seplaki CL et al. Rehabilitation providers'prediction of the likely success of the SNF-to-home transition differs by discipline. J Am Med Dir Assoc. 2019;20(4):492-496 PMID: 30630726 PMCID: PMC6451879 Free PMC article https://www.jamda.com/article/S1525-8610(18)30664-9/fulltext
  17. Gardner RL, Pelland K, Youssef R et al. Reducing hospital readmissions through a skilled nursing facility discharge intervention: a pragmatic trial. J Am Med Dir Assoc. 2020;21(4):508-512 PMID: 31812334 https://www.jamda.com/article/S1525-8610(19)30704-2/fulltext
  18. Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022
  19. Jones B, James P, Vijayasiri G et al. Patient perspectives on care transitions from hospital to home. JAMA Netw Open 2022 May 6; 5:e2210774. PMID: 35522278 PMCID: PMC9077479 Free PMC article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791965
  20. Baluyot A, McNeill C, Wiers S. Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project. Patient Safety. 2022;4(4):18-25. https://psnet.ahrq.gov/issue/improving-communication-hospital-skilled-nursing-facility-through-standardized-hand-quality
  21. Astik GJ et al. Utilizing care transitions for diagnostic error detection in hospital medicine patients. Ann Intern Med 2024 Oct 22; [e-pub] Not yet indexed in PubMed https://www.acpjournals.org/doi/10.7326/ANNALS-24-00563
  22. National Transitions of Care Coalition http://www.ntocc.org