Care System Fragmentation
Numerous factors have been identified that pose barriers to the provision of high-quality transitional care, but one of the most important is health system fragmentation. The higher rates of acute and chronic illness in older adults predispose them to require care across multiple settings or fragments within the US health system, yet the health system fragmentation they experience is a newer phenomenon which has emerged and evolved over the last half-century.
Decades ago, most health care was provided within just a few settings by a small provider team which accompanied the patient across all settings. However, following the implementation of US payment structures which incentivized services, settings, and practices that reduced acute care utilization and length of stay, there was substantial growth in subacute, postacute, hospice, and rehabilitative services. Concurrently, providers became more specialized, with clinical practice increasingly restricted to specific settings (eg, hospitalist, SNFist, emergency medicine physician, etc). While this ideally enabled more cost-effective use of resources at different stages in care, the rapid growth of single-site physician specialists and new service settings represented a fundamental change in the nature of care delivery in the United States.
In the mid-twentieth century, physicians commonly followed their patients across settings of care and specialist services were more often delivered following close communication with a patient’s primary provider. It is now common for patients to travel between different settings of care and specialty providers without being accompanied by a consistent provider. For patients, this shift in care delivery has led to large gaps in care during times after discharge from one setting but prior to being seen in the next, where it is unclear who is responsible for the patient’s care.
With a shift away from acute care delivery, patients are also discharged from hospital settings sooner and generally more ill, yet they are often not adequately prepared to follow increasingly complex posthospital care plans. These gaps are compounded by minimal and often inadequate communication between care teams across settings, leading to confusion and delays in necessary follow-up care. Additionally, systems have been slow to develop infrastructures capable of meeting patients’ needs in this new fragmented care delivery model. However, the need for high-quality transitional care to support patients during these system gaps is increasingly recognized.
Consequences of Poor-Quality Care Transitions
The various adverse consequences associated with poor-quality transitions have been well documented and include a range of undesirable outcomes for patients as well as their caregivers. Communication failures during the posthospital period are common, and may involve the omission of vital elements of a care plan, such as information regarding mobility restrictions or diet orders. This may lead to inappropriate, disjointed, and/or harmful care in the next setting. For example, approximately one-third of patients are discharged with pending laboratory tests that are not communicated to the next setting of care, and at least 10% of these could have led to actionable changes in patient care plans. Medication errors and/or discrepancies, which may be the result of poor-quality medication reconciliation or insufficient patient/caregiver education or support, occur in 30% to 50% of patients in the posthospital period, and, when serious, can lead to a number of adverse events including avoidable rehospitalization, emergency department utilization, and death. Rehospitalization within 30 days of discharge occurs in 20% to 25% of Medicare beneficiaries and is more likely among certain vulnerable populations, such as older adults with cognitive impairment. Research suggests that nearly half of these rehospitalizations could be avoided if better care were provided during transition periods.
Policies Surrounding Transitions in Care
Policy makers in the United States have long recognized poor-quality care transitions as a dangerous and costly health delivery problem. The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the US health delivery system as complicated, poorly organized, and decentralized resulting in “layers of processes and handoffs that patients and families find bewildering.” The 2010 Patient Protection and Affordable Care Act includes multiple provisions aimed at improving care transitions including provisions that mandate financial penalties for hospitals with higher than projected rehospitalization rates. The legislation also includes financial incentives for the development of care models that enhance coordination, such as the Medicare Shared Savings Program for accountable care organizations (ACOs). ACOs consist of a group of providers who are responsible for providing care for a group of patients across settings. The law authorizes financial incentives for ACOs that successfully keep patients out of acute care while maintaining high-quality care. The legislation also permits payment for care transition services to providers operating as medical home practices, which aim to manage and coordinate care for patients with chronic conditions. Following these policy changes, health systems have shown increased interest in adopting programs, policies, and interventions which improve care transitions and decrease health system fragmentation.
Other Factors That Contribute to Gaps in Care
Limited clinician training in transitional care
Transitional care is a relatively new concept that until recently has not been emphasized in clinical training programs. As a result, many clinicians are unprepared to successfully manage care transitions or to even recognize the consequences of health system fragmentation. Additionally, clinical training often takes place primarily in acute care settings. Many clinicians may have little to no exposure to other settings of care such as postacute care or home-based services. Postacute care services vary substantially in available resources, level of physician contact, and acuity of patient populations. Table 15-1 provides an overview of a continuum of postacute care settings. A lack of exposure to these various settings may contribute to a limited understanding of the unique needs/resources outside of hospital settings, leading to inappropriate care plans and communication failures between hospital-based and postacute-based providers.
TABLE 15-1POSTACUTE CARE CONTINUUM OF SERVICES |Favorite Table|Download (.pdf) TABLE 15-1 POSTACUTE CARE CONTINUUM OF SERVICES
|DOMAIN ||CHARACTERISTICS OF SETTING ||AVERAGE LENGTH OF STAY ||MANDATED AVAILABILITY OF PROVIDER ||QUALIFYING FEATURES FOR MEDICARE COVERAGE |
|Long-term care hospital (LTCH) ||Extended multidisciplinary care for patients with clinically complex problems ||27 d ||Daily physician visits ||Patient must be transferred directly from an acute care hospital, admitted within 60 d of being discharged from an inpatient hospital stay and require care with an average LOS of more than 25 d |
|Inpatient rehabilitation facility (IRF) ||Intense rehabilitation therapy typically for acute orthopedic patients or neurologically injured patients ||12 d ||Physician visits at least 3 d/wk ||Patient must require intensive rehabilitation at least 3 h/d, 5 d/wk |
|Skilled nursing facility (SNF) ||Constant nursing care for patients with significant deficiencies with activities of daily living ||< 100 d ||Physician visits at least once every 30 d for the first 90 d after admission, and at least once every 60 d thereafter ||Partial coverage if patient had prior hospital stay of at least 3 d, admitted to SNF within 30 d of prior hospital stay, and requires skilled care |
|Institutional long-term care ||Health care and services (above the level of room and board) not available in the community, needed regularly due to mental or physical impairment ||26 mo ||Varies by state ||Most long-term care facilities perform custodial care and thus are not covered by Medicare |
|Home health agency (HHA) ||Care services for homebound individuals including RN, PT, OT, ST, SW, aides ||N/A ||Physician or NPP visits no more than 90 d prior to home health start of care date ||Short-term coverage if the following conditions are met: patient is homebound and requires intermittent skilled nursing care or other health services such as PT, OT, ST, SW |
|Assisted living ||Communities of group living arrangements with minimal professional nursing staff; wide spectrum of care ||28 mo ||No physician on staff; physician/resident relationships are maintained independent of the facility ||Medicare does not pay for assisted living facilities |
|Hospice ||Palliative care for terminally ill; home or inpatient unit ||72 d ||Nursing and/or physician services available or on call on a 24-h basis, 7 d a week ||Patient must be terminally ill and be expected to live <6 mo |
Patient/caregiver underprepared for transitions
Limited or inadequate preparation of patients and caregivers regarding what to expect at the next setting of care is also a common problem. Patients and their caregivers are often unaware of what to expect following hospital discharge or care transitions. They often are not empowered to sufficiently take part in their plan of care. Patients’ and caregivers’ sense of underpreparation may not necessarily be due to a lack of discharge information, but more so to the issue that the complexity and amount of information communicated is often overwhelming and challenging to retain in the short time frame for discharge teaching that is typically provided. It is also common for patients and their caregivers to not recognize that they are unprepared to succeed within their next setting of care, until they arrive and experience a care failure in that setting.
Poor-quality communication among provider teams
High-quality communication between care teams at points of patient transition across settings is essential to patient safety, particularly at hospital discharge. More than half of all avoidable events following hospital discharge are related to poor communication among providers. Physicians have traditionally played the key role in communicating a patient’s care plan to the next setting provider at hospital discharge, typically in the format of a discharge summary. The discharge summary is the only The Joint Commission (TJC)-mandated form of communication at hospital discharge and must be completed within 30 days of discharge, according to TJC standards. In this new era of health system fragmentation, most experts believe that this 30-day time frame is much too long. While TJC has minimal standards for the content of discharge summaries, these are widely considered by experts to be insufficient. Despite the importance of discharge summaries in facilitating coordinated care, physicians receive little to no training discharge summary creation and there is no mandated standard format for these documents. Perhaps unsurprisingly, research examining the quality and content of discharge summaries has found that important care plan components, such as code status, diet, warfarin instructions, and pending laboratory tests are routinely omitted.
While a physician has historically been the recipient of hospital discharge summaries, patients are now discharged to a range of postacute care facilities with varying multidisciplinary clinician teams who may require different information than what has been traditionally included within discharge summaries. Poor-quality discharge communication is particularly problematic for transitions to skilled nursing facilities (SNFs) where staffs rely heavily on written discharge communication which may serve as the only source informing a patient’s care plan for up to 30-days postdischarge. In focus groups, SNF nurses have reported regularly receiving discharge information that is untimely, incomplete, inaccurate, or conflicting. Because discharge summaries often dictate a patient’s plan of care for a significant period of time postdischarge and clarifying confusing information in discharge summaries often take several days, nurses in SNF settings have identified a list of discharge summary components that they require to safely transition patients posthospitalization (Table 15-2).
TABLE 15-2HOSPITAL DISCHARGE INFORMATION THAT SKILLED NURSING FACILITY NURSES NEED TO DEVELOP AND IMPLEMENT A SAFE PLAN OF CARE |Favorite Table|Download (.pdf) TABLE 15-2 HOSPITAL DISCHARGE INFORMATION THAT SKILLED NURSING FACILITY NURSES NEED TO DEVELOP AND IMPLEMENT A SAFE PLAN OF CARE
Discharging unit and telephone number
Attending doctor and telephone number
Other providers who will manage specific conditions (eg, infectious disease, anticoagulation) and contact information
Registered nurse who cared for individual and telephone number
Spouse or partner and telephone number
Family member(s) involved in care and telephone number
Power of attorney, if activated, and telephone number
Past medical history and hospital stay
Remarkable medical history
Remarkable events during hospital stay
Discharge medication list
Diagnosis and rationale for every medication
Start and stop dates and last dose administered
Opioid prescriptions (signed hard copy)
Significant medication changes
Change in psychiatric medications during stay
Change in opioid medication at discharge
Withdrawal of medication because of side effects
Allergies and intolerances
Ability to perform and assistance required for activities of daily living
Sensory aids (dentures, glasses, hearing aids)
Level of assistance needed
Psychosocial and behavioral concerns
Personal interests/communication preferences
Behavioral symptoms related to dementia
Type and severity
Need for personal safety attendant during stay
Effective comforting and reorientation strategies
Peripherally inserted central catheter line care
Bladder or bowel incontinence and use of absorbent pads
Perineal skin concerns
Last bowel movement
Type and amount of medication administered for bowel-related problems before discharge
Use of indwelling urinary catheter and if and when discontinued
Swallowing or feeding concerns
Special eating devices
Follow-up laboratory tests that need to be done
Name and number of insurance policy
Special Considerations for Care Transitions Among Older Adults
Older adults are heavy users of a range of health care services including acute care stays, postacute care, subacute care, and home health care services. Those with one or more chronic condition see an average of eight different physicians annually. Figure 15-1 depicts the experience of an older adult receiving care in a series of fragmented systems, where the patient often serves as the only connecting link between providers, and communication and integration between providers is commonly infrequent.
Older adults experience a variety of transitions in care. Hospital discharge is a particularly vulnerable care transition for older adults, and results in an adverse event for approximately one in five adult medical patients within 3 weeks of discharge. Furthermore, nearly 20% of Medicare beneficiaries age 65 and older experience rehospitalization within 30 days of discharge accounting for over $17.4 billion in health care spending annually. Patients are increasingly discharged to a range of settings following hospitalization, with approximately 25% of older adults being discharged to a different institution and 12% being discharged to their homes with home health care services. Table 15-3 includes examples of different types of transitions in the level of care or setting that may be experienced by older adults. Older adults who may be at increased risk for rehospitalization include those with difficulty with activities of daily living (ADLs), depression, substance abuse disorders, a history of previous hospitalization, difficulty with treatment adherence or medication compliance, or cognitive impairment.
While patients do not always transition between institutional settings, transitions to community settings may still include a range of other care provider teams including home health teams and primary care providers who may manage medical needs following hospitalization.
System fragmentation example.
TABLE 15-3TYPES OF TRANSITIONS IN LEVEL OF CARE OR CARE SETTING COMMONLY EXPERIENCED BY OLDER ADULTS |Favorite Table|Download (.pdf) TABLE 15-3 TYPES OF TRANSITIONS IN LEVEL OF CARE OR CARE SETTING COMMONLY EXPERIENCED BY OLDER ADULTS
|Transitions Within Acute Care Setting |
| Emergency department to intensive care unit |
| Intensive care unit to medical unit |
|Transitions Out of Acute Care Setting |
| Medical/surgical unit to skilled nursing facility |
| Medical/surgical unit to community settinga |
| Medical/surgical unit to community settinga with home health services |
| Medical/surgical unit to inpatient hospice |
| Emergency room to community settinga |
|Transitions From Nursing Facilities |
| Skilled nursing facility to community settinga |
| Nursing facilityb to emergency room |
| Nursing facilityb to medical/surgical unit |
| Nursing facilityb to urgent care office |
| Nursing facilityb to primary care office |
| Nursing facilityb to inpatient hospice |
Patient and Caregiver Perspective on Care Transitions
Experiences of transitions for patients and families are often characterized by high levels of stress and dissatisfaction. In addition to poor communication between hospital providers, postacute providers, and primary care physicians (PCPs), ineffective physician-patient communication likely contributes to patients’ underpreparation for managing their care following transitions, particularly after hospitalization. Various communication failures involving and surrounding patients during transitions also lead to the lack of appropriate follow-up care (eg, visit with PCP following hospitalization), which likely increases risk for rehospitalization. Failure to receive follow-up care and the resulting subsequent negative sequelae may be incorrectly attributed to the patient’s noncompliance rather than other factors, such as inadequate preparation or education prior to discharge, leading patients and their caregivers to feel frustrated and unsupported.
Little research has examined patients’ and caregivers’ preferences surrounding transitional care. Some qualitative research has found that patients and caregivers struggle with hospital discharges. Patients report feeling anxious and reluctant to ask clarifying questions about posthospital care needs when hospital discharge occurs quickly or with little notice, leading to patients being discharged without a clear understanding of their posthospital care needs. Patients and caregivers also expressed insecurities about their ability to ask questions of the care team. Table 15-4 includes quotations provided by patients and caregivers in research studies that illustrate their experiences surrounding transitions in care.
TABLE 15-4THE EXPERIENCE OF CARE TRANSITIONS FROM THE PERSPECTIVE OF PATIENTS AND THEIR CAREGIVERS |Favorite Table|Download (.pdf) TABLE 15-4 THE EXPERIENCE OF CARE TRANSITIONS FROM THE PERSPECTIVE OF PATIENTS AND THEIR CAREGIVERS
|Patient Experience |
|“They put it in their technical words and then they [primary care physicians] will understand what happened to me … I can’t express what is written in this paper.”a ||Difficulty understanding discharge documentation, which is written for the PCP |
|“I needed some serious education about some things…I didn’t know if they were not explaining things to me because I was not going to live much longer and it was just not worth it…how do I know?”b ||Sense of underpreparation and inadequate education prior to discharge |
|“…to ask a question would be right but I have no clue what to ask…It’s like you don’t know what you don’t know.”b ||Uncertainty regarding how to ask questions prior to discharge |
|Caregiver Experience |
|“They prescribed her over $1000 in medicines…The discharge paper was blank…They didn’t give her what she needed. They changed what was working to other medicines. It seemed like we had never spoken to those people at all…”c || |
Medication changes made during hospitalization that were poorly communicated with caregiver
Lack of medication reconciliation
|“Several times we didn’t know what was out there to help us…She wanted to come home and we wanted to provide care for her at home…But we didn’t know what other type of care there was…We finally got some of that information but…We had to struggle to search it out, and answers weren’t readily available.”c ||Lack of involvement of caregiver in decision making surrounding transition |
|“The medical system, if you are not part of it, is a pretty foreign thing…If you find a person that will work with you, whether it be a doctor, a nurse…the scheduler…They are there to help guide you through the system. But finding them and really cultivating that relationship makes a huge difference.”c ||Difficulty connecting with clinical team to ask questions regarding transition |