Chapter 16. Transitions

In developed countries the care of complex older patients commonly entails their transfer from one health care setting to another and from one team of providers to another, as their medical and functional needs evolve. In theory, this allows an economical application of specialized resources to be applied at each stage. As an example (Figure 16-1), an elderly woman may be admitted to an acute hospital for diagnosis and initial management of community-acquired pneumonia. After stabilization and initiation of treatment, she is transferred to a skilled nursing facility (SNF) for rehabilitation, continued antibiotic treatment, and close monitoring by nursing. If she decompensates in some manner in the nursing facility (for example, by becoming acutely delirious), she may be transferred to an emergency department (ED) for urgent physician evaluation; rehospitalization may follow. After further diagnostic work and treatment, she returns to the nursing facility to complete her rehabilitative program before finally returning to her home in the community, where a visiting nursing agency assists family in her care. In this sequence her changing care needs prompted physical transfers and encounters with a succession of professionals—hospitalists and acute care nursing in the hospital; then a new provider, nursing, and rehabilitation staff at the SNF; then new providers and nursing in the ED; probably new hospitalists and nurses on her rehospitalization; and finally a new set of nurses, rehabilitation team, and outpatient provider when she returns home. To keep this patient from falling through the cracks, her various providers (and their organizations) must exercise considerable diligence and attention to detail. Active involvement from the patient and her family is necessary as well.

This chapter discusses transitional care, the actions taken to ensure coordination and continuity of health care as patients are transferred among various care settings. Good transitional care entails not just the physical transfer of a patient, but the orderly transfer of responsibility of care of the patient as well. The chapter is meant to be of particular use for those clinicians (physicians, physician assistants, and nurse practitioners) charged with direct responsibility for managing care transitions.

For a number of reasons, the challenges of transitional care appear to be growing in the United States. Compared to the situation faced by physicians a century ago, our patients are much older, with longer problem (and medication) lists, and greater functional disability. Families may live in other cities and offer little ability or willingness to provide care at home. Health care venues have proliferated and become specialized. Typical care settings found in many large American cities are listed in Table 16-1. Providers themselves have also become more specialized, and in some instances (as with hospitalists, intensivists, SNFists, or emergency medicine physicians), their specialty is defined by the setting in which they practice. Changes in medical education are introducing new challenges as well, with resident work hour limits forcing more handoffs than existed before. Finally, coordination and continuity of care is made more difficult by the fact that the United States lacks a health care “system” per se.

Transitional care is at the confluence of two ascendant movements in modern health care—improved patient safety and patient-centered care. Poorly executed transitions place patients at risk of injury and other adverse events. Well-executed transitions intrinsically incorporate patients' individual goals, needs, and values. The quality of transitions also influences resource use, such as ED utilization and need for rehospitalization. For all these reasons (Table 16-2), a number of influential advisory, professional, and funding organizations have shown interest in the topic. The Institute of Medicine has called for greater integration of care delivery across health care settings. The Society of Hospital Medicine, the American Geriatrics Society, and the American Board of Internal Medicine all have urged greater professional commitment to transitional care. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHCO) has adopted a patient tracer methodology, which allows surveyors to determine how a patient fares during a sequence of transitions. JCAHCO also has begun confirming that surveyed organizations employ medication reconciliation (discussed below) and standardized approaches for patient handoffs.

Hospitals are required, as part of Medicare Conditions of Participation, to employ a discharge planning process for all patients, with policies and procedures in writing. Further, hospitals must identify all patients who are likely to suffer adverse health consequences after discharge in the absence of adequate discharge planning. Hospitals also are required to provide for the initial implementation of the discharge plan. Despite Medicare's evident interest in promoting high-quality transitional care, the program currently lacks vigorous monitoring and reimbursement incentives.

Beyond an appropriate alignment of “sticks and carrots,” improvements in transitional care quality will require research advances, inculcation, and cultural change within health care organizations and professions, and discipline-specific training. In that spirit, this chapter is intended to provide didactic material for training health care providers who are responsible for managing the care transitions of elders with complex care needs. Much of the data presented and recommendations made apply to transfers from acute hospitals, but the key principles apply to transitions involving other health care settings as well.

With increasing pressures to shorten hospital lengths of stay, it is becoming less common for an older patient to be cared for in the hospital until she feels well, at which time she is discharged home in the care of her family. National statistics from 2004 for Medicare patients discharged from acute hospitals show that about a quarter of them were transferred to another institution (such as a nursing home or rehabilitation facility), and an additional 14% were discharged to their home with the involvement of home health professionals. Recent work also confirms many providers' impressions that the period immediately following hospital discharge can be characterized by continued movement from place to place. A recent study of Medicare beneficiaries examined the 30-day period following hospital discharge, and found that 60% of patients made a single transfer, 18% made two transfers, 9% made three transfers, and 4% made four or more. These frequent transfers represent discontinuities in patients' care where vital information may be lost and care plans become fragmented.

The risk for hospital readmission is greatest in the period immediately after discharge. A study of patients with hip fracture discharged from New York City hospitals, for example, found that 32% were readmitted within a 6-month period, and over a third of these readmissions occurred within the first month after discharge. It is increasingly recognized that the “peridischarge” period is a dangerous time for patients. In one prospective cohort study of patients discharged home from the medical service of an academic medical center, 6% of patients had suffered preventable adverse events by about 3 weeks after discharge. An additional 6% experienced adverse events whose severity might have been reduced by improved quality of care. In another single-institution study of patients discharged from an academic medical service, researchers examined inpatient and outpatient records for evidence of three types of errors arising from discontinuity of care: (a) medication continuity errors, (b) test follow-up errors (in which test results were pending at the time of hospital discharge, but were not acknowledged in the outpatient chart), and (c) work-up errors (in which an outpatient test was recommended or scheduled by the inpatient team, but did not take place). About half of the patients' charts were found to contain at least one of these discontinuity errors, and those patients with work-up errors were over six times more likely to be rehospitalized than patients without these errors.

A major cause of the peridischarge hazard may be communication failures between hospital physicians and physicians who see patients soon after discharge. Historically, the same physician attended to the patient in hospital and in clinic, but the increased use of hospitalists and covering physicians creates opportunities for information discontinuities. In one study, only 3% of primary care doctors reported discussions with hospital physicians about discharge plans. In other studies, about half of discharge summaries are received by primary care physicians by 4 weeks of discharge; a quarter of summaries never reach the primary physician. And those summaries that are received commonly lack important information. Diagnostic test results are missing in 38%, consultant recommendations in 52%, discharge medications in 21%, and test results pending at discharge in 65%. There is a pressing need to improve the fidelity of information transfer from hospitals to primary care providers and other physicians and care providers.

Poor communication between hospital providers and patients (or families) probably contributes as well to peridischarge risk. Patients often report that they do not understand potential adverse effects of their discharge medications, when they may resume normal activities, which questions to ask and whom to address them to, and which warning signs to watch for. More globally, many patients express a lack confidence in their ability to make sure the care plan reflects their particular preferences, goals, and needs.

Metrics are needed to implement a quality improvement effort in transitional care. Coleman et al. developed the Care Transitions Measure (CTM), a patient-focused instrument that can be used to track performance changes over time. Two versions of the instrument, one with three items and another with 15, can be found at www.caretransitions.org. The CTM encompasses four domains of quality in transitional care (Table 16-3). The first domain is the fidelity of information transfer. Is accurate information transferred from sending clinicians to receiving clinicians in a reliable and timely manner? The second domain is patient and family preparation. Do they understand the purpose of the new care setting? If the patient is going home, do they understand the things they are responsible for managing in the care plan? The third domain is support for patient self-management. Does the patient know the warning signs and symptoms to watch for after discharge, and the purpose and adverse effects of the medications? Finally, the fourth domain is patient empowerment to assert individual goals and preferences. Does the patient feel the hospital staff took into account her particular goals when determining what her health care needs are, and where they could best be met after discharge? Lower CTM scores have been shown to predict reduced likelihood of ED use and rehospitalization in the postdischarge period. While developed for quality improvement efforts, all clinicians would benefit from considering the CTM items or Table 16-3 when contemplating individual patient transfers. The National Quality Forum has endorsed the CTM for use in public reporting.

Experienced clinicians develop a sense for which patients are likely to experience difficulties after a transition to a new setting. In hospital jargon these patients are potential “bounce-backs” or candidates for early readmission. One statistical model that helps to identify such at-risk patients is provided in a study by Coleman et al. (Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res, 2004;39(5):1449). A consensus of factors that help to identify patients at risk of hospital readmission is listed in Table 16-4. Several of the items are not surprising—older patients, those with more serious illnesses, those with need for activity-of-daily-living assistance but with marginal support, and those with a history of previous hospitalizations are all more likely to require rehospitalization soon after discharge. In addition to physical ailments, however, depression predicts readmission, as does a worse self-rating of patient health. Patients who have difficulty with treatment adherence (to medication regimens or follow-up appointments) are at risk as well. Finally, patients (or families) who have not received education around the time of discharge are more likely to suffer complicated transitions.

Knowledge of risk factors for problematic transitions is important for clinical leaders who are contemplating new programs and innovations in transitional care. Such programs may be time- and labor-intensive; administrative leaders or funding agencies will look for evidence of cost-effectiveness. A key strategy in creating a cost-effective program is to employ targeting criteria that help in identifying patients most in need of special help. Patients who lack such criteria (such as those shown in Table 16-4) are less likely to require costly interventions in order to avoid transitions-related mishaps.

A number of interventions to improve care transitions have been studied; the majority involve discharge from the acute hospital. One systematic review of 54 randomized, controlled trials involving interventions designed to improve outcomes of discharge of elders from hospitals found that the location of the intervention appeared to be an important factor. The most successful interventions, in terms of reducing readmission risk, were those that took place in the patients' homes, or in both hospital and at home, but not exclusively in the acute setting. One such landmark trial, reported by Rich and coworkers, focused on the discharge of high-risk elders with congestive heart failure (CHF). This diagnosis is the leading cause of hospital admission for Medicare patients and is associated with frequent readmission. Rich's multifactorial intervention included intensive education about CHF provided by nurses; social work involvement for help with discharge planning and arrangement of care after discharge; review of the drug regimen by a geriatric cardiologist; dietary assessment and education by a dietician; high-intensity follow-up by the hospital's home care services; and additional home visits and telephone consultation as needed by the research team. Those patients in the intervention arm of this prospective, randomized, controlled trial demonstrated a lower risk of readmission, reduced cost of care, and greater quality-of-life scores.

A later study by Naylor and colleagues considered a broader range of diagnoses for hospitalized elders being discharged to the community. The study population in this prospective, randomized trial included elders with one of several medical or surgical diagnoses, and known to be at risk (using predetermined criteria) for poor discharge outcomes. The intervention made use of advanced practice nurses who assumed responsibility for transitional care from the time of admission to the hospital. These advance practice nurses followed their patients into the home following discharge, and substituted for visiting nurses during the first 4 weeks after patients left the hospital. As with the Rich study, the Naylor study found that the intervention reduced risk of readmission, as well as total cost of care.

Coleman and colleagues reported on the results of the Care Transitions Intervention, which introduced two conceptual innovations. First, this intervention was designed to encourage older patients (and their caregivers) to assert their own preferences, and to acquire self-management skills relating to transitions across care settings. Second, the intervention introduced the role of a “transition coach,” who, although a nurse practitioner by training, did not function as a health care provider. Rather, she encouraged self-management and direct communication with primary care providers. The transition coach visited patients in the hospital and at home, and also made frequent follow-up telephone calls. Patients worked with the transition coach for about 28 days after their discharge to home. Major areas of emphasis included medication self-management; use of a patient-centered record (maintained by the patient, and listing medical problems, medications, and other vital information); empowerment of the patient to schedule and complete follow-up visits with physicians; and patient's understanding of events that suggest that a health condition is worsening. Patients who received this program were significantly less likely to be readmitted to the hospital and the benefits were sustained for 5 months after the end of the 1-month intervention. More than simply managing posthospital care in a reactive manner, the Care Transitions Intervention imparted self-management skills that proved beneficial after the end of the program. Anticipated cost savings for 350 chronically ill adults extending from an initial hospitalization over 12 months is almost $296 000. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.

A number of hospitalist programs have set up postdischarge follow-up clinics in which patients are seen soon after discharge by the physician who provided care in the acute setting. The benefits of these programs have not yet been demonstrated in large, prospective trials. Nevertheless, a large cohort study using an administrative data base for hospitalized patients in Ontario, Canada, found that patients who followed up after discharge with their inpatient provider had a reduced combined rate of readmission and 30-day mortality.

Several pharmacist-led transitions interventions have been recently reported. One intervention involved simply a follow-up phone call placed by pharmacists to patients 2 days after discharge, during which patients were asked whether they had obtained their medicines and understood how to take them. Patients receiving the phone call returned to the ED less often than those who did not (10% vs. 24% at 30 days). Another randomized study examined the effect of pharmacists counseling patients at hospital discharge, and calling 3 to 5 days later. Patients receiving the intervention showed a lower rate of preventable adverse drug events 1 month after hospital discharge. The process of medication reconciliation (discussed below), conducted by pharmacists, was tested in a preintervention/postintervention study involving patients who resided at a nursing home, were hospitalized, and subsequently discharged back to the nursing facility. After the intervention began a pharmacist reconciled the nursing home and hospital medication lists, and reported discrepancies to patients' physicians. Compared to the preintervention group, the postintervention group showed significantly reduced odds of suffering discrepancy-related adverse drug events (odds ratio 0.11, p = 0.05).

Use of electronic methods to transfer patient information between various sites of care (e.g., hospitals, nursing facilities, EDs) is being piloted in a number of locations. Preliminary reports suggest these methods may improve outcomes, such as reducing the number of hospital readmissions. Although these approaches present challenges (nursing homes would need to master electronic interfaces and equipment and to use federally endorsed standards), they appear promising.

A crucial first step in making systematic improvements in transitional care is for the various parties in this activity—the team of clinicians sending a patient to a new setting, the receiving team, and the patient (and family)—to clearly understand their respective roles and responsibilities. As shown in Table 16-5, certain responsibilities belong to one party alone, but some are common or shared.

When the sending team plans to transfer a patient from a higher-acuity to a lower-acuity setting, it is incumbent on them to make a determination that the patient is clinically stable for the move. Predictors of instability for patients leaving a hospital include new incontinence, chest pain, dyspnea, or confusion; pronounced vital sign abnormalities, including fever and oxygen desaturation; poor oral intake; and wound infection. The sending team is also obliged to confirm that the new setting can meet the patient's needs for medical, nursing, and rehabilitative care. The sending team has several communication responsibilities. First, they must explain the purpose of the transfer and confirm that the patient (or caregiver) understands. Second, they must communicate essential information (described further below) to the receiving team and in a timely manner. This information includes recommendations made by consulting physicians and other health professionals of various disciplines. The sending team arranges follow-up appointments (e.g., with primary care providers, surgeons, consulting physicians), and notifies the patient, family, and receiving team. The sending team must provide contact information and be available for questions (from receiving team, patient, family) after transfer.

The receiving team has two general responsibilities in the transfer process. First, before or at the time of the patient's arrival, they must review the information and orders transmitted by the sending team. Second, after this review, and after their independent evaluation of the patient, they should identify any questions or discrepancies, and contact the sending team for assistance. An expected but missing beta-blocker on the medication list, for example, may represent an oversight or a deliberate decision.

A number of responsibilities are common to both the sending and receiving teams of clinicians. Both teams should begin planning for transfer of the patient at the time of admission to their own setting. Both elicit care goals and preferences (e.g., recovery of function, “comfort care”) from patients and families, and incorporate these into the care plan at their own setting. Both must identify their patients' social support (family, friends, church group, etc.), and surrogate decision makers. Both must determine their patients' baseline and current functional abilities, including activities of daily living and mobility. And both should attempt to employ the mode of communication (phone, fax, e-mail) preferred by clinicians in other care settings.

The division of these responsibilities among various disciplines (medicine, nursing, pharmacy, for example) on a team at a given setting divide will depend on local custom and capabilities. An organization choosing to launch a quality improvement program in care transitions might begin by convening a meeting of leaders of various disciplines, clarifying responsibilities, and obtaining commitments to fill the roles listed in Table 16-5.

Patients and families have important responsibilities as well. They need to participate in discussions with clinicians about the destination and purpose of contemplated transfers. They should keep a record of whom to contact if questions come up during or after their transfer. They need a basic understanding of their medication regimen—which drugs are on the list and why, how to take them, what side effects to watch for—as well as a system (such as a pillbox) for organizing them. Similarly, they must have a good understanding of their major health conditions, including what symptoms constitute “red flags” that should be reported, and to whom. Patients and families should remember or write down questions they should pose to their doctor or nurse before transfer. Finally, they should note and understand the follow-up arrangements that have been made for the next provider, their primary provider, and consultants.

Clinical teams or organizations endeavoring to provide outstanding transitional care first need consensus about the information that must be transmitted to the next care setting along with each patient. Table 16-6 offers a list of essential data elements in nine domains. Although it is not necessary or customary for clinicians to transmit each indicated piece of information, sending organizations should assign some member of the clinical team the responsibility for communicating each item.

Overall care goals refers to what the patient and family hope to accomplish at the new care setting. Examples of general goals include recovery from an acute illness, followed by return to the previous residence; custodial care for the remainder of the patient's life; or hospice care.

Medical information comprises the bulk of a typical hospital discharge summary, with an enumeration of the patient's various diagnoses, how they were treated, and how the patient fared.

Functional information includes the patient's self-care abilities (basic and instrumental activities of daily living), mobility, need for assistance, and assistive devices.

Treatments include a listing of the scheduled and as-needed medications, history of drug-related ill effects, and recommended nonpharmacogic therapies to be provided at the new setting (rehabilitative, psychological, etc.).

Social background and support provides vital background information about the patient's family and/or caregivers, their willingness to provide assistance to the patient, the presence of additional help from the community (e.g., from church groups), and the patient's previous (and ultimate) residence.

Communication and culture refers to important aspects of how patients comprehend health-related information and make decisions about their care. If a patient's primary language is other than English, this formation needs to be passed along. Low levels of literacy, if known, also should be communicated so that the receiving team does not provide written materials without the necessary assistance. Health beliefs (for example, a fatalistic view about stroke risk in a patient with atrial fibrillation) and decision-making style (for example, all major decisions are discussed with adult children) should be documented as well.

Advance directives must accompany patients to new care venues. These may be as simple as the designation of a surrogate, such as a durable power of attorney for health care, or may be more involved, such as instructions regarding the use of life-supporting technologies or resuscitation attempts.

Patients frequently need specialized durable medical equipment at their new site of care. Examples might include wound vacuum devices for use in the nursing home or provision of a hospital bed at home. Although not typically spelled out in detail by physicians, this information (devices, vendors' names) should be provided by the responsible disciplines at the sending institution.

Physicians also are unlikely to provide the receiving team or institution with information about details of insurance benefits and coverage, home health agencies, or provider networks. This responsibility should be assumed by a defined member of the sending team.

A succinct yet informative transfer summary is an important component of good transitional care. We offer as an example Table 16-7, a hospital discharge summary for a representative 85-year-old woman admitted for pneumonia. Several features of this model summary are worth noting. First, the discharge diagnoses list not only the usual medical problems (pneumonia, diabetes, and so forth), but also cognitive diagnoses (dementia from Alzheimer's disease), behavioral problems (“sundowning”), affective disorders (depression), and functional problems (gait disorder with history of falls). The Hospital Course portion of the summary includes multiple, brief, problem-labeled paragraphs; this format has been shown to be preferred to a chronological recollection of the hospital stay. The discharge instructions include red flags to watch for (worsening dyspnea, fatigue, etc.), as well as where to call if these problems arise.

The discharge medications section of Table 16-7 contains information that will be essential for the receiving care team, and which too often is neglected in hospital discharge summaries. In addition to the dose, route, and frequency for each drug, an indication is provided. Tapering schedules or stop dates (for drugs like systemic corticosteroids, antibiotics, or anticoagulants) are given as needed. Finally, the transfer medication list is reconciled with the regimen at entry to the facility. In the case of a hospital discharge, the discharge medication list would be compared to the patient's earlier outpatient list. Properly performed, medication reconciliation answers three questions: (a) Which of the patient's transfer medications are new, that is, were not taken until after the patient was admitted to the current venue? (b) Which of the patient's previous medications are to be stopped? (c) For those medications that have been continued from the earlier setting, which doses have changed?

A well-reconciled discharge medication regimen requires complete understanding of the preadmission regimen. Table 16-8 lists components of a thorough preadmission medication history. This includes not only information that is essential for the subsequent reconciliation (drugs, doses, use of over-the-counter remedies and herbals, etc.), but other beneficial items like identities of prescribing providers and pharmacies, assessment of the patient's understanding of the regimen, impression of adherence to the prescribed regimen, method of administration at home (pill boxes, etc.), history of adverse drug reactions, indication, and consideration of continued need.

Some additional important sections follow the discharge medications list in Table 16-7. Follow-up appointments, arranged before transfer, spell out which provider is to be seen and when. Pending laboratory studies highlight tests whose results are still outstanding. This situation occurs more frequently with short lengths of stay. The specification of caregiver/surrogate decision maker and of goals/preferred intensity of care in Table 16-7 illustrates how this information (called for in Table 16-6) might be spelled out in practice to good effect. Finally, information on functional status at transfer is typically provided in greater detail by documents prepared by nursing and rehabilitation disciplines, but deserves mention in a synthesized way by the physician as well.

Hospital discharge summaries ideally are available for review by the next care team or primary care clinician before their encounter with the discharged patient. Unfortunately, these summaries all too often fail to reach primary providers in a timely manner. To assure that these providers have access to vital information about their patients at the time of hospital discharge, we recommend that certain information (Table 16-9) be faxed or e-mailed by hospital providers. At the time of hospital discharge, a patient's primary provider should be apprised of the discharge diagnoses (with emphasis on the reason for the hospitalization), the complete list of discharge medications, results of major tests, a listing of tests that have been done but whose results are still outstanding (biopsy results, for example), and follow-up arrangements (especially those involving the primary provider and visiting nursing). A couple of other items also deserve inclusion in this abbreviated summary and may require a bit of thought on the part of the transferring clinicians. First, given what is known about the patient in question, what problems might arise soon after discharge, related perhaps to potential disease exacerbations or family dynamics? What action might be taken if these problems occur? Second, which issues will require follow-up attention at the first postacute visit?

Up to this point, we have emphasized communications between sending and receiving clinicians involved in a transfer. Excellent transitional care requires that effective communication take place with the patient (or caregiver) as well. Table 16-10 lists informational items that must be communicated to the patient, as well as tips on performing this function. It is not necessary that all these items be communicated by a physician—some might better be discussed by nursing or pharmacy personnel—but leaders in the transferring organization should assure that lines of responsibility are clear. Because of variations in the health literacy of patients and their families, transfer instructions should be provided at about a 6th grade level.

Important new diagnoses (particularly those that precipitated an acute illness episode) should be shared with the patient around the time of discharge, if this has not occurred already. The discharge medication list should also be reviewed, including the indications for the drugs, the changes made from the regimen the patient had followed before, and potential adverse drug reactions. Important limitations in the patient's activity, such as physical exertion or bathing concerns, should be discussed. Patients and families should be apprised of functional prognoses: “I think you have a good chance of getting back to your previous ability to walk around your home after about four to six weeks of rehabilitation at the nursing facility.” Signs or symptoms that may signal early trouble should be related, along with information on what the patient should do should they arise. Important follow-up appointments (with primary providers, surgeons, or specialists) should be made and communicated to patient and family.

If the patient is headed to a new care venue, such as a SNF, it is helpful to say a few words about what to expect there: “You will not be seeing your doctor or nurse practitioner at the rehabilitation center as often as you have in the hospital, particularly if things are progressing well. The emphasis there will be much more on rehabilitation. You and the therapy staff will be working hard to recover your ability to walk like before and take care of yourself.” Important self-care tasks, such as wound care techniques or glucose self-monitoring, must be taught or reviewed prior to discharge. To confirm that patients and families are learning what they need to know, clinical personnel should check for understanding by having them repeat back what they have heard and by demonstrating the requisite self-care skills: “Just to be sure I have done a good job of teaching you how to change this dressing, let's have you try it now.”

A great deal of information is transmitted by clinicians to patients and families around the time of transfer. Some communication routines may help to maximize the chances that this information is understood and remembered. First, information and instructions should be given in lay language: avoid jargon and Latin abbreviations. Second, written materials should be provided for later review and reference. Finally, at the completion of the discharge instructions, the patient and family should be asked, “What questions about your transfer can I answer?”

The Care Transitions Intervention, discussed earlier, was specifically designed to be low-intensity, low-cost, and brief in duration. One particular strategy was the encouragement of patient “ownership” over core elements of their medical history through the use of a portable personal health record. This record included medical diagnoses, current medications, allergies, and primary care providers. A second strategy was the employment of Transition Coaches. Several leading health care organizations, operating under different financial structures, have adopted the Care Transitions Intervention.

Clinician leaders (e.g., chiefs of medical staff) and managers of health care organizations may wish to employ well-established methods of quality improvement to foster better transitional care. One such method involves the collection of vital process data—such as the fraction of discharge summaries that include a reconciled medication list, the fraction of discharged patients who were given follow-up appointments, or patient satisfaction survey data—and the use of these data in Deming cycles (Plan-Do-Study-Act) designed to improve the studied measure. Another method is the use of regular “customer–supplier” exchanges. Regularly scheduled meetings between representatives of hospitals and postacute nursing homes, or between hospitalists and primary providers, allow for the identification of interface concerns, prioritization of improvement efforts, and the nurturing of improved communication and rapport.

More than a quarter of nursing home residents are transferred each year at least once to an ED for urgent evaluation. These transfers are often perilous given their urgency, the difficulties of many nursing home residents in recalling and relating their history, and the problems of reaching families or surrogate decision makers. Conversely, when nursing home residents return, facility staff often report confusion about diagnostic findings or therapeutic recommendations from the ED. A recent study reported on the results of focus groups involving nursing home staff, ED personnel, and emergency medical services providers. Table 16-11 summarizes the authors' findings on recommended information exchange between health professionals working in the two care settings. ED personnel need to know the reason for transfer, as well as whom to contact at the nursing facility for additional information. The patient's physician (with contact information) should be identified. Important clinical information the ED will need includes the patient's past medical history, medications and drug allergies, baseline cognitive and physical function, latest vital signs, and recent laboratory and x-ray results. Advance directives and surrogate decision maker or family contact are vital as well. Finally, in the event that the ED is contemplating a return of the patient to the nursing facility with new orders, it will be important for ED providers to be made aware of the capabilities of the facility to provide technical or nursing-intensive care, such as intravenous medication administration. Nursing home leaders (medical directors or directors of nursing) may wish to create a blank form listing the items from Table 16-11, and assure that nurses who transfer patients for emergency evaluation complete the form and send along photocopies of related documents.

Information needed by nursing home personnel when residents return from the ED includes the working diagnosis rendered by emergency personnel, vital signs from the ED, results of testing performed there, treatment provided in the ED, and recommendations for further treatment or follow-up. A legible copy of the chart from the ED is generally essential. Just as nursing facility leaders may implement a standardized transfer form for patients sent to the ED, leaders from emergency medicine and nursing may institute their own transfer-back-to-nursing-home form or checklist, and employ quality improvement methods to confirm that the needed information is reliably transmitted.

Another common transition involving older patients is the admission to the program of a home health nursing agency. As with transfers between nursing homes and EDs, it is helpful to employ a checklist (Table 16-12) of informational items that the home nursing agency will need. Much of this is “the usual”—provider name and contact information, patient name and demographics, medical history and problem list, medication list and drug allergies, functional status, advance directives, and names of surrogate decision makers. A few items are more peculiar to the home care setting. First, if the home health program services are to be covered by Medicare, it will be important to specify the skilled care needs and to state that the patient meets “homebound” criteria. Second, what are the goals of care that the nursing personnel should keep in mind? Articulating these will not only help to prioritize their work, but will indicate when discharge from their program is appropriate. Third, what are the clinical and psychosocial issues (e.g., laboratory values, functional improvements) that are to be reported?

A third common care transition involving elders is the handoff of the hospitalized patient from one physician to another, such as for night or weekend coverage. Solet and coworkers reviewed the literature on such handoffs (few high-quality studies exist), and evaluated the handoff process at the four hospitals staffed by one Midwestern internal medicine residency program. Based on their work, they make four overall recommendations. First, handoffs of hospitalized patients should generally be made face to face, to allow the doctor assuming care of the patients to ask questions, to practice read-back skills, and to register nonverbal information such as facial expression, tone of voice, and body language. Second, the format for information transfer should be highly standardized. Third, the skill of handing off the care of complex and potentially unstable patients to another provider needs to be explicitly taught. And fourth, handoff skills need to be practiced repetitively, as is done by professionals in other high-risk occupations, such as air traffic handling. We believe these are reasonable recommendations, based on the information available to date, and we also endorse the authors' list of essential elements that should be passed on at the time of handoff. These elements include: patient identification, location, date of admission, a brief synopsis of the patient's admitting presentation, a list of currently active and pertinent past medical problems, medications and drug allergies, venous access (and how important it is that this be maintained), code status, key laboratory data, foreseeable problems with recommended contingency plans, and psychosocial concerns. Some or all of this information should be transmitted in written or electronic form (via computer or personal data assistant) as well as orally.

Educational scholarship in the field of transitional care is at an embryonic stage. Reports of needs assessments have been few in number and have involved small sample sizes. One such assessment employed focus groups and surveys to determine the educational needs in geriatrics for medical students and internal medicine residents. Trainees perceived training gaps in four major areas; one of these was in transitional care (primarily involving discharge from the hospital). Another needs assessment performed at a single internal medicine residency of an academic medical center found that house staff received little instruction in, or role modeling of, good transitional care; that residents learned to create better discharge summaries primarily from experience; and that resident-generated discharge summaries demonstrated a need for improved format and information content.

Few reports are available describing transitional care educational interventions and their effects. Some medical schools are beginning to incorporate the topic into their curriculum using teaching methodologies such as lectures, video, group discussions, and interdisciplinary exercises. A number of residencies have also incorporated instruction on the subject, primarily on how to compose a proper hospital discharge summary. Educational techniques have included didactic instruction, individualized feedback to residents, and technologies that permit the incremental preparation of discharge summaries during a patient's hospital course.

Although we cannot (yet) cite studies to support our views, we believe that trainees will receive improved transitions education if a few approaches are adopted. First, attending physicians should be role models for excellence in this area. They should demonstrate mastery of the assessment and communication skills required to manage care transitions. Increased faculty development efforts at many centers will probably be required to assure that teaching faculty members master the needed skills. Second, attending physicians must evaluate their learners for transitional care performance, provide generous and specific feedback, and incorporate their assessments into learners' end-of-rotation formal evaluations. Third, transitional care topics should be incorporated into teaching conferences. One natural place to do so is the “M&M” (morbidity and mortality) conference. While usually a forum to discuss cases in which a patient suffered from a hard-to-diagnose malady, or in which some procedural misfortune ensued, the M&M conference presents an opportunity to dissect a systems breakdown, such as a fumbled patient handoff.

An indication that a training program has succeeded in incorporating transitional care into its curriculum is that its trainees give as much effort and thought to patient transfers as they do to admissions.

A confluence of trends in American health care is pushing transitional care quality onto the agendas of professional leaders, certifying and regulatory bodies, third-party payers, and patient advocacy groups. Well-executed transitional care is patient-centered and improves patient safety. Given the aging of the population, the accretion of chronic medical and functional problems, the specialization of care venues, the pressure to reduce lengths of stay, and increasing disincentives for many clinicians to provide care across a continuum of settings, transitional care will only grow in prominence.

Research has shown that older patients and members of other vulnerable populations are most likely to suffer mishaps during handoffs of care. Nevertheless, we are learning which approaches and techniques seem to improve the odds of good outcomes. There is a growing consensus about what informational elements should be transmitted to patients, families, and the next team of providers. Empowering patients and their caregivers is vital. Employing professionals, such as transition coaches, whose role definition includes navigating patients through the health care system, has proven beneficial. And providing explicit, dedicated training in care transitions to physicians, physician assistants, nurse practitioners, nurses, and pharmacists is imperative.

Yet substantial improvement in the quality of American health care transitions will require a combination of approaches and strategies. First, the scientific foundation for the field is still being constructed, and important research questions abound. What are the best measures of transitional care quality? Which factors predict transitions mishaps? Which transitional care interventions are beneficial and cost-effective?

Second, a commitment to improve care transitions creates a demand for educating the professionals who plan and execute these transitions. Health professions educators will need to incorporate the topic into an already crowded curriculum. Particularly challenging is that the best method for teaching the subject may require a genuinely interdisciplinary approach.

Finally, a refined scientific database at the disposal of committed and energetic teachers may only yield improvement around the edges. Health care professionals, being human, still respond to the mix of incentives and disincentives they face. The fee-for-service model that dominates provider payment in the United States hinders efforts at providing coordinated care for patients. Whether substantial and widespread improvements in transitional care can occur in the United States without extensive modifications of the payment system is open to doubt.

Web Sites

www.caretransitions.org

www.hospitalmedicine.org (visit the “Resource Center”)