If ever there was a conundrum, the post-hospitalization discharge, with its often intricate and difficult problems, is one.
So many stakeholders, so much information, so many opportunities for ineffective communication – all can promote and multiply the threats to patient safety and physician liability during the patient’s transition from one setting to another.
At any age and in any group – but especially among the elderly and the very young – chronic illness with multiple comorbidities, critical illness, cognitive impairment, a lack of health literacy, a first language other than English, can all increase the risks to patient, physician, and staff.
The Affordable Care Act, the implementation of CPT codes for managing transition of care, and the penalty for hospital readmissions within 30 days of discharge, have increased the pressure for finding workable solutions to the post-hospitalization conundrum. Responsibility, accountability, liability, and defensibility are warning flags along the track to patient, physician, and staff safety.
The recent history of research, analysis, and program development to achieve effective care transitions confirms what we know anecdotally: we need to have a system and use it relentlessly.
If we are to “promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” as described by Mary Naylor in her presentation, “Avoid Readmissions Through Collaboration,” we must broaden our view of the who, what, and how involved in achieving effective transitions of care.
There are multiple descriptions and definitions of transition of care, and a wide variety of models designed to improve the process. These models may include, unless limited by their state code of practice, non-physician practitioners such as nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives who are eligible to bill the CPT Transitional Care Management codes.
There are multiple descriptions and definitions of transition of care, and a wide variety of models designed to improve the process.
Naylor, et al. define transition of care as “…a broad range of time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.”
The Agency for Healthcare Research and Quality’s patient safety culture survey assesses staff perceptions of patient safety in more than 1,000 hospitals nationwide. In 2012, handoffs and transitions formed the second-lowest scoring area – non-punitive response to error was one percent lower.
More than 50 percent of staff responding agreed that:
- “Things ‘fall between the cracks’ when transferring patients from one unit to another.”
- “Important patient care information is often lost during shift change.”
- “Problems often occur in the exchange of information across hospital units.”
- “Shift changes are problematic for patients in this hospital.”
Accepting that these perceptions are accurate when the patient stays within the same organization and physical setting, we have to consider how much more likely is it that important patient information will be lost upon discharge.
The National Transitions of Care Coalition (NTOCC) was founded in 2006 to define solutions by addressing the gaps that impact safety and quality of care for transitioning patients. The NTOCC has seven recommendations for improving transitions of care:
- Improve communication
- Establish accountability
- Integrate information technology
- Expand pharmacists’ roles
- Develop quality measures
- Increase use of case management
- Align payment systems and incentives
Balaban, Weissman, Samuel, and Woolhandler, in their 2008 study, measured four undesirable outcomes after hospital discharge: 1) no outpatient follow-up within 21 days; 2) readmission within 31 days; 3) emergency department visit within 30 days; and 4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors.
In light of the concerns confirmed by the research noted above, and in view of the recommendations from NTOCC among others, how have organizations and providers responded to the demands for effective transition of care from one provider or entity to another?
Carole Lambert is assistant vice president, membership review and education and residents program director for the Cooperative of American Physicians, Inc. (CAP).