Background Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. Methods Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their pREFERENCES, and (3) continuity across settings and guidance from a “transition coach.” Rates of rehospitalization were measured at 30, 90, and 180 days. Results Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P  = .048) and at 90 days (16.7 vs 22.5, P  = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P  = .04) and at 180 days (8.6 vs 13.9, P  = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P  = .049). Conclusion Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization. Trial Registration clinicaltrials.gov Identifier:NCT00244491

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/410933/ioi60077.pdf

The care transitions intervention: results of a randomized controlled trial.

Emergency department visits and rehospitalization are common after hospital discharge. Jack and colleagues demonstrated that a nurse discharge advocate and clinical pharmacist working together to c...

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A Reengineered Hospital Discharge Program to Decrease Rehospitalization

Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.

Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.

Background Despite the national attention being given to the problem of medication safety, little attention has been paid to the medication problems that are encountered by older patients who are receiving care across settings. The objective of this study was to determine the prevalence and contributing factors associated with posthospital medication discrepancies. Methods The study population consisted of community-dwelling adults aged 65 years and older admitted to the hospital with 1 of 9 selected conditions (n = 375). A geriatric nurse practitioner performed a comprehensive medication assessment in the patient’s home within 24 to 72 hours after institutional discharge. The assessment focused on what older patients reported taking in comparison with the prehospital medication regimen and the posthospital medication regimen. Prevalence and types of medication discrepancies were categorized using the Medication Discrepancy Tool. Results A total of 14.1% of patients experienced 1 or more medication discrepancies. Using the Medication Discrepancy Tool, 50.8% of identified contributing factors for discrepancies were categorized as patient-associated, and 49.2% were categorized as system-associated. Five medication classes accounted for half of all medication discrepancies. Medication discrepancies were associated with the total number of medications taken and the presence of congestive heart failure. A total of 14.3% of the patients who experienced medication discrepancies were rehospitalized at 30 days compared with 6.1% of the patients who did not experience a discrepancy ( P  = .04). Conclusions A significant percentage of older patients experienced medication discrepancies after making the transition from hospital to home. Both patient-associated and system-associated solutions may be needed to ensure medication safety during this vulnerable period.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/486693/ioi50080.pdf

Posthospital Medication Discrepancies: Prevalence and Contributing Factors

Background For the purpose of this position statement, transitional care is defined 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 assisted living and long-term care facilities. Ideally, transitional care is based on a comprehensive plan of care and the availability of healthcare practitioners who are well trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses the sending and the receiving aspects of the transfer, is essential for persons with complex care needs and their caregivers. Persons whose conditions require complex, continuous care frequently require services from different practitioners in multiple settings, but practitioners in each setting often operate independently, without knowledge of the problems addressed, services provided, information obtained, medications prescribed, or preferences expressed in previous settings. 1 The growing national trend for physicians and other clinicians to restrict their practices to single settings (e.g., hospitals, skilled nursing facilities, or ambulatory clinics) and not to follow complex patients as they move between settings heightens this potential for fragmentation of care. 2,3 During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan “falling through the cracks.” 1,4,5 Ultimately, poorly executed care transitions may lead to poor clinical outcomes; dissatisfaction among patients; and inappropriate use of hospital, emergency, postacute, and ambulatory services. 1,6,7

Improving the Quality of Transitional Care for Persons with Complex Care Needs

Background: To improve the quality of care delivered to older persons receiving care across multiple settings, interventions are needed. However, the absence of a patient-centred measure specifically designed to assess this care has constrained innovation. Objective: To develop a rigorously designed and tested measure, the Care Transition Measure (CTM). Setting: A large, integrated managed care organisation in Colorado with approximately 55,000 members over the age of 65 years. Participants: Patients 65 years and older who were recently discharged from hospital and received subsequent skilled nursing care in a facility or in the home. Methods: Six focus groups of older persons and their caregivers (n=49) were established. Standard qualitative analytic techniques were applied to written transcripts and four key domains were identified: (1) information transfer; (2) patient and caregiver preparation; (3) self-management support; and (4) empowerment to assert preferences. Specific CTM items were developed, pilot tested, and refined. Psychometric testing, conducted in a different population but selected using the same entry criteria (n=60), included content and construct validity, intra-item variation, and floor/ceiling properties. Results: Older patients and clinicians found the measure to be highly relevant and comprehensive (i.e. content validity). Construct validity was assessed by comparing items from the CTM to selected items from a measure developed by Hendriks and colleagues (Medical Care 2001; 39(3): 270–283). Inter-item Spearman correlations ranged 0.388–0.594. No significant floor or ceiling effects were detected. Conclusions: The CTM was developed with substantial input from older patients and their caregivers. Psychometric testing suggested that the measure was valid. The CTM may serve to fill an important gap in health system performance evaluation by measuring the quality of care delivered across settings.

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Development and testing of a measure designed to assess the quality of care transitions

CTM 3 is a three question survey that is now a national voluntary consensus standard measure of the quality and effectiveness of the transition or discharge from an acute care hospital to another location of care. The CTM measures a patients understanding of their own role in their care, measures their understanding of their discharge medications and measures whether or not their own values and preferences were followed during their care (patient centered care).

Jill N. Thiare

Papers

Development and testing of a measure designed to assess the quality of care transitions

Care Transitions Measure