Why Are Care Transitions Important?
Highlights
Transitions of Care Consensus Policy Statement
Snow V et al, Journal of General Internal Medicine & Journal of Hospital Medicine, 2009
J Gen Intern Med 24(8):971–6, DOI: 10.1007/s11606-009-0969-x
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Medication errors during patient transitions into nursing homes: characteristics and association with patient harm
Desai R et al, Agency for Healthcare Research and Quality
PMID:22078862
The aim of the study was to describe characteristics of medication errors occurring during transitions to nursing homes, to compare characteristics of transition errors with errors not involving a transition, and to evaluate the impact of these errors on patient harm. The study results demonstrated that staff communication, order transcription, medication availability, pharmacy issues, and name confusion were particularly important contributors to medication errors during transitions.
The Published Literature on Handoffs in Hospitals
Cohen MD and Hilligoss PB, BMJ Publishing Group Ltd., 04/2010
Quality and Safety in Health Care (Online First), 19(6), pp.493-497
A review of existing research on handoffs in order to inform the improvement and standardization of the handoff process in hospitals found that in existing literature, key concepts remain poorly defined and that patient safety is not analyzed against handoffs’ other functions.
Handoffs In hospitals occur when responsibility for and information about a patient changes from one health professional to another, and they may result in increased patient risk. The authors collected and reviewed all published research in English on medical personnel handoffs through July 2008.
Executive High-Quality Care Transitions: A Call to Do It Right
Coleman EA & Williams MV, Journal of Hospital Medicine, 10/2007
Journal of Hospital Medicine Vol 2 / No 5 / Sept/Oct 2007, pages 287-290
This editorial incorporates unique contributions of three teams of investigators namely Kripalani and colleagues; Strunin and colleagues; and Flacker and colleagues. The editorial includes recommendations to ensure that the gains patients make in the hospital are maintained long after discharge.
Patient Handoffs
Runy LA, Hospitals and Health NetworksResearch, 2008
This article discusses the pitfalls and solutions of transferring patients safely from one caregiver to another.
Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians
Kripilani S et al, Journal of the American Medication Association, 2011
JAMA. 2007;297:831-841
This article describes how delayed or inaccurate communication between hospital-based providers and primary care physicians at discharge may contribute to adverse events.
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Transitions of Care Consensus Policy Statement
Snow V et al, Journal of General Internal Medicine & Journal of Hospital Medicine, 2009
J Gen Intern Med 24(8):971–6, DOI: 10.1007/s11606-009-0969-x
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Communication Failures and a Call for New Systems to Promote Patient Safety
Sehgal NL & Auerbach AA, Archives of Internal Medicine, 2011
(REPRINTED) ARCH INTERN MED/VOL 171 (NO. 7), APR 11, 2011, pages 684-685
This commentary identifies communication and teamwork failures as threats to patient safety and the need for new systems to enhance patient safety.
Scaling Up: Bringing the Transitional Care Model into the Mainstream
Naylor MD & Sochalski JA, Commonwealth FundPublication, 2010
This issue brief describes two projects that identified the essential elements for effective care management for the elderly population, and the facilitators of translating one such intervention, the transitional care model, into mainstream practice.
The Impact of Postdischarge Telephonic Follow-Up on Hospital Readmissions
Harrison PL et al, Population Health Management, 2011
POPULATION HEALTH MANAGEMENT, Volume 14, Number 1, 2011, DOI: 10.1089/pop.2009.0076, pages 27-32
This study was conducted to demonstrate the impact of post discharge calls on readmissions. The results show that readmissions rate fall considerably with post discharge calls compared to no post discharge calls.
Further Application of the Care Transitions Intervention
Parry C et al, Home Health Care Services Quarterly, 2011
Home Health Care Services,Quarterly, 28:2-3, 84-99
This study demonstrated an association between care transitions intervention and outcome improvement in a Medicare fee-for-service population.
Health Care Transitions and the Aging Population
Ross DM et al, Health Care Manager, 2011
This study examines the association between care transitions and rapid rehabilitations. Some of the findings suggest patients transitioned to rapid rehabilitation may be the most complex, have the longest length of stay (LOS), and be the most costly for the health care system.
A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes
Dedhia P et al, Journal of the American Geriatrics Society, 2009
J Am Geriatr Soc 57:1540–1546, 2009
This article describes the effect of a multifaceted, multidisciplinary Safe and Successful Transition of Elderly Patients Study (STEPS) intervention to facilitate safe discharge of hospitalized older patients from the medicine ward back to their homes.
A Seasonal Care Transitional Failure
Young JQ, Agency for Healthcare Research and Quality, Cases & Commentaries, 07/2011
The case describes how failure in communication process led to harm to a seventy year old patient. The commentary proposes important points for a safe year end transfer process.