Just like the critical handoff of the baton in a relay race, a smooth transition of care from one healthcare provider or setting to the next is key to reaching the finish line of positive health outcomes, lower hospital readmissions and fewer medication errors. In the move toward value-based reimbursement, best practices in transitions of care have never been more important.
“It’s not just looking at the medical aspects of what the patient is dealing with, but those non-clinical issues that so many times impact a transition and can cause avoidable hospital readmissions,” said Cheri Lattimer, executive director of the National Transitions of Care Coalition. “In good care coordination, the team understands their role is not done when the patient walks out their door. The team must put forth the effort to communicate, share and transfer information and make sure the patient and family caregiver are included.”
As an example of transitions of care best practice, Lattimer points to the Care Transitions Programdeveloped by Dr. Eric Coleman at the University of Colorado Denver, which trains nurses, social workers and case managers to be “transition coaches.” Such coaches follow a four-week program comprised of one visit and three phone calls with patients and family caregivers to navigate each transition of care coordination. The program claims a 20-50 percent reduction in hospital readmissions and a $365,000 net savings per transitions coach.
“These coaches can spend more time working with the patient and family caregiver to help them feel comfortable engaging with providers, knowing what questions to ask and watching for the red flags of their condition so they can become part of the team and be more proactive in their care,” Lattimer said.
Another cutting-edge approach to transitions of care, said Lattimer, is the Transitional Care Model developed by Dr. Mary Naylor at the University of Pennsylvania School of Nursing. This program focuses on training advanced care nurses to oversee care transitions. The essential elements of this model include the involvement of a transitional care nurse within and across healthcare settings, regular home visits and phone calls with patients and family caregivers and a focus on achieving long-term positive outcomes.
As a guide map to help providers achieve best practice in transitions of care, URAC offers a Transitions of Care Designation as part of its Case Management Accreditation program. The designation sets standards for creating a formal process to identify and track transitions of care across providers, care settings and levels of care. The standards also include creation of a clearly defined plan for each consumer that includes outreach, goals and monitoring, and encourages engagement among patients and caregivers to reinforce and achieve self-management goals.
A boost to transitions of care has come from the expansion of reimbursement codes since 2013; in 2017, code enhancement will integrate medical and behavioral health and allow delegation of care management between parts of the care team, Lattimer said.
The future of potential legislative or regulatory changes on healthcare delivery may be uncertain, “but no matter what happens, care coordination is a best practice, and improved quality of care needs to go forward in a patient’s journey toward not having to struggle with stress, miscommunication and medication errors,” she said. “If value-based payment continues, I see it as strong support for care coordination.”