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Transitional Care

The term “care transitions” refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, in the course of an acute exacerbation of an illness, a senior patient might receive care from a Primary Care Provider (PCP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.[i] After it has been determined that a patient should return home, they may receive care from a visiting nurse and or a non-skilled home care provider. Each movement between settings and providers is referred to as a transition in care or “care transition.”

Our Care Team has created a solution to help reduce hospital readmission. The program is structured to supplement care from healthcare providers and work with patients and their families to ensure a safe transition home from a facility. These services are designed to allow patients to get back on their feet, and back to their life.

The services typically provided by Golden Independence in these circumstances are for persons who lack some degree of physical and cognitive functional capacity. Home care services can consist of assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The typical recipient is older, with multiple ADL and complex health needs. Some recipients receive a few hours of care a week, while others receive around-the-clock coverage.  Services provided through Golden Independence Transitional Care program range from meal planning/preparation to ambulation/hygiene services and skilled nursing services such as wound care and I.V.-related therapies.

Why Hospitals are interested in transitional care?

Through healthcare reform and new initiatives, the federal government aspires to save $26 billion dollars in the coming years by leaning on hospitals to lower their preventable readmission rates.   According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[ii] The Medicare Payment Advisory Commission estimates that up to 76% of these readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200. With cuts to Medicare spending, hospitals with high readmissions are motivated to develop solutions within their community as their performance (of reducing readmission rates) will impact how much they will be paid by Medicare.

Care transitions programs allow hospitals to focus on reducing those numbers by improving the care coordination for patients between settings, which in turn lessens the likelihood that they will return for a related readmission.  The core benefits of these programs for hospitals are to improve patient outcomes and reduce costs.

What are some of the problems with the care continuum between healthcare settings?

Due to the infrastructure of our health care system, patients often encounter fragmented care when moving between health care settings.  Many elderly patients with chronic illnesses or conditions require care from more than one provider.  The following are some of the contributing outcomes of poor transition management:

  • Information is often fragmented in silos and there is poor communication between settings;
  • There is often a misunderstanding or confusion on the part of seniors and their family caregivers about how and who should manage their care;
  • Medication errors involving misunderstanding of instructions, medication adherence, drug-drug interactions and duplicate prescriptions;
  • Poor follow up with Primary Care Provider (PCP);
  • Lack of knowledge about alternatives (i.e. in-home care providers) in many communities.

How are care transitions initiatives addressing these issues?

  1. Information silos and poor communication between settings – A common misconception that many senior patients have is that information about their medical conditions is shared between settings; however, this is typically not the case.  While electronic health records are becoming more common place there are still issues with communication between providers.

To overcome this barrier, many care transitions models have implemented the use of Personal Health Records, forms that patients use to track information about the care they receive across settings. Patients are encouraged to record information about any chronic health problems, visits to each healthcare setting, dates they were treated, what they were treated for, what type of medications they take, the dosages associated with those medications, etc. Care transitions programs also employ transition coaches (explained in greater detail later on) who conduct home visits and/or place follow up calls to encourage patients to complete the Personal Health Record before and after each transition or follow-up visit.

  1. Confusion about care management– Patients are often confused about the discharge instructions set out by their care providers. Most elderly patients are contending with multiple chronic diseases/conditions and medications. They are often readmitted for an adverse event within 30 days of discharge because they do not understand or did not follow instructions given to them.  If there is no care coordination for seniors across settings, there is often conflicting and confusing information in the Care Plan or discharge instructions from different provider settings.

In order to contend with these challenges, care transitions programs are empowering seniors and their caregivers to advocate for themselves, since they are the constant thread through the care continuum.  These programs are doing this by educating patients and equipping them with tools to manage their own care and prepare them for transfer to and from each setting.

  1. Medication Errors – Care fragmentation impacts many aspects of the care continuum including patient safety. Medication errors account for many unnecessary readmissions to the hospital. In fact, an estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, or discharge of a patient.”[v]

To help ward off readmissions due to these types of errors, care transitions initiatives take a few approaches. During home visits, the transitions coach will typically review all prescribed medications, over the counter (OTC) medications and dietary supplements as well as prescribed dosages with clients.   The coach will also make recommendations regarding questions they should ask their physician at the next follow up visit. (Please note, not all of the amenities noted above are facilitated by Golden Independence Home Care.)

  1. Poor follow up with PCP – Another main cause for patients to be readmitted to hospitals is poor follow up with their PCP. Frequently patients are scheduled for a follow up visit after being discharged for a major procedure, such as heart surgery; however, they fail to make their appointment because they either forget about it, can’t drive themselves and/or do not have anyone that can take them.

Care Transition programs are trying to account for issues like this by beginning the care coordination process much sooner than traditionally done in the past. Many care transition models promote that care coordination (for the next setting) should begin when the patient is first admitted to the hospital. One key element that care coordinators are looking at is the patient’s support structure following discharge. If it doesn’t appear that the senior will be able to fully function on their own and they do not have a caregiver they can rely on, then alternative plans need to be arranged so that the senior will have a successful transition.

  1. Alternate Solutions –While hospitals and healthcare professionals are beginning to understand and embrace the idea of better care coordination, they may not see the connection or need for alternative (non-medical) care providers. Hospitals have long seen the connection between discharge and home health settings but there is a void between those services and companion care.  The Golden Independence Transitions program helps bridge the gap and supplement the hospital and home health’s clinical services.