Calling the Shots: Nursing News and Notes

Time to Care About Care Transitions

Time to Care About Care Transitions

Wednesday, March 25, 2015
Time to Care About Care Transitions

A woman hires a native guide to take her through the Brazilian jungle and safely back to civilization. The guide adeptly clears dense vegetation to forge a path, points out venomous snakes she would otherwise trample on, keeps predatory jaguars at bay and successfully leads her to a small boat waiting by the river. That boat will take her to the capital city, a place gloriously free of vampire bats, poison dart frogs, and other unfamiliar dangers of the rainforest.

The woman eagerly boards the boat, the guide gives it a shove, and then he turns to leave. His job is done, right?

Unbeknown to the woman, just yards away, electric eels, piranhas, and anacondas swim freely. Giving the oar a tentative row, she realizes she’s not too sure of the exact signs she’s looking for to find her way back to the city. Her pale, unprotected skin begins to burn under the sun’s strong rays. She’s thirsty.

Did the guide do his job?

“Bewildering” Handoffs

No matter how exceptional the care a hospital provides, a patient’s journey to healing can be perilous without proper care transitions from one setting to another. Simply getting patients through the jungle isn’t enough. For smooth sailing, they and their care team need the information and tools that will equip them for continued healing.

Unfortunately, in today’s complex and hectic healthcare environment where patients are many and staff is stretched, poor care transitions have become commonplace. Too often, after they perceive their part done, busy healthcare providers send off their patients without a second glance.

In its 2001 Crossing the Quality Chasm report, the Institute of Medicine declared the U.S. healthcare system poorly organized and complicated, containing “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.” Patients are often discharged without essential information on self-care, what medication side effects to monitor for, when they can safely resume activities, and where to go with questions, the institute reported.

Communication between hospitals and primary care providers was found lacking, too, in a 2007 Journal of the American Medical Association study. During post-discharge visits with patients, just 12% to 34% of primary care providers had a hospital discharge summary on hand. And when they did, important information was usually missing, such as test results, discharge medications, and plans for follow-up, according to the Robert Wood Johnson Foundation.

A Costly Problem

Given the dearth of post-discharge details, it’s not surprising that patients often run into trouble with worsening conditions that require rehospitalization. One in five Medicare patients is rehospitalized within a month of discharge, the Robert Wood Johnson Foundation reports. Better care coordination at discharge could potentially prevent readmission in three out of four cases.

Poor care transitions are costly in financial terms too. In 2011 alone, inadequate care coordination resulted in $25 to $45 billion in wasteful spending on complications that could have been avoided, and rehospitalizations. According to the National Quality Forum, Medicare spends about $15 billion a year on preventable hospital readmissions.  

Improving the Situation

Things are changing, however. Thanks in part to recent Medicare policies that promote care coordination, and others that penalize hospitals up to 3% of their reimbursement for excessive readmission rates, hospital and health system leaders are beginning to pay some much-needed attention to care transitions and how to make them better.

They—anyone in patient care, for that matter—may want to take note of this: The National Association for Healthcare Quality will focus its National Quality Summit, April 23-24 in Philadelphia, on the whys and hows of improving the quality and safety of care transitions. Conference content will focus, in particular, on the hows, featuring a host of takeaways that can easily be implemented for better care transitions, according to summit co-chair Nancy Terwoord, BSN, RN.

“Every speaker is going to come prepared with two or three concrete things that … most of us should be able take back to our own setting and make it work,” she said.

With more attention paid to providing effective care transitions, vulnerable patients will no longer be expected to navigate unfamiliar and potentially dangerous waters on their own.

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