transition of care; health care transition

Introduction

A process involving a shift in patient care from one setting to another.

The process may involve an increase or decrease in intensity of care, or a change in healthcare personal.

Examples include:

• hospitalization
  • hospitalization from the emergency department
    • emergency department to ICU
  • hospitalization from skilled nursing facility
• hospital to discharge home
• ICU to transitional care unit
• hospital to skilled nursing facility
• skilled nursing facility to home
• changes in hospital shifts, i.e. doctors, nurses

Complications

• poorly managed transitions can diminish health & increase costs
  • an estimates $25-$45 billion was wasted in 2011 through avoidable complications & unnecessary hospital readmissions
• risk factors for suboptimal care transitions
  • limited education (not high school graduate)
  • functional impairment due to physical or cognitive deficits
    • unmet need for assistance with at least 1 ADL
    • limited self-management ability
    • delirium, dementia
  • worse self-rating of health
  • poor healthcare literacy
  • living alone
  • transition to home with home-care services
  • prior hospitalization
  • low income or Medicaid eligible
  • older age
  • 5 or more comorbidities
  • specific diagnoses:
    • depression
    • heart disease
    • diabetes mellitus
    • cancer
  • transitions mid-surgery
    • anesthesia transition of care mid-surgery associated with poor outcomes (combined mortality, hospital readmission, & major complications within 30 days) 44% vs 29% with continuity of care - poor communication may play a role
  • treatment at a teaching hospital does not increase 30-day readmissions or mortality

Management

• most widely used method for handoff communication during transition of care is the SBAR technique
• successful hospital-to-home transitional care programs all center around interprofessional care coordination teams
  • a dedicated transition care provider who contacts inpatients before & after discharge is the most effective means of reducing hospital readmission (GRS9)
  • explicit communication with the primary care physician is fundamental to a successful transition of care after hospitalization
• effective communication between different care settings
  • often difficult
• support for self-management
• ensure patient & caregiver understand the purpose of the transfer & what to expect at the next site of care
• medication reconciliation at the time of transfer
• transfer summaries should include documentation of cognitive & functional status
• structured handoff tool for transition from hospital to skilled nursing facility can decrease wait time for receipt of controlled medications & intravenous antibiotics & time to medication administration
• advance directives can diminish burdensome care transitions from skilled nursing facility to hospital in the last 3 days of life
• care transitions may be opportunities to correct the differential diagnosis

Notes

• transitional care activities are largely unbillable in the current American reimbursement system
• a resident hand-off program, including written handoffs incorporated into electronic health records, diminished medical errors & adverse events (24-30%)
• billing codes to support Medicare's Transitional Care Manangement infrequently used
• occupational therapists & physical therapists can predict which patients can have successful skilled nursing facility (SNF) to home discharges
  • medical providers & social workers can not
  • most patients receive postdischarge follow-up telephone calls ~90% found them to be valuable

More general terms

• patient care

More specific terms

• admission to service
• complicated transition; hospital readmission; bounce back
• discharge from service
• hospitalization
• inpatient discharge (includes hospital discharge)
• skilled nursing facility discharge

Additional terms

• transitional care unit (TCU)