Combatting the Top Challenges During Transitions of Care

Transitions of care, or the coordination of health care during a movement from one setting to another or to home, are a critical piece of an overall positive health outcome. A well-planned transition of care ensures health care continuity, avoids preventable poor outcomes among at-risk populations, and promotes the safe and timely transfer of patients from one setting to the next.

During these important changeovers, medical errors and clinical deterioration are more likely to occur. According to The Joint Commission, one study estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers.

Ineffective transitions occur between almost every type of health care setting, but especially when patients are leaving the hospital. There are many root causes of the most ineffective transitions of care, and we explore those causes below.

There can be many communication breakdowns for care providers, including miscommunications with other care providers, with patients, and/or with caregivers. The Center for Transforming Healthcare’s hand-off communication project found several risk factors associated with communication:

• Expectations differ between senders and receivers of patients in transition
• Culture does not promote successful hand-off (for example, there is a lack of teamwork and respect present)
• Inadequate amount of time is provided for successful hand-off
• Lack of standardized procedures in conducting a successful hand-off

How Pascack Valley Medical Center is improving their communications during the discharge process

Pascack Valley Medical Center, a hospital located in Westwood, NJ, is focusing on improving the discharge process in order to create a smoother transition of care. Through Discharge Concierge™, patients are able to use a mobile device, tablet, or laptop to navigate their state-mandated coursework prior to discharge. This allows the patient to read through their educational materials at their own pace. They can submit questions directly to the nursing staff and share the information and documents with themselves or their caregiver via email. This allows them to bring the important information they need to their next setting. On the provider end, the standardized procedure allows staff members to focus their time on clinical care delivery and address the most important pieces of information – the specific questions of the patient.

Learn more about the Pascack Valley Medical Center Discharge Concierge » 

When patient education is lacking or insufficient, patients and caregivers are not able to follow the care plan they have been given. Patients and caregivers often go through their transition of care while experiencing:

• Conflicting recommendations
• Confusing medication regimens
• Unclear instructions about follow-up care
• Exclusion from transition planning
• Insufficient understanding of their medical condition or the plan of care

How CINJ is educating cancer patients while managing their day-to-day care

Rutgers Cancer Institute of New Jersey is NJ’s only National Cancer Institute (NCI)-designated Comprehensive Cancer Center and provides advanced and comprehensive cancer care. In order to provide clearer patient education and information about care plans for cancer patients, CINJ launched the Concierge program. Through this program, patients have access to their own Personal Page, a library of content generated based on their own symptoms, challenges, and feedback. This ensures that each and every patient has access to their own care plans and information about their condition.

Learn more about the Rutgers Cancer Institute of New Jersey Concierge Program »

In many cases, there is no physician or clinical entity that manages the responsibility of care coordination across many settings, amongst several providers. When many specialists are involved in one patient’s care planning, providers often fail to coordinate transitions of care effectively. Furthermore, steps are not taken to assure that resources will be available to the patient at their home or next setting.

How The Heart House maintains accountability for their patients

The Heart House is a multi-location cardiology practice that launched a Personal Concierge™ program for patients with systolic and diastolic heart failure. When a patient is discharged from the hospital, is going to have a scheduled surgery, or begins treatment for a condition, they are enrolled and receive access to their own Care Companion™. The Care Companion provides patients with educational resources, information, support, and assistance. The Heart House is able to ensure that their patients are able to transition from setting to setting while maintaining the same level of care each step of the way.

Learn more about The Heart House Personal Concierge program »

In order to reduce readmission rates and adverse effects, hospitals are implored by The Joint Commission and other organizations to improve the effectiveness of transitions of care in which they play a role.