Transition Of Care

Question 1

Transition of care

Answer 1

Movement of pts between….as needs change

1. Practitioners
2. Other settings
3. Home

Question 2

Ineffective transitions of care

Answer 2

Lead to:
1. Adverse events
2. Inc readmission rates
3. Med errors
A. 80% involve miscommunication at hand-off
B. Highest risk hospital -> home or other setting
4. Feds notice: inc readmittance -> fines
5. Root causes:
*communication issues
A. Drs don’t completely communicate
B. Sender/receiver expectations differ
C. Handoffs unsuccessful- not enough time
D. Lack standardized procedures

Question 3

Root causes of ineffective transitions

Answer 3

1. communication issues
  A. Drs don’t completely communicate
  B. Sender/receiver expectations differ
  C. Handoffs unsuccessful- not enough time
  D. Lack standardized procedures
2. Pt. Ed breakdown
  A. Conflicting recommendations
  B. Confusing meds
  C. Poor communication between caregiver and pt
  D. Exclusion: certain people from care/info
  E. Comprehension
3. Accountability breakdown
  A. Sometimes no accountable dr
  B. Too many drs - why PCP helpful
  C. Sufficient knowledge/resources for pts
  D. No PCP or communication w/ them

Question 4

Current care models

Answer 4

1. Multidisciplinary
2. Clinical involvement
3. Comprehensive planning

Question 5

Multidisciplinary care model

Answer 5

Communication, collaboration, Kane coordination of care w/ pts from admission to discharge
1. Standardized transition plan: use standardized procedures/forms
2. Standardized training: ensures uniformity to min transition errors
3. Timely transitions
A. Follow-up
B. Support
C. Coordination after pt. Leaves
4. Care team

Question 6

Clinical involvement model

Answer 6

1. Takes sending and receiving provider into account

2. Both ID of record and info exchanged

Question 7

Comprehensive planning

Answer 7

Planning and risk assessment throughout stages of care

Question 8

Comprehensive planning and risk assessment

Answer 8

1. Discharge risk assessment w/in 24-48 hrs of admission
2. Screen for
   A. Low literacy
   B. Other recent hospitalizations
   C. Chronic conditions/meds
   D. Poor self-health ratings

Question 9

Standardized transition plans

Answer 9

1. Active issues
2. Dx
3. Meds
4. Required services
5. Worsening symptoms
6. Contact 24/7
7. In preferred language
8. Pics for pts w/ low literacy

Question 10

Standardized training

Answer 10

1. Organization: define successful transition
2. Staff: taught necessary steps w/ simulations
3. Successful transitions
   A. .Org. Priority
   B. Performance expectation
4. Med schools teach
   A. Risk assessment
   B. Collaboration
   C. Care planning
   D. Med management w/ transition

Question 11

Timely follow-up and support

Answer 11

1. Organizations 
  A. Follow-up: phone, in person
  B. Support coordination
    1. Case manager
    2. Social worker
    3. Nurse
    4. Other 24-48 hr after discharge
2. Call centers: 24/7 support
3. Transitional care nurses

Question 12

Evaluate transitions

Answer 12

1. Monitor compliance
   A. Standardized forms
   B. Tools (online/institutional)
   C. Surveys

Question 13

Readmission w/in 30 days

Answer 13

1. Prevention: safe and effective transitions
2. Root cause analysis
   A. Meet w/ team and pt
   B. Ask pt about what happened after discharge