Transitions of Care

Question 1

Examples of Transitions of Care

Answer 1

Home to hospital
Hospital to home
Extended care to hospital
Extended care to home
Hospital Rx to Community Rx
ER to primary care
ER to community services
Primary care to speciality care
FQHC to primary/speciality care
Curative care to palliative care

ANY TIME A PATIENT MOVES FROM ONE LEVEL OF CARE TO ANOTHER

Question 2

Current Model of Care in US Impact on TOC

Answer 2

Harder:
- PCP is out of the loop and must read the EHR to see what happened in the hospital stay
- hospitalist is unknowing of you when admitted

Easier:
- if providers are in the same hospital system, it allows sharing of EHR to any HC worker

Question 3

Importance of TOC in Patients

Answer 3

address expectation of continuity of care within HC system

Question 4

Importance of TOC in hospitals

Answer 4

reimbursements are tied to readmission rates

cost avoidance

Question 5

Importance of TOC in insureres

Answer 5

improved outcomes

cost avoidance

Question 6

Accountable Care Organization

Answer 6

• groups of hospitals, providers, and community partners who come together with a health plan to improve patient outcomes and reduce HC costs

Goals:
- avoid ER trips
- better manage meds
- address SDOH
- reduce preventable hospital admissions

Question 7

Patients who TOC is Important

Answer 7

Elderly
Patients living alone
Patients with caregivers
Patients with complicated therapies/multiple meds
Patients with limited health literacy
Patients without a PCP
Patients without adequate insurance
Patients with disabilities
Patients with psychiatric illness/SUD

Question 8

Who participates in TOC

Answer 8

Patient
Caregiver
Physician
Nurse/Medical Assistant
Case Manager
Social Worker
PT/OT/RT
Community health worker
PHARMACISTS

Question 9

What goes wrong without good TOC

Answer 9

wrong medications, diagnosis, treatment
delay in treatment, diagnosis
duplicate tests, meds
increased costs
patient confusion
reduced patient satisfaction
poor outcomes
patients lost to follow-up

Question 10

How does the field of pharmacy play a role in TOC

Answer 10

Time of Admission: medication reconciliation

Throughout care: medication therapy management/reviews

Time of Discharge: communicating with community Rx & counseling

After Discharge: communication between clinical Rx and ambulatory care Rx

Question 11

How soon to follow up with patient following discharge from hospital?

Answer 11

24 hours (1-2 days)