Care transitions are complex, but crucial to patient safety and quality care

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Care transitions are complex, but crucial to patient safety and quality care

Journal for Healthcare Quality issue focuses on importance of involving patients and families

Care transitions have been a vital part of patient safety since the specialized discipline came to prominence in the 1990s. More than two decades later, a lot has changed in healthcare delivery, but the issue remains at the forefront of patient safety.

The complexities of care transitions, coupled with the involvement of a wide array of healthcare specialties, have made the care process an important but frequently elusive aspect of patient care. Now that hospitals are penalized by CMS for high readmission rates, the ongoing issues surrounding care transitions have cemented them as a financial concern as well as a quality care priority.

For all those reasons and more, the National Association for Healthcare Quality (NAHQ) recently devoted a special issue of its Journal of Healthcare Quality (JHQ) to improving care transitions and establishing best practices to approach the transition process. The issue includes nine original studies featuring perspectives that focus on providers and patient safety advocates, as well as patients and family caregivers.

In her editorial, Mary Huddleston, RN, MHSE, CPHQ, FNAHQ, president of Chicago-based NAHQ, called care transitions "the lynchpin for coordination of care in current and future delivery models."

She tells Patient Safety Monitor Journal that NAHQ chose to focus on care transitions because of its historical complexity for patient safety and quality professionals.

"It's not a new thing, it's a chronically challenging thing," Huddleston says.

Care transitions are often complicated and rife with potential failures because of the number of clinicians involved, she adds. Additionally, healthcare providers have to juggle a number of moving parts, including family members, equipment, medication, discharge planning, and the patients themselves.

"When you're trying to fix a process or improve a process in one department, you have a finite number of people you're working with," she says. "Once you start saying, 'Okay, this is a process that crosses the ambulatory setting to the ED, to an inpatient unit, to an ICU, to a long-term care setting, to a hospice,' then you're talking about everyone in the healthcare system."

The challenges surrounding care transitions are unique, says Eric Coleman, MD, MPH, head of the division of healthcare policy and research at the University of Colorado Anschutz Medical Campus in Denver. Coleman, who is also director of the Care Transitions Program, published two papers in the JHQ special issue focusing on the family's role in the process.

"Care transitions have gone from a relatively obscure topic to one that is front and center in current attempts to redesign healthcare to make it more value-based," he says. "The challenge is that the type of thinking and the type of solutions that have been used to advance other areas of healthcare delivery simply don't cut it when it comes to care transitions. There are no simple interventions or silver bullets."


Process improvement sparks change

Research surrounding care transitions is continually expanding, and more providers are developing and sharing interventions that improve patient outcomes across the continuum of care. Huddleston says that providers are recognizing the benefit of ongoing communication to help smooth transitions from one provider to the next. Focusing on ways to improve integrated care has been the foundation for improving care transitions.

"We've said discharge planning starts on admission?and that's more true now than ever?but now it starts before admission," she says. "Who is the primary care provider? Is there a medical home involved? What's the full story of this patient?"

Providers also need to prepare patients and caregivers for the transition from an inpatient environment, where every aspect of care is provided, to their home environment, where they will be responsible for multiple aspects of their own care. Part of that is ensuring the patient has the equipment and medication he or she needs, but it also means ensuring the patient or the caregiver has the knowledge to continue the plan of care.

"When we have a transition, it's not just who is going to provide the care, it's what equipment is needed, what medication is needed, what knowledge requirement is there from the patient and the caregiver?" Huddleston says. "It's a lot different lying in bed having your dressing changed to then being at home."


The importance of family caregivers

The two articles published by Coleman in the JHQ special issue focus specifically on the role of family caregivers, who have emerged as a vital part of the care transition process.

In the first, Coleman looked at ways he could enhance the Care Transitions Intervention?a program developed by Coleman based on rehospitalization reduction best practices?to include family caregivers. Researchers found that 64% of family caregivers met or exceeded their self-identified goals, and nearly every participant said they would recommend the model to a friend or family member. Additionally, transition coaches identified 71% of patients with medical errors post-discharge and were able to coach family caregivers on how to respond to those errors.

"We were able to demonstrate that engaging family caregivers positively influences outcomes that matter to health professionals, health insurers, and policymakers?namely better scores on patient experience measures, improved patient safety, and improved satisfaction," Coleman says.

The second study offered a qualitative look at family caregiver involvement. Four separate focus groups involving 32 family caregivers found that caregivers fell along a broad spectrum of readiness, willingness, and ability. Additionally, caregivers felt unprepared for post-discharge medication management, and they had unique goals compared to those of the patient.

The qualitative data also showed that clinicians often shift the burden of providing care from their shoulders to the shoulders of family caregivers, but that those caregivers may not be adequately prepared for this transition, Coleman says. Where caregivers fall on the spectrum will determine what kind of education or preparation they need going forward.

"Many individuals who are labeled as 'family caregivers' acquire this label following an acute hospitalization?yesterday I was a spouse or son or daughter and today I am a family caregiver," he says. "Some embrace the role; others may be in denial or shell-shocked. Their readiness to step into this role should help direct how health professionals support and prepare them."

Huddleston says these two studies offered a new and previously unexplored look at an aspect of care transitions that healthcare providers don't often consider. Although clinicians often discuss care plans with patients, the patients may not understand the discussion due to their condition. This can lead to complications after discharge.

Coleman says that family caregivers are currently undervalued and that their contributions frequently go unnoticed. By focusing on their role and making them feel comfortable with their responsibilities, providers open up a new avenue to improve care transitions and avoid errors and readmissions.

"Currently, family caregivers have little to no identity in the eyes of healthcare professionals," he notes. "In most cases, electronic health records don't even have a field dedicated to identifying the family caregiver and his or her roles."

Additionally, healthcare workers frequently indicate they are too busy and that interacting with or educating family caregivers takes away from other tasks. Others mistakenly believe HIPAA prevents them from discussing care plans with family members, Coleman adds. But clinicians that may have personally seen the impact of family caregivers may be more apt to offer education and counseling.

"I suspect that healthcare professionals who have gone through transitions of their own or for their immediate family may be more sympathetic and receptive," he says.