Practice Tips

The Institute of Medicine (IOM) defines transitions of care as "the movement of patients between healthcare practitioners, settings, and home as their condition and care needs change" (IOM, 2001). Effective transitions of care require good communication, comprehensive discharge planning, and coordination among healthcare providers to ensure continuity of care, appropriate follow-up, and patient safety.  These are crucial moments in healthcare, where miscommunication or lapses in care can lead to significant patient harm. Effective management of these transitions is essential for improving patient outcomes, reducing readmissions, and enhancing the overall quality of care.

Here are key tips for healthcare organizations to improve transitions of care:

Standardize Communication

• Implement Handoff Protocols: Ensure that communication during transitions is standardized using tools like SBAR (Situation, Background, Assessment, Recommendation), which helps structure communication between healthcare providers.
• Patient-Centered Communication: Encourage clear, jargon-free communication between the care team and patients. This includes discussing the patient’s care plan, medications, follow-up appointments, and self-care instructions.
• Include the Family: Involve family members or caregivers in discussions about the patient’s condition and care plan, ensuring they understand discharge instructions, medication regimens, and red flags to watch for at home.

Utilize Electronic Health Records (EHR)

• EHR Handoff System: Leverage your EHR to streamline the sharing of patient information between providers during transitions. Ensure that all relevant clinical data (medications, treatment plans, diagnostic results) is updated and easily accessible to the next provider.
• Ensure Data Accuracy: Double-check that all patient information, particularly medications and allergies, is accurately entered and updated in the EHR to prevent errors during transitions.

Create a Discharge Checklist

• Discharge Summary: Ensure every patient is given a clear, comprehensive discharge summary that includes diagnoses, prescribed medications, instructions for follow-up care, and any necessary lifestyle modifications.
• Medication Reconciliation: Conduct medication reconciliation at every transition point. Make sure the patient and/or caregiver understand their medication regimen and how to avoid potential drug interactions or errors.

Follow-Up Care Plans

• Schedule Follow-Ups: A common failure point in transitions is the lack of proper follow-up. Make sure follow-up appointments with primary care providers or specialists are scheduled before discharge. Ideally, these appointments should be within 7 days of discharge.
• Telehealth and Remote Monitoring: Use telehealth services or remote monitoring tools to help track the patient’s progress and address any concerns early. This is especially important for patients with chronic conditions or those recently discharged from the hospital.

Patient Education

• Tailored Education Materials: Provide patients with easy-to-understand educational materials about their condition, treatment plan, and what to expect after the transition. Consider including visual aids or instructional videos to support literacy levels.
• Teach-Back Method: Use the teach-back method to confirm patient understanding. Ask patients to repeat back key information (e.g., their medication instructions, follow-up appointments) to ensure they understand.

Collaboration with Community Partners

• Community Resources: Collaborate with community healthcare providers, home health agencies, and social services to support patients after they leave your facility. This can include coordinating home visits or providing assistance with transportation to follow-up appointments.
• Continuity of Care Agreements: Establish agreements with local providers to ensure smooth transitions and shared responsibility for patient care. This can help reduce readmission rates and ensure that patients receive continuous support.

Monitor and Evaluate Transitions

• Track Readmission Rates: Regularly track and audit hospital readmission rates, particularly those that may be related to poor transitions of care. Identify trends and specific areas for improvement where something failed in the handoff process.
• Patient Feedback: Collect feedback from patients about their transition experience. This can provide valuable insight into areas that need improvement, such as communication, understanding of care instructions, or follow-up processes.

Risk Stratification

• Identify High-Risk Patients: Use risk stratification tools to identify patients who are at higher risk of complications or readmission after a transition. These patients may require more intensive follow-up or additional care coordination efforts.

Training and Team Education

• Ongoing Staff Training: Ensure that all staff involved in transitions of care receive regular training on the best practices for handoffs, communication, and care coordination. This includes physicians, nurses, discharge planners, and administrative staff.
• Multidisciplinary Approach: Foster a team-based approach to transitions of care, encouraging collaboration between different healthcare providers, including specialists, social workers, and pharmacists.

Conclusion:

Effective transitions of care are essential for improving patient outcomes, reducing readmissions, and enhancing the overall quality of healthcare. By standardizing communication, utilizing technology like EHRs, ensuring proper follow-up, and educating both patients and care teams, healthcare organizations can significantly improve their transition processes and support patient recovery.

The resources below provide further evidence and guidelines that support best practices for managing transitions of care, helping healthcare organizations reduce readmission rates, improve patient outcomes, and ensure that patients receive the appropriate care across different settings.

Agency for Healthcare Research and Quality (AHRQ)
Guide to Patient and Family Engagement in Hospital Quality and Safety
AHRQ Engaging Patients and Families

The Joint Commission
Transitions of Care
Joint Commission Quick Safety Issue 26: Transitions of Care

National Institute for Health and Care Excellence (NICE)
Transition between hospital and community or care home settings
NICE Guidelines

Centers for Medicare & Medicaid Services (CMS)
Improving Transitions of Care
Medicaid Quality of Care Improving Care Transitions

American College of Physicians (ACP)
Improving Transitions of Care
ACP Recommendations to Improve Transitions Between Health Care Settings

World Health Organization (WHO)
Patient Safety and Quality Improvement
WHO Guidelines

American Hospital Association (AHA)
Improving Care Transitions
Care Transitions

Sources

Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027