The Journal of the Arkansas Medical Society Med Journal Dec 2019 | Page 12

EDITORIAL PANEL: Chad T. Rodgers, MD, FAAP | Elena M. Davis, MD, MPH | Shannon Edwards, MD | William L. Mason, MD | Michael Moody, MD | J. Gary Wheeler, MD, MPS
Creating Safer
Transitions of Care
KIMBERLY GARNER, MD, JD, MPH, and LYNDA BETH MILLIGAN, MD
A
s a health care provider,
after discharging an
older gentleman who
was recently admitted
from home with a left, lower-lobe
pneumonia, you wonder how he
is managing at home. Is he safe
or do changes need to be made
in his home environment? Does
he have supportive family and
friends who can assist him? Can
he understand and follow the
discharge instructions? Does he
have transportation to follow-up
appointments and his pharmacy
for medications? Even though you
think he could be safely discharged
home, you instead recommended
admission to a skilled nursing
rehabilitation facility to assist with
his potentially complex transition of
care to home.
“Transitions of care” refer to the
hand-off of patients between health
care providers and settings as their
health status and care needs change.
In the case above, the patient was
receiving care from a primary care
physician, then transitioned to care
from a hospitalist physician and
nursing team during his inpatient
stay. At discharge he transitioned
to another care team at a skilled
nursing facility. Finally, he returned
home, where he received care from a
home health nurse and support from
family members and a next-door
neighbor.
Care transitions are very complex
processes that are often the weak
link in the chain of care. All too
often they do not go smoothly.
Research has shown that inadequate
or uncoordinated care transition
processes can lead to adverse
events 1,2 and higher hospital
readmission rates and costs. 2 One
study found that 80% of serious
medical errors during these hand-
offs between providers 3 are related
to ineffective communication of
important details that can affect
patient outcomes and increase
the risk of complications. Poor
transitions are more likely when
multiple providers and specialists
are involved. Coordination of care
among more than one provider is
complex and can create confusion
for the patient and those responsible
for transitioning care to the next
setting and provider. 5
Safe transitions should include
most or all of the following elements:
132 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
• Create a culture of
multidisciplinary collaboration
and communication. This should
start at admission and continue
throughout the patient’s inpatient
stay to assure a successful
transition to the next level of care. 8
In addition to daily rounding and
meetings, this step should include
actively teaching the patient and
his family caregivers what is in
the care plan and how to practice
it, 4,5,7,8 including how to self-
manage medications. 6
• Share health care provider
accountability, involvement
and communication between
both the sending and receiving
providers. 9 Identify health care
providers by name and exchange
all necessary information verbally,
electronically or by fax before and
at the time of transition. 9
• Begin discharge planning at
admission by assessing patients
for risk factors that may limit
their ability to perform necessary
aspects of self-care. 4 In-depth
patient risk assessment is another
way to ensure safe transitions of
care. Risk assessment includes
examining potential risk factors
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