The Journal of the Arkansas Medical Society Med Journal Dec 2019 | Page 13

AFMC: A CLOSER LOOK AT QUALIT Y
with the goal of mitigating those
risks, such as whether patients
have adequate support upon
discharge, transportation, a way
to fill prescriptions, and if they are
likely to be active and engaged in
their community after discharge.
These potential impediments to
a safe transition home are often
a factor in patient success and
satisfaction, as well as in the risk of
hospital readmission and negative
patient outcomes.
• Create a detailed written tran-
sition plan using standardized
transition procedures and forms.
The plan should include active
issues, diagnosis, medications,
required services, warning signs
of a worsening condition and
whom to contact 24/7 in case of
emergency. 8 Plans are provided in
the patient’s preferred language
and appropriate reading level
with pictures or diagrams. 4 Health
care providers and staff should be
trained on how to create a safe
transition of care, the risks associ-
ated with transitions and commu-
nicate performance expectations
about patient care transitions.
• Followup, support and coordi-
nate care in a timely manner
after the patient leaves each care
setting. Organizations should
develop, follow and maintain a
process that provides for timely
post-discharge follow-up for all
patients and all discharge settings.
Telephone or in-person follow-up,
support and coordination can be
performed by a case manager,
social worker, nurse or another
health care provider 24 to 48 hours
after discharge. A 24/7 call center
can provide a recently transitioned
patient or family member with
information or reassurance after
regular clinic hours. 4 Follow-up
support helps patients achieve
successful recoveries. 4,7,8
• Perform continuous quality
improvement that includes evalu-
ating if a patient was readmitted
or had any negative discharge
outcomes within 30 days and
gain an understanding of why.
Readmissions within 30 days of
discharge often signal ineffective
transitions of care from the hospi-
tal to other settings. 9 Identifying
gaps in care can be used by orga-
nizations to improve care transi-
tions. Using surveys and other data
collection can help identify the
root causes of ineffective transi-
tions. They can also identify patient
and caregiver satisfaction with
transitions and their understand-
ing of the care plan.
In summary, if a health care orga-
nization doesn’t have a culture that
values teamwork and accountability,
plus an environment that encour-
ages speaking up, then it is more
likely to provide unsafe care transi-
tions. It is important for all members
of the health care team to take the
time to identify and communicate
about potential barriers before the
transition occurs. Effective communi-
cation among team members helps
prevent problems that can occur
from and to virtually every type of
health care setting, especially when
leaving the hospital to another set-
ting or home. To reduce both read-
mission rates and adverse events, all
members of the health care team,
including the patient and his caregiv-
ers, must be included in the dis-
charge planning and empowered to
identify and mitigate gaps in care to
ensure that patients safely transition
to their next level of care. s
Dr. Garner is a dual-boarded in
geriatrics, hospice and palliative care,
and an associate professor at UAMS.
Dr. Milligan is a family physician. Both
work at the Central Arkansas Veteran
Affairs Health Care Sytem, are AAFP
Fellows and board certified by the
American Board of Quality Assurance
and Utilization Review Physicians.
REFERENCES
1. Forster AJ, et al: Adverse drug
events occurring following hospital
discharge. Journal of General Internal
Medicine, April 2005;20(4):317-23
2. Medicare Payment Advisory Commission,
Report to the Congress: Reforming
the Delivery System, Washington,
D.C.: MedPAC, June 2008
3. Solet DJ, et al: Lost in translation: challenges
and opportunities in physician-to-physician
communication during patient hand-offs.
Academic Medicine, 2005;80:1094-9
4. Coleman EA, et al: Preparing patients and
caregivers to participate in care delivered
across settings: the Care Transitions
Intervention. Journal of the American
Geriatric Society, 2004;52:1817-1825
5. Zander K: Case management accountability
for safe, smooth, and sustained transitions.
Professional Case Management, 15(4):188-199
6. Coleman EA, et al: The Care Transitions
Intervention: results of a randomized
controlled trial. Archives of Internal
Medicine, 2006;166(17):1822-1828
7. Naylor MD, Sochalski JA: Scaling up:
bringing the Transitional Care Model into
the mainstream. The Commonwealth
Fund, November 2010; Pub. 1453, Vol. 103
8. Agency for Healthcare Research and
Quality: Preventing avoidable readmissions:
information and tools for clinicians.
Project RED, http://www.ahrq.gov/qual/
impptdis.htm (accessed April 11, 2012)
9. Holland DE, Hemann MA: Standardizing
hospital discharge planning at the
Mayo Clinic. The Joint Commission
Journal on Quality and Patient
Safety, January 2011;37(1):29-36
AFMC WORKS COLLABORATIVELY WITH PROVIDERS,
COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO
PROMOTE THE QUALITY OF CARE IN ARKANSAS THROUGH
EDUCATION AND EVALUATION. FOR MORE INFORMATION
ABOUT AFMC QUALITY IMPROVEMENT PROJECTS,
CALL 1-877-375-5700 OR VISIT AFMC.ORG.
DECEMBER 2019
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