Q. What is transitional care? A. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. “Transitional Care” refers to when they move across settings. When they “transition” they often are treated by many different health care professionals.

August 7, 2019

The Patient Education Forum: Transitional Care—Eric Coleman

Q. What is transitional care? A. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. “Transitional Care” refers to when they move across settings. When they “transition” they often are treated by many different health care […]
Q. What is transitional care? A. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. “Transitional Care” refers to when they move across settings. When they “transition” they often are treated by many different health care professionals.
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http://eldercare.health-first.org/docs/forums/transitional_care.pdf

August 7, 2019

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ, January 20, 2009; 180 (2). doi:10.1503/cmaj.081491.

Background: Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient’s home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring […]
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Background: Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care. Methods: We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.
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http://www.cmaj.ca/cgi/content/abstract/180/2/175

August 7, 2019

Strengthening primary care with better transfer of information CMAJ November 4, 2008 179:987-988

The reality of modern health care is that patients commonly receive care from multiple providers, both physicians and nonphysicians, who often work in disconnected offices and facilities. This makes it a tremendous challenge to connect and integrate a patient’s care into a coherent whole. Widespread lack of information continuity is […]
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The reality of modern health care is that patients commonly receive care from multiple providers, both physicians and nonphysicians, who often work in disconnected offices and facilities. This makes it a tremendous challenge to connect and integrate a patient's care into a coherent whole. Widespread lack of information continuity is troublesome because of the unnecessary tests, medical errors and inconsistent treatment plans that can result.1 The transition from hospital to community care is a particularly vulnerable time when coordination lapses can result in serious adverse events.2
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http://www.cmaj.ca/cgi/content/full/179/10/987

August 7, 2019

Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care JAMA February 28, 2007 297:831-841

Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: […]
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Context: Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives: To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources: MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection: Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction: Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis: Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions: Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
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http://jama.ama-assn.org/cgi/content/abstract/297/8/831

August 7, 2019

Health Care Leader Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
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http://www.commonwealthfund.org/Publications/Fund-Manuals/2010/Jan/Health-Care-Leader-Action-Guide.aspx

August 7, 2019

NQF Quality Connections, October 2010: Care Coordination

Abstract: Care coordination—a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time—is foundational to high-quality healthcare. All patients, but especially the growing num¬ber of Americans who suffer from multiple chronic con¬ditions, can benefit from […]
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Abstract: Care coordination—a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time—is foundational to high-quality healthcare. All patients, but especially the growing num¬ber of Americans who suffer from multiple chronic con¬ditions, can benefit from care coordination. Care coordi¬nation is an information-rich, patient-centric endeavor that seeks to deliver the right care (and only the right care) to the right patient at the right time. NQF has completed significant work to advance care coordination, including the endorsement of a definition and framework for care coordination; the NQF-convened National Priorities Partnership; the designation of care coordination as one of six “National Priorities” for national action; and the endorsement of preferred practices and performance measures for care coordination. Ultimately, achieving coordinated care will be possible only when healthcare entities collectively agree to place the patient at the center of care.
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http://www.qualityforum.org/Publications/2010/10/Quality_Connections__Care_Coordination.aspx

August 7, 2019

NQF: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination

Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated […]
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Abstract: Care coordination is a vital aspect of health and healthcare services. When care is poorly coordinated—with inaccurate transmission of information, inadequate communication, and inappropriate follow-up care—patients who see multiple physicians and care providers can face medication errors, hospital readmissions, and avoidable emergency department visits. The effects of poorly coordinated care are particularly evident for people with chronic conditions, such as diabetes and hypertension, and those at high risk for multiple illnesses who often are expected to navigate a complex healthcare system. In this report, NQF has endorsed a portfolio of care coordination preferred practices and performance measures. These standards will provide the structure, process, and outcome measures required to assess progress toward care coordination goals and to evaluate access, continuity, communication, and tracking of patients across providers and settings. Given the high-risk nature of transitions in care, this work will build on ongoing efforts among the medical and surgical specialty societies to establish principles for effective patient hand-offs among clinicians and providers. Measurement and improvement efforts will be upgraded over time as interoperable health information technology (HIT) systems evolve.
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http://www.qualityforum.org/Publications/2010/10/Preferred_Practices_and_Performance_Measures_for_Measuring_and_Reporting_Care_Coordination.aspx

August 7, 2019

Transitions of Care Consensus Policy Statement

Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives […]
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Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. Journal of Hospital Medicine 2009;4:364–370. © 2009 Society of Hospital Medicine.
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http://onlinelibrary.wiley.com/doi/10.1002/jhm.510/abstract

August 7, 2019

The Remington Report: Improving Outcomes Through Re-Engineered Care Transitions: The New York Experience

The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care […]
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The Centers for Medicare & Medicaid Services (CMS) is funding an initiative with 14 state-based Quality Improvement Organizations (QIOs) to test a variety of interventions and approaches to improving the quality of care for Medicare beneficiaries as they transition from one setting to another. A primary objective of the Care Transitions Theme is to reduce unnecessary hospital readmissions and the resultant morbidity, mortality and quality of life issues. The project began in August 2008 and will continue through July 2011. The structure of this CMS initiative provides QIOs the flexibility to develop approaches tailored to local needs, while using evidence-based interventions to target improvement across settings.
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http://www.cfmc.org/integratingcare/files/rem_mj10-care_transitions.pdf

August 7, 2019

Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure

Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to […]
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Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Med Care. 2005 Mar;43(3):246-55. http://www.ncbi.nlm.nih.gov/pubmed/15725981. Accessed August 13, 2014. BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand. Performance measurement is one potential strategy towards improving the quality of transitional care. A valid and reliable self-report measure of the quality of care transitions is needed that is both consistent with the concept of patient-centeredness and useful for the purpose of performance measurement and quality improvement.
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http://www.ncbi.nlm.nih.gov/pubmed/15725981