Seamless Transitions: Achieving Patient Safety Through Communication and Collaboration

BACKGROUND: Although more than a decade has passed since the imperative to reduce fragmentation of care, high rehospitalization rates among Medicare patients with chronic diseases persist; at least 25% of these are considered preventable. Transitional care models that emphasize coordination among providers have demonstrated significant reductions in hospitalization rates. However, achieving effective collaboration among providers across disciplines and/or facilities through implementation of transitional care models can be challenging. OBJECTIVES: The aims of this article are to (1) describe a collaborative transitional care program implemented by a 7-hospital health care system and a postacute senior care service provider organization to pilot a transitional care program (Transitions Across Care Settings [TRACS]) for improving coordination of care for their mutual patients and (2) share results and lessons learned from this quality initiative. METHODS: The goal of the TRACS program, which used the Coleman Care Transitions Intervention model, was to reduce 30-day readmissions to lower than the national averages for an initial target population of inpatients with pneumonia, congestive heart failure, and acute myocardial infarction diagnoses. RESULTS: The overall readmission rate for 104 patients in the pilot TRACS program was 4.8%. Readmission rates were 0% for acute myocardial infarction, 7.1% for congestive heart failure, and 4.4% for pneumonia. CONCLUSIONS: A culture of patient safety was facilitated by a registered nurse transitions coach through consistent communication and flow of patient information during patient hand offs across the care continuum. More than 1000 patients are already admitted to the next iteration of the TRACS program, resulting in a sustainable enterprise.