Transitions of Care

In the Clinic5 March 2013Transitions of CareChristopher S. Kim, MD, MBA, Scott A. Flanders, MD, Deborah Cotton, MD, MPH, Darren Taichman, MD, PhD, and Sankey Williams, MDChristopher S. Kim, MD, MBA, Scott A. Flanders, MD, Deborah Cotton, MD, MPH, Darren Taichman, MD, PhD, and Sankey Williams, MDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-158-5-201303050-01003 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail "Transitions of care" refers to changes in the level, location, or providers of care as patients move within the health care system. One critical transition of care that has garnered great attention and is the focus of this review is the transition involving hospital discharge. Acute hospitalization represents a significant event in a patient's life, and health care providers in partnership with patients need to address myriad issues related to the hospitalization and subsequent posthospitalization care for a safe transition out of the hospital. The care of the hospitalized patient has evolved over time, such that patients are sicker; length ...References1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354] Google Scholar2. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345-9. [PMID: 14757670] Google Scholar3. Payment Policy for Inpatient Readmissions. In: Report to the Congress: Promoting Greater Efficiency in Medicare. Medicare Payment Advisory Commission. Washington DC; June, 2007:103-20. Google Scholar4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. [PMID: 19339721] Google Scholar5. Goodman DC, Fisher ES, Chang C-H. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. The Dartmouth Institute for Health Policy & Clinical Practice; September, 2011:1-52. Google Scholar6. Bray-Hall ST. Transitional care: focusing on patient-centered outcomes and simplicity [Editorial]. Ann Intern Med. 2012;157:448-9. [PMID: 22986380] Google Scholar7. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155:520-8. [PMID: 22007045] Google Scholar8. Medicare To Penalize 2,217 Hospitals for Excess Readmissions. Kaiser Health News; August 13, 2012. Google Scholar9. Allaudeen N, Schnipper JL, Orav EJ, Wachter RM, Vidyarthi AR. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011;26:771-6. [PMID: 21399994] Google Scholar10. Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306:1688-98. [PMID: 22009101] Google Scholar11. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182:551-7. [PMID: 20194559] Google Scholar12. Project BOOST. Philadelphia, PA: Society of Hospital Medicine; 2012. Google Scholar13. Ho PM, Tsai TT, Maddox TM, Powers JD, Carroll NM, Jackevicius C, et al. Delays in filling clopidogrel prescription after hospital discharge and adverse outcomes after drug-eluting stent implantation: implications for transitions of care. Circ Cardiovasc Qual Outcomes. 2010;3:261-6. [PMID: 20407117] Google Scholar14. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360:1102-12. [PMID: 19279342] Google Scholar15. Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists and care transitions: the divorce of inpatient and outpatient care. Health Aff (Millwood). 2008;27:1315-27. [PMID: 18780917] Google Scholar16. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-41. [PMID: 17327525] Google Scholar17. Hesselink G, Vernooij-Dassen M, Pijnenborg L, Barach P, Gademan P, Dudzik-Urbaniak E, et al. Organizational culture: an important context for addressing and improving hospital to community patient discharge. Med Care. 2013;51:90-8. [PMID:23132202] Google Scholar18. Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121-8. [PMID: 16027454] Google Scholar19. Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167:1305-11. [PMID: 17592105] Google Scholar20. LaMantia MA, Scheunemann LP, Viera AJ, Busby-Whitehead J, Hanson LC. Interventions to improve transitional care between nursing homes and hospitals: a systematic review. J Am Geriatr Soc. 2010;58:777-82. [PMID: 20398162] Google Scholar21. Shah F, Burack O, Boockvar KS. Perceived barriers to communication between hospital and nursing home at time of patient transfer. J Am Med Dir Assoc. 2010;11:239-45. [PMID: 20439042] Google Scholar22. Gandara E, Moniz T, Ungar J, Lee J, Chan-Macrae M, O'Malley T, et al. Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. J Hosp Med. 2009;4:E28-33. [PMID: 19827041] Google Scholar23. Rogers MA, Mody L, Kaufman SR, Fries BE, McMahon LF Jr, Saint S. Use of urinary collection devices in skilled nursing facilities in five states. J Am Geriatr Soc. 2008;56:854-61. [PMID: 18454750] Google Scholar24. Mody L, Bradley SF, Galecki A, Olmsted RN, Fitzgerald JT, Kauffman CA, et al. Conceptual model for reducing infections and antimicrobial resistance in skilled nursing facilities: focusing on residents with indwelling devices. Clin Infect Dis. 2011;52:654-61. [PMID: 21292670] Google Scholar25. Ouslander JG, Diaz S, Hain D, Tappen R. Frequency and diagnoses associated with 7- and 30-day readmission of skilled nursing facility patients to a nonteaching community hospital. J Am Med Dir Assoc. 2011;12:195-203. [PMID: 21333921] Google Scholar26. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90. [PMID: 12523921] Google Scholar27. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, D.C.: The National Academies Press; 2012. Google Scholar28. Hesselink G, Flink M, Olsson M, Barach P, Dudzik-Urbaniak E, Orrego C, et al. Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Qual Saf. 2012;21 Suppl 1:i39-49. [PMID:23118410] Google Scholar29. Cumbler E, Carter J, Kutner J. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient. J Hosp Med. 2008;3:349-52. [PMID: 18698595] Google Scholar30. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5:392-7. [PMID: 20578046] Google Scholar31. Doctoroff L. Interval examination: establishment of a hospitalist-staffed discharge clinic. J Gen Intern Med. 2012;27:1377-82. [PMID: 22810356] Google Scholar32. Bumpus S, Kline-Rogers E, Kosteva A, Smith C, Montgomery D, Eagle K, et al. A Nurse Based Bridge Transitional Care Model Reduces Readmissions and ED Visits. Journal of the American College of Cardiology. 2011;57(14):E1182. Google Scholar33. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-28. [PMID: 22986379] Google Scholar34. Joshi DK, Bluhm RA, Malani PN, Fetyko S, Denton T, Blaum CS. The successful development of a subacute care service associated with a large academic health system. J Am Med Dir Assoc. 2012;13:564-7. [PMID: 22748721] Google Scholar35. Chang R, Spahlinger D, Kim CS. Re-engineering the post-discharge appointment process for general medicine patients. Patient. 2012;5:27-32. [PMID: 22217264] Google Scholar36. Physician Orders for Life-Sustaining Treatment Paradigm. 2012:www.ohsu.edu/polst/index.htm. Google Scholar37. Hickman SE, Nelson CA, Moss AH, Tolle SW, Perrin NA, Hammes BJ. The consistency between treatments provided to nursing facility residents and orders on the physician orders for life-sustaining treatment form. J Am Geriatr Soc. 2011;59:2091-9. [PMID: 22092007] Google Scholar38. Greenwald JL, Halasyamani LK, Greene J, LaCivita C, Stucky E, Benjamin B, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf. 2010;36:504-13, 481. [PMID: 21090020] Google Scholar39. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172:1057-69. [PMID: 22733210] Google Scholar40. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-12. [PMID: 22111719] Google Scholar41. Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157:1-10. [PMID: 22751755] Google Scholar42. Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE, et al. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169:2003-10. [PMID: 19933963] Google Scholar43. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71. [PMID: 16534045 Google Scholar44. van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183:E391-402. [PMID: 21444623] Google Scholar45. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-8. [PMID: 17000937] Google Scholar46. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120:999-1006. [PMID: 8185149] Google Scholar47. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20. [PMID: 10029122] Google Scholar48. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PMID: 19189907] Google Scholar49. 2012 Measures Maintenance Technical Report: Acute Myocardial Infarction, Heart Failure, and Pneumonia 30-Day Risk-Standardized Readmission Measure. Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation; 2012. Google Scholar50. Maynard GA, Budnitz TL, Nickel WK, Greenwald JL, Kerr KM, Miller JA, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level. Jt Comm J Qual Patient Saf. 2012;38:301-10. [PMID: 22852190] Google Scholar51. Boutwell AE, Johnson MB, Rutherford P, Watson SR, Vecchioni N, Auerbach BS, et al. An early look at a four-state initiative to reduce avoidable hospital readmissions. Health Aff (Millwood). 2011;30:1272-80. [PMID: 21734200] Google Scholar52. Giordano A, Scalvini S, Zanelli E, Corrà U, Longobardi GL, Ricci VA, et al. Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure. Int J Cardiol. 2009;131:192-9. [PMID: 18222552] Google Scholar53. Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363:2301-9. [PMID: 21080835] Google Scholar54. Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012;172:773-9. [PMID: 22507696] Google Scholar55. Kertesz SG, Posner MA, O'Connell JJ, Swain S, Mullins AN, Shwartz M, et al. Post-hospital medical respite care and hospital readmission of homeless persons. J Prev Interv Community. 2009;37:129-42. [PMID: 19363773] Google Scholar56. Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4:364-70. [PMID: 19479781] Google Scholar Author, Article, and Disclosure InformationAffiliations: Acknowledgment: The authors would like to thank Dr. Mark Williams, Professor of Medicine, Northwestern University, for comments on an earlier version of draft of this manuscript. 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