CMO message from Amy Scanlan, MD
The importance of Transitions of Care
Early on in my career I had an experience that brought home to me the importance of care transitions. Elaine was a 75-year-old woman who was admitted to the hospital with a pulmonary embolus. She was put on a heparin drip (yes, this was a while ago) and started on coumadin. When she was stable, she was discharged and told to “follow up with her PCP.” She got home, got settled, and forgot about those instructions. I had no idea that she had even been in the hospital until I received a phone call 2 weeks later from the ER – she had fallen, hit her head, and now had a very large subdural hematoma. Her INR was 10.
Transitions of care are pivotal moments in the healthcare journey of a patient, involving the movement between different healthcare settings, providers, or levels of care as their medical conditions and needs evolve. This process can occur in various forms, such as transferring a patient from a hospital to a rehabilitation facility, from a rehabilitation facility to home, or from primary care to specialist care. Each transition represents a critical juncture where the continuity, quality, and safety of care must be meticulously maintained to avoid adverse outcomes.
So, what are the most important elements of a successful transition of care?
1. Comprehensive discharge planning
Successful transitions of care start when the patient is still in the hospital. Ensuring that patients and their caregivers have a clear understanding of the patient’s condition, the course of care in the hospital or SNF, the discharge process, and what will need to happen once the patient is home to continue recovering is key.
2. Medication reconciliation
Ensuring that medication lists are accurate and consistent across care settings is a critical component of care transitions. Misunderstanding, omission or discrepancies can lead to adverse outcomes and patients ending up back in the hospital.
3. Communication and education
Patients and their families should have a clear understanding of the recovery process, how to watch for any worsening of the condition they have been treated for, and who to contact should their condition change. Clear, timely and accurate communication between providers, patients, and caregivers ensures that everyone involved in the patient’s care is on the same page. Education also equips individuals with the knowledge needed to manage the patient’s condition, recognize warning signs, and seek timely medical assistance.
4. Follow up
Follow up is crucial for monitoring the patient’s progress and addressing any issues that arise after the patient moves to the next stage of their journey. Ensuring that the patient has the necessary home services, follow up appointments with the PCP, and any specialty care appointments helps to ensure that the patient’s recovery continues smoothly and that any complications are promptly addressed. Ultimately, this proactive approach can significantly reduce hospital readmissions and emergency visits.
We at Trinsic are working hard to support you in this process. We are using our data to identify our patients when they are discharged from the hospital, so that we can ensure their journey home is a smooth and well supported one. Our Care Managers reach out to our high-risk patients and their families soon after they arrive at home to ensure they have what they need to continue to recover. They can set up follow-up appointments with both PCPs and specialists and ensure that patients have what they need to get to those appointments. They are an extra set of hands and eyes in the transitional care process.
Spotlight: Trinic-Transitions of Care
How are Trinsic teams helping to support this work? See below for stories.
Mary was a 71-year-old female with cirrhosis and went to the ED with edema and ascites. She was discharged from the ED on 20 mg of furosemide and 50 mg of spironolactone. The ED provider originally ordered 40 mg of furosemide, before discontinuing the order and putting in the 20 mg dose. However, when the patient went to the pharmacy she was dispensed BOTH doses of furosemide in addition to the spironolactone. In a discharge follow up call, the Trinsic care coordinator realized the patient was confused about which dose to take. Working with a Trinsic pharmacist, the care coordinator was able to educate the patient about which dose she should be taking.
Charlie was an elderly patient who had gone to the ED with severe depression. In a discharge follow-up call, a Trinsic social worker reached out by phone to check on him.Unable to reach the patient, she later received a call back from the patient’s son who requested help with resources for his father. The social worker was able to provideinformation on home healthcare, homemaker services and transportation options. The social worker also suggested the Senior Resource Development Agency (SRDA) as a way to re-engage the patient with available social support. The social worker and the son – who lived in another state – were able to partner and work together with the SRDA to find several local low cost or free activities that got Charlie out of the house and interacting with others. The social worker also stayed connected to Charlie and continued to support him with low-cost or free counseling in the form of peer mentorship and support groups. Charlie remained at home, no longer isolated and depressed, with a growing support network around him.
Reflections: Articles and podcasts from outside experts.
- This interview features our very own expert, Dr. Amy Scanlan.