Care Settings and Transitions in Care

Care Settings and Transitions in Care

Susan B. Fowler

Joanne V. Hickey

This chapter briefly discusses health care settings from the perspective of the continuum of care and illness as it applies to neuroscience nursing practice. The configuration of a health care system to support varying intensity of care is driven by the needs of society and by economic and other resources allocated to support the system. All of these factors plus population-specific needs have an impact on neuroscience nursing practice.


A complex system of financing health care continues to evolve. The pace of health spending continues to grow, accounting for 17.6% of the gross domestic product. The Congressional Budget Office projects this percentage to increase to 25% by 2025, 37% by 2050, and 49% by 2082.1 Spending for Medicare and Medicaid is also projected to grow as the population ages. It is anticipated that Medicare/Medicaid spending will increase from 4% to 9% of the gross domestic product by 2035 and 19% by 2082. In the United States, about 49.9 million Americans, 16.3% of the total population, have no health insurance, and those with health insurance have a wide range of benefits from minimal to comprehensive and full-service coverage.2 Health insurance organizations, the “third party payers,” have become the universal vehicles through which health care providers are paid. Health insurers have become powerful controllers and interpreters of services and reimbursement provided under the provisions of a contract. Control of services is intended to restrain cost and maintain quality of care. However, differences in opinion about application of cost-effective policies have created a discontinuity among the receivers, providers, and payers of health services.

Over the years, a trend of rising copayments by recipients of care is evident, and services previously covered in full now require a deductible resulting in more out-of-pocket expense for recipients. Despite these cost-sharing measures, it is questionable whether the current financing system can be sustained, particularly as a greater proportion of the population ages and becomes eligible for Medicare health benefits. Those without health care insurance and with limited financial assets receive some health care through Medicaid, the government program for the poor and disabled. Others without health insurance who do not qualify for Medicaid receive limited and sporadic care, often through hospital emergency departments (ED) with the cost transferred to the health insurance system. The uninsured are using the ED as their primary source of primary care. Although the overall number of ED visits has increased, the number of visits considered emergent or urgent has not.3

In March 2011, the President of the United States signed into law the Patient Protection and Affordable Care Act (PPACA) which extended health care coverage to 32 million Americans. States are mandated to assume responsibility to redesign their payment plans. The focus of this reform is to link payment to efficiency and better patient outcomes. Opportunities for improvement lie in areas of potentially preventable events (PPE), patient-centered medical homes (PCMH), bundled payments or episodes of care, and accountable care organizations (ACO).4


The term managed care refers to any system of health payment or delivery arrangements where the plan attempts to control or coordinate use of health services by its enrolled members in order to contain health costs, improve quality, or both. Types of managed care organizations include group model Health care Management Organizations (HMO), network HMO, independent practice association model (IPA), direct contract model HMO, point of service HMO, preferred provider organization (PPO), exclusive provider organization (EPO), and physician hospital organization (PHO). A primary care practitioner usually acts as a gatekeeper through whom the patient goes to obtain other health services such as specialty care.5

Managed care systems are oriented toward measurable outcomes, cost containment, quality indicators, and patient satisfaction. As managed health care systems have developed and matured, the processes employed to achieve goals have also developed and include the following.

  • Analyzing structures, processes, and outcomes of health care using sophisticated data management and information technology to determine best practices

  • Developing and communicating practice guidelines for cost-effective quality outcomes that are evidence based

  • Building networks of providers and models of care to improve coordination and continuity of cost-effective care

  • Integrating processes for continuous quality improvement programs

  • Facilitating access to health promotion and preventive services and early diagnosis and treatment

Managed care integrates the financing and delivery of health care through contracts with selected health care providers and facilities that provide comprehensive health care services to enrolled members of a health care plan. The provider network is
an important feature distinguishing a managed care from a fee-for-service plan. Other characteristics of managed care plans are lower hospital use (both for admissions and length of stay), greater use of less costly procedures and tests, and greater emphasis on disease prevention and screening. Central components of a managed care environment include projected length of stay designation, use of case managers and care maps, and the requirement for approval before care is provided. Projected length of stay is guided by diagnostic related groups (DRGs) and insurer experience.

Managed care relies heavily on case managers assigned to each patient to provide continuity of care through timely, coordinated care. According to the American Case Management Association, eight services are provided by case management practices including (1) advocacy and education; (2) clinical care coordination and facilitation; (3) continuity and transitions management; (4) financial management; (5) performance and outcome management; (6) psychosocial management; (7) research and professional development; and (8) utilization management.6

Health care markets vary greatly across the United States, and many factors influence market penetration and maturity. As managed care markets mature, many smaller managed care organizations are being absorbed by a few large megastructure conglomerates, creating powerful integrated systems.

Continuity and Coordination of Care

A few basic concepts that are often addressed in health care delivery are continuity of care and coordination of care (more recently called care coordination) are discussed briefly.

Continuity of care is a concept that describes the ideal result of goal-directed, well-coordinated care throughout a person’s illness and across health care settings through involvement of all people involved in a person’s health care including the person receiving the care. It is an expeditious process of providing uninterrupted, cohesive, continuous, seamless care that is maintained throughout the transition points of illness, including the transition from institutional care to community-based care or to the home.7 Interdisci-plinary teams of health professionals working with the patient and family are needed to provide continuity of care.

Coordination of care implies that there is an active and effective coordinator (often the case manager or nurse) working with a health care team who is dedicated to providing coordinated, timely, and effective care. The case manager sees the “big picture” and helps team members identify short-term and long-term patient needs and key transition points in care to move the patient along the continuum of care through appropriate and timely use of resources and services. The coordinator must be able to communicate information to the appropriate stakeholders (e.g., patient, family, care providers) regarding specific needs with rationales and the expected measurable outcomes to be achieved. The person responsible and accountable for coordination must also be effective in follow-up to monitor the progression of activities and be able to identify when course modification or implementation of an alternative plan is necessary to achieve optimal outcomes.

The National Quality Forum (NQF) has provided a new focus on addressing care coordination. Care coordination, as defined by NQF is a “function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites that are met over time.” The framework for examining and understanding care coordination identified five key domains: Health care “home”; proactive plan of care and follow-up; communication; information systems; and transitions or handoffs.8 A project completed in 2010 endorsed 25 care coordination practices and 10 performance measures. See


Much attention in health care has been on defining and ensuring quality. The Institute of Medicine (IOM) defines quality as “the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”9 Although this definition was first published in 1990, it is still the premiere definition that is considered comprehensive and current.


In this section, health care is discussed from the perspectives of the focus of care. The three areas addressed include primary care, acute-critical care, and chronic care. Neurological patients may need different care settings with one injury or disease. Many patients move from one health care setting to another over the course of an illness.

Primary Care

The IOM defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”10 This definition, although first published in 1996, continues to be the most frequently cited definition. According to the American Academy of Family Physicians, primary care is comprehensive, collaborative, and cost-effective by coordinating health care services.11 In addition, primary care includes health promotion, disease prevention, health maintenance, patient education, diagnosis, and treatment of acute and chronic illnesses in a variety of settings. The diagnosis and treatment of some neurological problems will be managed exclusively by primary care practitioners or collaboratively with neurologists and neurosurgeons who act as consultants. This positions the primary care practitioner as the gatekeeper for care, including referrals for specialty neurological care. The Affordable Care Act defines a primary care practitioner as (1) a physician who has a primary specialty designation in family, internal, geriatric, or pediatric medicine; or (2) a nurse practitioner, clinical nurse specialist, or physician assistant, and in all cases, for whom primary care services accounted for at least 60% of allowed charges under Part B for the practitioner in a prior period as determined.12

Keeping people healthy through health promotion and disease prevention sets the course for a proactive health care system that provides for general and age-specific risk assessment, education of people about healthy lifestyles, and interventions designed to treat and control health problems. The U. S. Preventive Services Task Force, an independent panel of nonfederal experts in prevention and evidence-based medicine, describe preventive measures to include screening tests, counseling, immunizations, and preventive medications. Especially important to the neurosciences is carotid artery and dementia screening.13 Risk assessment is the basis for
tailoring an individualized plan of care. Risk of disease is being partially predicted through the study of genetic variants, alone or in interaction with other variants or environmental factors.14 Genomics is presenting new ethical issues about patient confidentiality and informed decision making.

When prevention is considered, three levels of prevention are generally recognized.13

  • Primary prevention: any intervention that prevents a pathologic process from occurring. Examples include immunization or identification and control of risk factors, such as smoking, with the ultimate goal of preventing vascular disease such as stroke.

  • Secondary prevention: interventions after a pathologic process has begun, but before symptoms occur. For example, a prescription for a statin drug ordered for a patient with an elevated cholesterol level is designed to prevent coronary artery disease and stroke.

  • Tertiary prevention: prevention of progressive disability or other complications in individuals with established disease. For example, community management of patients with Parkinson disease or multiple sclerosis includes prevention of complications such as injury due to falls and decreased levels of mobility.

Health promotion and health maintenance are related terms that refer to the advocacy and provision of programs and strategies that have been demonstrated through research and practice to be beneficial in maintaining optimal health and preventing disease and disability. For instance, a low-fat diet, exercise, and sensible personal habits are essential for all people to live healthy and productive lives. Health promotion is every health professional’s responsibility regardless of practice setting.

Primary care physicians are the gatekeepers for coordinating care and referring patients to other specialists. As life expectancy continues to increase, primary care providers will be caring for an increasingly number of elders with Alzheimer disease. As obesity rates continue to rise, hypertension will need to be managed by primary care provides with a focus on stroke risk. As primary care physicians become more involved in managing care of neurological patients, there will be an increased emphasis on maintaining and promoting health. This will be beneficial in preventing exacerbation of neurological conditions due to problems in other body systems and in preventing effects on other systems due to poorly managed neurological conditions. Primary care physicians and neuroscience health professionals are forging new collaborative partnerships. Neurological specialists will continue to assume oversight in coordinating and managing the care of patients with complex neurological problems that requiring acute care management or hospitalization, and those needing long-term management of chronic illnesses. Chronic diseases mandate a team approach to care. The neurological specialist assuming the role for oversight of care may be a physician, an advanced practice nurse, or a collaboration of both.

The efficient and economical movement of patients along the continuum of care remains focused on outcomes. The criteria for deciding when the patients should be moved from one level of care to another will change on the basis of the new research findings related to knowledge of key indicators and transition points of diseases and illnesses. Transitions in care settings are occurring more rapidly, necessitating quick and efficient responses in health care services to provide transitional care and control costly delays in services.

Acute-Critical Care

One can view illness as a continuum of severity anchored by two distinct systems, acute-critical care at one end and chronic care at the other end. The purposes and underpinnings of the two systems are in sharp contrast to each other. Acute-critical illness is characterized by an abrupt onset of a disease process with the potential for single-system or multisystem complications. Treatment often takes days or weeks, and significant changes in condition can occur within hours or days. Patients require acute-critical care because they are physiologically unstable, are technologically dependent, are at high risk for complications, and/or require close monitoring. The vulnerability for complications is compounded by comorbidity and advancing age particularly in the elderly, who are often living with multiple chronic health problems that increase the complexity of illness and need for care. In serious acute illness, care is usually provided within hospital settings where a wide variety of acute care services and cutting-edge treatment options are offered by multidisciplinary specialists working together in sophisticated high-tech environments to achieve a cure or the best outcomes for critically ill patients. Historically, in this physician-dominated model, the attending physician assumes the primary role of decision maker and directs the overall plan of care. The role of the acute care nurse practitioner (ACNP) is evolving in this model with a focus similar to that of a hospitalist, moving patients through the hospital efficiently, maximizing resource utilization, and meeting national guidelines while improving quality of care.15 Patients and families are included in decision making to the degree that it is possible, but the physician or NP primarily maintains control over care. Acute care, and particularly critical care, is the most expensive care provided, and access is uneven depending on geographic location and health insurance of the recipient.

Chronic Care

Chronic illness is an irreversible condition characterized by an accumulation or latency of disease states or impairments that have an impact on a person’s functional abilities and quality of life. Persons with chronic illness need supportive care and self-care management strategies that go beyond patient education and include problem-solving skills, self-efficacy, and support applications for real-life situations.16 Chronic illness tends to involve multiple, long-term diseases that span many years or a lifetime and follow an uncertain course. A major focus of management is stabilization of the disease, and may include palliation. Because cure is usually not possible, the goal of care is adaptation, that is, to learn to live with the illness in the least intrusive way and to maintain the highest functional level and quality of life for as long as possible. Care is provided mainly in a low-tech, community-based, primary care model with consultation from specialists as needed. The patient is the primary decision maker and coordinator of care, thus maintaining a high level of control. Emphasis in chronic illness management is on empowering the patient with knowledge through education and counseling to optimize self-management, adaptation, and symptom management.

How illness is viewed shapes care. A key transition point in illness comes when a patient moves from an acute care model to a chronic illness model, thus redefining the illness and needed care. The Corbin and Strauss17 chronic illness trajectory model provides a comprehensive framework for understanding chronic illness and the roles of health care providers, the patient, and the family in management. This model is particularly helpful for elucidating the nurse’s role in symptom management, rehabilitation, education, support, and advocacy for the patient-family dyad. The trajectory model is based on the fundamental idea that chronic illnesses have a course or trajectory that changes over time. The course can be optimally
shaped and managed by an effective and collaborative partnership of the patient, family, and health care providers to support optimal outcomes. Although shaping may not change the direction of the illness, the course of the illness can be stabilized, and symptoms may be controlled and managed. The shaping process is complicated by the use of technology, which has a potential impact on the patient’s personal identity, well-being, and activities of daily living.

The success of the United States’ health care system in developing effective acute and critical care models has resulted in many people surviving acute episodes they might otherwise not have survived. These people survive with chronic health problems that must be managed for the remainder of their lives. The quality of their management directly influences their quality of life and that of their families. Both the acute-critical care and the chronic illness models are essential to meet the needs of modern society. Acute-critical care and chronic illness models have blended together in transitional care models, which are often nurse-lead and include multidisciplinary interventions. The focus is patient safety and health care outcomes including quality of life, patient satisfaction, and decreased costs. Neurological patients require both acute-critical care and chronic illness care. For those persons who survive major neurological trauma, they survive with long-term chronic health problems that must be addressed. For others with neurological degenerative conditions, chronic illness management is the focus of care with acute care needs being required for periodic exacerbations that are quickly stabilized.

Jul 14, 2016 | Posted by in NURSING | Comments Off on Care Settings and Transitions in Care

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