Transitional Care   36  

Fidelindo Lim, Janice B. Foust, and Janet H. Van Cleave

OVERVIEW

Persons with continuous complex care needs frequently require care in multiple settings. The American Geriatrics Society defines transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” (Coleman, 2003, p. 549). Representative locations include (but are not limited to) hospitals, subacute and postacute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities (Coleman, 2003). During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. For example, among Medicare patients, 20% were hospitalized within 30 days and 34% were rehospitalized within 60 days (Jencks, Williams, & Coleman, 2009) of a care transition. Despite how common these transitions have become, the challenges of improving care transitions have historically received little attention from policy makers, clinicians, and quality improvement entities (Coleman, 2003), until recently.

With hospital readmission now heralded as a quality indicator, there is more incentive to correct transition-related problems. The enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010 has helped formalize and implement transitional care services with federal funding. In addition, the focus on reducing 30-day hospital readmissions is further generating the adoption of TCMs or the redesign of hospital discharge processes (Balaban, Weissman, Samuel, & Woolhandler, 2008).

Many factors contribute to gaps in care during critical transitions. Poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care all contribute to transition-associated problems (Naylor, 2002; Naylor & Keating, 2008). The practice of nursing is closely tied to health illness transitions in a person’s lifetime. The quality of the outcomes during these transitional events is largely determined by the degree of care coordination among health care environments and proactive involvement of the patient and their families in the process, wherein a nurse plays a pivotal role. Success in implementing evidence-based transition-care strategies will help curtail preventable rehospitalizations and save health care dollars.

This chapter reviews issues and trends associated with transitional care mainly from the acute care setting and presents evidence-based TCMs, redesigned hospital discharge models, as well as strategies to enhance outcome performance.

BACKGROUND AND STATEMENT OF PROBLEM

In 2012, an estimated 43.1 million U.S. residents (13.7% of the U.S. population) were older than 65 years (National Center for Health Statistics, 2013). This population subset remains the core consumer of health care resources. There were 19.6 million emergency department (ED) visits among adults aged 65 years and older reported in 2010 (Albert, McCraig, & Ashman, 2013). Approximately 8.8 million ED visits by patients older than 65 years resulted in hospital admission (Weiss, Wier, Stocks, & Blanchard, 2014). Therefore, the likelihood of older adults being in a state of transition between care environments is very high.

Although current trends indicated a decrease in hospitalization rates from 2008 through 2012 (4% per year) for those aged 65 years and older (Weiss & Elixhauser, 2012), an estimated 13.5 million discharges (38.7% of total discharges) from short-stay hospitals among this age group were reported in 2010 (U.S. Department of Health and Human Services, 2012) and 16% of all hospitalizations in 2012 (National Center for Health Statistics, 2013). This cohort is also reported to have the highest average length of hospital stay of 5.2 days in 2012 (Weiss & Elixhauser, 2012) and the highest mean hospitalization cost ($13,000 per episode in 2012 dollars; Moore, Levit, & Elixhauser, 2014).

The top five most common diagnoses for the hospitalized adult older than 65 years are septicemia, nonhypertensive congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease and bronchiectasis, and cardiac dysrhythmias (Weiss et al., 2014). This is notable because evidence-based TCMs have targeted these high-volume, high-risk conditions (Naylor et al., 2013).

Transitions are considered high-stress events for patients, their families, and care providers alike. Evidence suggests that transitions are particularly vulnerable to breakdowns in care and, thus, there is a need for transitional care services (Naylor et al., 2013). Two especially problematic areas are medication discrepancies and poor posthospital follow-up with primary care providers. Forster, Murff, Peterson, Gandhi, and Bates (2003) found that nearly 20% of recently discharged medical patients experienced an adverse event during the first several weeks at home. Of these, 66% involved medications and were the most common type of adverse event (Forster et al., 2003). In a study on home medication discrepancies, Corbett, Setter, Daratha, Neumiller, and Wood (2010) found that the problems were astoundingly widespread, with 94% of the participants having at least one discrepancy. The average number of medication discrepancies identified was 3.3 per patient during hospital-to-home transition (Corbett et al., 2010). Similarly, 71% of the hospital discharge records of older adults with heart failure had at least one type of medication reconciliation problem (i.e., discrepancies, partial discharge instructions, or incomplete discharge summaries; Foust, Naylor, Bixby, & Ratcliffe, 2012). Another major area of breakdown is patient follow-up visits after discharge. For example, one study reported that among Medicare patients rehospitalized within 30 days, up to 50% did not have documentation of physician follow-up visits postdischarge (Jencks et al., 2009). Standardizing handoff processes and developing metrics for transfers of care have been shown to improve transition care to and from the ED (Kessler, Williams, Moustoukas, & Pappas, 2012).

Patients and their caregivers are often unprepared for transitions and are overwhelmed by discharge information. Poor preparation of the patient and his or her informal caregivers for the next level-of-care interface, be it the home or another facility, compromises overall patient safety (Coleman, Parry, Chalmers, & Min, 2006). Follow-up visits after discharges provide opportunities to reinforce discharge education and monitor for changes in conditions.

The 2001 Institute of Medicine (IOM) landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century, pointed out that the health care delivery system is poorly organized to meet the challenges at hand. The delivery of care is often overly complex and uncoordinated, requiring steps and patient “handoffs” that slow down care and decrease rather than improve safety (IOM, 2001).

At an increasing rate, patients are being discharged home or to other health care environments with both complex and complicated treatment plans with limited timely follow-through by professionals, causing undue stress to the patient and his or her informal caregivers once they leave the hospital. Levine, Halper, Peist, and Gould (2010) have described informal caregivers’ essential role and called for more proactive involvement of caregivers as partners during transitions, especially when they could be the major source of continuity for the patient. The stress of caregiving is likely to be exacerbated during episodes of acute illness (Naylor & Keating, 2008), readmissions, and transfers to various health care environments.

Health care disparity and lack or inadequate access to transition care resources will be more pronounced in the disenfranchised segment of older adults, namely, those who are living alone, have multiple comorbidities, are undomiciled, suffering from mental illness, victims of elder abuse and neglect, the uninsured, and those lacking in legal status.

ASSESSMENT OF THE PROBLEM

Until very recently, sustained transitional care programs outside of funded randomized controlled trials (RCTs) were lacking largely because of limited third-party reimbursement of transitional care services (Naylor & Keating, 2008). Federal funding of transitional care programs was launched in 2012 with the implementation of the Community-Based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act (Centers for Medicare & Medicaid Services [CMS], n.d.). CCTP is currently evaluating various TCMs for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program (CMS, n.d.).

Several studies have delineated the problems that patients encounter during transitions. Coleman, Min, Chomiak, and Kramer (2004) identified four major content areas that patients and caregivers who recently underwent post-hospital care transitions expressed as most essential and most needed: medication self-management, a patient-centered health record, primary care and specialist follow-up, and knowledge of “red-flag” warning symptoms or signs indicative of a worsening condition. Similarly, Miller, Piacentine, and Weiss (2008) identified posthospital difficulties faced by adults during the first 3 weeks at home. Among those patients who had difficulty coping, pain was the most frequent stressor, followed by managing complications and recovery challenges. These recently discharged patients also described relying on family or friends for emotional support, and were concerned about being a burden. A lack of written detail and accessibility of hospital discharge instructions were significant problems described by patients, informal caregivers, and home health care clinicians when patients returned home from the hospital (Foust, Vuckovic, & Henriquez, 2012).

A study that compared the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care found that transitional care nurses (TCNs) judged that 96 of 99 of the control-group patients discharged without home care had unmet discharge needs that may have benefited from a postdischarge referral (Bowles, Naylor, & Foust, 2002).

A prospective observational cohort study to evaluate the quality of discharge practices at an academic medical center (N = 395) found that, although the majority of patients (95.6%) reported understanding the reason for their hospitalization, fewer patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews (Horwitz et al., 2013). Other key findings include deficiencies in follow-up appointments and advance discharge planning, and patient understanding of key aspects of postdischarge care (Horwitz et al., 2013). The impetus to implement high-quality discharge instructions stems from the CMS and The Joint Commission’s (TJC) Core Measures to meet accreditation and public reporting requirements.

A retrospective cohort study of age and other risk factors for medication discrepancies reported that 96% of all hospitalized patients have at least one medication or dosage change compared with their home medication regimens (Unroe et al., 2010). Only 44% of them were notified of the changes at hospital discharge. A study of older Chinese Americans, who transitioned from hospital to home care, reported that 24.3% of participants were prescribed at least one potentially inappropriate medication (PIM) at hospital discharge, whereas 67.1% experienced at least one medication discrepancy. A positive correlation was found between the occurrence of PIM and medication discrepancy (Hu, Capezuti, Foust, Boltz, & Kim, 2012). It is imperative that during discharge medication reconciliation and instructions, a standard guideline, such as the Beers Criteria for PIM use in older adults, be hardwired in the transition process (Hu, Foust, Boltz, & Capezuti, 2014).

Another medication-related concern is posthospitalization adverse drug events (Kanaan et al., 2013). Among 1,000 hospital discharges, 19% of them involved an adverse drug event within 45 days among older adults discharged home from the hospital (Kanaan et al., 2013). More than half of these events occurred within 2 weeks of discharge. This highlights the importance of medication reconciliation in care transitions (TJC, 2012).

The current Joint Commission National Patient Safety Goals (NPSG; TJC, 2015a) now focus on the safe use of medicines. The goals include patient education, steps on obtaining an accurate list of medications from patients, and encouraging patients to bring a current medication list to physician or provider visits (TJC, 2015a).

A review of literature noted that direct communication between hospital and community physicians was relatively rare (3%–20%), and available discharge summaries at the first primary care visit were low (12%–34%; Kripalani et al., 2007). Additionally, discharge summaries did not always have essential information (i.e., medications and diagnostic results) when available.

The most common example of communication breakdown is when systems of care fail to ensure that the essential elements of the patient’s care plan that were developed in one setting are communicated to the next team of clinicians (i.e., preparation for the goals of care delivered in the next setting, arrangements for follow-up appointments and laboratory testing, and reviewing the current medication regimen; Coleman, 2003). Language and health literacy issues and cultural differences exacerbate the communication breakdowns encountered in health care transition (Hu et al., 2014; Naylor & Keating, 2008). The use of pictographs in discharge instructions for older adults with low-literacy skills has been demonstrated to be effective (Choi, 2011).

INTERVENTIONS AND CARE STRATEGIES

Various TCMs have been described in the literature, and several RCTs have tested interventions. Key outcome variables from these RCTs include rehospitalization rate, cost reduction, patient satisfaction, and quality of care. Specific features of the two well-known evidence-based models are summarized in Table 36.1.

The Two Leading Examples of Transitional Care Interventions

The Advanced Practice Nurses TCM

The TCM developed at the University of Pennsylvania provides a comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical and surgical conditions (Naylor & Keating, 2008). The central facilitator of the model is an advanced practice TCN, who follows patients from the hospital into their homes and provides services designed to streamline plans of care, interrupt patterns of frequent acute hospital and ED use, and prevent health status decline. Although the TCM is nurse led, it is a multidisciplinary model that includes physician, other nurses, social workers, discharge planners, pharmacists, and other members of the health care team, all of whom implement tested protocols uniquely focused on increasing the ability of patients and their caregivers to manage their care (Naylor et al., 2009).

This model involves advanced practice nurses who assume a primary role in managing patients and coordinating the transition from hospital to home and vice versa. APNs implement a comprehensive discharge planning and home follow-up protocol. A qualitative analysis highlighted the barriers and facilitators faced by advanced practice TCNs and emphasized how individualized approaches, providing care that exceeds the type of care typically staffed and reimbursed by insurers, and advanced clinical judgment influenced positive outcomes in the implementation of TCM (Bradway et al., 2012). When compared with the control group, members of the intervention group had improved physical function, quality of life, and satisfaction with care. People in the intervention group had fewer rehospitalizations during the year after discharge, resulting in a mean savings in total health care costs of $5,000 per patient (Naylor & Keating, 2008). An RCT using the TCM for older adults hospitalized with heart failure showed an increase in the length of time between hospital discharge and readmission or death, reduced the total number of rehospitalizations, and decreased health care costs (Naylor et al., 2004).

Among cognitively impaired older adults, a comparative effectiveness RCT among three models (Augmented Standard Care [ASC], Resource Nurse Care [RNC], and TCM) has demonstrated a statistically significant decrease in mean 30-day rehospitalization per patient using TCM, with similar effects 90 days after the index hospitalization (Naylor et al., 2014).

There are currently more than 300 health care organizations using the TCM in the United States and ongoing program evaluations are in progress (Lucinda Bertsinger, personal communication, May 4, 2015).

The Care Transitions Intervention Model

Coleman, Parry, Chalmers, and Min (2006) developed the Care Transitions Intervention Model through the Division of Health Care Policy and Research at the University of Colorado Health Sciences Center in Denver. This model involves a nurse (social workers and occupational therapists may also serve as a coach) functioning as a “transition coach,” who teaches patients self-management skills and ensures their needs are met during a transition between health care settings. The transition coach helps the patients achieve positive outcomes outlined in the four pillars of care transitions intervention (CTI), which include medication self-management, dynamic patient-centered health record keeping, follow-up care with primary physician, and learning how to recognize and respond to red flags that indicate their condition is worsening.

Providing patients with support and tools to participate in their transitional care using this model has been shown to reduce hospital readmissions and associated costs (Coleman et al., 2006). An RCT found that patients who received this intervention had lower all-cause rehospitalization rates through 90 and 180 days after discharge compared with control patients. At 6 months, mean hospital costs were approximately $500 less for patients in the intervention group compared with controls (Coleman et al., 2006).

TABLE 36.1

Transition Care—Strategies for Implementation

A self-care model of the CTI has been demonstrated to improve outcomes in a Medicare fee-for-service population. There were significantly fewer hospital readmissions at 30, 90, and 180 days in the intervention group as compared with those who did not receive the CTI (Parry, Min, Chugh, Chalmers, & Coleman, 2009). When compared with matched internal controls (N = 321), patients who received the CTI had significantly lower utilization in the 6 months postdischarge and lower mean total health care costs ($14,729 vs. $18,779, p = .03). The cost saving per patient receiving the CTI was $3,752 (Gardner et al., 2014). The CTI has been adopted by more than 900 health care organizations in 44 states (Care Transitions Program, 2014).

A qualitative exploration of the value of CTI has demonstrated that patient-centered coaching interventions improved care transitions in chronically ill older adults, particularly because it fostered the perception of a caring relationship, leading to greater patient investment in the program (Parry, Kramer, & Coleman, 2006). A study aimed at understanding the barriers and facilitators for successful implementation of the CTI has been described in the literature (Hung & Leidig, 2015). Several studies have been conducted to explore quality-improvement processes in CTI implementation, particularly its dissemination and sustainability (Bennett, Coleman, Parry, Bodenheimer, & Chen, 2010; Coleman, Rosenbek, & Roman, 2013; Parrish, O’Malley, Adams, Adams, & Coleman, 2009).

Other Transitional Care Interventions

Naylor et al. (2013) describe the core features of transitional care, which can be used as a guide for program planning and implementation to include the following:

Hospital Discharge Redesign

Randomized trials have demonstrated the benefits of redesigned hospital discharge processes to strengthen timeliness of primary care visits and/or reduce hospital readmissions or emergency room use (Balaban et al., 2008; Jack et al., 2009). The interventions included redesigned discharge forms or individualized information sent to primary care providers, medications with specific forms or having a clinical pharmacist call patients after discharge, and arranging patients’ primary care visits and facilitating communication with the outpatient offices (i.e., sharing discharge forms). Redesigned discharge processes led to comparatively lower hospital use, especially for those with prior hospitalizations (Jack et al., 2009) and more patients following up with their primary care providers within 21 days (Balaban et al., 2008).

Other transition models that have been described in the literature include the following:

Whichever model is adopted by the institution and stakeholders, staff training is of vital importance. Competency in cross-site collaboration is critical to the management of patients with complex acute and chronic illnesses.

Starting February 2012, the government established support of community-based transition programs under the PPACA with a $300 million budget. The CCTP, created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The law aims to dedicate transitional care services to patients with multiple chronic conditions or other risk factors associated with a hospital readmission or substandard transition into posthospitalization care. The law also provided funding for pilot projects with incentives for transitional care, including bundled payments to one entity for services by several providers (Health Affairs, 2012). The adaptation of these best practice models into legislation is a fine example of research translated into practice.

Initial evaluation of the federally funded CCTP (47 programs) for the first year of implementation did not show differences in 30-day unadjusted readmission rates between treatment and comparison hospitals. Only 9% of community-based organizations (CBO) achieved some reduction in 30-day readmission (Econometrica, 2014).

This evaluation demonstrates some of the challenges of implementing transitional care. Challenges included hiring qualified personnel and gaining access to hospitals’ electronic records and case management data to identify those who are at risk. Critics of the report state that the statistical analysis lacked transparency and does not provide information about what works and what does not work to improve care transitions (Lynn, 2015).

CASE STUDY

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Lin Kwon Ying is a 70-year-old widower who lives alone in an apartment in Chinatown. He was mostly independent up until 5 months ago when he started to develop shortness of breath, increasing fatigue, and cough. He has had three admissions for CHF exacerbation. His medical–surgical history includes hypertension (HTN), arthritis, peptic ulcer disease, and gastrointestinal (GI) bleeding. He is back in the hospital for another CHF exacerbation, a small left pleural effusion, and a left leg deep venous thrombosis (DVT). Although cognitively intact, Mr. Ying does not speak English and his family is very much involved in his care. A relative is present during most of the day and evening while he is in the hospital. Most of his relatives have poor English proficiency. Mr. Ying is scheduled for discharge home the next day after being in the hospital for 6 days. His current medications have been satisfactorily reconciled, with the addition of enoxaparin (low-molecular-weight heparin) injection for 7 days and to check with his primary care provider for possible oral anticoagulation. He is to continue taking prehospitalization medications: metoprolol, esomeprazole, multivitamins, and furosemide. The family reports that Mr. Ying uses Chinese liniment to ease his joint pains. He is described by his family as an obedient patient who will do whatever his doctor recommends although he has received little advice or “teachings” during his previous CHF admissions. He cannot recall being informed what lifestyle changes are required of him.

Factors, such as Mr. Ying’s rehospitalization, a diagnosis of CHF, language barrier, family involvement, being cognitively intact, and a complex plan of care (i.e., self-injection of enoxaparin), indicate that he is an ideal candidate to receive dedicated transitional care services. If transition-care service were available in the current institution, he would have been referred for a consult on his admission. An assessment would have been made by an advanced practice TCN or “coach,” preferably in the presence of the informal caregiver and a staff translator. From this transition-care evaluation, a multidisciplinary plan of care with emphasis on applying best practices, on family involvement, and patient teaching by the staff nurses would be drawn up. The handoff report would mention Mr. Ying’s status as a transition-care patient and a disease-specific clinical pathway (in his case CHF) would be implemented and followed through during rounds and discharge planning.

To meet TJC standards, all his medication should have been reconciled within 24 hours of his admission and the record placed in a prominent location in his chart. The challenge is to create a medication reconciliation record written in Mr. Ying’s own language (Mandarin) that he can take with him on discharge.

At the bedside level, the nurses (mostly bilingual Chinese) provided random or “ambush” teachings when they saw Mr. Ying consuming Chinese food brought from home that they considered high in sodium. No dedicated patient teachings were delivered and no printed materials in the patient’s language were provided. How best to standardize patient teachings in acute care transitions is an ongoing challenge. Staff often report not having the time to teach patients and their families. Patient education must be held as an essential and independent nursing intervention. The facility must provide adequate training, not only for the licensed providers (nurses, APNs, physicians, and social workers), but also for the auxiliary staff such as patient-care technicians and other staff members with direct patient contact. Repetition and reinforcement with use of traditional printed media can easily be achieved. Numerous online patient teaching materials are now available. The institution could translate these materials into various languages based on local needs. In Mr. Ying’s case, his ability to self-inject enoxaparin should be assessed, reinforced, and documented. During the handoff, the nurse would include the patient’s teaching needs and the follow-up needed, focusing on health-promotion content, follow-up appointments, telephone numbers to call for questions, or to report changes in condition.

Depending on the TCM applied, Mr. Ying would receive a home visit from the nurse TCM coordinator or nurse “coach” within 24 hours postdischarge with an individualized and explicit plan of care, including following up on medications, availability of equipment, and self-report of any “red-flag” signs for CHF exacerbation or pulmonary embolism. On his first visit to his primary care provider, he would be accompanied by his transitional care coordinator/coach. In this visit and in future encounters with health care providers, Mr. Ying would be encouraged and provided with the skills necessary for self-advocacy and self-management of his condition. Success would depend on various factors such as patient readiness, literacy, and longitudinal follow-up. From the evidence-based models mentioned in this chapter, follow-up varies from day 1 of hospitalization to up to 3 months postdischarge. Patient follow-up must also address patients’ and informal caregivers’ satisfaction with the care received. Additionally, the postacute transition care nurse could also coordinate referrals to relevant, local community organizations to provide greater continuity and long-term social support.

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