Conference highlights 7 transitional care interventions

With providers across the country experimenting with transitional care improvements, many models that are spearheading the movement share some common interventions, said Cheri Lattimer, executive director for the non-profit National Transitions of Care Coalition, in a keynote address at Friday's World Congress 3rd Annual Leadership Summit on Hospital Readmissions.

Lattimer outlined several models at the Falls Church, Va., event, including transition coaching, advanced nurse practitioner participation, the use of a guided care nurse, Boston University's Project RED and the Society of Hospital Medicine's Project Boost.

The best transitional care model is "not about the [individual] model; it's what they have in common," Lattimer said in a keynote address. The current models leading the national experiment all focus on a team approach to reengineer the entire discharge process.  In fact, she said she would like the term "discharge" to turn into a focus on "transition."

"When we send [patients] home, did we really do the job?" Lattimer asked the audience. "It's a transition. Our job is not done until info is communicated ... When that patient moves, it's your role to make sure they have the right info." 

Current programs share some of the following interventions, Lattimer noted:
1. Medication management: Providers assess the patients' medications and patients and families engage in their own education.
2. Transition planning: A clearly-identified practitioner, such as a transitional care nurse or advanced practice nurse, conducts a comprehensive assessment of patient needs in a formal process that facilitates the safe transition of patients from one level of care to another.
3. Patient and family engagement and education: For the most part, patients and families want to take part in their own care, according to Lattimer. "Questions are the answer," she said, advising providers to do the simple task of putting out a pad of paper and pen for patients to write down three questions they have. Doing so helps to develop patients' self-care management skills.
4. Information transfer: Also key to transitional care is a clearly defined communication model. For example, the identified caregiver can help manage patient needs, using timely transition tools, such as a transition summary, a transmission of information that is expedited ahead of the traditional discharge summary. 
5. Follow-up care: Equally as important as care while in the hospital is care that comes after the hospital visit. For example, does the patient's primary care physician even know that the patient was admitted? Did the patient attend their scheduled follow-up visit? Telephone calls and home visits help to reinforce the transition plan.
6. Healthcare provider engagement: Lattimer stressed the importance of the care team ("team" being the operative word), who must be responsible and accountable for the patient. "We can do this, but it's a change in culture," Lattimer said. "We have to start talking to everyone who touches the patient." 
7. Shared accountability across providers and organizations: Likewise, the provider or the organization must be responsible for sharing information across provider lines to ensure the timely communication of the patient care plan.

For more information:
- visit the National Transitions of Care Coalition tools for healthcare professionals