I may sound like a broken record, but it's probably impossible to downplay the importance of — and need to — improve how patients transition from one care setting to another.


Last month, I blogged about a JAMA study that looked at how QIOs had helped communities come together to tackle the vexing problem of preventable readmissions. A big part of the puzzle was improving communication between care settings. In a blog a couple of weeks ago, I referenced an AMA report that highlighted the important role physicians play in post-discharge care. "When patients leave the hospital to go home, they are transitioning back into the care of their outpatient primary care and specialty physicians," said AMA President Jeremy Lazarus, M.D. "These physicians play integral roles in helping patients fully recover, and coordination between inpatient and outpatient teams is key to ensuring success."

Striving for the hat trick (hey, my Chicago Blackhawks are on fire!), today's blog takes a look at a new Joint Commission paper on the topic. "Transitions of Care" is part of a three-year initiative the commission is undertaking to focus on improving, you guessed it, transitions of care.

Four health care systems participated in this part of the project. Joint Commission staff visited and studied operations at the organizations for two to three days. There were also focus groups with front-line staff. The report found that there's generally agreement on "what comprises positive transition," but also "uncovered many variables on how to make a successful transition from one organization to another."

For example, there was no uniformity around such things as who would call a patient after discharge or who the patient calls if she has questions. Also, there's no standard for how information between providers is sent — mail, fax, email or EHR.

Kathy Clark, R.N., associate project director specialist in the commission's Division of Healthcare Quality Evaluation, stated that the delivery system needs to better address how transitions of care are handled. "The current Joint Commission standards and survey process address the discharge from an organization, but do not adequately address the gap between the sending and receiving care providers," she stated. The report goes on to suggest that the commission might include new standards and a survey process after the project runs its course.

But it's not all doom and gloom. The report highlights some innovations at the four participating health systems. "Avera Health's care transitions program arranges for a home health nurse to visit patients within two days of discharge. The program also emphasizes medication management, disease-specific patient education" and continual follow-up over a 30-day period. Between February 2012 and November 2012, more than 820 patients moved through the program. Readmissions for four major diagnoses — congestive heart failure, AMI, pneumonia and COPD — ranged from 8.8 to 15.8 percent.

Ultimately, it comes down to better collaboration and communication. As Jennifer Wilson-Norton, associate director for coordinated care at Everett Clinic, says in the report, "You have to be able to reach out to the people you're working with. There has to be ongoing collaboration. If I'm sending you a patient, what do you need to come with that patient, and if you're sending a patient back to me, what do I need?"