Evidence-based Transitions of Care Crosswalk

Written on March 2nd, 2011 by tasha

The National Transitions of Care Coalition (NTOCC) has put together a superb, evidence-based crosswalk detailing essential elements needed for a successful program that eases a patient’s move from one care setting to another. Included in the document are seven intervention categories with descriptions and examples based on a very large compendium of research the coalition generously makes available free to the public.

As you have no doubt heard by now, CMS will be penalizing doctors and hospitals that have high 30-day readmission rates. A recent study demonstrated that within a month of discharge, over 20% of Medicare beneficiaries were re-hospitalized for the same condition they had been treated for earlier. This has been very costly for Medicare (and therefore us taxpayers!). The thinking is that patients are being released before they are fully stabilized, or being released to a home situation that is unable to cope with the demands of their serious condition.

The penalty is designed as an incentive to be sure patients are being discharged responsibly with adequate follow-up care. (Amen to that! Too often family members are called upon to perform fairly complicated care regimens with little to no training, or choice in the matter.)

This new penalty provides an excellent opportunity for elder care professionals to collaborate with doctors and hospitals by offering a home care team that is able to provide the necessary coaching and support to patients and their families.

There is a strong patient/family empowerment intent on the part of CMS. I’m pleased to say that my clients and those who read my blog share this ethic, which is also a key component in NTOCC’s outline. Since our mission is to help families and providers make better use of the Internet for superior care, I’ve included empowering tech suggestions here within this synopsis of the coalition’s crosswalk.

If you are planning to present yourself as a partner-in-care, here are the 7 intervention categories recommended to create a successful care transitions program:

1. Medication Management: A method to ensure the safe use of medications by patients and their families, based on patients’ plans of care. We blogged about tools to assist with medication reconciliation in our post on HIPAA-compliant online medication management.
2. Transition Planning: A formal process that facilitates the safe transition of patients from one care setting to another, or from one practitioner to another.
3. Patient and Family Engagement/Education: Education and counseling of patients and families to enhance their active participation in their own care including informed decision-making. Elder Pages Online can help you with this one! Check out our new, brandable, chronic care e-library, in particular the articles on CHF, COPD and dementia (chief culprits in the list of high 30-day re-admission diagnoses).
4. Information Transfer: Sharing of important care information among patient, family, caregiver and healthcare providers in a timely and effective manner. Read our blogpost about examples of HIPAA-compliant tools for collaboration such as MyRemCare (now morphed into Care Team Connect). I don’t get paid by these folks, by the way. I just think they are a good example of research and heart intersecting with technology to provide better coordination between all the players, including patients and family members.
5. Follow-Up Care: Facilitating the safe transition of patients from one care setting or care provider to another through effective follow-up activities.
6. Healthcare Provider Engagement: Demonstrating ownership, responsibility and accountability for the care of the patient and family/caregiver.  Examples of ownership and responsibility include the use of evidence-based guidelines to inform clinical protocols as well as accessible patient and family education materials that address concerns for health literacy. Again, you may want to check out our branded chronic-care e-library. It provides articles for family caregivers written to the 8th grade level, yet based on current literature reviews. I have been working on NIA-funded family caregiver interventions for 15 years. I don’t include information from “Patty’s Home Page.”
7. Shared Accountability across Providers and Organizations: Enhancing the transition of care process through accountability for care of the patient by both the healthcare provider (or organization) transitioning and the one receiving the patient.

What is your company doing to ease transitions for patients and families?

Tags: Care continuum, Elder Pages Online
Posted in Collaboration, Elder Care

Put your brand on a monthly e-newsletter for families