Care transitions

Care transitions
Name	Care transitions
Caption	Healthcare handover between providers
Specialty	World Health Organization; Centers for Medicare & Medicaid Services; The Joint Commission
Type	Clinical process
Activity	Discharge planning; medication reconciliation; follow-up coordination

Care transitions are the movements patients make between healthcare practitioners, settings, and home, typically following hospitalization, surgery, or changes in clinical status. These shifts involve coordination among clinicians, institutions, insurers, and community services to maintain continuity, safety, and effectiveness for patients. Effective transitions draw on models developed by organizations such as Institute for Healthcare Improvement, Agency for Healthcare Research and Quality, and Johns Hopkins Medicine to reduce readmissions and adverse events.

Definition and Scope

Care transitions encompass the transfer of responsibility and information for patient care among providers like primary care physicians, hospitalists, nurse practitioners, physician assistants, and teams at institutions including Mayo Clinic, Cleveland Clinic, and Massachusetts General Hospital. Scope includes movement across settings such as intensive care unit, skilled nursing facility, rehabilitation center, home health agency, long-term acute care hospital, and outpatient clinic. Relevant stakeholders include payers such as Centers for Medicare and Medicaid Services and private insurers like UnitedHealth Group and Aetna as well as regulatory bodies like The Joint Commission and research funders like Robert Wood Johnson Foundation.

Models and Processes

Widely used models include the Transitional Care Model developed at University of Pennsylvania, the Care Transitions Intervention from Eric Coleman and Columbia University, and the Project RED protocol from Boston University Medical Center. Process elements span admission planning at systems like Kaiser Permanente, medication reconciliation protocols used by Veterans Health Administration, interdisciplinary rounds pioneered at Johns Hopkins Hospital, and discharge summaries standardized by American Medical Association workflows. Implementation often leverages electronic systems from vendors such as Epic Systems Corporation, Cerner Corporation, and Allscripts integrated with health information exchanges like eHealth Exchange.

Transitional Care Interventions

Interventions include medication reconciliation led by pharmacists from American Pharmacists Association, bedside handoff procedures inspired by TeamSTEPPS from Agency for Healthcare Research and Quality, post-discharge phone calls by nurses affiliated with Magnet Recognition Program hospitals, home visits coordinated with Visiting Nurse Service of New York, and telehealth follow-up via platforms developed by Teladoc Health and American Well. Care coordination roles feature transitional care nurses, case managers certified through Case Management Society of America, and community health workers associated with Centers for Disease Control and Prevention programs. Clinical pathways draw on evidence from trials at institutions like Johns Hopkins University and Yale University.

Outcomes and Quality Measures

Common outcomes assessed include 30-day readmission rates tracked by Centers for Medicare and Medicaid Services, emergency department utilization monitored by Agency for Healthcare Research and Quality, patient-reported outcome measures endorsed by National Quality Forum, and patient experience metrics from Hospital Consumer Assessment of Healthcare Providers and Systems. Quality measures involve medication error rates audited by Institute for Safe Medication Practices, continuity indices used in studies at Harvard Medical School, and cost analyses reported by Health Affairs and The Commonwealth Fund.

Barriers and Challenges

Barriers include fragmented information exchange across systems like Veterans Health Information Systems and Technology Architecture, interoperability limitations among vendors such as Epic Systems Corporation and Cerner Corporation, workforce shortages highlighted by World Health Organization reports, and misaligned incentives under payment models by Centers for Medicare and Medicaid Services and private insurers like Blue Cross Blue Shield Association. Additional challenges arise from social determinants addressed by programs at Robert Wood Johnson Foundation and Kaiser Family Foundation, medico-legal concerns overseen by American Bar Association health law sections, and variability in accreditation standards from The Joint Commission and National Committee for Quality Assurance.

Policy, Payment, and Accreditation

Policy frameworks include initiatives by Centers for Medicare and Medicaid Services such as the Hospital Readmissions Reduction Program and Accountable Care Organizations under the Affordable Care Act. Payment models affecting transitions include bundled payments piloted by Center for Medicare and Medicaid Innovation and value-based purchasing schemes referenced by Office of Inspector General (United States Department of Health and Human Services). Accreditation and standards come from The Joint Commission, quality reporting requirements from National Quality Forum, and certification programs from URAC.

Special Populations and Settings

Special populations require tailored approaches: older adults managed in programs from American Geriatrics Society and Society of Hospital Medicine; patients with mental health conditions served by Substance Abuse and Mental Health Services Administration initiatives; pediatric transitions coordinated with American Academy of Pediatrics; and veterans supported by United States Department of Veterans Affairs services. Settings with distinct needs include rural hospitals affiliated with Rural Health Information Hub, correctional health systems connected to Federal Bureau of Prisons, and post-acute networks involving Skilled Nursing Facility consortia.

Category:Healthcare