Academic journal article Online Journal of Issues in Nursing

Successes and Challenges in Patient Care Transition Programming: One Hospital's Journey

Academic journal article Online Journal of Issues in Nursing

Successes and Challenges in Patient Care Transition Programming: One Hospital's Journey

Article excerpt

The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Centers for Medicare and Medicaid Services. 2015); enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions, both internal to the hospital and between settings. Quality healthcare delivery is contingent upon a patient's understanding and retention of education, involvement in care, and self-management activation. Patient care delivery transitions can quickly develop complex issues while clinicians focus on patient safety, satisfaction, and clinical outcomes within a hospital environment of cost containment, rising workloads, and increasing patient comorbidities.

The Context of Care Transitions

Patient transitions from the hospital to alternate settings (e.g., home, rehabilitation facility) and within-hospital transfers between units, or the emergency department and inpatient setting, are areas of increased national focus within healthcare. In 2013, the Institute for Healthcare Improvement (IHI) released a hospital how-to guide which included recommendations for transitions from the hospital setting, typical failures, and implementation resources; practical methods and resources for the adoption and testing of changes within the clinical setting; the inclusion of successful case studies; and suggested measures, resources, and references (Rutherford. Nielsen, Taylor, Bradke, & Coleman. 20131.

Organizations such as The Joint Commission have developed videos to help clinicians improve patient transfer communication skills (Joint Commission Resources, n.d.T A repository of information for healthcare individuals can be found at The Joint Commission Transition of Care portal that includes performance measures; articles and publications; links to other government and professional organization sites with transition programs; and recorded webinars and education offerings, all at no cost (The Joint Commission, 2014).

Seven elements that must be in place for a safe transition to occur from one health setting to another include: leadership support; multidisciplinary collaboration; early identification of patients/clients at risk; transitional planning; medication management; patient and family action/engagement; and the transfer of information (Figure 1. The Joint Commission, 2014). The Joint Commission has incorporated transition measures into their disease specific care certification programs as a component to ensure excellence in the delivery of healthcare services for several designated conditions. Their certification program began in 2012 as an additional designator of a higher level of service through evaluation of clinical programs across the continuum of care (The Joint Commission. 2014). Organizations that have the certification have undergone a rigorous review process.

The HCAHPS survey was implemented in October 2006 by the Centers for Medicare and Medicaid Services (CMS) as a national, standardized method to evaluate patient perception of care received. Formal public reporting of HCAHPS results for hospitals began in March 2008. Until January 2013, the required questions for the HCAHPS survey had remained unchanged. Five additional questions were added to the HCAHPS Survey in 2013: three questions related to transitions to post-hospital care, one question about admission to the hospital through the emergency department, and one question related to mental and emotional health (HCAHPS Fact Sheet, 2013T The three questions that comprise the HCAHPS survey Care Transition Measures include (Coleman, n.d.. Box 2):

* "The hospital staff took my preferences and those of my family or caregivers into account in deciding what my health care needs would be when I left the hospital" (focus on when the patient was in the hospital)

* "When I left the hospital, I had a good understanding of the things I was responsible for in managing my health" (focus on discharge preparedness)

* "When I left the hospital, I clearly understood the purpose for taking each of my medications" (focus on medication understanding at time of hospital discharge)

Data are emerging from the additional Care Transition Measures and benchmarks have been developed. …

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