Creating Regional Partnerships to Improve Care Transitions

07 Jan 2015
Creating Regional Partnerships to Improve Care Transitions
As patients move from one care setting to another, problems such as lack of follow-up care and miscommunication among clinicians often occur and can put patients at risk for serious complications and hospital readmission. Some patients have additional problems such as depression, social isolation, or a lack of housing or transportation that may increase their risk of hospital readmission. Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, at a cost of more than $26 billion every year. 
Several Aligning Forces for Quality (AF4Q) Alliances have implemented or are partnering in care transitions programs using care transition coaches to ensure patient care that is coordinated across care settings. This series of briefs highlights the successes of Alliances that have developed relationships with organizations and providers in the community so they can collaborate to achieve the shared goal of reducing hospital readmissions through participating in a 30-day care transitions program.
Creating a Behavioral Health Intervention
Patients with comorbid physical and behavioral health conditions are at greater risk of being readmitted to the hospital and tend to have worse health outcomes. Care transitions coaches can identify mental health problems that the hospital staff and other health care providers may have overlooked using behavioral health screening tools.
Supporting Patients Who Are Nearing the End of Life
Care transitions coaches are discovering that they have an important role to play in starting conversations with patients about planning for end-of-life care. Health care providers and family members are frequently uncomfortable with broaching this topic and may wait to
do so until a patient is very ill. Coaches can help patients make decisions about treatment goals and get access to resources like palliative and hospice care earlier, which can improve their overall quality of life.
Hiring Care Transition Coaches
Care transitions coalitions hire coaches who can conduct assessments and help patients gain the knowledge, skills, and confidence to become active participants in their own care and achieve their personal health goals. The qualifications coalitions look for when hiring a coach vary depending on the settings in which the coach will work and whether the coach will take on a specialized role such as working mainly with patients with behavioral health problems.
To read more, see Hiring Care Transition Coaches.
Addressing the Needs of Patients Discharged to Skilled Nursing Facilities
Some of the patients who are enrolled in a 30-day care transitions program as hospital inpatients wind up being transferred to a skilled nursing facility (SNF). Typically, the coach will visit the patient in the SNF and provide support and tools to prevent the patient from being readmitted to the hospital. Patients may encounter gaps in care when transferred to an SNF—for instance, important information like physician’s orders may not have been relayed from the hospital, some of the staff may lack adequate training, and there may be delays in obtaining medication because the SNF doesn’t have an onsite pharmacy. Care transitions programs are increasingly partnering with SNFs to work together to address these issues and provide patients with better continuity of care.
Building Relationships with Providers
Effective care transitions programs call for building and sustaining strong partnerships with health care providers in the community so they can collaborate to achieve shared goals. Accomplishing this is difficult in single-setting work and becomes even more challenging and complex when bringing providers from different care settings together who do not typically work with one another and approach their work differently.
Identifying and Recruiting Patients for Participation
Each care transitions program has a target population of patients who are about to be discharged from the hospital. Partners identified community-specific root causes of readmissions and specific conditions and diseases with higher rates of readmission to target for the care transitions program. Care transition coaches seek to enroll as many of this target population, with the goal of reducing hospital readmission.
Improving Handoffs
Effective handoffs help to reduce medical errors that may result from miscommunication. Many physicians, nurses, and other providers are involved in a patient’s care, so effective communication is critical. Aligning Forces for Quality (AF4Q) Alliances have identified that it is critical to implement methods that make it easier to communicate up-to-date information on the patient’s condition and treatment when patients move from one care setting to another.
To read more, see Improving Handoffs.
Tracking Performance Metrics
By collecting and analyzing data, care transitions programs can gauge whether they are achieving their program goal of reducing hospital readmissions for Medicare fee-for-service patients. Alliances have identified it is important not just to measure the programs’ outcome goal of lowered readmissions, but also to measure and monitor key program processes to drive quality improvement. Data are shared with care transitions coaches and hospital management and staffs at least monthly so any needed changes can be identified and made quickly. 
To read more, see Tracking Performance Metrics.