why are we involved? transitions of care: what we need to know
TRANSCRIPT
Why are we involved?
Transitions of Care: Transitions of Care: What We Need to What We Need to
KnowKnow
www.ntocc.orgwww.ntocc.org
Current State of HealthcareCurrent State of Healthcare
Care is complexCare is complex Care is uncoordinatedCare is uncoordinated Information is often not available to those who Information is often not available to those who
need it when they need itneed it when they need it As a result patients often do not get care they As a result patients often do not get care they
need or do get care they don’t needneed or do get care they don’t need
IOM, Crossing the Quality Chasm
What is “Transition of Care”What is “Transition of Care”
The The movement of patientsmovement of patients from one health care from one health care practitioner or setting to another as their condition and practitioner or setting to another as their condition and care needs changecare needs change
Occurs at multiple levelsOccurs at multiple levels– Within SettingsWithin Settings
Primary care Primary care Specialty care Specialty care ICU ICU Ward Ward
– Between SettingsBetween Settings Hospital Hospital Sub-acute facility Sub-acute facility Ambulatory clinic Ambulatory clinic Senior center Senior center Hospital Hospital Home Home
– Across health statesAcross health states Curative care Curative care Palliative care/Hospice Palliative care/Hospice Personal residence Personal residence Assisted living Assisted living
(c) Eric A. Coleman, MD, MPH
What is “Transitional Care?”What is “Transitional Care?”
A set of actions designed to ensure the coordination and A set of actions designed to ensure the coordination and continuity of health care as patients transfer between continuity of health care as patients transfer between different locations or different levels of care within the same different locations or different levels of care within the same locationlocation
Based on a comprehensive care plan and availability of well-Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the trained practitioners that have current information about the patient's goals, preferences, and clinical status.patient's goals, preferences, and clinical status.
Includes:Includes:– Logistical arrangementsLogistical arrangements– Education of the patient and familyEducation of the patient and family– Coordination among the health professionals involved in Coordination among the health professionals involved in
the transitionthe transition
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
Ineffective Transitions Ineffective Transitions Lead to Poor OutcomesLead to Poor Outcomes
Wrong treatmentWrong treatment Delay in diagnosisDelay in diagnosis Severe adverse eventsSevere adverse events Patient complaintsPatient complaints Increased healthcare costsIncreased healthcare costs Increased length of stayIncreased length of stay
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf
PatientPatientPatientPatient
ERERERER ICUICUICUICU
In-PatientIn-PatientIn-PatientIn-Patient
PatientPatientPatientPatient
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
SNFSNFSNFSNF ALFALFALFALF
Transition Issues Dramatically Transition Issues Dramatically Impact Patient CareImpact Patient Care
Transition Issues Dramatically Impact Transition Issues Dramatically Impact Patient CarePatient Care
Patient
ER ICU
In-Patient
Patient
OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
SNF ALF
NOMedication
Reconciliation
NOPersonal
Medicine List
NO Coordinated
Care Plan
NODischargeCare Plan
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
What Can We Do …What Can We Do …
Keep A Medication List Keep A Medication List
Develop your “My Medicine List”Develop your “My Medicine List” You can get started with a simple tool by You can get started with a simple tool by
NTOCCNTOCC Download the tool from the websiteDownload the tool from the website Complete the tool with your personal Complete the tool with your personal
medicationsmedications Share that information with each clinician you Share that information with each clinician you
see whether in the ER, hospital, doctor’s office, see whether in the ER, hospital, doctor’s office, clinic or pharmacyclinic or pharmacy
SNFSNFSNFSNF ALFALFALFALF
ERERERER ICUICUICUICU In-PatientIn-PatientIn-PatientIn-Patient
The NTOCC Tools Make it PossibleThe NTOCC Tools Make it Possibleto Address the Transition Issuesto Address the Transition Issues
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
PatientPatientPatientPatient
My
Med List
Medication ReconciliationData Elements
+Care / Case
Transition Process
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Watch for New Patient Watch for New Patient Tools Over the Next Few Tools Over the Next Few
MonthsMonths