Geriatrics Society, American College of
Emergency Physicians, and Society for
Academic Emergency Medicine issued a
statement on Transitions of Care in 2009.12
This focused only on discharges from inpatient to outpatient, but acknowledged the
importance of other transitions.
The HITECH Act of 2009 recognized
some TOC practices in Stage 1 of its Meaningful Use program, including medication
reconciliation and exchange of a “Summary
of Care Record.” 13
The National Quality Forum (NQF)
issued a set of measures for “care coordination,” but did not suggest guidance for
actions or measures specifically aimed at
TOC. These compare outcomes for emergency department transfers, plans of care,
e-prescribing, timely transitions, medication management, transition records, and
medical homes. 14 The NQF commissioned
a series of papers that analyzed capabilities
and barriers of health information technology to facilitate transitions and care coordination in general, and to generate data on
quality. 15
Concurrently with work of this sort on
TOC logistics, information content, and
workflow, technologists were building
Health Information Exchanges (HIE) as
platforms for the electronic data to support it. In 2011, the Office of the National
Coordinator for Health Information Technology (ONC) launched the Standards
and Interoperability (S&I) Framework14 to
support interoperability objectives within
Meaningful Use. 16 The Referral & Tran-sition/Transfer of Care standard is now
under development by HL7.17 Integrating
the Healthcare Enterprise (IHE) published
a Technical Framework for Patient Coordination in 2014.18
Economic and regulatory tools are
also being brought to bear on TOC. The
Accountable Care Act of 2010 (ACA)
aims to impact quality across episodes
of care through value-based reimbursement. Section 3026, the Community-Based
Care Transition Program, provides $300
million to test models for improving
care transitions from hospitals to other
settings.
CARE TRANSITIONS
AND CARE COORDINATION
Care transitions and care coordination are
different2 but expose patients to the same
risks. The NTOCC defines care coordination as, “The deliberate organization of
patient care activities among two or more
participants (includes patient and family) to
facilitate the appropriate delivery of health
care services.” 19 We use Coleman’s definition of transitions of care: “The movement of
patients bet ween health care locations, providers, or different levels of care.” 20 Coordination implies continuity of caregivers,
even if roles change. Transition implies that
a caregiver detaches from direct responsibility – temporarily or indefinitely. Both
entail the transfer of information (always)
and materials (sometimes). Both require
the same set of conditions for success.
On the basis of professional experience, literature reviews, and failure mode
analysis, we identified 16 elements necessary and sufficient for planning successful
transitions or analyzing failed ones. We
organized these in a tabular format that
helps explain and critique them methodically (see Table 2).
Our goal was to address the full spectrum of transitions, from simple verbal
handoffs at shift change, to complex transports of critically ill patients between distant facilities. Transfers of patients to and
from home are subject to many of the same
success and failure modes as transfers
between providers, or planning for care
needs in future circumstances.
Transitions fail in myriad ways. Transport carrier accidents are catastrophic but
rare. Perhaps the commonest risk is losing
critical information or property, such as
verbal and written records, personal possessions, assistive devices, medications,
and sometimes patients themselves(!).
Among the most critical information lost
in transitions are plans, tasks, contingencies, and agendas for follow up. TOC losses
impose a toll on patient safety and cause
waste, duplication, delay, cost, inefficiency,
and frustration. Because transitions are so
frequent, this inflicts a large burden on the
healthcare system.
PURPOSE AND DESIGN
OF THE FRAMEWORK
To our knowledge, this is the first attempt
to create a general framework describing
a common set of considerations across all
TOC scenarios.
The Framework allows analysis of transition processes prospectively and retrospectively. A prospective use would be
planning for safe and efficient transfers
between two facilities. Retrospective uses
would be reviewing events where gaps in
transition processes caused unintended
outcomes, comparing the effectiveness of
different strategies. The Framework can
be used as a template for collecting data;
measuring performance; guiding process
improvement; for quality, cost and root
cause analysis; and for reporting, training
and planning.
A widely held view is that EHR interoperability is the key to improving TOC safety
and effectiveness. However, one powerful
conclusion suggested by this Framework is
that the mere ability to view content across
EHRs, while certainly valuable sometimes,
does not represent anything like a complete
solution. This fact does not diminish the
need to develop electronic data interchange
standards, represented by projects such as
CCR, 21 CDA/CCD, 22 and FHIR. 23 But standards and even applications are insufficient
in the absence of a general model of the
TOC process.
Patient transitions can be associated
with waste, inefficiency, error and cost –
and risk of preventable injury. Unfortunately, provider compensation traditionally undervalues the work involved in this
activity. No compensation system recognizes every kind of effort; however, alignment of provider incentives to reward TOC
success factors is a tangible way to support
the effort needed. ACO models of care can
also assure that both initiating and receiving facilities find transition safety and efficiency aligned with their interests. Patient
participation is also critically necessary in
many TOC processes.
Another intended use of the Framework
is as a blueprint for technology vendors. It
is hoped that EHR developers and others
would consider accessories, plug-ins and
