Care Transitions Critical to Quality and Patient Safety

1
Care Transitions Critical to Quality and
Patient Safety

• Society of Hospital Medicine
• Lakshmi K. Halasyamani, MD

2
Society of Hospital Medicine

• Professional Society for Hospitalists and other
  hospital-based healthcare professionals (nurses,
  pharmacists, AHP, etc.)
• Total number of members gt 6000

3
Areas of Interest/Focus

• Management of patient populations in hospital
• Teamwork
• Hand offs
• Care Transitions

4
Overview of Care Transitions

• Admission to Hospital (From ED or Direct
  admission)
• Transitions within hospitalization (shift/service
  change transitions/handoffs)
• Transition from hospital to post-acute setting
  (home, subacute facility/nursing home, hospice,
  other acute care setting)
• Transitions within outpatient care delivery
  settings

5
SHM and Care Transitions

• Defining Standards
• Developing Team-based Interventions
• Evaluating Interventions
• Influencing Policy

6
Defining Standards

• Participation in consortiums regarding care
  transitions
• SUTTP Stepping Up to the Plate
• TOCCC Transitions of Care Consensus Conference
• NTOCC National Transitions of Care Coalition
• Development of Hospitalist Standards for
  Discharge and Shift/Service change transition

7
Key Messages

• Patient-Centered
• Transitions involve two-way communication of
  information
• Timely
• Clinician accountability
• Development of standardized care transition data
  set
• Need for communication infrastructure

8
Developing Interventions

• SafeSteps pilot initiative to improve
  medication safety
• Hartford BOOST initiative -- Better Outcomes for
  Older Adults through Safe Transitions
• Common Theme Focus on Implementation and
  real-world sustainability of initiatives

9
SHM/Hartford Partnership

• BOOST Advisory Board
• American Geriatrics Society
• American Society of Health-System Pharmacists
• Case Management Society of America
• Blue Cross Blue Shield Association
• Centers for Medicare and Medicaid Services
• The Families and Healthcare Project
• Society of General Internal Medicine
• Institute for Healthcare Improvement
• John A Hartford Foundation
• Joint Commission
• Agency for Health Research and Quality
• National Quality Forum

10
Philosophy of Initiative

• Patient/Family/Caregiver centered
• Multi-disciplinary Team-based
• Embedded in care delivery to promote
  sustainability
• Includes both academic and community settings
• Includes rigorous evaluation

11
Components of Initiative

• Develop Interventions to Improve Discharge Care
  Transition
• Patient-centered risk assessment
• Identification of Gaps
• Engagement of patient/family/caregiver through
  teach back strategy

12
Components of Initiative

• Develop Implementation Guide
• Develop Network of Institutions to implement
  discharge interventions
• Identify Facilitating Factors
• Identify Barriers

13
Influencing Policy

• Work with organizations developing care
  transition measures
• Focus on discharge and shift/service change as a
  standardized team process
• Work collaboratively with other organizations to
  develop a multi-disciplinary strategy to improve
  care transitions

14
Future Directions

• Alignment of payers and systems around safe care
  transitions
• Work with major HIT vendors regarding
  standardization of pathways to improve care
  transitions
• Partner with home and community services to
  facilitate seamless care transitions across the
  continuum