Transitional health care for disabled, children and older adults

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Transitional care is an essential and crosscutting area of health care for persons with complex health care needs, including older adults, children with special health care needs, and disabled populations. As such, performance in this area needs to be measured including in coordination of care, and continuity of care. Representative locations include (but are not limited to) hospitals, nursing facilities, the patient's home, primary and specialty care offices, assisted living and long-term care facilities. Transitional care is primarily concerned with the relatively brief time interval that begins with preparing a patient to leave one setting and be received in the next. Many transitions are unplanned, result from unanticipated medical problems, occur in "real time" during nights and on weekends, and happen so quickly that formal and informal support mechanisms cannot respond in a timely manner.

Whether our goals are to improve quality, enhance patient-centered care, ensure patient safety, or implement cost effective practices, performance measurement for transitional care provides useful information. Studies on performance measurement for transitional care has come up with multiple factors: accountability is poorly defined, financial incentives are not aligned, information systems are not well connected across settings, each setting requires the use of unique data bases and documentation, and most practitioners have received minimal training for cross-site collaboration. Attention is needed to stimulate quality improvement in transitional care, define accountability, re-align financial incentives, and establishing electronic health information systems.

To date, the area of transitional care has been underrepresented. Ideally, transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition (Coleman and Boult, 2003).

The focus of transitional care is to ensure that the health care needs of patients with complex care are met irrespective of where care is delivered. But the health care delivery system, whether examined by payment, quality improvement initiatives, accreditation, performance measurement, or how clinicians define their practice, is increasingly setting-centered. In many respects, the term "health care system" is a misnomer. There are few mechanisms in place for coordinating care across settings, and often no practitioner or team assumes responsibility during patients' transitions. Further, health care professionals are often unfamiliar with the capacity of these settings for delivering care. There have been concerns for hospital patients being discharged and readmitted in short time.

A discussion of the context within which transitional care occurs need describing the factors that contribute to patients' vulnerability. Not surprisingly, transitions in patients' care settings parallel transitions in their physical health status. These patients are not only adjusting to new settings but also to new or worsening health symptoms or changes in their ability to carry out daily functional tasks. Patients in institutional settings often adapt to the environment by becoming dependent and complacent while their needs are being addressed; however, upon discharge to home, patients and family members are abruptly expected to assume a considerable self-management role in the recovery of their condition, with little support or preparation. The prevalence of transient or mental impairment and limited health literacy among patients experiencing care transitions only exacerbates this challenge to preparing for self-care. Family caregivers are both the first and last line of defense for assuring safe and effective care transfers for these vulnerable patients. Their contributions in this area are vastly underestimated as they compensate for the many deficiencies of health care system. It is difficult to discuss family care giving without discussing the challenges of coordinating care across settings. Conversely, it is nearly impossible to discuss the challenges of coordinating care across settings without recognizing the essential role of family caregivers.

An expanding evidence base demonstrates that quality problems exist for patients undergoing transitions across sites of care. Qualitative studies performed in the US, Europe, Canada, and Australia, have produced remarkably consistent results.
These studies have shown that patients are often unprepared for their self-management role in the next care setting, receive conflicting advice regarding chronic illness management, are often unable to reach an appropriate health care practitioner who has access to their care plan when questions arise, have minimal input into their care plan, and are annoyed by having to repeatedly provide the same information to each new set of practitioners. Family caregivers voice feelings of frustration that they are often excluded from care planning meetings, despite their central role in the execution of this care plan. They are also dissatisfied with having to perform tasks that their health care practitioners have left undone (Coleman et al., 2002;Grimmer et al., 2000;Harrison and Verhoef, 2002;Levine, 1998;vom Eigen et al., 1999;Weaver et al., 1998).

Quantitative studies have documented that patient safety is jeopardized due to high rates of medication errors and lack of appropriate follow-up care. During care transitions, patients receive medications from different prescribers who rarely have access to patients' comprehensive medication list. As such, no one clinician is ideally positioned to monitor the entire regimen and intervene to reduce discrepancies, duplications, or errors. Thus although much of the recent attention on medication errors has been setting-specific, the lack of coordination between prescribers across settings may pose challenge. It was found that patients discharged from the hospital experienced associated adverse drug events. Studies indicate that there is a need to more formally support the role of family caregivers in general and in the context of coordination of care across settings in particular since patients who did not have a recommended work-up initiated were 6 times more likely to be re-hospitalized (Moore et al., 2003). Significant lapses in information transfer also threaten patient safety. Each time a patient's medical record is recreated, it increases the chance for a medical error to occur. Further, inadequate information transfer potentially increases health care expenditures. There is the danger for the information that is transferred to be incomplete and even inaccurate. Each of the types of qualitative and quantitative problems conspire to increase rates of recidivism to high intensity care settings when patients' care needs are not met, increase the frequency of medical errors, and increase costs of healthcare.

The absence of performance measurement for transitional care is one of the barriers to quality improvement. Lack of financial incentives and accountability make these "hand-offs" of care extremely vulnerable to medical errors, service duplication, and unnecessary utilization. And without processes in place to measure performance, the serious quality problems will remain undetected, and consequently, ignored. From this perspective, integrating transitional care into performance measurement activities can have impact as a primary driver of quality improvement.

There are a number of points of leverage addressed by transitional care from which to build such initiative. These include attention to the problem of patient safety in general and medication safety in particular, efforts towards making the health care system more patient-centered, cost containment, and expansion of health information technology. Performance measurement could drive improved quality, patient safety, cost containment, and development and dissemination of health information technology.