Managing Patient Care Transitions: A Report of the HMO Care Management Workgroup

Healthplan (March/April 2004)

By Eric A. Coleman, MD, and Peter D. Fox

An 80-year-old man fractures his hip while playing golf and is taken to the hospital. Following repair of his hip, he is transferred on a Friday to a skilled nursing facility (SNF) for rehabilitation without orders and without the SNF physician being notified. Eventually, the SNF physician writes his orders but, because information on the patient's allergies was not transferred from the hospital, the physician prescribes Oxycodone for pain relief, unaware of the patient's history of intolerance to this medication. The patient suffers an adverse reaction that leaves him unable to participate in rehabilitation for four days. When he returns home from the SNF, his wife feels overwhelmed by his care needs; she has not received adequate instruction about what to expect and what her role is.

Problems often occur when an individual is transferred from one health care setting to another because each setting typically operates in its own silo, with little understanding of what transpires in other settings. National attention to the problem of medical errors has largely focused on care delivered within individual settings. Yet care delivered across settings can create even greater vulnerabilities.

Patients often receive medications from multiple prescribers. Frequently, no single clinician oversees the entire medication regimen, creating the potential for adverse reactions.

• The medical record may not follow the patient from one setting to another or may be delayed, leaving the receiving physician unaware of the medical issues, allergies, functional status, patient goals, advanced directives, or the family support situation.
  
  
• Patients are often ill-prepared for what to expect at the next site of care, limiting their ability to engage in self-care. Family members are often asked to assume a major role in following the care plan without adequate preparation. That may lead to increased use of the emergency department or the hospital.

A recent report of the HMO Care Management Workgroup, One Patient, Many Places: Managing Health Care Transitions, addresses this important issue.

Formed in 1994, the workgroup comprises senior medical leadership from health plans and medical groups that are capitated by Medicare. (See Box) The workgroup is funded by The Robert Wood Johnson Foundation and is located at the America's Health Insurance Plans Foundation; America's Health Insurance Plans staff provides administrative and other support. An underlying principle of the workgroup is that the capitation method of payment creates incentives to coordinate care across settings and ensure seamless transitions, although transition problems arise under all payment mechanisms. The report addresses the following topics:

• Ensuring accountability for patients in transition
• Facilitating effective information transfer
• Enhancing practitioners' skills and support systems for conducting transitions
• Enabling patients and caregivers to play a more active role in their transitions
• Aligning financial and structural incentives to improve patient flow across care venues.

Accountability

Accountability for transitions among venues of care needs to be established for health plans, capitated provider organizations, and individual providers. Does the patient have a physician to call on during the transition, and does the patient know what to expect at the next setting? Does the physician in charge of the patient at the receiving setting have information on the patient's medical history and functional status? Does the health plan or medical group collect data on the quality of transitions from both a technical perspective and that of the patient?

Information Needs

Successful care transitions require that the transfer of information be timely and accurate. Practitioners need to understand the patient's goals, baseline functional status, active medical and behavioral health problems, medication regimen, family support resources, durable medical equipment needs, and ability to care for himself or herself. Otherwise, practitioners may duplicate services, overlook important aspects of the care plan, subject patients to unnecessary tests, and convey conflicting information to the patient and informal caregiver. Incomplete information transfer can result in critical errors, including the patient returning home without life-sustaining equipment such as supplemental oxygen.

A plan for information flow that includes a list of the type of data and how it will be conveyed is important. For example, Horizon Blue Cross and Blue Shield of New Jersey has created protocols for standardized information transfer. Every member who is transferred is accompanied by a standard documentation template that includes demographic information, prior and current functional status, short- and long-term care goals, medical and rehabilitative needs, and contact name and phone number of a key member of the sending team.

Practitioner Skill Sets and Support Systems

Most practitioners lack the training necessary to manage effective transfers and may not recognize their role in transition planning. Also, most practitioners lack exposure to sites of care other than those where they practice and are unfamiliar with the ability of the receiving institution to manage complex patients. Within a single institution, multiple practitioners may see the patient during the course of a stay (or even a day), none of whom has a composite picture of the patient's medical situation.

Practitioners require training to care for patients in transition and need to shift their mindset from the concept of a patient discharge toward that of a patient transfer as part of a continuous care management process. Core skills for practitioners include how to communicate across sites and collaborate to formulate a care plan that reflects the contributions of different disciplines; how to evaluate a patient's system of social support, baseline level of function, and potential for discharge; and how to initiate care planning for the next setting well before transfer.

At the Harvard Vanguard medical group, the respective rounding teams from the hospital and the SNF meet to discuss pending transitions of specific high-risk patients with complex care needs. At the Lahey Clinic in Massachusetts, clinicians complete a paper form that provides direction to the receiving care team (primary care or home health) regarding the patient's needs following hospital transfer.

Patient and Caregiver Preparation

Patients who are transferred from the hospital to the SNF or home often feel ill-prepared for what to expect and feel that they have little input into the decision to transfer. They also sense that the various practitioners responsible for their care communicate poorly across settings. Many patients believe that they have not received adequate instruction for how to care for themselves in the next setting (e.g., managing their conditions and taking their medications), and they often regard practitioners' expectations for care delivered by informal caregivers as impractical. They may also feel unprepared for the emotional impact of a change in health or functional status. Discrepancies between patients' and practitioners' goals may be compounded by barriers of language, education, values, and culture.

Many opportunities exist to engage patients and informal caregivers in discussions that elicit their care needs and preferences. For example, the prehospital admission planning process is an ideal opportunity to discuss the potential content and location of the posthospital care experience. Alternatively, since the majority of hospital admissions are acute and unplanned, patients can be identified who have advanced chronic illness and are likely to be hospitalized or require postacute care services within the year. These patients could be scheduled for a pretransition planning discussion with the primary care physician or care manager during a routine ambulatory visit.

As an example of pretransition planning, Group Health Cooperative's older members are asked the following question at the time of their annual comprehensive evaluation: “You may need to go to the hospital, and when this happens you may be too weak to care for yourself at home and need time to recover. Do you have someone who could take care of you for three days or so after a hospitalization?” Members who are not able to identify a short-term caregiver are referred to a social worker or registered nurse to develop an advanced care plan that becomes part of their medical record.

Financial Incentives and Structural Barriers

Payment mechanisms commonly lack incentives for assuring optimal care coordination across settings. For example, per-stay (or per-case) payment mechanisms can promote premature patient transfer without adequate focus on the patient's needs at the next setting, and reducing the length of stay in one setting may negatively influence care, as well as costs, in a subsequent setting. Furthermore, each additional care transition provides another opportunity for an adverse transition-related event.

Structural barriers also can be problematic. For example, health plans that attempt to construct a continuum of care by contracting for a variety of acute and post-acute services often encounter differences among providers with respect to mission, staffing, internal incentives, and professional culture. These differences can contribute to poor communication, insufficient information transfer, and inadequate preparation of the patient and caregiver.

To ameliorate the situation, the capitated entity can, for example, monitor premature discharge, change financial incentives, require as part of provider contracts that certain information be transmitted in a timely manner, and pay practitioners from the receiving institution for pretransitional visits. At Sierra Health Services in Nevada, hospitalists and primary care physicians have cell phones that are dedicated to communication between them. Phone calls from the hospitalists to primary care physicians are tracked, and hospitalists' financial compensation is tied to the percent of discharged patients whose physician they contact.

First Steps to Address Transitions

For organizations that have not addressed issues of patient care transitions, the problems may seem daunting, because they involve interactions with significant numbers of providers. One approach is to select one patient population and one transition of interest and then to gather data to quantify the extent of the problem. The patient population might be patients with particular conditions such as stroke, hip fracture, or dementia or those who reside in particular settings, such as nursing homes or assisted living facilities. Examples of transitions include the transfer from the hospital to a SNF or from the hospital to home with home care. The data, for example, might record whether the requisite information was transferred in a timely fashion, whether patient safety was compromised (e.g., by medication errors or by transferring the patient before he or she was medically stable), or the rate of recidivism within a defined time period. Transitions can also be evaluated from the perspective of their members, who can be telephoned after returning home and asked about their transition experience.

Whatever the approach, what is critical is that a process for addressing transitions of care be initiated, including quantifying the magnitude of the problem and identifying possible solutions that are consistent with the structure and culture of the organization. 

Single copies of the report can be downloaded from www.aahp.org (click on “Inside AAHP-HIAA” and then “Care Management”). Or e-mail to Ericka Goss at egoss@ahip.net (202-778-3222). The report is not copyrighted and may be freely reproduced.

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The primary writer of the report was Eric A Coleman, MD, associate professor of Geriatric Medicine, University of Colorado Health Sciences Center, and clinician researcher, Kaiser Permanente Colorado Region. Peter D. Fox, President, PDF, LLC is an independent consultant; he formed and served as chair of the workgroup.