Not long ago, I was working with a colleague on documenting a Transitions of Care workflow loop between the acute care setting and ambulatory care setting. We had reached the point where we wanted feedback from others and invited a group of peers to listen our presentation. We eagerly set out explaining our workflow diagram and emphasizing the key areas we were focusing on. We talked about Transitions of Care, the opportunities for care coordination and discussed the patient centered focus of our work. To our chagrin and a little bit to our surprise, the first question we received was “What is the definition of Transitions of Care?” It’s mentioned in the Meaningful Use requirements and is accepted as one of the key areas of risk for patients along the entire care continuum. However, do we as clinicians really have the same idea as to what “Transitions of Care” means?
The Care Transitions Program ® defines “Transitions of Care” as “the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.” This is a fairly general statement and not all clinicians or patients can agree on what a transition is nor can they agree on the level of risk in each transition. This is where the confusion begins. The definition of Transitions of Care doesn’t define the “levels of care” nor does it discuss why this is important.
In our workgroup, we identified the Transition of Care as any point where a patient was handed off to another level of care or facility, e.g., ED to Imaging, ED to PCP/Specialist, PCP to acute care, or ED to either inpatient or observation (another unit). The possible combination of transitions is extensive and complex. Some in our discussion group were surprised when I identified specific events as a transition. Our group discussion became focused on the need to clearly identify, first the action of a “Transition of Care” or “hand off” and then the potential impact on the patient. We were then able to move on to our original goal of mapping the care coordination responsibilities that exist on both sides of the hand off.
In essence, Transitions of Care really cannot be addressed in healthcare effectively without including the care and communication around the transition, how our use of technology enables, enhances or hinders effective transitions. Defining the specific responsibilities of the care team in relation to their patients is imperative to effective execution of true Transitions of Care. Ultimately, though, this foundational work towards improvement in coordinating transitions of care and the resulting patient care improvement is hindered when stakeholders don’t have a shared understanding around the meaning of “Transition of Care.” Beginning your care improvement project by clearly defining relevant transitions of care is critical to a successful program.