Care Transitions Management: Challenges and Advances

By Kindred Healthcare

This afternoon’s panel discussion at Kindred’s fourth Clinical Impact Symposium addressed the challenges and advances in care transitions management as they affect all four of Kindred’s divisions.

Division executive vice presidents represented the divisions: Traci Shelton from the Hospital Division; Mary Pat Welc and Jim Douthitt from RehabCare; Michael Beal from the Nursing Center Division and Jim McDonald from PeopleFirst Homecare and Hospice. Other panelists were:

  • Eric A. Coleman, MD, MPH, Professor of Medicine, Director, Care Transitions Program, Head, Division of Health Care Policy and Research at the University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
  • Joseph G. Ouslander, MD, Professor and Senior Associate Dean for Geriatric Programs at the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU), and Professor (Courtesy) at the Christine E. Lynn College of Nursing at FAU in Boca Raton, Florida
  • Mark V. Williams, MD, FACP, MHM, Professor and Chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine

Care Transitions Management: Challenges and Advances

Some of the challenges identified were:

  • The absence of “warm hand-offs.” When patients are discharged from an acute care hospital to a post-acute facility, better communication between discharging clinicians and those who will inherit a patient’s care or to whom care will be returned, is important.
  • The subgroup of patients who have immediate, post-acute care needs, such as a needed blood draw, and how that information is communicated to either the patient or a caregiver who will be responsible for ensuring that care is obtained.
  • The creation of redundancies and the assumption that a program that worked in one market might work in another. We must bear in mind: Culture Eats Change Plans for Lunch. A facility or a market’s unique characteristics must be considered when change plans are considered for implementation.
  • Our discharge-driven healthcare system puts emphasis on what the patient was hospitalized for versus the condition they are in at discharge, what is needed post-discharge and whether the patient understands his or her own condition and how to manage it.

While many challenges remain to be addressed as we consider ways to improve transitions of care, advances are being made. Many of these have been or will be presented at this symposium, including the Care Transitions, INTERACT and BOOST programs. Other exciting advances in the field include:

  • New technology such as PointClickCare, a Web-based application in use in the Nursing Center Division that replaces the traditional paper chart and has already made patient records easier to access and update while protecting patient privacy
  • Training programs that use standardized patients to educate students and residents to invest in patients and their families
  • Bridge-building in some markets, including Cleveland, so that physicians have access to the electronic record across sites of care
  • Simple communications tactics such as patient care summaries sent to primary care physicians with straightforward information about why the patient was hospitalized and contact numbers for the clinicians caring for the patient, followed by a second letter upon discharge