Transitions of Care Integral to HM Patient Care


Transitions of Care Integral to HM Patient Care

I just finished my internal-medicine training and started a job as a hospitalist. We are a new hospitalist group, and I have been told that “transitions of care” is important to HM groups. I understand that getting information back to the patients’ primary-care physicians (PCPs) is important, but I am worried that I don’t have the whole picture. Is there something I am missing?

E. Parkhurst, MD

Tampa, Fla.

Dr. Hospitalist responds: Congrats on your new job. I am pleased to hear that you are motivated to learn more about transitions of care. It is important to hospitalist groups, but even more important to patients. I suspect your instincts are correct. You have an idea of what is meant by “transitions of care,” but probably do not appreciate all the nuances of the term. I certainly did not when I came out of training many years ago.

Transitions of care is a critical aspect of every patient’s care, and thus should be important to every healthcare provider. Our job is to care for the hospitalized patient and help them navigate through the complex systems of the hospital. How well we guide the patients through these transitions is reflected in their outcomes.

What is the definition of “transitions of care”? I find it useful to think about the patient’s journey when the decision is made to hospitalize the patient. When the patient is hospitalized, it is easy to recognize that the patient’s physical location is different; some, if not all, of the patient’s providers are different, too. The patient might have the same PCP caring for them in the hospital, but the nurses are different. The contrast is more evident if all of the patient’s providers are different. The ED is the point of entry for most patients. This is another location with another group of providers who do not have knowledge of all of the patient’s medical issues.

The hospital discharge is another inevitable transition. Most patients go home, but some will go to another healthcare facility (e.g., rehabilitation hospital) with another group of providers.

As you can see, the admission and discharge from the hospital involves multiple transitions. But multiple transitions also occur within the hospital. The patient could move from the general medical ward to the ICU and back; the patient might spend time in the surgical suite or operating room. Many patients go to radiology or other parts of the hospital for testing or procedures. At each location, the patient has a new group of providers.

But even if a physical location does not change, there could be a transition in care. During the day, one hospitalist or nurse might care for the patient. At night, another group of doctors and nurses are responsible for the patient’s care. Information must be transmitted and received between all of the parties at each transition in order for the appropriate care to proceed.

Effective transitions can improve provider efficiency. Think about how much easier it is to care for a patient whose care you assume when you have a clear understanding of the patient’s issues. Minimizing medical errors and increasing effective communication can reduce medical and legal risks. Effective transitions also minimize the length of hospital stay for the patient and minimize the risk of unnecessary readmission to the hospital. These can result in enhanced financial outcomes.

I think the key to effective and safe transitions of care is to create a mutually-agreed-upon process of communication and a level of expectation from all providers to carry out their role in the process. This is always easier said than done. In fact, the lack of an agreed-upon process often is a common barrier to effective transitions of care. Each participant’s role in the patient’s transitions might compete with another set of agendas.

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