“The best transition of care is when there is no transition at all.” James Lett, MD, coined this maxim many years ago, and it’s still the mantra of post-acute and long term care providers.

Rajeev Kumar, MD“Of course, sometimes transitions are necessary, so we need to focus on doing this as seamlessly as possible,” says Rajeev Kumar, MD, CMD, FACP, chief medical officer of Symbria in Warrenville, Ill. “Even though we are well into the third decade of meaningful EHR [electronic health record] use, we still have discordant records, and what happens in the hospital doesn’t always filter back to the nursing home, and vice versa.”

Working Toward the Ideal Transition

The Centers for Medicare and Medicaid Services (CMS) defines transitions of care as the movement of a patient from one setting of care to another. This setting may include hospitals, ambulatory care practices, ambulatory specialty care practices, long term care facilities, home health, and rehabilitation facilities. It involves care coordination that ensures accurate clinical information is available to support medical decisions by both patients and providers.

“An ideal transition is grounded in knowing who the patient is—their goals, wishes, needs, and support systems,” says Kathleen McCauley, PhD, RN, FAAN, FAHA, professor of cardiovascular nursing at the University of Pennsylvania School of Nursing. “And there have to be partnerships that happen between the person and their network and where they’re going in the continuum.”

McCauley refers to a study she was part of—a qualitative analysis of what patients and families feel on discharge: “One thing that stood out was they often felt like they were out in the wilderness,” she says. “Good transitions anticipate what will be needed and help the patient and family prepare. You can’t do this in a 30-minute interview at the bedside. Everyone needs to work together, starting with identifying what’s important to the person and knowing what their goals are.”

From Miscommunication to Connection

Transitions have always been a challenge, plagued by miscommunication, lack of communication, and delays in communication. Value-based care initiatives have helped, suggests Kumar, “because no one wants to be penalized for high readmission rates or wasteful utilization.” This has motivated better communication between settings, but gaps still exist, he says, and while it may seem obvious that better communication is the answer, it’s easier said than done.

While EHRs have evolved over the years to improve communication, Kumar says, “Even today, we are facing challenges getting hospitals to understand what is happening in nursing homes. The hospitals and hospitalists are looking after their facilities’ interests and want to move COVID patients out sooner, but we need to protect our vulnerable residents, so we want patients tested first before they can enter our facilities.”

Nonetheless, some good has come out of the pandemic. Robert Choi, chief executive officer of Caraday Healthcare in Austin, Texas, says, “The pandemic revealed that hospital and skilled nursing facility partnerships are strong, and that nursing homes are seen as an essential part of the health care continuum. It also exposed opportunities for greater innovation, integration, and interoperability.”

Having a care management company or dedicated team to follow up on and track patients throughout the continuum can help promote seamless movement. “We formed our own home health and home-based care program to navigate patients from the hospital to the skilled nursing facility to home,” Choi says. “We also have strong partnerships with physician groups through the continuum of care who are essential across these transitions.”

Choi says his company has focused its internal analysis, research, and development of systems and processes with the goal of facilitating a safe discharge home. “We are building integrations and working with our health care partners and physicians to ensure we aren’t beholden to 17-plus different communication platforms and software subscriptions,” he says.

Despite these kinds of advances, data exchange continues to be a challenge. “We always strive to keep open lines of communication and provide real-time information,” Kumar says. “And we continue to highlight the challenges related to EHRs and the importance of nursing homes having access to real-time data. In particular, real-time medication reconciliation is crucial.”

Warm Handoffs Are Hot

Warm handoffs have always been shown to be effective, Kumar notes. Communication is important, but sometimes a lack of time gets in the way. “However, a quick text or a two-minute phone call can be a tremendous help when a patient is being transferred,” he says. “In fact, it goes a long way to help the physician and care team understand what is happening with that patient. It’s important to put some time and effort into it.”

Kumar says that it is also essential to have a protocol for “mandatory warm handoffs.” One option is to have a dedicated liaison who can talk to families, patients, and providers when patients leave or come back to the facility. That can go a long way toward ensuring patient safety, he says.

“It would be helpful to have nurse practitioners onsite who are trained in transitions of care and who can be contacted if a patient experiences an acute change,” McCauley adds. “They can focus on putting the pieces together and keeping patients out of trouble and, whenever possible, out of the hospital.”

It helps to have a good rapport with hospitalists so that patient transfers aren’t the only time providers initiate communication. “Periodically I go to their meetings, and sometimes they ask me to do educational presentations,” Kumar says. “For instance, I’ve talked about the Beers list and medications that should be prescribed carefully, particularly in frail, older patients.”

It also can help, McCauley suggests, to have tip sheets or checklists to address problems the patient is likely to experience, such as constipation or ambulation challenges. This can help prevent surprises and issues that can fall through the cracks after a transition.

Telemedicine helped enable virtual communication during the pandemic. However, Choi notes, “As a veteran of telemedicine and virtual care, I am the largest supporter of digital health. However, a telemedicine visit doesn’t solve the need for more information sharing and care coordination. There is a lot of communication and interactions among multiple parties that need to happen. There also are processes that need to be designed and implemented between health care ecosystem partners.”

Education Makes a Difference

“The tool I’ve found to be most useful is education,” Kumar says. “People want to do the right thing, but there is a lot of misinformation, doubts, and questions. Having something like a one-on-one dialogue or a webinar to ensure everyone has consistent, up-to-date information helps.”

The need for education isn’t limited to providers and staff. “Sometimes families or patients misunderstand what they are told, and by the time they come to us, they can have a lot of misconceptions,” he says. “First we need to sit down and find out where they’re coming from and what happened. It’s all about transparency, honesty, and humility.”

Family communication and education also need to involve what the patient will need on returning home and what that involves, McCauley says. “We don’t have a system designed to meet the needs of elders when they go home. We expect family members to deliver care that would be challenging for a trained nurse, and the patient is stuck in the middle.”

Strong partnerships and consistent, ongoing communication between nursing homes and their primary care provider are key to ensuring no one feels that they’re in the wilderness or being asked to provide care that is beyond their skill and knowledge levels.

Most people are open to communication “if you take a blame-free approach and not point fingers,” Kumar says. “If there is a problem at the other end, we need to be able to talk about it, and we expect them to tell us if we could have done something better or different.” It is essential to espouse patient-safety culture with a focus on brainstorming for success instead of placing blame or making excuses. “We need to prioritize patient-safety culture to enable everyone to perform at their best,” he says.

The Road Home

“In our research, the most common goal patients have is to go home, live and function in their house, and not be a burden,” McCauley says. “That’s a phenomenal goal, but first you have to be safe, be able to make or get meals, take medications safely, and so on. You have to participate in physical therapy to get stronger and have the stamina to care for yourself and not deteriorate.

“Using goals as a driver is a way to get people motivated and help them appreciate small successes in physical therapy. “

To identify these goals, it is essential to give patients and families, including family members who know the patients and their history, a place at the table and really listen to their goals and expectations. It’s important to realize they may have unrealistic expectations.

To help them focus on what they can do and to set realistic expectations, “We need to find out what gives them joy and what quality of life means to them,” McCauley says. “Start with what’s important to the patient, and then you can put a plan into place that includes good symptom management.”

When Readmissions Happen

It’s imperative to look at each readmission and understand what happened, Kumar says. “We do a root-cause analysis of every hospitalization—what happened, what caused it, and if/how it was avoidable.”
McCauley says that while it’s essential to prevent avoidable readmission, there are times when it’s appropriate to send a patient out.

“An urgent visit with the physician is better than an ER [emergency room] visit, and an ER visit is better than a hospitalization. But we need partnerships between nursing homes and the hospital to plan, communicate, and determine when a transfer is essential and what it will take to ensure a smooth transition.”

Putting all the pieces in place to ensure smooth transitions of care is easier than it used to be because value-based care principles and technology are available. However, transitions aren’t yet as smooth as they can be. Everyone has been stretched, but there will be greater opportunities to improve care transitions as the entire health care industry gains bandwidth. Then, all the lessons learned will present ways and means to re-evaluate and re-engineer gaps in care and communication.

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Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.​