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Leadership Blog

Building Effective Transitions of Care Provides Benefit to Patients

By Tracy Maddox, CIN, Director of Quality at St. Luke’s Health

November 19, 2023 Posted in: Leadership

Good communication during transitions between health care facilities or to the patient’s home helps preserve patient health. Patients who don’t experience smooth continuity of care may not fully understand what they should do or expect from care providers for optimal results. Their health may spiral deeper into the disease process or recovery may not progress at the expected pace, leading to rehospitalization.

Put simply, patient health suffers when transitions of care are not handled appropriately. Patients grow frustrated with the health care system, reducing their motivation to seek out needed care. Because this lack of motivation decreases a patient’s likelihood of achieving optimal health, it is incumbent upon health professionals at every level to ensure transitions of care support the patient’s enthusiasm to care for themselves. Health leaders should optimize transitional periods in the patient’s journey for the patient’s good.

The Case for Communication

Medicare anticipates care providers will work with patients for 30 days after they return home. During this time, providers are tasked with managing and coordinating care to ensure patients return home with a full understanding of their ongoing care needs and what they need to do to avoid rehospitalization. Providers also help patients schedule follow-up appointments and encourage them to attend. 

To help health organizations achieve ideal transitions of care, Medicare guidelines outline what, how and when to move patients through the transition and what to document. At the center of the process is communication. Specifically, communication must be strong within the following arenas:

  • Among providers, patients and caretakers. Before discharging patients, providers should clearly explain the patient’s diagnosis, prescribed treatment and ongoing need for follow-up care. Providers should also give patients agency in their care early in the process. All involved parties should understand that, upon returning home, good health is largely the patient’s responsibility. Providers should also relay this same information to caretakers, giving both the patient and caretaker the opportunity to ask questions. Following discharge, ongoing communication should encourage continued compliance.

  • Between providers. Inpatient and outpatient providers must communicate clearly and frequently to ensure continuity in care. With electronic health record (EHR) systems that communicate with one another, such communication is smooth and simple. EHR systems that do not communicate require a more intensive effort by providers, such as additional phone calls and direct mail or email.

Common Pitfalls in Transitional Care 

Maximizing transitions in care places significant demands on inpatient and outpatient team members. Both must take the effort to protect continuity of care and ensure patients follow through on prescribed rehabilitation and more.

At St. Luke’s Health, readmission prevention committees identify and rectify obstacles that prevent optimized transitions in care. These groups include inpatient physician leaders, hospitalists, case managers, quality specialists, care managers, nurses and administrators. Together, these committee members study readmitted patients to determine what course of action may reduce future hospitalization. They seek solutions, hold one another accountable and consider no issue too large or small for discussion.

The following are examples SLH identified as causes of poor transitions of care. These dilemmas and their solutions may also apply to your organization:

  • Insufficient staff to make phone calls. Following up with patients may take more than one phone call, which puts a heavy burden on staff members. SLH clinical initiatives nurses fill in communication gaps by contacting patients and providers on behalf of physicians. 

  • Non-standardized calendars. A variety of scheduling preferences complicates scheduling with providers. Standardizing calendars may improve workflow and help ensure more patients get scheduled for timely follow-up care.

  • Not getting discharged to a PCP. According to the National Association of Community Health Centers, one out of three Americans does not have a PCP. These individuals often seek non-emergent care in the ED. A pilot program at SLH aims to address this issue and promote health justice. While a patient is in the hospital, staff members provide education on the role of PCPs. Staff then help connect patients to a PCP, thereby increasing the likelihood that the patient will access the proper level of care moving forward.

Improving Care Transitions Requires Whole Team Support

Successfully updating transition of care processes depends upon the full support of your whole organization. Two key groups that determine whether updated procedures and processes will succeed or fail are:

  • Leadership. Their buy-in is of utmost importance. To obtain it, you must educate hospital leaders on the current status of your facility’s transitions of care. Clearly identify any existing shortcomings and propose solutions. Ideal solutions must meet two goals. First, they must be cost-effective and demonstrate reliable return on investment. Second, they must fulfill the hospital’s mission of improving the health of those served.

  • Clinicians. Physicians, nurses, pharmacists and other health workers enter health care to help others achieve improved health. When approaching clinicians about changes in care transition processes, tap into their purpose. Let care providers know that by improving how they handle transitions of care, they move patients toward better health.

In addition, we engage team members beyond our hospital walls, regularly talking with partners across CommonSpirit to discuss what works in their areas. This provides insights we may not have conceived on our own, which further moves us toward our goal of reducing rehospitalization and improving care for all.

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