Processes in Care Transitions from the Patient

1
Processes in Care Transitions from the Patient
Provider Perspectives A Mixed Methods
Study Kevin T Fuji, PharmD Amy A. Abbott, PhD,
RN Joan Norris, PhD, RN Kimberly A Galt,
PharmD, PhD(c)
Background
Results
Results
Conclusions
Four distinct processes that occur during all
care transitions emerged from the focus group
transcripts and questionnaires. The overarching
themes common to both patients and providers in
each process are described along with
representative quotes from patients and
providers. Pre-admission planning Patients and
providers agreed that the most well-managed care
transitions occurred with pre-planned admission.
This involved educating patients prior to
admission about what to expect during the
hospital stay and aftercare needs.
Representative provider quote Ideal
discharges involve our orthopedic patientswe
plan on them being there 3 days and it is quite
possible they will need more therapy before they
go home so we tell them to check facilities out
before coming to the hospital. So they know what
to expect and they are not surprised they are
going to rehab. Those probably work out the
best. Representative patient quote They
started from the beginning from the
introduction of signing papers, they said when
you wake up this will happen, this will happen.
So right from the beginning, you kind of knew how
awake you had to be, what you had to be doing
before they released you from the center.
Physical transfer of the patient to another
setting The arrangement of and transfer to the
appropriate receiving facility (community
facility or home) can be difficult for both
patients and providers. Compromise often has to
be established between what the patient wants and
needs, and what the next care setting is able to
provide. Representative provider quote It
becomes a matter of assessing what is medically
the best practice, what is the best practice the
patient will accept, and where you find that
point compromise between those two, which is
frequently not what the physician thinks is best
practice and frequently not what the patient
considers the best outcome. Representative
patient quote They provided nothing as far as
communication for a deaf person. He thought that
when he was discharged, he was going to go to a
nursing home, and the cab dropped him off at his
front door. He had a knee replacement and had
steps up to his home, and the cab literally
dropped him off and left him.

• Care transitions is 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 1
• Reducing rehospitalization is also an important
  part of President
• Obamas health care reform plans, while the
  Centers for Medicare and
• Medicare services want to make
  rehospitalization rate a measure for
• payment2,3
• There is a disconnect between policies and
  procedures and what
• actually happens both within and across
  facilities and among all
• disciplines4
• 1 in 5 Medicare patients are readmitted within 30
  days of discharge and
• half end up back in the hospital within a
  year.5 Researchers believe that
• rehospitalization is a frequent, costly, and
  sometimes life-threatening
• problem that could be prevented through
  better care coordination.

• There is a lack of shared understanding between
  patients and
• professionals about the care transitions
  process.
• There is a lack of ownership and responsibility
  both by patients and
• professionals during the care transitions
  process.
• This lack of understanding, ownership, and
  responsibility leads to
• time constraints, knowledge deficiencies, and
  gaps in communication,
• which delay or prevent effective care
  transitions between facilities
• and/or home.
• Problems described are either sequential across
  transitions of care
• (e.g. disconnect between what level of care a
  facility can provide and
• the patients actual needs) or coordination
  barriers within a facility
• (e.g. if the patient or provider should be
  responsible for follow-up
• care).

Implications for Policy and Practice
Objective
The need for a shared vision and understanding
between hospital and community providers, and
between all providers and patients is evident.
The complex nature of care transitions makes it
necessary for patients and providers to
communicate a shared understanding of roles and
responsibilities in a community-wide model. A
more comprehensive picture of the different
processes involved in care transitions is needed
to potentially identify and help address patient
and provider needs.
The objective of this study was to describe how
patients experiences in care transitions between
health care facilities and home compares to
providers viewpoints about how care is delivered
in one Midwestern community.
Methods
Post-discharge evaluation and follow-up Patients
and providers both describe lacking a formal
mechanism for evaluating the care transitions
process and conducting follow-up care. Patients
often did not receive a phone call or follow-up
from the discharging facility. Providers did not
describe a standard procedure for following up
with patients or receiving facilities to assess
the care transitions process and how the patient
is doing post-discharge. Representative provider
quote Not that everybody is going to be able
to follow everything that is written but what
if theres somebody they can call, that could
handle this over the phone so they dont have to
go to the emergency room. Representative
patient quote Is it reasonable to think maybe
it might be a nice thing if the hospitals do
call, How is everything going? You were a
patient here on such and such a time and how are
you doing, do you have any questions?
An exploratory, mixed methods design was
conducted using 9 focus groups of providers from
4 hospitals and 5 community agencies, 3
physicians, and 20 patients or patient family
members. A written questionnaire was completed by
each participant collecting demographic
information and knowledge about their facilitys
discharge policies and procedures, and . The
data obtained from the focus groups was compared
to the questionnaire response to obtain a more
complete picture of the care transitions process
and highlight similarities and differences
between providers and patients.
The peri-transfer process The preparation and
transfer of information about the patient from
the transferring facility to the receiving
facility is time-consuming and frustrating for
both providers and patients. Providers often
need additional information about the patient.
Patients are anxious to leave, and feel rushed
and uninvolved in their care. Representative
provider quote I think the information that is
more helpful to us is verbal. Because you can
get information and look at but not understand
until you talk to the social worker, discharge
planner, or nurse. Representative patient
quote When you are in that room all you want
to do is get out. You just kind of minimize
everything you just want to get through it and
get out.
References

• The Care Transitions Program. Definition of
  transitional care. Available at
  http//www.caretransitions.org/definitions.asp.
  Accessed March 2009.
• Application of incentives to reduce avoidable
  readmissions to hospitals. Fed Regist.
  20087323673-23675.
• Connolly C. Obama proposes 634 billion fund for
  health care. Washington Post. February 26,
  2009A1.
• Pham HH, Grossman JM, Cohen G, Bodenheimer T.
  Hospitalists and care transitions the divorce of
  inpatient and outpatient care. Health Aff.
  200827(5)1315-1327.
• Jencks SF, Williams MV, Coleman EA.
  Rehospitalizations among patients in the Medicare
  fee-for-service program. N Engl J Med.
  2009360(14) 1418-1428.

Sample
A total of 40 individuals representing the health
provider and patient communities participated.
Providers (n 20) were physicians, nurses,
social workers, pharmacists, physical and
occupational therapists, and case managers who
reported being in practice an average of 16 years
(range 3-40 years). Sixteen were women and four
were men. Patients or patient family member (n
20) averaged 51 years of age 13 reported a
hospitalization within the year and 16 reported
more than one hospitalization.
For More Information
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