© Eric A. Coleman, MD, MPH 2011
What Will It Take to Ensure High Quality Transitional Care?
Eric A. Coleman, MD, MPH
Director, Care Transitions Program
University of Colorado Denver

Complex problems are rarely remedied by simple solutions. Improving the quality of transitional care is no exception as there are no quick fixes. Rather our response will require a multifaceted approach; the centerpiece will feature a renewed commitment to patient centered care and establishment of effective cross setting communication and collaboration. Improving quality and safety during care handovers is fundamentally different from improving quality or safety in single setting. . In its essence, transitional care aims to facilitate a match between an individual’s care needs and his or her care setting. What follows are seven strategies that collectively hold promise for ensuring high quality transitional care.

1. Foster Greater Engagement of Patients and Family Caregivers

Greater engagement of patients and their family caregivers represents the centerpiece of any attempt to improve the quality of transitional care. To do so requires that we meet consumers where they are with respect to health literacy, cognition, and level of activation in order to provide customized care planning. Engagement includes encouraging patients to express their preferences and then honoring these preferences for type of services they desire, the intensity of health care services they receive, and the settings in which they receive them. Patients should not only have access to their care plan, they should have the opportunity to provide direct input. We recognize that transitions in health status are a key driver for transitions in care settings. It follows that in some instances, the best strategy may be to reduce or minimize the number of care transitions.

2. Elevate the Status of Family Caregivers as Essential Members of the Care Team

Closely related to honoring the preferences of older adults is the importance of recognizing the valuable contributions made by family caregivers. Family caregivers are the unsung heroes of transitional care and yet their valuable contributions often go unrecognized or taken for granted. We simply cannot afford to ignore or avoid the very same individuals that we implicitly rely upon to execute the care plan, monitor for threats to patient safety, and serve as de facto care coordinators. Family caregivers deserve our respect and by necessity need to be treated as full-fledged members of our interdisciplinary teams with direct input into the development of the care plan. Building the capacity for greater engagement of family caregivers represents an immediate solution and perhaps our best investment for the future.

3. Implement Performance Measurement

The lack of quality measurement of transitional care represents a significant barrier to improving quality and safety. With few exceptions, quality is not routinely measured. In contrast to all that we have learned in applying the principles of “Lean Thinking” to health care, all too often we do not explicitly reach out to our “customers” [patients] for their input as to whether the services we provide add value. Thus an important quality improvement strategy incorporates the patient’s voice in performance measurement and paves the way for establishing accountability.

4. Define Accountability During Transitions

Patients making transitions across care settings need to understand who is the accountable professional overseeing their care at all times. As articulated in by the Transitions of Care Consensus Policy Statement [a coalition representing six physician professional societies], the sending care team should maintain responsibility for the care of the patient until the receiving care team has had the opportunity to review the goals for care and the accompanying transfer information, clarify any outstanding questions, and acknowledge assumption of responsibility.

5. Build Professional Competency in Care Coordination

Most health care professionals had little exposure to strategies that promote effective care coordination. Transition-specific core competencies for health care professionals encompass more than the mechanics for facilitating cross-setting communication and collaboration, it also requires an appreciation for the differences in culture and care delivery capacity needed to ensure an ideal match between a patient’s care needs and his or her care setting. Training should also include how to meet patients at their level in order to prepare them to self-manage their acute and chronic conditions and understand how to get their needs met during care transitions.

6. Explore Technological Solutions to Improve Cross Setting Communication

Cross setting communication represents a central core competency. We need to establish standard operating procedures for the content, timeliness, and mode of health information exchange. Health care is woefully behind other industries with respect to the use of technological solutions for ensuring that our “product” is reliably delivered with high quality and safety. There are many new opportunities for widespread adoption of existing and emerging technology into the arena of transitional care. Federal guidelines aimed at promoting the meaningful use of health information technology represent a significant step forward in this regard.

7. Align Financial Incentives to Promote Cross Setting Collaboration

Transitional care further exposes one of the greatest weaknesses of our health care delivery system—namely that it is not in fact a system. Thus potential solutions will also require efforts to promote greater “systemness” to an otherwise fragmented delivery model. There are an increasing array of opportunities to create synergy between efforts to improve transitional care and newly introduced complementary approaches aimed at bending the cost curve. The CMS Community Care Transitions Program, patient-centered medical home, the President’s hospital patient safety initiative, bundled payment, and accountable care organizations all provide opportunities to align financial incentives toward promoting greater cross setting coordination and collaboration.

© Eric A. Coleman, MD, MPH 2011