We all know that moving from one health care setting to another can often be a very stressful experience for patients and their family members. Changes in health status, treatment plans, medications and working with multiple, unfamiliar clinicians can be overwhelming. Even for patients with complex medical conditions, hospital admissions are often brief, without sufficient time to educate the patient and family members about disease management at home. As transitions occur, there is often a breakdown in communication about critical information involving home safety, medications, plans for post acute care follow-up, and social supports.
As one piece of a broader effort at healthcare system redesign, health care providers across the state of Massachusetts have come together to focus on improving care transitions. A White Paper – “Massachusetts Strategic Plan for Care Transitions” prepared by state officials in concert with members of a broad Care Transitions Forum- has laid down both the challenges and a plan for establishing that every health care “hand-off” includes complete information about the patient’s status, care plan and that there is clearer and more explicit “transfer of authority” from one care setting to the next.
The elevation of care transitions to a priority issue with policy makers and payors should be music to the ears of home health agencies. But it will be so, only if we rise to the challenge – on two levels.
First, home care agencies need to do a more aggressive job of gearing any care transitions policy conversations toward helping hospitals (and especially the new breed of hospitalists) in screening people into home care. A big part of this effort needs to be helping hospitals understand what they can expect from a home care referral in terms of skilled and supportive care, medication management and patient teaching. Sometimes integral parts of a care plan that are obvious to us are not well known to doctors and other providers.
Second, we need to look internally at our clinical skills. We need to match our competencies to those that the evidence indicates make for a positive transition (defined for many in health right now as “no readmission”). This is where CHAMP’s resources and tools can be helpful (see the newly added Transitions topic under Evidence Base). CHAMP’s web site also includes a number of patient-centered tools that can help maximize the transitional period, including Talking with Your Healthcare Provider, Your Personal Health Record, and the Patient PASS: A Transition Record.
In Massachusetts, improving care transitions has been identified as meeting the Institute for Health Care Improvement’s (IHI) “triple aim” in health care: care of higher quality, with lower costs and more patient centered. With these tools and resources, let’s make sure that home care can help lead the way.
