in the clinic transitions of care in...

Inthe

ClinicIn the ClinicTransitions of

CareBackground page ITC3-2

Hospital Discharge page ITC3-6

Practice Improvement page ITC3-11

Tool Kit page ITC3-14

Patient Information page ITC3-15

CME Questions page ITC3-16

Physician WritersChristopher S. Kim, MD, MBAScott A. Flanders, MD

Section EditorsDeborah Cotton, MD, MPHDarren Taichman, MD, PhDSankey Williams, MD

The content of In the Clinic is drawn from the clinical information and educationresources of the American College of Physicians (ACP), including PIER (Physicians’Information and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinicfrom these primary sources in collaboration with the ACP’s Medical Education andPublishing divisions and with the assistance of science writers and physician writ-ers. Editorial consultants from PIER and MKSAP provide expert review of the con-tent. Readers who are interested in these primary resources for more detail canconsult http://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current evidence for the prevention, diagnosis, andtreatment of transitions of care.

The information contained herein should never be used as a substitute for clinicaljudgment.

© 2013 American College of Physicians

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How frequent are adverse eventsthat contribute to patient harmafter hospital discharge, andwhich are most important?A prospective cohort study publishedin 2003 found that 19% of patientsdischarged from a single U.S. aca-demic medical center had an adverseevent within 2 weeks of hospital dis-charge—one third of which couldhave been prevented and anotherthird ameliorated. Injuries due tomedications were most common, fol-lowed by procedure-related complica-tions, infections, and falls (1). Similarresults with respect to rate, preventa-bility, and type of adverse postdis-charge events were noted in a studyat a Canadian academic medical cen-ter (2). Although many of the com-plications required no intervention,49% of the patients who did have anadverse event required additionalstudies, evaluation by a physician inthe clinic or emergency department,or readmission to the hospital. Sys-tems issues, including communica-tion of unresolved problems, patienteducation regarding medications andtreatments, monitoring medicationadherence and complications, andmonitoring the status of patientssoon after discharge, were noted asareas needing improvement (1).

Hospital readmission is viewed asone of the more undesired postdis-charge events by patients, providers,and health systems. Patients are frus-trated over the need for readmission,and providers fear that hospital-based treatments and interventionswere ineffective. For health systems,readmissions are an inefficient andcostly solution to problems oftenbetter managed in an alternativevenue (the outpatient clinic) or pre-vented entirely through improvedsystems of care. Although manyreadmissions are unanticipated orunavoidable, recent work has high-lighted disturbingly high hospitalreadmission rates.

A 2007 report by the Medicare Payment Ad-visory Commission showed that 17.6% of allMedicare admissions resulted in rehospital-ization within 30 days, with 6% readmittedwithin just 7 days (3). A subsequent study us-ing a Medicare database confirmed thatnearly 1 in 5 Medicare patients were rehospi-talized within 30 days of the index discharge(4). The Dartmouth atlas reported that read-mission rates increased for many regionsover the period 2004–2009 (5). These studiesshowed significant variation across hospitalreferral regions and between states andopened the door for subsequent analyses ofwhat may be contributing to patients’ needfor readmission to the hospital.

© 2013 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 5 March 2013

1. Forster AJ, Murff HJ,Peterson JF, GandhiTK, Bates DW. The in-cidence and severityof adverse events af-fecting patients afterdischarge from thehospital. Ann InternMed. 2003;138:161-7.[PMID: 12558354]

2. Forster AJ, Clark HD,Menard A, Dupuis N,Chernish R, ChandokN, et al. Adverseevents among med-ical patients after dis-charge from hospital.CMAJ. 2004;170:345-9. [PMID: 14757670]

3. Payment Policy for In-patient Readmissions.In: Report to the Con-gress: PromotingGreater Efficiency inMedicare. MedicarePayment AdvisoryCommission. Wash-ington DC; June,2007:103-20.

4. Jencks SF, WilliamsMV, Coleman EA. Re-hospitalizationsamong patients inthe Medicare fee-for-service program. NEngl J Med.2009;360:1418-28.[PMID: 19339721]

5. Goodman DC, FisherES, Chang C-H. AfterHospitalization: ADartmouth Atlas Re-port on Post-AcuteCare for MedicareBeneficiaries. TheDartmouth Institutefor Health Policy &Clinical Practice; Sep-tember, 2011:1-52.

“Transitions of care” refers to changes in the level, location, or providers of careas patients move within the health care system. One critical transition of carethat has garnered great attention and is the focus of this review is the transitioninvolving hospital discharge. Acute hospitalization represents a significant eventin a patient’s life, and health care providers in partnership with patients need toaddress myriad issues related to the hospitalization and subsequent posthospi-talization care for a safe transition out of the hospital. The care of the hospital-ized patient has evolved over time, such that patients are sicker; length of stayhas decreased; medical technology and knowledge have advanced; and newmodels of hospital-based care have evolved, such as the advent of hospitalists asthe principal hospital-based providers. All of these factors have contributed tothe complexity of coordinating transitions of care. In addition, as patients aredischarged from a setting in which providers are available to address mosthealth needs or questions on a continuous basis, patients and family membershave good reason to wonder what will happen next. Recent research has high-lighted the gaps in quality of hospital discharge transitions that may contributeto postdischarge complications. To address this problem, several federal, state,and local initiatives have prompted health care organizations and communitiesto identify, measure, and improve their care transition processes.

Background


© 2013 American College of PhysiciansITC3-3In the ClinicAnnals of Internal Medicine5 March 2013

Important but less commonly report-ed measures that may reflect the qual-ity of the hospital discharge includemortality, functional status, quality oflife, and caregiver burden (6).

What are the financialconsequences of adverse eventsafter hospital discharge?While difficult to quantify, the cost ofadverse postdischarge events from theperspective of patients and their fami-lies include loss of potential earnings,co-pays for physician visits, rehospi-talization, skilled nursing, transporta-tion to appointments, or the need tocare for their family member.

Adverse postdischarge events cost theU.S. health care system an estimated$12–$44 billion annually (7). Thefederal government intends to holdindividual hospitals and health sys-tems accountable for the quality andappropriateness of hospital dis-charges. The 2010 Patient Protectionand Affordable Care Act specifies in-centives and penalties based on read-mission rates, including reductions inpayments to hospitals with severity-adjusted readmission rates exceedingthose expected for Medicare benefi-ciaries with congestive heart failure,pneumonia, or acute myocardial in-farction. On 1 October 2012 (the be-ginning of fiscal year 2013), morethan 2000 hospitals were notified ofpenalties for excessive readmissionrates, ranging from 0.01%–1.00% ofMedicare reimbursements. The Cen-ters for Medicare & Medicaid Serv-ices (CMS) expects that hospitalswill forfeit about $280 million in thisfirst year of penalties. Starting in Oc-tober 2013, the maximum penaltyrate will double to 2% and top out at3% in 2014 (8). Also beginning infiscal year 2013, the Hospital ValueBased Purchasing program from theU.S. Department of Health and Hu-man Services (HHS) will reserve aportion of diagnosis-related grouppayments for hospitals showinghigh-quality practices at discharge,including enhanced communicationand planning for postdischarge care.

Who is at risk for adverse eventsafter hospital discharge, and howshould physicians identify them?Multiple social and environmentalfactors related to both the patientand health care system contribute toadverse postdischarge events. Predict-ing which patients are at risk is complex—in 1 study, hospital-basedproviders, including attending physicians, residents, interns, casemanagers, and bedside nurses, wereunable to accurately predict which oftheir general medicine patients wouldbe readmitted within 30 days (9). Areliable method to predict risk forpostdischarge complications wouldbe helpful, but validated, reliable, andgeneralizable risk stratification mod-els are lacking. A recent systematicreview concluded that while somemodels may be useful in certain set-tings, most available risk predictionmodels perform poorly (10). TheLACE index has been proposed as arisk model and incorporates Lengthof stay, Acuity of admission, Comor-bidity, as measured by the Charlsoncomorbidity index, and Emergencydepartment use to identify patientswith a high predicted risk for read-mission or death (11). It identifiespatients who may benefit from moreintensive postdischarge management.Another risk assessment tool, the“8Ps” (see the Box: The 8Ps Risk As-sessment Tool) identifies patient fac-tors linked to high rates of adverseevents after discharge. Each of therisk categories requires a different setof interventions—some may be im-plemented by the hospital staff, andothers require ongoing supportivecare after hospital discharge. For ex-ample, a patient prescribed multiplehigh-risk medications may benefitfrom counseling and follow-up con-tact from a pharmacist. Prior hospi-talization has been shown to be thesingle most predictive risk factor forsubsequent rehospitalization, andthese patients may benefit from in-tensive case management support(12). Other “P”-based risk factorsthat have been suggested include lackof Primary care or Public support

6. Bray-Hall ST. Transi-tional care: focusingon patient-centeredoutcomes and sim-plicity [Editorial]. AnnIntern Med.2012;157:448-9.[PMID: 22986380]

7. Hansen LO, Young RS,Hinami K, Leung A,Williams MV. Inter-ventions to reduce30-day rehospitaliza-tion: a systematic re-view. Ann InternMed. 2011;155:520-8.[PMID: 22007045]

8. Medicare To Penalize2,217 Hospitals forExcess Readmissions.Kaiser Health News;August 13, 2012.

9. Allaudeen N, Schnip-per JL, Orav EJ,Wachter RM, Vid-yarthi AR. Inability ofproviders to predictunplanned readmis-sions. J Gen InternMed. 2011;26:771-6.[PMID: 21399994]

10. Kansagara D, Eng-lander H, Salanitro A,Kagen D, TheobaldC, Freeman M, et al.Risk prediction mod-els for hospital read-mission: a systematicreview. JAMA.2011;306:1688-98.[PMID: 22009101]

11. van Walraven C,Dhalla IA, Bell C,Etchells E, Stiell IG,Zarnke K, et al. Deri-vation and valida-tion of an index topredict early deathor unplanned read-mission after dis-charge from hospitalto the community.CMAJ. 2010;182:551-7. [PMID: 20194559]

The 8Ps Risk Assessment ToolProblem medications (e.g. warfarin,

insulin, digoxin)PolypharmacyPsychological conditions (e.g. depression)Principal diagnosis (e.g. cancer, stroke,

diabetes, COPD, congestive heartfailure)

Poor health literacyPatient support (the absence of social

support, either formal or informal)Prior hospitalizations (in the past 6

months)Palliative care


12. Project BOOST.Philadelphia, PA: So-ciety of HospitalMedicine; 2012.

13. Ho PM, Tsai TT, Mad-dox TM, Powers JD,Carroll NM, Jackevi-cius C, et al. Delaysin filling clopidogrelprescription afterhospital dischargeand adverse outcomes afterdrug-eluting stentimplantation: impli-cations for transi-tions of care. CircCardiovasc QualOutcomes.2010;3:261-6.[PMID: 20407117]

14. Kuo YF, Sharma G,Freeman JL, Good-win JS. Growth inthe care of older pa-tients by hospitalistsin the United States.N Engl J Med.2009;360:1102-12.[PMID: 19279342]

15. Pham HH, GrossmanJM, Cohen G, Boden-heimer T. Hospitalistsand care transitions:the divorce of inpa-tient and outpatientcare. Health Aff (Millwood).2008;27:1315-27.[PMID: 18780917]

16. Kripalani S, LeFevreF, Phillips CO,Williams MV, Basavi-ah P, Baker DW.Deficits in communi-cation and informa-tion transfer be-tweenhospital-based andprimary care physi-cians: implicationsfor patient safetyand continuity ofcare. JAMA.2007;297:831-41.[PMID: 17327525]

17. Hesselink G, Ver-nooij-Dassen M, Pij-nenborg L, Barach P,Gademan P, Dudzik-Urbaniak E, et al. Or-ganizational culture:an important con-text for addressingand improving hos-pital to communitypatient discharge.Med Care.2013;51:90-8.[PMID:23132202]


(community based programs to assistpatients), and Poor mobility status(falls) and can be incorporated intothe hospital’s discharge transitionswork. The goal of the tool is to iden-tify and address these high-risk vari-ables by an interdisciplinary healthcare and social support team prior tohospital discharge (12).

Medication-related adverse events af-ter discharge warrant particular at-tention. One study found that amongpatients who had implantation of adrug-eluting stent, 16% did not filltheir clopidogrel prescription on theday of discharge. These patients werefound to have 50% increased risk fordeath or myocardial infarction, with alarge proportion occurring in the first30 days after hospital discharge (13).Health systems should identify pa-tients needing high-risk medicationsbefore discharge, reconcile their dis-charge medication with regard toaccuracy, develop innovative practicesolutions to educate these patients,and ensure that they have access tothese medications after discharge.

What factors contribute toadverse events caused by poorlycoordinated transfers of care outof the hospital to home?Because inpatient care is increasinglyprovided by hospitalists at many U.S.hospitals (14), direct involvement ofprimary care physicians has becomeless common and the coordination ofcare more complex (15). The dis-charge summary is the usual methodof communicating the hospital coursefrom one provider to another, and al-though standards of required elementshave been defined by the Joint Com-mission, content, timeliness, availabili-ty, and quality vary widely.

In a systematic review evaluating dischargesummaries, availability at the first postdis-charge visit was found to be low (12%–34%),and the summary often lacked important in-formation, such as diagnostic test results(33%–63% of the time) or pending results(65%) and discharge medications (2%–40%).Lack of availability and insufficient contentof discharge summaries affected the quality

of follow-up care visits approximately 25% ofthe time (16).

Discharge summaries may also lackimportant patient-specific informa-tion (social–emotional status, prefer-ences, and needs). In addition, fragmented communication at thetime of discharge, such as unclear in-formation transmitted in illegiblehandwriting, incomprehensible infor-mation due to abbreviations unknownto primary care physicians, and exces-sive information without prioritizingrelevant aspects of the hospitalization,all contribute to poorly coordinateddischarge. A recent qualitative studyof providers, patients, and familymembers reported that hospitalsshould take an inventory of theircommitment to the hospital dischargeprocess and the quality of informationtransmitted at the time of discharge.Examples of underlying dischargebarriers included lack of time, workpressure, work routines, priority onproviding undervalued administrativedischarge tasks relative to providingurgent clinical care, and lack ofknowledge and understanding be-tween hospital and primary careproviders (17). Health care organiza-tions should evaluate their culture ofreadiness for improvement in theseareas.

Care coordination problems are com-pounded when patients are unable tosee ambulatory care providers in atimely manner due to such patientfactors as severity of illness, trans-portation or financial concerns,provider availability or access, or in-sufficient information and educationat discharge. A study of Medicare pa-tients readmitted within 30 days ofdischarge found that more than halfhad no billing encounter with an out-patient care provider, suggesting anopportunity to support patients’ clini-cal needs to preclude readmission (4).

Diagnostic test results pending at thetime of discharge create an importantpotential safety problem if care tran-sitions are not well-coordinated.


18. Roy CL, Poon EG,Karson AS, Ladak-Merchant Z, John-son RE, Maviglia SM,et al. Patient safetyconcerns arisingfrom test results thatreturn after hospitaldischarge. Ann In-tern Med.2005;143:121-8.[PMID: 16027454]

19. Moore C, McGinn T,Halm E. Tying uploose ends: dis-charging patientswith unresolvedmedical issues. ArchIntern Med.2007;167:1305-11.[PMID: 17592105]

20. LaMantia MA, Sche-unemann LP, VieraAJ, Busby-White-head J, Hanson LC.Interventions to im-prove transitionalcare between nurs-ing homes and hos-pitals: a systematicreview. J Am GeriatrSoc. 2010;58:777-82.[PMID: 20398162]

21. Shah F, Burack O,Boockvar KS. Per-ceived barriers tocommunication be-tween hospital andnursing home attime of patienttransfer. J Am MedDir Assoc.2010;11:239-45.[PMID: 20439042]

22. Gandara E, Moniz T,Ungar J, Lee J, Chan-Macrae M, O’MalleyT, et al. Communica-tion and informationdeficits in patientsdischarged to reha-bilitation facilities: anevaluation of fiveacute care hospitals.J Hosp Med.2009;4:E28-33.[PMID: 19827041]

23. Rogers MA, Mody L,Kaufman SR, Fries BE,McMahon LF Jr,Saint S. Use of uri-nary collection de-vices in skilled nurs-ing facilities in fivestates. J Am GeriatrSoc. 2008;56:854-61.[PMID: 18454750]

24. Mody L, Bradley SF,Galecki A, OlmstedRN, Fitzgerald JT,Kauffman CA, et al.Conceptual modelfor reducing infec-tions and antimicro-bial resistance inskilled nursing facili-ties: focusing on res-idents with in-dwelling devices.Clin Infect Dis.2011;52:654-61.[PMID: 21292670]


At 2 tertiary care academic hospitals, 40%of patients had pending results on 1 ormore tests at the time of discharge; ofthese, 10% potentially required a clinicalintervention. A survey of inpatient and pri-mary care physicians found that one thirdof physicians did not know the test hadbeen ordered and 60% were unaware ofthe result (18).

Problems completing planned diag-nostic tests or evaluations after dis-charge may also create patient safetyproblems. One study found that27% of patients discharged from amedical or geriatric service had fur-ther diagnostic procedures (e.g., en-doscopies), subspecialty referrals,and laboratory tests (e.g., anticoagu-lation monitoring) recommended,but 36% were not completed. Twofactors were determined to be maincontributors: increased time to firstpostdischarge follow-up visit withthe primary care provider, and avail-ability of the discharge summaryrecommending further workup (19).

What factors may contribute toadverse events when patients aredischarged from a hospital toanother health care facility?Increasingly, patients requiring ongo-ing facility-based care are being tran-sitioned to an acute rehabilitationhospital or skilled nursing facility. Apoorly coordinated exchange of infor-mation contributes to high rates ofmedication-related adverse events(20) and duplication of testing. Vari-ability in the quality of hospital staff

preparation and communication ofthe discharge information to nursingfacilities and the timing of transfers(i.e., sudden transfers or those occur-ring at night or on weekends) havebeen identified as primary reasons forpoor information exchange (21). Onestudy found that discharge summariessent to postacute care facilities oftenmissed important information, suchas the list of preadmission medica-tions, reasons for changes to medica-tions at discharge, pending test re-sults, and postdischarge follow-upplans (22).

Also problematic is the high frequen-cy with which patients with in-dwelling devices are transferred toother facilities (23). Insufficient com-munication around indications andanticipated duration of use for thesedevices put patients at risk for compli-cations, including catheter-associatedurinary tract infections, centralline–associated bloodstream infec-tions, and venous thromboembolism.Infections are a leading cause of hos-pital readmission among patients atskilled nursing facilities (24, 25), andeven if these patients do not requirereadmission, managing these infec-tions can lead to unintended conse-quences. For example, while healthcare facilities need to implement ap-propriate infection control measures,prolonged or inappropriate contactprecautions may lead to less attentiongiven to patients, causing isolationand functional or clinical decline (24).

Background... Hospital discharge can be a perilous process. Many patients haveunintended adverse events after discharge, with an estimated 20% of patients be-ing readmitted to the hospital within 30 days. Because patients are transitioningfrom not only their location of care but also from most of their health careproviders, it is critical to ensure that the quality and timeliness of communicationamong health care providers are monitored and improved. Determining which pa-tients will have adverse postdischarge events is difficult, but risk assessment toolshave been developed to help providers address specific barriers before discharge.Patients often continue their recovery out of the hospital, and thus it is imperativethat the posthospital health care providers are aware of ongoing needs to ensure asmooth recovery and timeliness of follow-up care without duplication of effort.

CLINICAL BOTTOM LINE


25. Ouslander JG, Diaz S,Hain D, Tappen R.Frequency and diag-noses associatedwith 7- and 30-dayreadmission ofskilled nursing facili-ty patients to a non-teaching communi-ty hospital. J AmMed Dir Assoc.2011;12:195-203.[PMID: 21333921]

26. Schillinger D, PietteJ, Grumbach K,Wang F, Wilson C,Daher C, et al. Clos-ing the loop: physi-cian communicationwith diabetic pa-tients who have lowhealth literacy. ArchIntern Med.2003;163:83-90.[PMID: 12523921]

27. Best Care at LowerCost: The Path toContinuously Learn-ing Health Care inAmerica. Washing-ton, D.C.: The Nation-al Academies Press;2012.

28. Hesselink G, Flink M,Olsson M, Barach P,Dudzik-Urbaniak E,Orrego C, et al. Arepatients dischargedwith care? A qualita-tive study of percep-tions and experi-ences of patients,family members andcare providers. BMJQual Saf. 2012;21Suppl 1:i39-49.[PMID:23118410]


Hospital Discharge regularly reviews the established

care plan.

It is critical that the home careproviders communicate closelywith the outpatient team about thepatient’s progress and about anysignificant clinical needs that war-rant intervention. For example, theoutpatient physician can helparrange home care services thatmay not have been requested before discharge, appropriatelymanage medications (e.g., discon-tinuing low-molecular-weight heparin injections once the patientis therapeutic on warfarin), and fa-cilitate removal of peripherally in-serted central catheters or otherindwelling devices when therapy isno longer required.

Patients may choose their ownhome health agency. To assist,CMS has established a Web siteto help beneficiaries better under-stand home care, what they canexpect, the types of services of-fered, and quality ratings forhome care agencies. Providers andpatients can find home care quali-ty and satisfaction reports atwww.medicare.gov/HomeHealthCompare.

How should families prepare for apatient’s discharge from thehospital?Establishing a patient- and family-centered approach to hospital tran-sitions is essential and should be apriority for every health system.Smooth transitions start with part-nerships among health careproviders, patients, and their fami-lies to facilitate education and activeparticipation in postdischarge plan-ning. Unfortunately, this is not al-ways well-executed (27). Ineffectivecommunication by hospital staffmay contribute to poor transitionsand may involve multiple problems,including failure to identify and ac-commodate the appropriate timing

Who should be involved indischarge planning and how andwhen should it be done?Preparing for hospital dischargeshould involve an interdisciplinaryteam, including the patient andfamily members. Combined into a“discharge transitions bundle,” keyprocesses and steps include med-ication reconciliation, patient andfamily engagement with such in-teractive methods as “teach-back”(Figure 1) (26), timely and accu-rate transmission of informationto the patient and providers at thenext site of care, and outreach tothe patient soon after discharge(Figure 2).

When a patient is dischargedhome, which services should beconsidered and how should carebe coordinated with outpatientcare teams?Home care service providers areoften responsible for completingcritically important care that wasstarted in the hospital, such as theadministration of intravenous antibiotics. Skilled home careproviders can also evaluate a patient’s safety, vital signs, oral intake and diet, medication adher-ence, and pain control; clarify in-structions; and reinforce educationprovided in the hospital.

Patients may be eligible for manyhome care services throughMedicare Part A or private insur-ance, including intermittentskilled nursing care; physical,speech–language, or occupationaltherapy; medical social services;and use of an intermittent homehealth aide. Further, patients mayreceive certain medical supplies,such as wound dressings, durablemedical equipment, and injectableosteoporosis drugs. Eligibility forskilled home care services requiresphysician certification that the pa-tient is homebound and under thecare of a doctor who oversees and


29. Cumbler E, Carter J,Kutner J. Failure atthe transition ofcare: challenges inthe discharge of thevulnerable elderlypatient. J Hosp Med.2008;3:349-52.[PMID: 18698595]

30. Misky GJ, Wald HL,Coleman EA. Post-hospitalization tran-sitions: Examiningthe effects of timingof primary careprovider follow-up. J Hosp Med.2010;5:392-7.[PMID: 20578046]

31. Doctoroff L. Intervalexamination: estab-lishment of a hospi-talist-staffed dischargeclinic. J Gen InternMed. 2012;27:1377-82. [PMID: 22810356]

32. Bumpus S, Kline-Rogers E, Kosteva A,Smith C, Mont-gomery D, Eagle K,et al. A Nurse BasedBridge TransitionalCare Model ReducesReadmissions andED Visits. Journal ofthe American Col-lege of Cardiology.2011;57(14):E1182.


and settings for effective communi-cation. For example, acutely ill patients may receive sedating med-ications or other treatments that in-terfere with effective communication.Thus, it is imperative that thehealth care team identify the appro-priate timing for important conver-sations on transition planning andfamily members to participate, be-cause they are often active partici-pants in postdischarge care.

A qualitative study by Hesselink andcolleagues (28) illustrates that astandard discharge consultation withpatients and family members is of-ten not done at all. Discharge infor-mation is provided piecemeal between other care activities. Thisincreases the risk for discharging un-informed patients because they arenot aware of the importance of theinformation and are unable to re-member it. To improve the discharge

Figure 1Teach-back concept, to help patients improve adherence and reduce errors in self-management.From reference 26.

Figure 2Key process steps in discharge planning and transitioning patients to primary care (“DischargeTransitions Bundle”).



process, essential information shouldbe provided to patients and familiesbefore discharge (see the Box: Mini-mal Required Information To BeProvided to Patients and Families atHospital Discharge).

How should discharges onweekends or when access toprimary care for follow-up islimited be handled?Because staffing and services are fre-quently limited on weekends, hospi-tals and health care providers shouldensure that discharge needs are thor-oughly addressed during weekdaysbefore the weekend discharge. Pro-viding appropriate clinical serviceson holidays and weekends on a lim-ited basis and offering a home visitto the patient, while awaiting usualhome care services, should also beconsidered. Rarely, it may be prudentto delay discharge until care transi-tions can be better coordinated witha full complement of care providers,including the primary care providersand family members (29).

In a prospective cohort study of patientsdischarged from 1 academic medical cen-ter, patients who lacked timely follow-upfrom a primary care physician (defined aswithin 4 weeks of discharge) had a 10-foldincreased risk for readmission for the samecondition (30).

When access to primary care is lim-ited, some organizations have estab-lished creative models as a bridge,such as a discharge or transitionsclinic. These clinics, which are oftenstaffed by hospitalists or nurse prac-titioners, can see patients withindays of their discharge to assess clin-ical status, address new problems,reconcile medications, discuss testresults that were pending at the timeof discharge, arrange home healthservices, and admit patients to askilled nursing facility from home ifthey are not doing well (31, 32).

How is care best coordinatedwhen a patient is discharged?Effective coordination of care startsin the hospital with interdisciplinary

rounds. Hospital-based providersshould strive to complete a qualitydischarge summary within 24–48hours of the patient’s discharge andconfirm with the providers at thenext setting (i.e., primary care orskilled nursing facility) that the dis-charge information has been re-ceived. Until a universally accessibleelectronic medical record systemconnects all care providers through-out the spectrum of care settings,health care providers will need touse a combination of methods tocommunicate essential discharge in-formation. These include secure e-mails, telephone calls, electronicmedical record–based notificationapplications, and discharge summarytransmission via fax or U.S. mail.

A recent systematic review on interventionsto improve hospital discharge to primarycare found that medication reconciliation,use of electronic tools to generate dis-charge summaries and communicate in-formation to other providers, and sharedresponsibility for patient follow-up effec-tively reduced rehospitalizations and im-proved patient satisfaction (33).

The same principles apply to coor-dinating care for patients dischargedto skilled nursing facilities. An aca-demic medical center employed onsite geriatricians and advancednurse practitioners in privately oper-ated skilled nursing facilities andwas able to reduce their 15-dayreadmission rates throughout thefirst 5 years of their program (34).The skilled nursing facility program attributed its successes to having ac-cess to the hospital’s electronic medical records, such as dischargesummaries and laboratory and studyresults, and through enhanced rela-tionships and communication withhospital-based providers.

Timely follow-up with clinical careproviders after hospital discharge isimperative; hospitals should at-tempt to arrange follow-up ap-pointments before discharge,which may reduce readmissionsand emergency department visits

Minimal Required Information To BeProvided to Patients and Families atHospital DischargeReason for hospitalization (in medical

terminology and lay language;information further explained andelaborated by the use of pictures andimages)

Self-care instructions (e.g., on woundcare) explained in writing and bypictures and images

Pertinent tests and treatment renderedduring hospitalization

Signs and symptoms to watch out for,with instructions on what to do ifsuch events occur

List of tests and studies that requirefurther follow-up as an outpatient

List of medications, noting any changesfrom admission and the reason forthat change

Contact information (who is primarycontact person and available at whattime) for hospital-based providers andprimary care physician

Instructions for primary care physicianfollow-up, including appointment timeand location if already arranged

Home care services arranged

33. Hesselink G,Schoonhoven L,Barach P, Spijker A,Gademan P, KalkmanC, et al. Improvingpatient handoversfrom hospital to pri-mary care: a system-atic review. Ann Intern Med.2012;157:417-28.[PMID: 22986379]

34. Joshi DK, Bluhm RA,Malani PN, Fetyko S,Denton T, Blaum CS.The successful de-velopment of a sub-acute care serviceassociated with alarge academichealth system. J AmMed Dir Assoc.2012;13:564-7.[PMID: 22748721]


35. Chang R, SpahlingerD, Kim CS. Re-engi-neering the post-discharge appoint-ment process forgeneral medicinepatients. Patient.2012;5:27-32.[PMID: 22217264]

36. Physician Orders forLife-Sustaining Treat-ment Paradigm.2012:www.ohsu.edu/polst/index.htm.

37. Hickman SE, NelsonCA, Moss AH, TolleSW, Perrin NA,Hammes BJ. Theconsistency be-tween treatmentsprovided to nursingfacility residents andorders on the physi-cian orders for life-sustaining treatmentform. J Am GeriatrSoc. 2011;59:2091-9.[PMID: 22092007]

38. Greenwald JL, Halasyamani LK,Greene J, LaCivita C,Stucky E, BenjaminB, et al. Making inpa-tient medication rec-onciliation patientcentered, clinicallyrelevant, and imple-mentable: a consen-sus statement onkey principles andnecessary first steps.Jt Comm J Qual Pa-tient Saf.2010;36:504-13, 481.[PMID: 21090020]


(35). Although the ideal interval isnot well-established, lack of fol-low-up with a primary care physi-cian after hospital discharge hasbeen associated with higher read-mission rates for the same condi-tion (30).

When applicable, end-of-life treat-ment preferences must also be con-veyed at discharge. The PhysicianOrders for Life Sustaining Treat-ments (POLST) form is a portablemedical order that indicates the patient’s preferences to have car-diopulmonary resuscitation at-tempted, receive artificial nutritionby tube, be administered antibi-otics, and specify the extent ofmedical treatments. Health careproviders carry out these orders re-gardless of the setting or situation.The POLST program exists or isbeing developed in 39 states (36)and has been shown to achieve ahigh rate of care consistent withpatient wishes (37).

What are the most effective waysto ensure safe, appropriatemedication reconciliation?The Joint Commission designationof medication reconciliation—maintenance and communicationof accurate patient medication in-formation across settings—as oneof its National Patient Safety Goalshighlights the importance of thisaspect of the discharge process. Ef-fective medication reconciliationmust be patient-centered, clinicallyrelevant, and include a comprehen-sive review of all current medica-tions to ensure that medicationsbeing added, changed, or discontin-ued are accounted for and an accu-rate list is maintained across settings (see the Box: SuggestedFormat for the Discharge Recon-ciled Medication List). This listmust be available to the patient orfamily member and all providersinvolved in the patient’s care (38).Interventions in the postdischargeperiod should also be considered,where home care providers and

ambulatory based nurses, pharma-cists, and primary care physicianscontinue appropriate medicationreconciliation with the patient. Arecent systematic review of hospi-tal-based medication reconciliationprocesses reported that interven-tions, such as the use of pharma-cists, information technology, staffeducation and feedback, and a stan-dardized medication reconciliationtool, reduced medication discrepan-cies and preventable adverse drugevents but showed inconsistentbenefit in overall health care use (39).

Despite ongoing efforts to improvemedication reconciliation, the im-plementation of an effective med-ication reconciliation program remains challenging in most healthsystems, and medication-relatedproblems continue to be among themost common adverse postdis-charge events (40). Many institu-tions have enlisted the help of clinical pharmacists to facilitatemedication reconciliation; thesestudies have shown mixed resultswith respect to health care use,such as return visits to emergencydepartments and rehospitalizations.Pharmacist involvement in the as-sessment of medication appropri-ateness, medication reconciliation,screening for adherence concerns,patient counseling, and postdis-charge phone calls may reduce therate of medication-related compli-cations, such as preventable adversedrug events (41–43). Each organi-zation should consider how thesehealth care providers can optimallysupport the medication reconcilia-tion process.

Which interventions can preventhospital readmission?A systematic review to evaluatethe preventability of hospitalreadmissions found that ratesranged widely, from 5%–79%,with a median of 27% consideredavoidable (44).

A recent systematic review evaluating inter-ventions designed to reduce readmissions

Suggested Format for the DischargeReconciled Medication ListNew medications—started during

hospital stay that should continueafter discharge (including informationabout the reason and intendedduration for each new medication)

Continued medications—includemedications patient was taking beforehospitalization that should continueafter discharge• Medications that should be contin-

ued, but dose and/or frequency orother directions have changed (in-clude information about the reasonfor the change and intended dura-tion of the change)

• Medications that should be contin-ued and the dose, frequency, andother directions remain the same

Discontinued medications—includemedications that the patient wastaking before the hospital stay that heor she should stop taking


39. Mueller SK, SponslerKC, Kripalani S,Schnipper JL. Hospi-tal-based medica-tion reconciliationpractices: a system-atic review. Arch In-tern Med.2012;172:1057-69.[PMID: 22733210]

40. Budnitz DS, Love-grove MC, Shehab N,Richards CL. Emer-gency hospitaliza-tions for adversedrug events in olderAmericans. N Engl JMed. 2011;365:2002-12. [PMID: 22111719]

41. Kripalani S, RoumieCL, Dalal AK,Cawthon C, BusingerA, Eden SK, et al;PILL-CVD (Pharma-cist Intervention forLow Literacy in Car-diovascular Disease)Study Group. Effectof a pharmacist in-tervention on clini-cally importantmedication errors after hospital dis-charge: a random-ized trial. Ann InternMed. 2012;157:1-10.[PMID: 22751755]

42. Walker PC, BernsteinSJ, Jones JN, PiersmaJ, Kim HW, Regal RE,et al. Impact of apharmacist-facilitat-ed hospital dis-charge program: aquasi-experimentalstudy. Arch InternMed. 2009;169:2003-10. [PMID: 19933963]

43. Schnipper JL, KirwinJL, Cotugno MC,Wahlstrom SA,Brown BA, Tarvin E,et al. Role of phar-macist counseling inpreventing adversedrug events afterhospitalization. ArchIntern Med.2006;166:565-71.[PMID: 16534045

44. van Walraven C,Bennett C, JenningsA, Austin PC, ForsterAJ. Proportion ofhospital readmis-sions deemed avoid-able: a systematic re-view. CMAJ.2011;183:E391-402.[PMID: 21444623]

45. Coleman EA, Parry C,Chalmers S, Min SJ.The care transitionsintervention: resultsof a randomizedcontrolled trial. ArchIntern Med.2006;166:1822-8.[PMID: 17000937]


reported that most interventions were notstudied in isolation and often involved acombination of pre- and postdischargecomponents. Common elements acrossstudies included providing a patient-centered discharge instruction sheet and apostdischarge telephone call. There was nosingle intervention that reliably reduced 30-day readmission rates. The authors conclud-ed that bundling groups of interventionswas likely to have the most benefit (7).

The following 3 highly successful,multicomponent care transitionmodels have been described.

In a randomized, controlled study done ina large integrated delivery system in Col-orado, patients with 1 of 11 conditionswere randomized to receive usual care or acare transitions intervention with 5 com-ponents: 1) medication self-management,2) a patient-centered record owned andmaintained by the patient, 3) timely fol-low-up care with an ambulatory provider,4) a list of common symptoms that mayindicate a worsening condition, alongwith instructions on how to respond tothem, and 5) utilization of a “transitionscoach” to conduct a home visit and assistpatients with their self-management skills.The intervention resulted in a significantreduction in 30- (8.3% vs. 11.9%) and 90-day (16.7% vs. 22.5%) readmission ratesand lower hospital costs at 180 days($2058 vs. $2546) (45).

In another trial, patients older than 70 yearswho were being discharged from a med-ical/surgical cardiac service were randomlyassigned to receive a nurse-implementedcomprehensive discharge planning tool or

usual care. Those with medical diagnosesin the intervention group had a lower rateof readmission during the first 6 weeks afterdischarge (10% vs. 23%) (46). In a follow-uprandomized trial, advanced practice nursesassisted with discharge planning andhome follow-up. Patients who were as-signed to the nurse-administered interven-tion were less likely to be readmitted andtime to first readmission was increasedcompared with control patients (47).

The third trial, the Reengineered HospitalDischarge Program (Project RED), studiedthe impact of an intervention that includ-ed use of a nurse discharge advocate toarrange follow-up appointments, conductmedication reconciliation, and utilize apersonalized instruction booklet to providepatient education and communicate withthe primary care provider; a clinical phar-macist contacted the patient 2–4 days lat-er to highlight the recent discussions withthe nurse discharge advocate and reviewmedications. Patients assigned to the in-tervention group had lower rates of hospi-tal utilization defined by readmissions andreturn visits to the emergency departmentwithin 30 days leading to lower overallcosts incurred by the patients in the inter-vention group (48).

Of note, Project RED excluded pa-tients admitted from or dischargedto skilled nursing facilities. Thestudy was also done at an urbansafety net hospital, the average ageof patients enrolled in the study was50 years, and the mean length ofstay was 2.6–2.8 days.

Hospital Discharge... An interdisciplinary group of care providers along with thepatient and family should communicate and coordinate the care needs for thedischarged patient. Each discipline can offer specific risk-mitigating interven-tions that should be discussed with the patient and family to ensure that care iscoordinated and follow-up is established. While most patient-centered inter-ventions should be started in the hospital, ongoing assessment and adjustmentsto the care plan can and should take place in the home with home care serviceproviders and the outpatient team. Communication of information about thepatient’s health condition and treatments should incorporate appropriate healthliteracy tools and utilize such methods as “teach-back” to enable providers toassess knowledge and skill gaps requiring additional and ongoing reinforcement.Interventions aimed at reducing risk for adverse postdischarge events are oftennot effective in isolation but need to be bundled in a consistent manner by thehealth system.



46. Naylor M, Brooten D,Jones R, Lavizzo-Mourey R, Mezey M,Pauly M. Compre-hensive dischargeplanning for thehospitalized elderly.A randomized clini-cal trial. Ann InternMed. 1994;120:999-1006.[PMID: 8185149]

47. Naylor MD, BrootenD, Campbell R, Ja-cobsen BS, MezeyMD, Pauly MV, et al.Comprehensive dis-charge planning andhome follow-up ofhospitalized elders: arandomized clinicaltrial. JAMA.1999;281:613-20.[PMID: 10029122]

48. Jack BW, Chetty VK,Anthony D, Green-wald JL, SanchezGM, Johnson AE, etal. A reengineeredhospital dischargeprogram to decreaserehospitalization: arandomized trial.Ann Intern Med.2009;150:178-87.[PMID: 19189907]

49. 2012 MeasuresMaintenance Techni-cal Report: AcuteMyocardial Infarc-tion, Heart Failure,and Pneumonia 30-Day Risk-Standard-ized ReadmissionMeasure. Yale NewHaven Health Servic-es Corporation/Cen-ter for Outcomes Re-search & Evaluation;2012.


monitored across settings of carefor patients (www.jointcommission.org/standards_information/npsgs.aspx).

To better assess key processes sur-rounding hospital discharge, theNational Quality Forum has endorsed a metric called the“timely transmission of transitionrecord.” The measure would trackthe percentage of discharge transi-tion records provided to the next“site provider” within 24 hours ofhospital discharge (www.qualityforum.org/News_And_Resources/Press_Releases/2012/NQF_Endorses_Care_Coordination_Measures.aspx). Similar to thismeasure, stage two of the mean-ingful use criteria for adoptingelectronic health records providescredit toward incentive paymentsfor providers sending an electronicsummary of care record for a per-centage of hospital discharges. Asa result, providers have additionalfinancial motivation to enhancetheir electronic record transmis-sion process in a timely manner(www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html).

How can hospitals and health careproviders work together withcommunity-based organizationsand the patient’s support networkto facilitate a smooth patienttransition after discharge?The Community-based Care Tran-sitions Program (CCTP), a compo-nent of the Partnership for Patientsinitiative, identifies hospitals havinghigh readmission rates that are theneligible to partner with community-based organizations to apply forfunding and implement an evi-dence-based care transitions modelto reduce readmissions. At the timeof this writing, funding has been ap-proved for 47 sites that have created hospital–community organizationpartnerships to implement, test, and

What measures do stakeholdersuse to evaluate the quality of carefor transitions of care? How arethese measures reported, and howare regulations enforced?The most widely used metric to assess the quality of the hospitaldischarge has been the 30-dayreadmission rate. Although manysuggest that a shorter duration (7or 14 days) might better reflect thequality of the discharge, transitionimprovement trials, demonstrationprojects, and federal reporting pro-grams have established the 30-daywindow as the benchmark. TheCMS publically reports 30-dayreadmission rates for U.S. hospitalsand levels financial penalties forhospitals with excess readmissionrates for certain conditions. Toavoid penalizing hospitals for fac-tors outside their control, CMShas adjusted for hospital case-mixand allowed for certain patient-level exclusions, including “leftagainst medical advice,” dischargedto another acute care facility, ordied in the hospital (49). Somestakeholders have taken a firmerstance in measuring 30-day read-mission rates. The National Com-mittee for Quality Assurance hasdeveloped an all-cause readmis-sions measure in which all commercial and Medicare read-missions for patients older than 18years of age, regardless of whetherthey were planned or unplanned,are included in this quality metric(www.qualitymeasures.ahrq.gov/content.aspx?id=34747).

The Hospital Consumer Assess-ment of Health care Providers andSystems report provides hospitalswith patient survey results regard-ing the quality of discharge andcommunication with health careproviders (www.hcahpsonline.org/home.aspx).The Joint Commis-sion requires hospitals and healthsystems to ensure that medicationreconciliation is conducted and

PracticeImprovement


50. Maynard GA, Bud-nitz TL, Nickel WK,Greenwald JL, KerrKM, Miller JA, et al.2011 John M. Eisen-berg Patient Safetyand Quality Awards.Mentored imple-mentation: buildingleaders and achiev-ing results through acollaborative im-provement model.Innovation in patientsafety and quality atthe national level. JtComm J Qual Pa-tient Saf.2012;38:301-10.[PMID: 22852190]

51. Boutwell AE, John-son MB, RutherfordP, Watson SR, Vec-chioni N, AuerbachBS, et al. An earlylook at a four-stateinitiative to reduceavoidable hospitalreadmissions. HealthAff (Millwood).2011;30:1272-80.[PMID: 21734200]

52. Giordano A, ScalviniS, Zanelli E, Corrà U,Longobardi GL, RicciVA, et al. Multicenterrandomised trial onhome-based telem-anagement to pre-vent hospital read-mission of patientswith chronic heartfailure. Int J Cardiol.2009;131:192-9.[PMID: 18222552]

53. Chaudhry SI, Mat-tera JA, Curtis JP,Spertus JA, Herrin J,Lin Z, et al. Telemon-itoring in patientswith heart failure. NEngl J Med.2010;363:2301-9.[PMID: 21080835]


measure the effect of new transitionsprograms. The CCTP awardeeshave established partnerships withdiverse organizations, including theArea Agency on Aging, local hospi-tals, pharmacies, medical plans, fed-erally qualified health centers, skillednursing facilities, rehabilitation cen-ters, home health agencies, hospiceagencies, and Medicare’s QualityImprovement Organizations, to address care transitions needs forhigh-risk Medicare beneficiaries. Inaddition to the CCTP, the Partner-ship for Patients initiative providesresources and support through Hos-pital Engagement Network (HEN)organizations. The 26 HEN organi-zations represent national, regional,state, and local systems that identifysuccessful strategies to reduce hospi-tal readmissions and helps dissemi-nate these ideas to hospitals andhealth care providers (http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html).

The CMS Center for Medicare andMedicaid Innovations has severaldemonstration and pilot programsthat aim to better understand howhealth care delivery can be improved.Many of these programs call for the creation of partnerships acrosshealth care organizations, communi-ty organizations, and health careproviders. Improving care transitionsis a key goal of the demonstrationprograms, and 30-day readmissionrates will be reported (www.innovations.cms.gov/initiatives/index. html). Many of these innova-tive programs are ongoing, and anythat show positive results will be ex-pected to share their findings andhelp disseminate best practices.

What are some other innovativepractice solutions that effect asuccessful transition from thehospital?The Society of Hospital Medi-cine’s national care transitionsimprovement program titled

Better Outcomes by OptimizingSafe Transitions (BOOST) pro-vides a mentored implementationprogram for hospitals to analyzeand redesign their systems of careused in care transitions (50). Cur-rently, there are over 100 BOOSTsites throughout the UnitedStates and Canada. Similarly, theState Action on Avoidable Re-hospitalizations initiative hasbrought together 148 hospitalsacross 4 states to collaborate andshare best practices on reducingreadmissions (51).

At the state level, the MichiganTransitions of Care Collaborative(M-TC2) was created to engageboth hospitals and physician or-ganizations in improving caretransitions and reducing readmis-sion rates. Supported by BlueCross Blue Shield of Michigan,M-TC2 has implemented theBOOST principles while also tak-ing advantage of existing state-wide efforts to assist hospitals andphysician organizations in im-proving population health man-agement through creation of robust advanced medical homesand organized systems of care.Blue Cross Blue Shield of Illinoishas similarly funded the Prevent-ing Readmissions through Effec-tive Partnerships initiative, whichhas enrolled 27 hospitals acrossIllinois in Project BOOST.

There is significant interest in theuse of telemonitoring technologyto facilitate smooth transitions inwhich patients receive ongoingsupport in their homes throughvirtual communication with healthcare providers. Results have beenmixed, with some studies suggest-ing benefit in populations withcertain conditions (e.g. heart fail-ure) (52), whereas other studieshave been unable to demonstratereduced readmissions or improvedmortality rates after hospital dis-charge (53, 54). The field oftelemedicine continues to advance


54. Takahashi PY, PecinaJL, Upatising B,Chaudhry R, ShahND, Van Houten H,et al. A randomizedcontrolled trial oftelemonitoring inolder adults withmultiple health is-sues to prevent hos-pitalizations andemergency depart-ment visits. Arch In-tern Med.2012;172:773-9.[PMID: 22507696]

55. Kertesz SG, PosnerMA, O’Connell JJ,Swain S, Mullins AN,Shwartz M, et al.Post-hospital med-ical respite care andhospital readmissionof homeless persons.J Prev Interv Com-munity. 2009;37:129-42. [PMID: 19363773]

56. Snow V, Beck D,Budnitz T, Miller DC,Potter J, Wears RL, etal. Transitions of CareConsensus policystatement: AmericanCollege of Physi-cians, Society ofGeneral InternalMedicine, Society ofHospital Medicine,American GeriatricsSociety, AmericanCollege Of Emer-gency Physicians,and Society for Aca-demic EmergencyMedicine. J HospMed. 2009;4:364-70.[PMID: 19479781]


in technology and should be con-sidered by health care organiza-tions for patients appropriate forthis intervention.

Homeless persons are a particu-larly challenging population andrequire innovative solutions foreffective transitions from the hos-pital back to the community.Medical respite programs aimedto assist homeless patients mayhelp them recover from theiracute illness and reduce the likeli-hood of being readmitted to thehospital (55). Support for suchprograms has been obtainedthrough both public and privatefunding sources.

What do professionalorganizations recommendregarding transitions of care?In 2007, several professional soci-eties, including the American College of Physicians, Society ofGeneral Internal Medicine, the So-ciety of Hospital Medicine, estab-lished the standards needed to address quality gaps in transitions ofcare and the components necessaryto address these standards (56).

The American College of Cardiol-ogy, in partnership with the Insti-tute for Healthcare Improvement,provides information on strategies

to reduce cardiovascular-relatedhospital readmissions(www.h2hquality.org/), and the As-sociation of American MedicalColleges, in partnership with Uni-versity HealthSystem Consortium,has developed Best Practices forBetter Care, in which medicalschools and teaching hospitals par-ticipate and commit to improvingpatient care and medical educationon such topics as reducing hospitalreadmissions for high-risk patients(https://www.aamc.org/initiatives/bestpractices/commitment/180550/reduce_readmissions.html).

Other guides on improving caretransitions have been developed bythe National Transitions of CareCoalition (www.ntocc.org), CareTransitions Program (www.caretransitions.org/), Transitional CareModel (www.innovativecaremodels.com/care_models/21/key_ elements), and Institute forHealthcare Improvement’s StateAction on Avoidable Rehospital-izations program (www.ihi.org/offerings/ Initiatives/STAAR/Pages/ default.aspx). These organi-zations provide information ontheir care transition improvementprograms, how to implement theirmodel, and how to access a com-munity of organizations and indi-viduals utilizing these practices.

Practice Improvement... Research studies, learning collaboratives, and profes-sional medical societies have established best practices to assist hospitals andhealth systems in tracking and improving their care transition processes. Regu-latory agencies and other key stakeholders increasingly use financial mecha-nisms to incentivize or penalize hospitals and health systems to improveprocess and outcomes measures related to care transitions. To develop theirimprovement efforts, hospitals can align themselves with providers, externalcare facilities, and other organizations based in the community to help pa-tients navigate the health system. In the era of payment reform and paymentmodels in which health care organizations are reimbursed for episodes of care,innovative practice solutions in which payers, hospitals, and providers partnerto assist patients could help improve care transitions, reduce risk for adversepostdischarge events, improve patient satisfaction, and potentially realize costbenefit.



Inth

eC l

inicTool KitIn the Clinic

Transitions ofCare

PIER Modulehttp://pier.acponline.org/physicians/ethical_legal/el755/el755.htmlhttp://pier.acponline.org/physicians/diseases/d1057/d1057.htmlPIER modules on ethics and palliative care and drug

prescribing in the older patient from the American Collegeof Physicians (ACP).

Patient Informationhttp://pier.acponline.org/physicians/ethical_legal/el755/el755

.html-pi.htmlAccess the patient information material that appears on the

following page for duplication and distribution to patients.www.ntocc.org/WhoWeServe/Consumers.aspxInformation for patients and families on improving transitions

of care from the National Transitions of Care Coalition.www.medicare.gov/campaigns/caregiver/caregiver.htmlResources on caring for someone with a chronic illness, care-

giver support, and Medicare home health coverage, from theCenters for Medicare & Medicaid Services (CMS).

www.cancer.gov/cancertopics/pdq/supportivecare/transitionalcare/Patient

Patient summary on transitional care planning for adults withcancer, adapted from a summary by cancer experts for healthprofessionals, from the National Cancer Institute.

www.acponline.org/patients_families/end_of_life_issues/Series of brochures on end-of-life care transitions, from ACP.

Clinical Guidelineswww.ncbi.nlm.nih.gov/pmc/articles/PMC2710485/2009 transitions of care consensus statement from several

societies, including ACP, Society of General Internal Medicine,and Society of Hospital Medicine (SHM).

www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html

Roadmap to Better Care Transitions and Fewer Readmissions,a program from HHS to reduce preventable hospitalreadmissions within 30 days of discharge.

Diagnostic Tests and Criteriawww.hospitalmedicine.org/ResourceRoomRedesign/RR

_CareTransitions/html_CC/06Boost/07_Boost_Tools.cfmPatient PASS, a transition record from SHM to prepare for

successful discharge.www.hospitalmedicine.org/ResourceRoomRedesign/RR

_CareTransitions/html_CC/06Boost/02_TARGET.cfmTARGET, a geriatric evaluation form to address risk during

transitions of care, from SHM.

Quality-of-Care Guidelineshttp://psnet.ahrq.gov/primer.aspx?primerID=11Patient safety information related to adverse events after

hospital discharge from the Agency for Healthcare Researchand Quality of HHS.

www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_caretransitions/index.aspx

Information on evidence-based care transition models from theAging & Disability Resource Centers program, a projectfunded by the Administration on Aging and CMS.

www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

The BOOSTing Care Transitions resources from SHM helpproviders optimize the discharge process.

www.bu.edu/fammed/projectred/index.htmlThe project RED (Re-Engineered Discharge) tool kit in-

cludes 5 tools that provide step-by-step instructions as aspringboard for hospitals to proactively address avoidablereadmissions.

5 March 2013Annals of Internal MedicineIn the ClinicITC3-14© 2013 American College of Physicians


In the ClinicAnnals of Internal Medicine

Pati

ent

Info

rmat

ion

THINGS YOU SHOULDKNOW ABOUTTRANSITIONS OF CARE

What are transitions of care?• When patients move from an inpatient setting to an

outpatient setting. Often the transition is from hos-pital to home.

• The transition can be hard on patients and theirfamilies and other caregivers as they adjust to newroutines and responsibilities.

• Careful planning and coordination and effectivecommunication can ease the transition.

Who should be involved in dischargeplanning?• Patient.• Hospital staff (nurses, therapists, and doctors

involved in patient care).• Primary care doctor.• Home care nurse• Pharmacist (for prescription information).• Family and any other caregivers.

What are the risks of transitions ofcare?• Patients are at risk for complications after hospital

discharge, such as needing rehospitalization due tomedication errors, inadequate medical follow-up,and other medical management problems

What can improve transitions of care?• Anticipate the hospital discharge and discuss with

your hospital-based health care providers aboutwhen you’ll be going home and what to expect.

• A discharge instruction to patients outlining impor-tant, understandable, and well-structured informa-tion about diagnosis (reason for hospitalization), a

reconciled medication list, a follow-up appointmentplan with their primary care provider, test and studyresults that need further follow-up, list of warningsigns with instructions on what to do, and whom tocontact in case questions arise after going home.

• Timely communication between the hospital doctorsand your primary care doctors.

• Access to resources for posthospital care.• A visit with your primary care physician soon after

discharge, which allows him or her to assess yourprogress, provide any needed treatment, and answerquestions about your care.

For More Informationwww.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=2312A guide on hospital discharge planning for families and

caregivers from the Family Caregiver Alliance.

http://nextstepincare.org/http://nextstepincare.org/Caregiver_Home/What_Do_I_Need/www.caretransitions.org/caregiver_resources.aspWeb sites to help caregivers and health care providers work

together towards achieving safe transitions of care.

AcknowledgmentThe authors would like to thank Dr. Mark Williams, Professor of Medi-cine, Northwestern University, for comments on an earlier version ofdraft of this manuscript.


CME Questions

5 March 2013Annals of Internal MedicineIn the ClinicITC3-16© 2013 American College of Physicians

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/

to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

1. A 67-year-old woman is admitted to thehospital with pneumonia. Blood culturesare obtained and she is started onparenteral antibiotics. She clinicallyimproves over the next 2 days, and is to bedischarged from the hospital to complete acourse of oral levofloxacin.

On the morning of discharge, the physicianreceives a call from the microbiology labthat one of the two sets of blood culturesis growing gram-positive cocci in chains.The physician felt that the culturedorganism likely represented Streptococcuspneumonia from her community-acquiredpneumonia, and discharged the patient.

Two weeks later, the patient is readmittedto the hospital with fever, chills, andgeneral malaise. She states that shecompleted the course of oral antibiotics,but started to feel sick again. Uponevaluation of the patient’s medicalrecords, the admitting physiciandiscovers that the blood culture resultfrom the previous hospitalization wasfinalized as Enterococcus faecalis, andresistant to fluoroquinolones. The patientdid not see her primary care physiciansince leaving the hospital, and thedischarge summary was completed 1week ago, which was sent to the primarycare physician’s electronic medical recordinbox.

Which of the following discharge processimprovement efforts is the best strategy toreduce the risk for this type ofpostdischarge event?

A. Discharge patients only after all cultureresults and sensitivities are finalized

B. Tell patients with pending cultureresults to call the hospital 72 hoursafter discharge for results

C. Complete discharge summariesimmediately and highlight any pendingtest results, recommend timelypostdischarge appointments withprimary care physicians, andcommunicate this information topatients and PCPs

D. Have patients follow up with the pri-mary care physician within 30 days ofhospital discharge

2. An 83-year-old man with a history ofcoronary artery disease is admitted to thehospital with shortness of breath. Anechocardiogram reveals a reduced leftventricular ejection fraction, which is newfor the patient. He is diagnosed withcongestive heart failure and started onappropriate medications.

Medicare is his primary insurance. He isable to drive and carry out all activities ofdaily living. He lives with his wife anddaughter.

Which of the following characteristics ismost likely to contribute to this patient’srisk for adverse postdischarge events?

A. His ageB. His home family supportC. His insurance statusD. His congestive heart failure

3. A 45-year-old woman is admitted to thehospital with symptoms of poorlycontrolled diabetes. Her blood glucoselevel in the emergency department was558 mg/dL, and her hemoglobin A

1Cis

12.2%. She is started on an insulin dripand intravenous fluids, and quicklyimproves. Over the prior 6 months, herprimary care physician has discussed theneed to start insulin, which she is nowwilling to accept. She has never takeninsulin before.

She lives with her husband near herprimary care physician’s office. She worksas an administrative assistant and hascommercial insurance.

What is the best approach to help thispatient become familiar with theadministration and use of her new insulinregimen?

A. Refer her to her insurance company’sdiabetes educator

B. Provide instructions on how to use theinsulin and have her demonstrate whatshe needs to do

C. Provide a discharge summary, areconciled list of medications, andprescriptions for insulin and supplies,and refer her to a diabetes supportgroup

D. Provide prescriptions for insulin andsupplies and arrange follow up with herprimary care physician within 7 days

4. A 72-year-old man with a history ofhypertension, diabetes, and atrialfibrillation maintained on warfarin isadmitted to the hospital and found tohave an acute myocardial infarction. Heundergoes coronary reperfusion therapy,and receives two coronary stents.

At the time of discharge from the hospital,the patient is given prescriptions for hisnew medications and is instructed toresume his previous home medications.

Four weeks later, the patient presents tothe emergency department with newonset of slurred speech and right facialdroop. His admission labs reveal aninternational normalized ratio of 1.0.When asked about his warfarin, thepatient states that he discontinued thatmedication after he read on the Internetthat taking warfarin in combination withclopidogrel could increase his risk forbleeding.

Which of the following approaches wouldbe most likely to prevent this type ofpostdischarge event?

A. Provide a reconciled dischargemedication list, along with medicationeducation and the support of a clinicalpharmacist for high-risk patients

B. Provide patients with Web sites thatpost only reliable information

C. Ensure that the patient’s primary carephysician receives a dischargesummary, including an updatedmedication list

D. Make sure the patient fills allprescriptions in the hospital beforedischarge


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