Transitional care

Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. The term “care transitions” refers to 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. “Transitional care” refers to the actions of healthcare providers designed to ensure the coordination and continuity of health care during this movement.

A recent position statement from the American Geriatrics Society defines transitional care as follows: For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

Why is there interest in defining and understanding transitional care?

During transitions, patients with complex medical needs, primarily older patients, are at risk for poorer outcomes due to medication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers. Most research in the area of transitional care has studied the transition from hospitalization to the next provider setting – often a sub-acute nursing facility, a rehabilitation facility, or home either with or without professional homecare services. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability, and death. Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being readmitted to the hospital. As healthcare expenditures rise at an unsustainable rate there is increasing focus by patients, providers and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations.

Measuring and improving the quality of transitional care

After leaving a particular care setting, older patients may not understand how to manage their health care conditions or who to call if they have a question or if their condition gets worse. Poorly managed transitions can lead to physical and emotional stress for both patients and their caregivers. During a transition, the patients' preferences or personal goals in one setting may not be passed on to the next setting. This may result in important elements of the care plan "falling through the cracks".

The only currently nationally endorsed measure of transitional care quality is the Care Transitions Measure (CTM), which is a 15-item survey for administration to patients after discharge from the hospital. The measure also exists as a 3-item survey. Patient responses to the survey predicts return to the emergency department and/or hospital. Dr. Eric Coleman and his team at the University of Colorado Denver Health Sciences Center developed the CTM, as well as an intervention designed to improve patient outcomes during transitions. The Care Transitions Intervention (CTI) is a coaching intervention to assist patients in resuming self-care following a change in health status. It uses coaching techniques to ensure that patients are comfortable in managing their own medications and their own health information, understand the signs and symptoms that should lead them to contact a healthcare provider, and have assertion skills to ask important questions of providers. Although the coaching intervention occurs for the first 30 days following the transition, this approach has been shown to significantly reduce hospital readmission as far out as 6 months. Please visit www.caretransitions.org for additional information.