1. Best Practices in Documentation Transfer Amanda Robbins, APRN, MSTexas Health Harris Methodist Hospital Fort Worth Emily Belew, MHA, LNFA Brookdale Senior Living

2. American Medical Directors Association (AMDA): 2010 Transitions of Care Clinical Practice Guidelines “Transitions of care involves the movement of a patient between care settings and the transfer of information with them to facilitate a seamless continuum of care and to enable patients’ wishes to be followed - no matter where in the continuum of care they are.”

3. American Medical Directors Association (AMDA): 2010 Transitions of Care Clinical Practice Guidelines “Poorly executed care transitions increase hospital admissions, duplication of services, and waste of resources…” http://www.amda.com/tools/clinical/transitionsofcare.cfm

4. Traditional Communication Model

5. NTOCC Conceptual Model for Transitions of Care

6. How are documents transferred?  Delivery-System Level  Clinician Level  Patient/Family Level Current PracticesBarriers  Inconsistent  Without purpose  Potentially harmful  Do not focus on the patient/resident

7. Barriers to Effective Care Transitions: Delivery-System  Care settings working in “silos”  Information systems – inoperable or incompatible  Financial incentives  Modification of drug regimens  Insurance-driven changes  Under-recognized issue to health policy makers

8. Barriers to Effective Care Transitions: Clinician  Continuity across care settings  Multiple Referrals without relevance to the patient’s overall care goals  Multiple Care Managers

9. Barriers to Effective Care Transitions: Patient/Family  Rarely advocate for improved transitions  Not informed about disease processes  Feel powerless  Knowledge v. complexity of the current medical model  Conflicting information  Culture, expectations, barriers

10. Recommended Best Practice? To ensure that patients and their critical medical information are transferred safely, timely, and efficiently. Transitions of Care Checklists Interventions to Reduce Acute Care Transfers