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

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.”

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…”

Traditional Communication Model

NTOCC Conceptual Model for Transitions of Care

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

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

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

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

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