Care Transitions – Critical to Quality and Patient Safety Society of Hospital Medicine Lakshmi K. Halasyamani, MD

Society of Hospital Medicine Professional Society for Hospitalists and other hospital-based healthcare professionals (nurses, pharmacists, AHP, etc….) Total number of members > 6000

Areas of Interest/Focus Management of patient populations in hospital Teamwork Hand offs Care Transitions

Overview of Care Transitions Admission to Hospital (From ED or Direct admission) Transitions within hospitalization (shift/service change transitions/handoffs) Transition from hospital to post-acute setting (home, subacute facility/nursing home, hospice, other acute care setting) Transitions within outpatient care delivery settings

SHM and Care Transitions Defining Standards Developing Team-based Interventions Evaluating Interventions Influencing Policy

Defining Standards Participation in consortiums regarding care transitions: –SUTTP – Stepping Up to the Plate –TOCCC – Transitions of Care Consensus Conference –NTOCC – National Transitions of Care Coalition Development of Hospitalist Standards for Discharge and Shift/Service change transition

Key Messages Patient-Centered Transitions involve two-way communication of information Timely Clinician accountability Development of standardized care transition data set Need for communication infrastructure

Developing Interventions SafeSteps – pilot initiative to improve medication safety Hartford BOOST initiative -- Better Outcomes for Older Adults through Safe Transitions Common Theme: Focus on Implementation and real-world sustainability of initiatives

SHM/Hartford Partnership BOOST Advisory Board: –American Geriatrics Society –American Society of Health-System Pharmacists –Case Management Society of America –Blue Cross Blue Shield Association –Centers for Medicare and Medicaid Services –The Families and Healthcare Project –Society of General Internal Medicine –Institute for Healthcare Improvement –John A Hartford Foundation –Joint Commission –Agency for Health Research and Quality –National Quality Forum

Philosophy of Initiative Patient/Family/Caregiver –centered Multi-disciplinary Team-based Embedded in care delivery to promote sustainability Includes both academic and community settings Includes rigorous evaluation

Components of Initiative Develop Interventions to Improve Discharge Care Transition –Patient-centered risk assessment –Identification of Gaps –Engagement of patient/family/caregiver through teach back strategy

Components of Initiative Develop Implementation Guide Develop Network of Institutions to implement discharge interventions Identify Facilitating Factors Identify Barriers

Influencing Policy Work with organizations developing care transition measures Focus on discharge and shift/service change as a standardized team process Work collaboratively with other organizations to develop a multi- disciplinary strategy to improve care transitions

Future Directions Alignment of payers and systems around safe care transitions Work with major HIT vendors regarding standardization of pathways to improve care transitions Partner with home and community services to facilitate seamless care transitions across the continuum