Transition planning, management focus on continuity of care
Have we moved beyond the concept of "discharge"?
Don't say "discharge" to Hussein Michael Tahan. He prefers that you use the word "transition," as in transition planning and management.
Tahan is an independent consultant in hospital development, management and operations, and health care delivery system design. He also holds a doctorate in nursing science. He recently served as the executive director of International Health Services at the New York-Presbyterian Hospital and the University Hospital of Columbia and Cornell, in New York City.
In a hospital setting, discharge may imply an end, he says, while transition implies continuity. It suggests that care will be continuing, either with different healthcare professionals in a new setting or with the patient's family at home.
Whoever is taking over the job of providing care must understand the patient's needs, says Tahan, a member of the Case Management Society of America (CMSA) and a participant in the National Transitions of Care Coalition (NTOCC).
And the first need is for timely, comprehensible information.
In the past, Tahan says, health care professionals were focused primarily on discharges from a hospital setting. But he would like to see more attention paid to transition planning.
There are many types of transitions, he said. They can be from the emergency room to critical care, to a different floor in a hospital, or from one part of a healthcare organization to another for example, from acute care in a hospital to skilled care in a rehabilitation facility or a nursing home. Or it may be a matter of just going home. Transitions may be made from general practitioner to specialist, or from acute care to hospice care, with the consequent shift from curing to end-of-life care.
Transition planning is important, Tahan says, in order to maintain quality of care, patient safety, and the efficient and effective delivery of care, and to assure a good, comfortable, rewarding experience for the patient.
To deal effectively with transitions, you have to be a superior communicator, Tahan says. In every setting and at every stage, there's a message that needs to be communicated.
There's someone who wants to share the message, and someone who needs to receive it. To do this well, an organization needs to develop a basic communication model, a way to implement these messages within the system, so that transitions will produce the most positive outcomes possible.
Case managers may assume somebody is going to inform other healthcare providers about the patient when he or she goes from one setting to another. But such assumptions often result in a failure to pass on the necessary information in a timely fashion. Or the message given may not tell the total picture of what needs to be shared.
To set up the system properly for any given situation, one needs to step back and identify the owner of the communication, and the person responsible for making sure the communication is taking place, Tahan says. Then one needs to be sure the proper people know that a particular person is responsible for ensuring that the message is passed along.
More often than not, he says, the person responsible for passing on such messages is the case manager.
Tahan says the National Transitions of Care Coalition looked into the situation and identified relevant issues in the health care system that enabled members to come up with a model of communication that's simple and applicable in any setting. Anyone can take it and implement it. (It can be found online, along with other helpful information, at http: www.ntocc.org.)
Patients and their families have to consent to the plan of care, Tahan says, and become partners with the healthcare professionals. Is the patient going home to nothing? Or home to receive outpatient care? Or to another facility?
"It's important to communicate with all the team members," and to understand the transition plan and the associated financial and reimbursement implications, he says.
It's not enough to say, "'Well, we're going to get an MRI.' We're going to see what the results show and whether the patient meets the criteria for a skilled care facility," he said.
One person on the team assumes responsibility for communication. If the patient is moving to a skilled care facility, the team member in charge of communication contacts the skilled care facility and informs it of the plan of care.
"In the past, we may have faxed information, but not followed up to make sure the information went to the right office," Tahan says. "It sat there and nothing was done with it. Opening lines of communication is important, and it's got to be done in a timely fashion."
If the right information is shared, when the patient goes to the next healthcare provider, he, and/or his caregiver, knows whom to call when questions come up. If you first establish who is responsible on both ends, the continuity of care is maintained.
"In any transition, we tend to communicate medical procedures, but we have to communicate more than the medical plan; we have to communicate psychological, social and financial matters as well," Tahan says.
Does the patient have a DNR order? Have all medications been reconciled? Have all the issues been explained and documented? Where does the patient stand financially? Are they running out of benefits? Do they need transportation to dialysis treatment? Do they need equipment for home? Is there a social support system waiting for them?
"Whatever you do, you need to evaluate if it's working or not," Tahan says. "You need to come up with indicators of what you've done and measure its impact. You need to make sure that at every transition the provider has received the information, understood it, and can act on it."
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