Transitional Care Can Reduce Hospital Readmissions
Transitional Care Can Reduce Hospital Readmissions
Transitional care programs that reduce both healthcare costs and readmissions include the care transitions intervention model (Coleman model), transitional care model (Naylor model), and Better Outcomes for Older Adults through Safe Transitions (BOOST) model.
Eric Coleman's care transitions intervention model is a 4-week program designed to foster patient engagement and promote a smooth transition from the hospital or skilled nursing facility to the home. It has been shown to decrease rehospitalizations. This model rests on four pillars:
A transition coach focuses on the patient's self-identified goals and helps the patient develop self-management skills. The relationship is relatively short, spanning only the 4-week intervention period, and the coach doesn't assume home-care or case-management responsibilities. Coaching starts in the hospital, where the coach describes the transitional care program, obtains the patient's consent to participate, and introduces the Coleman personal health record (www.caretransitions.org/documents/phr.pdf). This recordguides the patient in documenting medication and other medical information and generates a list of questions for the healthcare provider. A home visit is scheduled within 72 hours of discharge.
During the home visit, the coach assists the patient with a pre-/posthospitalization medication review and addresses any discrepancies. The patient develops his or her own list of questions for the primary care provider. The coach and patient review the discharge plan and update the personal health record. Finally, the coach discusses symptoms and drug side effects and establishes an alert-and-response system.
After the home visit, three follow-up calls take place to address the patient's remaining medication questions, discuss the outcomes of follow-up primary care provider visits, describe available support services, and assist with scheduling additional follow-up appointments as needed.
Mary Naylor's transitional care model involves a 1-to-3 month period of interventions with high-risk older adults to prevent hospital readmission. An advanced practice registered nurse (APRN) performs a predischarge patient assessment, and then collaborates with the hospital team to develop a transitional care plan.
The APRN makes multiple home visits, uses telephone outreach throughout the transitional care period, and promotes information transfer between the acute-care and primary-care settings by accompanying the patient to the first primary care follow-up visit. Cornerstones of this model are patient engagement, goal setting, and communication with patients, families, and healthcare team members. The APRN helps the patient identify early signs and symptoms of a worsening condition to expedite prompt intervention and avoid future hospitalization.
Patients with specific risk factors are good candidates for this care model. (See the box )
An initiative of the Society of Hospital Medicine, Project BOOST was developed by a team of payers, regulators, and leaders in healthcare transitions and hospital medicine to improve the quality of care transitions. This model focuses on discharge processes and communication with patients and receiving providers. It uses a systemic approach to enhance the quality of transitions and gives clinicians tools to help them standardize, initiate, and improve hospital practices. Evidence-based tools are available in a toolkit available free of charge to healthcare professionals with an interest in transitional care. Project BOOST also provides technical support and education to project management teams and helps develop a community of organizations that freely share strategies and struggles with program implementation.
Project BOOST involves discharge planning, medication reconciliation, patient and family communication, and primary care provider communication before discharge. It includes post-discharge telephone follow-up (including facilitating appointment scheduling). Patient-centered discharge instructions actively involve the patient in his or her own care.
The BOOST Risk Assessment Tool, called the "8 P's," identifies modifiable risk factors that guide discharge planning. (See the box )
Project BOOST aligns evidencebased interventions with specific problems identified by the "8 P's" tool. It maximizes patient involvement in the plan of care through concise patient-centered discharge instructions tailored to the patient's literacy level. The instructions include the reason for hospitalization, red flags signaling complications, follow-up appointments, post-discharge care, key contact information, and space for the patient to list questions for the primary care provider. Before discharge, nurses use the teach-back method to review this information with the patient.
Specific Care Transition Models
Transitional care programs that reduce both healthcare costs and readmissions include the care transitions intervention model (Coleman model), transitional care model (Naylor model), and Better Outcomes for Older Adults through Safe Transitions (BOOST) model.
Care Transitions Intervention Model
Eric Coleman's care transitions intervention model is a 4-week program designed to foster patient engagement and promote a smooth transition from the hospital or skilled nursing facility to the home. It has been shown to decrease rehospitalizations. This model rests on four pillars:
medication self-management
maintenance of a personal health record
primary care physician follow-up
alertness to red flags.
A transition coach focuses on the patient's self-identified goals and helps the patient develop self-management skills. The relationship is relatively short, spanning only the 4-week intervention period, and the coach doesn't assume home-care or case-management responsibilities. Coaching starts in the hospital, where the coach describes the transitional care program, obtains the patient's consent to participate, and introduces the Coleman personal health record (www.caretransitions.org/documents/phr.pdf). This recordguides the patient in documenting medication and other medical information and generates a list of questions for the healthcare provider. A home visit is scheduled within 72 hours of discharge.
During the home visit, the coach assists the patient with a pre-/posthospitalization medication review and addresses any discrepancies. The patient develops his or her own list of questions for the primary care provider. The coach and patient review the discharge plan and update the personal health record. Finally, the coach discusses symptoms and drug side effects and establishes an alert-and-response system.
After the home visit, three follow-up calls take place to address the patient's remaining medication questions, discuss the outcomes of follow-up primary care provider visits, describe available support services, and assist with scheduling additional follow-up appointments as needed.
Transitional Care Model
Mary Naylor's transitional care model involves a 1-to-3 month period of interventions with high-risk older adults to prevent hospital readmission. An advanced practice registered nurse (APRN) performs a predischarge patient assessment, and then collaborates with the hospital team to develop a transitional care plan.
The APRN makes multiple home visits, uses telephone outreach throughout the transitional care period, and promotes information transfer between the acute-care and primary-care settings by accompanying the patient to the first primary care follow-up visit. Cornerstones of this model are patient engagement, goal setting, and communication with patients, families, and healthcare team members. The APRN helps the patient identify early signs and symptoms of a worsening condition to expedite prompt intervention and avoid future hospitalization.
Patients with specific risk factors are good candidates for this care model. (See the box )
Project BOOST
An initiative of the Society of Hospital Medicine, Project BOOST was developed by a team of payers, regulators, and leaders in healthcare transitions and hospital medicine to improve the quality of care transitions. This model focuses on discharge processes and communication with patients and receiving providers. It uses a systemic approach to enhance the quality of transitions and gives clinicians tools to help them standardize, initiate, and improve hospital practices. Evidence-based tools are available in a toolkit available free of charge to healthcare professionals with an interest in transitional care. Project BOOST also provides technical support and education to project management teams and helps develop a community of organizations that freely share strategies and struggles with program implementation.
Project BOOST involves discharge planning, medication reconciliation, patient and family communication, and primary care provider communication before discharge. It includes post-discharge telephone follow-up (including facilitating appointment scheduling). Patient-centered discharge instructions actively involve the patient in his or her own care.
The BOOST Risk Assessment Tool, called the "8 P's," identifies modifiable risk factors that guide discharge planning. (See the box )
Project BOOST aligns evidencebased interventions with specific problems identified by the "8 P's" tool. It maximizes patient involvement in the plan of care through concise patient-centered discharge instructions tailored to the patient's literacy level. The instructions include the reason for hospitalization, red flags signaling complications, follow-up appointments, post-discharge care, key contact information, and space for the patient to list questions for the primary care provider. Before discharge, nurses use the teach-back method to review this information with the patient.
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