Annals of Long Term Care

This series of articles addresses how health care organizations (ie, organized or integrated care systems or large provider groups that receive payment under either a capitated or fee-for-service basis) can improve the quality of transitions among care venues for patients with complex care needs. Part I provided an introduction and discussed strategies for ensuring accountability for patients in transition and facilitating the effective transfer of information. Part II focuses on enhancing practitioners’ skills and support systems, and enabling patients and caregivers to play a more active role in their transitions. Part III will address the need to align financial and structural incentives to improve patient flow across care venues, and will recommend steps organizations can take to initiate a quality improvement strategy for transitional care.

Practitioner Skill Sets and Support System

Recommendations
Health care organizations (HCOs) should:
1. Improve practitioner knowledge of the services and settings available across the continuum of care to facilitate the best match between a patient’s care needs and the care setting.
2. Ensure that practitioners have support systems that facilitate providing treatment, information, durable medical equipment, and other services during a patient’s transition.
3. Assure that practitioners incorporate patients’ goals, preferences, and functional status into both short- and long-range care plans.

Statement of Problem
Practitioners generally lack training on how to execute effective transfers and often do not recognize their role in transition planning. The amount of effort expended in admitting a patient is often far greater than that expended in discharging a patient, when in fact the two should be comparable. Compounding the problem is the fact that most practitioners (eg, hospitalists, hospital discharge planners, skilled nursing facility [SNF] nurses, home health care nurses, care managers, primary care physicians [PCPs]) have had little exposure to sites of care other than those in which they practice, and are therefore unfamiliar with the ability of the receiving institution to manage complex patients. Without such knowledge, a patient may be transferred to a receiving care team that does not have the resources or skills necessary to meet the needs of particular patients.

Only rarely does a single clinician provide ongoing care to a patient transferring from one care setting to the next. Increasingly, PCPs do not follow their patients into the hospital or a rehabilitation facility. Furthermore, with the growing movement toward using institution-based physicians (ie, “hospitalists” and “SNFists”), who often work in rotating shifts, patients commonly receive care from multiple physicians in the same setting. Also, institution-based physicians often presuppose that a patient has a PCP who will assume care after discharge, which is not always the case.

Problems of continuity are not limited to physicians. A case manager or other professional in charge of coordinating care may be unaware when one of his or her patients has accessed an emergency department or was admitted to a hospital. Although the hospital or SNF may employ its own case managers, these professionals rarely have responsibility for patients after discharge, and rarely communicate directly with other case managers, disease managers, or staff at community-based organizations involved with the patient’s overall care. Thus, these patients may not have the benefit of continuity and advocacy at a time when they are acutely ill and vulnerable.

Nursing shortages further exacerbate the challenge of ensuring safe and efficient transfers. This shortage disproportionately affects post-acute and long-term care nursing facilities, which commonly experience high turnover and have difficulty attracting nurses, even when they are in reasonable supply.