Download Transitions of Care

Transitions of Care
Michael LaMantia MD, MPH
Kristen Barrio MD
Kevin Biese MD, MAT
Definition & Fundamental Concepts
“A set of actions designed to ensure the coordination and continuity of healthcare as
patients transfer between different locations or different levels of care within the
same institution.”
–American Geriatrics Society (2003)
During transitions, patients are at risk for:
• Medical errors
• Service duplication
• Inappropriate care
• Critical elements of care plan “falling though the cracks”
-American Geriatrics Society (2003)
Conceptual model of effective transitional care (Coleman 2003):
• Communication between sending and receiving clinicians
• Preparation of the caregiver and patient for transition
• Reconciliation of medication lists
• Arranging a plan for follow-up of outstanding tests
• Arranging an appointment with receiving physician
• Discussing warning signs that might necessitate more
emergent evaluation
SAEM suggested Quality Measures to improve Transitional Care

If nursing home patient goes to emergency department, then paperwork
should state:
 Reason for Transfer
 Code Status
 Medication Allergies
 Contact Information for:
o Nursing home
o Primary care or on-call MD
o Resident’s health care power of attorney or
closest family member

If nursing home patient goes to emergency department, then
paperwork should include:
 Patient’s medication administration record

If nursing home patient goes to emergency room for requested studies, then:
 Document the performance of requested tests or the reason
why such tests were not performed

If nursing home patient goes to emergency department and will be released
from the emergency department, then:
 Emergency department provider should speak with the
nursing home provider, primary care or on-call MD for the
nursing home prior to discharge from the emergency
department

If nursing home patient goes to emergency department and will be released
from the emergency department, then written paperwork should state:
 Emergency department diagnosis
 Tests performed with results (and tests with pending results)

If nursing home patient goes to emergency department and is released back
to the nursing home, then:
 The patient should receive the recommended follow-up
 The recommended changes to the patient’s medications or
plan of care should be followed (or the reason why not
followed documented)
References:
Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic Emergency
Medicine 2009; 16:441-449.