Download 6 Optimization Strategies for Transitions of Care and

Section 6.1 Optimize
Optimization Strategies for Transitions of
Care and Care Coordination
This tool can help you improve transitions from one care setting to another and coordination and
information sharing between health care organizations and between clinicians.
Time needed: 2 hours
Suggested other tools: NA
Introduction
The National Transitions of Care Coalition (NTOCC) has observed: “In spite of world-class clinical
advancements and talent, the United States’ health and long term care system is plagued by
suboptimal care quality. Problems of underuse, overuse, and misuse of health care all contribute to
these quality issues. Care episodes often involve numerous settings and multiple highly-specialized
professionals, with little or no communication between them.”1A study conducted for the National
Partnership for Women & Families
(www.nationalpartnership.org/site/DocServer/Lake_Poll_Media_Report_Final.pdf?docID=6242)
found that 74 percent of those surveyed said that they wished their doctors talked and shared
information with each other; 45 percent said that they have had to act as communicators between
doctors who were not talking to each other.
Improving transitions of care and care coordination are essential to improving the quality of our care.
How to Use
1. Distinguish between transitions of care and care coordination.
2. Plan approaches to how your home health agency may be able to improve transitions of care and
care coordination.
3. Utilize electronic health records (EHRs), health information exchange (HIE), and other health
information technology (HIT) to support transitions of care and care coordination.
Key resource: http://www.ntocc.org/WhoWeServe/HealthCareProfessionals.aspx
Transitions of Care and Care Coordination
The NTOCC distinguishes between transitions of care and care coordination:

Transitions of care “refer to the movement of patients between health care locations,
providers, or different levels of care within the same location as their conditions and
care needs change” and “are a set of actions designed to ensure coordination and
continuity of care. They should be based on a comprehensive care plan and the
availability of practitioners who have current information about the patient’s
treatment goals, preferences, and health or clinical status.”
1
National Transitions of Care Coalition, 2010. Position Paper: Improving Transitions of Care with Health
Information Technology, available at: http://www.ntocc.org/Portals/0/PDF/Resources/HITPaper.pdf
Section 6 Optimize—Optimization Strategies for Transitions of Care and Care Coordination - 1

Care coordination is a broader concept. NTOCC describes care coordination as “the
deliberate organization of patient care activities among two or more participants
(including the patient and/or the family) to facilitate the appropriate delivery of
health care services.” The Agency for Healthcare Research and Quality (AHRQ) 2
has identified five key elements comprising care coordination:
o Numerous participants are typically involved in care coordination.
o Coordination is necessary when participants are dependent upon each other
to carry out disparate activities in a patient’s care.
o In order to carry out these activities in a coordinated way, each participant
needs adequate knowledge about their own and others’ roles, and available
resources.
o In order to manage all required patient care activities, participants rely on
exchange of information.
o Integration of care activities have the goals of facility-appropriate delivery of
health care services.
The AHRQ study also notes some key attributes of care coordination. You can use
these attributes as a checklist or springboard for discussion among the participants in
care coordination to break down traditions and improve results:
o Collaboration
 Interactions based on shared power and authority and mutual respect
for the unique abilities of each participant.
 Cooperative problem-solving and decision making, where
participants achieve better patient care by working together than
would have been possible individually.
o Teamwork
 Individuals from different disciplines contribute specialized
knowledge.
 Nonhierarchical relationships.
 Participants act according to situational demands rather than
traditional organizational roles.
 Mutual adjustments are made among participants to coordinate care,
especially as the level of interdependence among participant’s
separate activities increases.
o Continuity of care, which is the extent to which the appropriate care is
provided at the right time and in the right order by the right persons.
 Informational continuity is use of information on past events and
personal circumstances to make current care appropriate for each
individual.
 Interpersonal continuity is ongoing therapeutic relationships between
a patient and one or more clinicians.
 Management continuity is a consistent and coherent approach to
managing a health condition that responds to the patient’s changing
needs.
2
McDonald, KM et al. 2007 Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol.
7 Care Coordination) Agency for Healthcare Research and Quality. Available at:
http://www.ncbi.nlm.nih.gov/books/NBK44012/
Section 6 Optimize—Optimization Strategies for Transitions of Care and Care Coordination - 2
Approaches to Improving Transitions of Care and Care Coordination
The following table lists key considerations proposed by the NTOCC and others for contributing to
successful transitions of care and care coordination. Also listed are the types of EHR functions, HIE
services, and other HIT that may be needed for support. Determine the areas of potential progress for
your home health agency and the type of technology you would strive to acquire.
Considerations for Improving Transitions
of Care (Adapted from NTOCC)
Improve communications during transitions
between providers, patients, and family
caregivers.
Ensure medication reconciliation at every
transition of care.
Expand the role of pharmacists in transitions
of care with respect to medication
reconciliation.
Establish points of accountability for
sending and receiving care, especially for
physician oversight.
Increase the use of case management and
professional care coordination.
Implement payment systems that align
incentives.
Develop performance measures to
encourage better transitions of care.
Adopt standardized way to exchange
information to avoid adverse consequences
for patient care.
Utilize clinical decision support to alert user
that additional information is needed
Technology Suitable for Supporting
Transitions of Care
 Clinical summaries in CCD or C-CDA
format
 Health information exchange
organization (HIO) to support querying for
additional needed information
 Personal health record
 ADT
 E-prescribing system with access to all
prescribed medications
 Medication list management from HIO
 Medication reconciliation software in
EHR
 Tele-pharmacy consults
 Drug knowledge database accessible to
all stakeholders
 Use of fill status notification in eprescribing systems
 Provider portal to agency EHR
 Workflow support in EHR
 HIO support for tracking patient episodes
of care
 Directory of community services
maintained by an HIO
 Directory of providers, care
coordinator/case manager specific to each
patient maintained by an HIO
 Although this requires national health
reform, on a local level an HIO could be a
convener for accountability in care
 Integrate clinical and financial
information and use analytics tools at the
local and community levels to promote the
health care value proposition
 Embedded evidence-based knowledge in
EHR
 Ensure EHR and HIE follow technical,
semantic, and process interoperability
standards
 Inclusion of clinical decision support
rules that look for necessary information
and alert user to query HIO
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Utilize clinical decision support to alert
caregivers of signs or symptoms that could
worsen and require re-hospitalization or
emergency visit
 Inclusion of clinical decision support
rules in EHR
Copyright © 2013
Section 6 Optimize—Optimization Strategies for Transitions of Care and Care Coordination - 4
Updated 03-18-14