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Transitions of Care:
What We Need to
Why areKnow
we involved?
www.ntocc.org
Current State of Healthcare
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Care is complex
Care is uncoordinated
Information is often not available to those who
need it when they need it
As a result patients often do not get care they
need or do get care they don’t need
IOM, Crossing the Quality Chasm
What is “Transition of Care”
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The movement of patients from one health care
practitioner or setting to another as their condition and
care needs change
Occurs at multiple levels
–
Within Settings
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Between Settings
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Primary care  Specialty care
ICU  Ward
Hospital  Sub-acute facility
Ambulatory clinic  Senior center
Hospital  Home
Across health states
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Curative care  Palliative care/Hospice
Personal residence  Assisted living
(c) Eric A. Coleman, MD, MPH
What is “Transitional Care?”
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A set of actions designed to ensure the coordination and
continuity of health care as patients transfer between
different locations or different levels of care within the same
location
Based on a comprehensive care plan and availability of welltrained practitioners that have current information about the
patient's goals, preferences, and clinical status.
Includes:
– Logistical arrangements
– Education of the patient and family
– Coordination among the health professionals involved in
the transition
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
Ineffective Transitions
Lead to Poor Outcomes
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Wrong treatment
Delay in diagnosis
Severe adverse events
Patient complaints
Increased healthcare costs
Increased length of stay
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature
Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/
AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf
Transition Issues Dramatically
Impact Patient Care
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
In-Patient
SNF
Patient
ALF
Transition Issues Dramatically Impact
Patient Care
NO
Discharge
Care Plan
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
NO
Medication
Reconciliation
NO
Personal
Medicine List
NO
Coordinated
Care Plan
In-Patient
SNF
Patient
ALF
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
What Can We Do …
Keep A Medication List
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Develop your “My Medicine List”
You can get started with a simple tool by
NTOCC
Download the tool from the website
Complete the tool with your personal
medications
Share that information with each clinician you
see whether in the ER, hospital, doctor’s office,
clinic or pharmacy
The NTOCC Tools Make it Possible
to Address the Transition Issues
Medication
Reconciliation
Data Elements
+
Care / Case
Transition Process
My
Med List
ER
ICU
In-Patient
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
Patient
SNF
ALF
Watch for New Patient
Tools Over the Next Few
Months
www.ntocc.org