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• Evidenced-Based Interventions to Improve Care Transitions

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BETTER OUTCOMES FOR OLDER ADULTS THROUGH SAFE TRANSITIONS (BOOST)

Toolkit implementation improves hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific Interventions and written discharge Instructions.

Purpose: Enhances information flow between hospital and outpatient physicians; ensures that high-risk patients are identified and specific interventions are offered to mitigate their risk; improves patient and family education practices to encourage use of the teach-back process around risk specific issues.

Resource: http://www.hospitalmedicine.org/ResourceRoomRedesign/

References to Support Intervention Selection
Preen et al. (2005): Improved quality of life, involvement and satisfaction with discharge care.
Systematic review
Kripalani, Jackson et al. (2007): Approaches to promoting effective transitions of care include “…improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician–patient communication.” Kripalani, LeFevre et al. (2007): Deficient communication between hospital-based physicians and PCPs; need for improvements to discharge summaries and health information technology.
Other support
Simon et al. (1998): PCP involvement in hospitalization associated with reduced problems with diagnostic tests, post-discharge activity and health habits. van Walraven et al. (2004): Follow-up care with hospitalization physician associated with lower readmission rate, versus community physician or specialist.

BEST PRACTICES INTERVENTION PACKAGE (BPIP): TRANSITIONAL CARE COORDINATION

Comprehensive manual for home health agency leadership and staff to identify tools and processes to improve patient transitions; focus on the four pillars, or conceptual domains, of patient transition; includes tools and resources for patients and staff, guidelines and podcasts

Purpose: Reduce avoidable acute care hospitalizations.

Resource: http://www.homehealthquality.org/hh/resources/

Home Health Quality Improvement National Campaign

References to Support Intervention Selection
Esslinger (2008): Preliminary data demonstrate modest improvements in hospitalization rata among participating HHAs and worsening among non-participating HHAs. Schade et al. (2009): Agencies w/ improvement more likely to report activities consistent with campaign and use of campaign interventions, regardless of participation status.

INTERVENTIONS TO REDUCE ACUTE CARE TRANSFERS (INTERACT)

Toolkit developed for Skilled Nursing Facility (SNF) personnel to reduce avoidable hospital admission. Three types of tools: 1) communication; 2) clinical care paths and 3) advance care planning. Utilization specified for selected members of the care team.

Purpose: Reduce transfers to acute care setting.

Resource: http://interact.geriu.org/

References to Support Intervention Selection
CMS Nursing Home Special Study
Ouslander (2008): Higher hospitalization rates associated with larger facilities, more Medicaid and Medicare skilled care residents, lower percentage of Caucasian residents and higher percentage of residents with impaired decision making; 68% of hospitalizations were avoidable, per expert panel record review.

TRANSFORMING CARE AT THE BEDSIDE (TCAB)

Hospital interventions built around four themes: 1) safety and reliability, 2) care team vitality, 3) patient-centeredness and 4) increased value. Four core elements of the intervention: 1) enhanced admission assessment for post-discharge needs; 2) enhanced teaching and learning; 3) patient and family-centered handoff communication; and 4) early post-acute care follow-up.

Purpose: Transform the care experience of patients in hospital medical/surgical units, as well as the experience of health care professionals who care for them.

Resource: http://www.ihi.org/IHI/Programs/StrategicInitiatives/

References to Support Intervention Selection
Program evaluation
Lorenz et al. (2008): Reductions in patient wait times; increase in patient and staff satisfaction by 30 percentiles; shortened turnaround for laboratory results; improvement of visitors' first impressions through new signage and a concierge program

RE-ENGINEERED DISCHARGE (RED)

Standardized discharge intervention; includes patient education, comprehensive discharge planning, post-discharge telephone reinforcement.

Purpose: Minimize post-discharge hospital utilization.

Resource: http://www.bu.edu/fammed/projectred/index.html

References to Support Intervention Selection
Jack et al. (2009): Nurse discharge advocate support (follow-up appointments, medication reconciliation, patient education, individualized instruction booklet sent to PCP); telephone follow-up by clinical pharmacist (reinforce the discharge plan, review medications) associated with lower rate of post-discharge utilization overall; non-significant reduction in readmission rate.

THE HOSPITAL TO HOME

The Hospital to Home (H2H) is a national quality improvement initiative, developed by the American College of Cardiology and the Institute for Healthcare Improvement to address the complex challenge of creating a coordinated health care team across different settings of care and to provide reliable, safe and health-enhancing transitions for patients. Cross setting interventions built around three main domains: 1) Medication Management Post-Discharge 2) Early Physician Follow-Up 3) Symptom Management.

Purpose: Tool kit of best practices, instructional webinars, and surveys to better understand and improve the quality of care transitions for patients hospitalized with cardiovascular conditions like heart failure and acute myocardial infarction.

Resource: http://www.h2hquality.org