Transitions of care in healthcare occur when a patient or resident moves from one provider type in the continuum of care to another. Transitional care refers to the coordination and continuity of care between healthcare practitioners and settings.
An ideal transition is one where a patient/client enters a care pathway where providers work together to facilitate successful outcomes. Such outcomes lead to a decrease in adverse events, higher care satisfaction and lower rehospitalization rates. Yet, that’s not always an easy task; any transition in the healthcare space, no matter how basic it may seem, carries with it multiple considerations from clinical, operational and financial standpoints. Indeed, patients/clients across the continuum are more complex than ever. Many have numerous comorbidities, including behavioral health challenges. High-acuity patients/clients have clinical needs requiring above-average intensity of support or nursing care. And many patients/clients require advanced treatments that home health agencies may or may not have previous experience with.
If you own or operate a home health agency, what are some best practices you can employ to help optimize transitions of care for your patients/clients?
Identifying a point person at your agency to communicate with hand-off personnel at referring providers. This person should coordinate with a hospital or SNF case manager or discharge manager on the specific discharge date; communicate internally with stakeholders in your agency to ensure timely admission depending on risk level and/or policy; and ensure timely DME delivery.
Performing a risk assessment to determine a patient/client’s risk for rehospitalization. For example:
High risk is defined by the patient/client having had two or more in-patient admissions in the past year, failing the teach-back or having a caregiver express low confidence in the patient/client carrying out self-care at home
Moderate risk is defined by the patient/client having one in-patient admission in the past year or having a caregiver express moderate confidence in the patient/client carrying out self-care at home
Having a plan in place – a standardized procedure, if you will – for every patient/client transition. This should include:
Ensuring a successful handoff by pre-planning handoff timing and details
Making sure all transfer-related information is complete (e.g., medication list, do not resuscitate (DNR), concerns/issues, contact information)
Ensuring the patient/client’s homebound status
Conducing a medication error risk assessment
Identifying who will serve as a patient/client’s primary physician for home care admission – particularly if a hospitalist made the referral – and contacting that physician regarding signing home care orders
Verifying that the face-to-face encounter has been accurately completed
Clarifying whether the home care staff will assume responsibility of making any follow-up appointments with the primary physician
Pursuing opportunities to discuss the handoff with the sender before, during and after it occurs
Communicating with patients/clients and family members/caregivers to ensure they are in the loop on care plans and other key details of care.
Identifying any patient/client and/or family member/caregiver barriers (e.g., language, health literacy, cultural differences) and working to address them.
Working toward long-term transition success by standardizing processes, evaluating them, analyzing results and continuously improving. This can entail collecting quantifiable evidence on the effectiveness of your efforts, as well as improving your organization’s ability to manage transitions through staff training and other initiatives.
In the end, care transition success for your home health agency comes down to patient satisfaction (as measured by HHCAHPS), as well as a reduction of (or minimal) rehospitalizations following an acute-care setting stay. An efficient and thorough transition will help ensure you and your staff know everything you need to know about that patient/ client up front—so you won’t have to waste time backtracking for information, or negatively impact patient/client care in doing so.