All right, thank you, Barbara and Vicki, and thanks to everybody on the Hepatology Associates SAIG leadership for really inviting me here today to talk about a topic that's very central to patient safety and patient quality of care, and that's transitions of care. I have no disclosures. So as an overview of my talk today, we will start by defining transitions of care and related terms. We'll look at why transitions are a high-risk scenario for our patients. We'll identify root causes of ineffective transitions of care, and we'll review commonalities between transition of care models. And finally, we'll understand aspects of a successful transition of care program. So Professor Naylor and her associates at the University of Pennsylvania define transition of care as a broad range of time-limited services designed to ensure healthcare continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another, or from one type of setting to another. And handoffs are defined as the transition of responsibility and accountability for patient care from one healthcare professional to another, and these can occur within a healthcare setting, between care settings, across levels of care, and between providers. Handoffs are simply just the transfer of responsibility so that this can occur, if you think about nurses on a unit, between shifts, between call schedules, between different settings, so from the ICU to a transfer to the floor. And then a sign-out refers to the act of transmitting information about a patient during those handoffs or transitions. And so this is really the act of communication between the person who is handing off responsibility and the person receiving that responsibility of the patient. So transitions can be difficult, really, for anybody, but those defined as being the most at-risk for poor outcomes are the elderly, the very young, the critically ill, the cognitively impaired, those with low health literacy, language barriers, and social barriers. So you can kind of see where many of our liver patients would fall into this at-risk population. And a transition represents change, and change is just simply difficult. So if we can bring to mind one of our patients, perhaps a cirrhotic patient who's being admitted with their first decompensation, perhaps hepatic encephalopathy, you can see that that patient would have a new diagnosis, new medications, there's a change in their baseline, mental capacity, decline in functional status. They're leaving the hospital probably with new referrals, a new diet or activity restrictions. We may be asking them to not drive anymore. And sometimes there's an inability to return to home, so they're getting discharged into unfamiliar space like a skilled nursing facility. And all this change leads to increased safety risks for our patients. The literature shows that when patients are transitioning out of the hospital, they have increase in mortality, an increase in morbidity, an increase in adverse events. There can be delays in receiving appropriate treatment and community support, additional emergency room visits, which can lead to preventable readmissions to our hospitals. Oftentimes there's additional or duplicated tests during this transition period, and at times people are discharged from the hospital with tests still pending, and there's really no accountability of who will follow up on those tests. Patient and provider, so all of this really leads to patient and provider dissatisfaction with care coordination. As we begin to identify root causes of ineffective transitions of care, you'll notice a theme, and it's really communication. And so I found this quote, it's by George Bernard Shaw, who was a poet and playwright, and he says, the single greatest problem in communication is the illusion that has taken place. And so I think that this quote kind of represents a universal truth in our healthcare system that just because something's said, it's not always heard. Just because we write it in a discharge note, our patients don't always read that. I know many of us, I'm sure, can understand. We take the time, we educate our patients, we see a smiling patient, nodding, following along, and then the next day they're back in the hospital or they're back with the same question. So I think we all understand this. Okay, on that note, the first cause of an ineffective transition of care is communication breakdown. Our patients are getting discharged in a hospital, and there are many distractions, there's emotion, there's stress, there's noise, there's a lack of time. There can be workplace culture that does not promote communication. This can be a culture that just doesn't let nurses take the time to really educate at the bedside or pharmacists to educate at the bedside. It can be a culture that does not promote multidisciplinary care, and so people are not able to really feel that they have a voice in advocating for their patients and their needs. There can be patient factors, so there's low English proficiency that may require time to find appropriate translation services. There's low health literacy. Sometimes our patients do not have family or caregivers to support, really, that extra set of ears to understand the discharge instructions. And lack of standardized process or procedure around sign-outs. So we might not have a standardization of how we communicate between settings. So how does your inpatient team communicate to your outpatient team? Okay, moving on, patient education breakdown is the second root cause of ineffective transitions. So patient and caregivers may receive conflicting recommendations. Perhaps their hepatologist says you need a high-protein diet. They follow up with their kidney specialist and they say, ooh, watch the protein. There can be confusing medication regimens. Titration is really a difficult one for our patients. We all understand that. So titrating to bowel movements. Sometimes their instructions say titration to BMs. What's a BM? Unless you're in healthcare, you don't know. And also unclear or not specific follow-up instructions. There can be patient and caregivers that are not included in the transition of care planning. And they're not included, they really can't advocate for what works for them in their life. So as a result of not being included, they can also not understand, while this was a really important medication, maybe it should have been a priority of what I picked up at the pharmacy. And there could be an accountability breakdown. So no provider or clinical entity takes responsibility to assure that there's a coordination across various settings. There isn't that handoff and there's no one dedicated to really watch over that patient as they're leaving the hospital and until they get to their primary care provider or their outpatient provider. The patient is not established with a primary care prior to a transition. We see this a lot. Perhaps their insurance company assigned them to a primary care home, but they've never been seen in that home. And so they call to make an appointment with their primary care and they're told, well, you're a new patient, you need to come in three months for a physical first. So that can be a breakdown. There's access limitations to short interval follow-up. Both in specialty and primary care, we're all busy. We all have limitations to our clinic schedules. And sometimes it's difficult to get these very at-risk patients in within one to two weeks. And then it can be a lack of defining who is responsible to set follow-ups. Sometimes this is with our patient. They think that someone's gonna call them to make that appointment. We don't really give the job of, when you leave here, please go to the pharmacy, pick up these medications today. Sometimes there's medications prescribed that no one followed up to see if it was on their insurance formulary, if there would be a delay in getting those medications. And we do a lot of assuming sometimes. So assumptions that the patient and caregivers have resources to follow the care plan. Many of our patients have food insecurity. We ask them to take a boost every day or two boosts every day. It's not covered by their insurance. And even if they wanted to follow that care plan, it's difficult. Okay, so in this systematic review, there's a lot of different transitions of care programs. And so I wanted to really review what is out there about the benefits of transition of care programs. And so this is a systemic review of 23 studies. It's across six different countries. And they really found four outcomes attributed to these studies. And so transitional care reduces re-hospitalization rates over time. It's the largest effect is seen within 30 days. Transitional care may increase the utilization of primary care services, thus have a favorable impact on preventative care. And transitional care may reduce home health usage. And it is transitional care interventions of one month or less seem to do as well as longer interventions. So really if we're gonna focus this energy, it should be within that 30 days post-discharge. Okay, and several evidence-based transitions of care models have been developed to improve patient outcomes. These models are listed on the top. I'm gonna focus your attention to the first four columns here. And those are the TCM, or transitional care model. The CTI, which is the care transitions intervention. Boost better outcomes for older adults through safe transitions. And RED, re-engineered discharge. So I focus your attention on these first four because they really focus on the hospital to the home. They focus on discharge planning and discharge instructions. Medication reconciliation, medication management. Patient and family education, and a patient-centered care. So really keeping the patient as part of all the planning. And all of these methods, I think, except for the last one, have been shown to reduce hospital readmissions, reduce overall healthcare costs, and improve patient outcomes. Okay, so now we'll get into the aspects of successful transition of care models. Tiffany did a great job really going over medication management. And this is a group of two pharmacy organizations. First, the American Society of Health Systems Pharmacists, and the American Pharmacists Association. They jointly came together to develop strategies around transitions of care and what pharmacy can do. And so the first is that they recommend that clinical pharmacists attend daily rounds as part of a multidisciplinary team in the hospital. They recommend completion of medication reconciliation at admission, at transfers, and at discharge. They recommend to ensure that patients have access to appropriate medications. There should be a review of formulary before patients are discharged. Assistance with prior authorizations. Patient assistance programs or co-pay cards. They recommend patient-centered education and comprehensive counseling. Okay, and then patient and family engagement and education. So keeping the plan of care really patient-centered. Ensure that they are knowledgeable about diagnosis and plan of care. Develop self-management skills. So make sure the patient, when they're leaving the hospital, understands what to report. What are those red flag kind of warning symptoms that they should be worried about? And make sure that they know how to express those worries. So who are they gonna call when those symptoms come up? And then what to avoid in the home. So what foods to avoid, what herbal supplements they should not be having. Okay, and so then a meta-analysis published in JAMA in 2007 looking at deficits in provider communication found that only 12 to 34% of discharge summaries had reached outpatient care teams by the time the patient saw the outpatient provider. Don't think that's surprising to anybody that sees patients after they get discharged from the hospital. I think we all know that when you have that discharge paperwork, it's so much easier to understand what happened with the patient during that admission, what things that are really critical to be followed up on. And so this is really one of the challenges, I think, that if you're working on an outpatient basis, you feel when you're seeing these patients. Use of a standardized communication tool to streamline information transfer. This is recommended, it really, just standardization really makes it a pattern that you get used to doing for all patients. It usually uses some kind of form or format that then can review medications administered, functional status of the patient, care needs for the family. The continuity assessment records and evaluation or care was developed by CMS as such a tool. And that's available online, it's a really good resource. A lot of hospitals already use this, and so you might see patients coming in, especially if you see them after discharge from a skilled nursing facility, they might still have this paperwork with them. It's pretty comprehensive about their care needs. Okay, and then use of the health information technology can be an asset for us during the transition time period. So use of EHRs can increase providers' access to health information. It reduces redundancies in diagnostics and in patient's health histories, and it can improve the provider-to-provider communication. There are obvious limitations in that there is limited interconnectivity amongst various health information technology or EHRs. I think we're getting better with this. Working with your community providers, maybe trying to figure out with IT how you can communicate with your hospital. Sometimes there are links that we can at least get directly discharge reports faxed to you or received in your EHR. Different settings vary in use of this technology. You'll see that nursing facilities and rehab facilities are really kind of behind the time as far as adopting to electronic medical records. And then gaps to health information technology are being addressed on a federal level. So hopefully we'll see this improve, but there are large grants right now that are being awarded to advance interconnectivity of systems, I think with the ultimate goal that we can all electronically communicate with each other. Okay, and follow-up phone calls. So transition of care programs such as Project RED, Medication Reach, and Boost have implemented follow-up telephone calls to patients to improve transitions of care. Phone calls are typically completed by an RN, sometimes by an advanced practice provider, and occur between 24 and 72 hours after discharge. These calls can really immediately address the patient's needs. They can resolve any problems in transition between care settings and assess proper self-management. Most hospitals have adopted having a transitions care team that will call patients after a discharge, at least large hospitals do this. But I recommend thinking about this as far as specialty care. You know, seeing if within your practice in hepatology if you have a nurse that's working with you, sometimes even a medical assistant that can then look for red flags. But just to assess where are you at in the transition process, is there anything that you needed? Maybe it'll get alerted that they were unable to pick up a prescription, that they're having new symptoms, they didn't understand something. So I think it's a really good asset. Okay, and then follow-up care. So patients need to have timely access to key healthcare professionals and services. So are they able to be seen within one to two weeks with their primary care and their specialty care? Were they referred to physical therapy? Do they need an endoscopy? Do they need imaging? And can we help to arrange these in a more urgent fashion? Establishing a dedicated clinic space to accommodate short interval follow-ups. So if you find that you just don't have the access, I think it's an important area that we can look to see how we can increase that access. Maybe it's with hiring an APP into your practice or just looking at where you can shift clinic schedules and have a dedicated hospital discharge program. Ensuring patients and external providers have a direct way to contact the transition of care team. Sometimes our patients, they'll follow up in primary care. The primary care may not have had the discharge instructions. They have a question. Are those providers, are community providers able to communicate with the specialty care in a direct way? Okay, and then shared accountability across providers and organizations. So we really need to ensure that healthcare providers are responsible for this patient at all times. That we're not doing a hot potato. You know, that we have somebody that's watching these patients as they transition out of the hospital. That somebody is really accountable and responsible for these patients as they transition. Assuming responsibility for the outcomes during this transition of care really should fall both on the organization that's discharging the patient and the organization or the provider or the specialty team that's receiving them after the discharge. So both shared responsibility and just having that sense of accountability. Okay, so as I'm wrapping up, I just wanted to kind of do a little call to action. So, you know, so that we can all kind of work on this together. It's a big task. But I'd recommend that you get to know your own department's post-discharge outcomes. You know, what are your department's 30-day readmission rates regarding, you know, your cirrhotic patients? Do you know what your 30-day, 90-day mortality rates are? Are your patients able to get linked to care early? I feel like data really speaks, and so if you are looking to make a process improvement project, you can have those numbers. You can show the benefit that you may be able to do if you can implement one of these processes. Understand how you fit into the multidisciplinary care required for a successful transition. Know your role. You know, this is really a multidisciplinary approach. See what aspects of these models maybe you could take on, whether you're inpatient or you're outpatient. And then develop relationships with a clinical pharmacy team. You know, do you have a pharmacist that's invited on a daily clinical rounds with you? Is there a medication reconciliation being provided by your pharmacist or pharmacy team at the bedside before discharge? Do you have a pharmacist, if you're lucky, you have a clinical pharmacist in the clinic with you at post-discharge follow-ups that can do a really good medication reconciliation? If you don't have access in your own practice, can you develop a community, a relationship with a community pharmacy where you can call them and ask them to maybe investigate insurance formulary? You could ask them about maybe options for patient assistance or co-pay assistance. And then do your patients have access to a hospital discharge visit within one to two weeks? And if not, really find out why. How can you create that access for your patients? Okay, so in summary, a successful transition of care program will take a multidisciplinary approach. There'll be clear communication, collaboration, and coordination across many settings, including hospital systems, specialty care, and primary care. So who's patient is it anyway? It's really everyone's patient, everyone's responsibility. Thank you.

transitions of care

patient safety

quality

communication breakdown

medication management