Transitioning patient care from one setting to another has long been recognized as a time of vulnerability, especially for older adult patients. It is the time when communication can fail, important information can be missed, and essential care can "fall through the cracks," leading to poor health outcomes, emergency department visits, and costly rehospitalizations. I will never forget a home visit I made to an older gentleman after his hospitalization. His wife had dutifully filled his new prescriptions and added them to the many vials already on the kitchen table. Unfortunately, she didn't know that Coumadin and warfarin are the same drug, as well as levothyroxine and Synthroid. Fortunately, my visit was the day after he arrived home so he had only taken one double dose of each drug. (To top it off, she had given him aspirin for a headache and was unaware this is contraindicated with anticoagulant therapy.) After a phone call to the physician, I drew the appropriate lab work, created an explicit medication schedule, ensured she understood, and returned for follow-up the next morning.
So I was very happy to read a recent article by an interprofessional team of experts led by Dr. Mary Naylor of the University of Pennsylvania School of Nursing, who, along with key stakeholders (patients and caregivers), embarked on a project to identify components of transitional care that are essential for safe, positive patient experiences and outcomes (Naylor et al., 2017). Once they identified the components of transitional care, the group operationally defines each element and developed tools with which to measure the degree to which each component's outcomes were achieved.
The Patient-Centered Outcomes Research Institute sponsored "Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE)." A component of transitional care was defined as: "a critical element of traditional medical care, community- based services, and non-traditional services provided by the healthcare team that patients and caregivers should receive to promote positive health outcomes throughout periods of acute illnesses extending from hospital to home" (Naylor et al., 2017, p. 1120).
Eight categories of interrelated concerns were identified. They are:
1. Patient engagement-Valuing and recognizing the patient's wishes, abilities, and role in decision making and accountability.
2. Caregiver Engagement-Valuing and recognizing the caregivers' wishes, abilities, and role in decision making and accountability.
3. Complexity Management-Anticipating and being vigilant in prevention or early recognition of the health problems that can occur with older adult patients.
4. Patient Education-Engaging patients in learning what is needed to meet their self-identified goals and to fully engage in self-care, adhere to medications and other therapies, and return to independent living to the degree possible.
5. Caregiver Education-Continuously interacting with caregivers so they are able to provide needed care following hospitalization, identify signs and symptoms that should be self-managed or communicated to professional care providers, and recognize their own unique needs as caregivers.
6. Patient and Caregiver Well-being-Recognize patients' and caregivers' emotional needs, provide support, and validate feelings.
7. Care Continuity-Planning care that recognizes the unique needs of individuals, communicating necessary information among all stakeholders, and maintaining a relationship with patients and caregivers that promotes trust.
8. Accountability (Clinician, Team, Organizational)-The expectation that all team members will contribute to patient care to whatever extent is needed.
I especially appreciate number 8. We talk a lot about patient "compliance," and we are quick to label patients as noncompliant when they fail to adhere to the prescribed plan. But we don't hear as much about the failure of professional providers to apply consistent, timely, evidence-based care. Without the eighth category, none of the rest are attainable.
This work by Dr. Naylor and colleagues provides a basis for evidence-based care during times of transition. The eight transitional core components should all be addressed, and emphasis placed on those that would best meet the needs of an individual patient during this particularly vulnerable time. This represents a leap forward for patient safety and the positive outcomes we hope to achieve.
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