1. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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As I get older and more "mellow," I just do not seem to get passionate about things the way I used to. Perhaps, with age, brings the knowledge that all things go through their stages and most things work out in their own way and in their own timing. But one thing has never waned in my respect and commitment-and that is that case managers are the angels that are there when people need them the most. So every year, during Case Management Week, it is time to reflect and celebrate the case managers that give so many comfort during the most trying times in their lives. This year, Case Management Week is October 12-18, 2008. Every morning, when you wake up, know that you matter!! You make a difference, and what you do that day for a patient would probably not get done, if not for you!!


Hand in glove with this passion is another that is just becoming a national issue: one in which case managers are the key. This issue is about safe and thorough transitions as patients move from one arena in healthcare to another. This movement of patients occurs at multiple levels-all of which case managers play critical roles and are vital links:


* Within settings, for example, from the intensive care unit to the ward, and vice versa


* Between settings, for example, from the hospital to home or a subacute facility; and


* Across health states: from curative care to palliative care (hospice) or from personal residence to assisted living



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The Health Research for Action from University of California, Berkley, did an extensive study on the hospital-to-home transition. The study, which culminated in several important findings and critical problems, is worth reading (Brown-Williams et al, 2006). In a shorter piece, Dangerous Transitions: Seniors and the Hospital-to-Home Experience, Brown-Williams (2006) recommended a "prescription for change." Recommendations were addressed at many levels (Brown-Williams, 2006, pp. 5-6):


1. Increase public awareness of transitional care issues for seniors with a campaign to educate seniors and their families about the risks of hospitalization and care transitions.


2. Begin discharge planning before hospitalization when possible. Review and update the plan at admission, before discharge, 72 hr after discharge, and at intervals up to 6 months after discharge.


3. Integrate risk/needs assessment for both patients and caregivers into discharge planning. Assess medical, psychological, social, and environmental factors. For caregivers, specifically, assess health status, ease of access to patient, and ability to provide care in the home. Integrate this into discharge planning at all stages.


4. Improve transitional care coordination. Create a consent mechanism for patients to approve sharing of information among providers (and volunteers) at inpatient, outpatient, and postdischarge care sites. Assign responsibility to hospital staff or volunteers to follow-up with patients after discharge to ensure that they are getting needed services. Develop peer support programs that use seniors as volunteers helping hospitalized patients, especially for those who have no family caregivers.


5. Make transitional care a priority of professional associations, health systems, and government organizations. Recommend that government agencies include transitional care as a priority within their areas of oversight.


6. Develop materials for seniors and caregivers to help them navigate the system of care during and after a hospital stay. Provide caregivers with information on obtaining home care, providing condition-specific and direct care (e.g., bathing, lifting, and giving injections), and self-care. Provide integrated, easy-to-use, and culturally appropriate resources in multiple formats suitable for all literacy levels. Partner with existing groups to distribute materials.


7. Create care support centers in hospitals, where patients and caregivers can watch educational videos/DVDs, find print and online resources, connect with volunteers, and are referred to community-based caregiver support programs and in-home services.


8. Train healthcare providers. Develop professional trainings on discharge planning and transitional care and create opportunities for cross-disciplinary and cross-site education.


9. Acknowledge the vital role of caregivers and enhance caregiver support. Promote family-centered care. Recognize caregivers as part of the unit of care and integrate them into the care team. Encourage the development and evaluation of innovative models in team caregiving in which family, volunteer, and professional caregivers are partners. Expand the availability of support groups and other services to provide emotional aid and respite for caregivers.


10. Change federal and state policies to improve transitional care. Major policy shifts need to occur. To ensure continuity and coordination of care, we need integrated care delivery systems that incorporate medical and social services as well as caregiver assessment, training, and support. We also need a system that focuses on preventive care and long-term case management, not just acute care. Finally, we need to make in-home care a higher priority than more expensive institutional care.



It should not be so hard-after all, there is only one "constant" in transitions-the patient!! But as we have said many times in these editorials, the devil is always in the details. HOW do we make these changes and where do we go for templates and roadmaps? Fortunately, there is very good news!! Just go to In 2006, the National Transitions of Care Coalition (NTOCC) was formed to bring together thought leaders and healthcare providers from various care settings to address care coordination issues. The NTOCC is chaired and coordinated by the Case Management Society of America in partnership with sanofi-aventis U.S. LLC.


It is common knowledge that improving transitions of care is a formidable task. But this coalition has built and moved mountains-and continues to build more. Do not let another day go by without going on the Web site, signing up for their Impact Newsletter, joining as an individual subscriber, and asking your facility to join as an associate member. The Web site is easy to navigate, with sections such as Consumers, Health Care Professionals, Policy Makers, and the Media. Each section is further divided and provides details of tools customized for that sector of healthcare.


By the time this Editorial goes to press, more tools will be added. But here is a current selection from the Health Care Professionals section, which can be downloaded (NTOCC, 2008).


My Medicine List-This is a list of important recommended information about a patient's medications. The data elements indicate the prescriptions that patients have been prescribed and are currently taking along with information about their over-the-counter medications, vitamins, and nutritional supplements. The goal of the personal medicine list is to help patients improve their understanding of their current medicine regimens, including why they need to take the medication and for how long.


Transitions of Care Checklist-This list provides a detailed description of an effective patient transfer between practice settings. Implementing this process developed by the NTOCC can help ensure that patients and their critical medical information are transferred safely, timely, and efficiently.


Medication Reconciliation Essential Data Specifications-At last count, there were more than 2,000 medication reconciliation tools. This is not just another tool. Rather, these are elements that will help healthcare professionals collect, transmit, and receive critical medication information needed when patients move from one practice setting or level of care to another. The use of these elements in the reconciliation process required by the Joint Commission could help reduce medication errors.


Informational Slide Deck-Download this presentation to learn more about how transitions of care impact care delivery and how you and other professionals can use the NTOCC tools to improve transitions. Note that these can also be used in your personal presentations on transitions of care. On different sections of the Web site, versions of this slide deck speak to different audiences. If you are talking to the media, check out that version; if you are speaking to political leaders or CEOs, the Executive Slide Deck may be the correct one to use.


Informational Brochure-This brochure contains information about transitions of care that can help you in sharing and discussing this critical healthcare issue.


Policy Paper-This detailed concept paper outlines steps to be considered by the healthcare industry and policy makers to improve transition performance.


And last, but not least, Improving on Transitions of Care: How to Implement and Evaluate a Plan. This guidebook was created to provide institutions and their staff with basic concepts of evaluation in an easy-to-read format. Essentially, it is a "project in a box." It walks the facility through the whole process, from how to get your baseline data (suggested tools included) to interventions to remeasuring your progress. A case scenario of a patient leaving one care setting (i.e., hospital, nursing home, assisted living facility, skilled nursing facility, primary care physician, home health, or specialist) and moving to another is used to illustrate the process. I have spent several years doing quality improvement projects and this guide makes the processes as direct and simple as possible.



In addition to the Introduction and Background sections, there are two other sections worth noting. The section, Evaluating and Improving Transitions of Care in Your Institution, discusses the seven steps to implementing and evaluating the plan. For each transition point, or "exchange," a thorough explanation of each step is outlined. The discussion includes:


* Framing the transition in terms of structure, process, and outcomes


* Creating a process map


* Writing key evaluation questions


* Measuring and reporting performance


* Implementing a strategy to address deficiencies



Sample evaluation questions, data collection forms, data results, and interventions are offered to provide you with a better understanding of the concepts. Practical ideas, available resources, tools, and Web sites are given to help institutions get started.


The information in the Appendices are also worth noting. The details of several exchanges are included here to make the main document easier to navigate. The remainder of the appendices includes a variety of tools, background information, and references:


* EMS/ambulance transfer of patient from a nursing home to hospital


* Hospital receipt of patient from nursing home


* Emergency department/hospital to nursing home transfer


* EMS transport of patient to nursing facility


* Nursing home receipt of patient from the hospital


* Evaluation: A basic primer


* Literature review-Transitions from the nursing home to and from the hospital


* Institute for Healthcare Improvement tips for effective measures


* NTOCC tools


* Suggested common/essential data elements for medication reconciliation


* Elements of Excellence in Transitions of Care Checklist


* My Medicine List


* Taking Care of My Health Care


* NTOCC proposed framework for measuring transitions of care


* Annotated bibliography



It is said that for really important changes, it takes a village. This is infinitely true if we are to make patient transitions safe, reduce unnecessary rehospitalizations, and improve quality of life for the people we serve. Silos in healthcare can no longer be tolerated. Safe transitions are a team sport!! And we are all on the same team with the same goal. Celebrate you during our week, roll up your sleeves, and put on the team hat.




Brown-Williams, H. (2006). Dangerous transitions: Seniors and the hospital-to-home experience. HealthResearch for Action, 1(2). Retrieved June 21, 2008, from[Context Link]


Brown-Williams, H., Neuhauser, L., Ivey, S., Graham, C., Poor, S., Tseng, W., et al. (2006). From hospital to home: Improving transitional care for older adults. Berkeley: Health Research for Action, University of California. Retrieved June 21, 2008, from


National Transit ions of Care Coalition. (2008). Retrieved June 21, 2008, from

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