Care Transitions – Tips for Bridging the Gaps

By Leigh Ann Myers  /  16 Jun 2015

few months ago, I discussed the many motivations behind the need for providers to improve their patient care transitions. With the shift to value-based care and population health improvement, care transitions are happening more frequently and involve a larger care team, so the ability to move patients seamlessly between care settings becomes increasingly complex.

Awareness for the need to improve care transitions across the spectrum of healthcare organizations is widespread, but actually executing to perfect those transitions is a whole different story. I recently connected with Eric A. Coleman, MD, MPH of The Care Transitions Program who offered some helpful advice for organizations to consider for improving patient care transitions:

  • Trade places for a different view – If you only have perspective on your role, it can be difficult to understand what will make the transition work for other members of the team. Walk a mile in the shoes of your colleague who typically passes the patient to you. What’s their last step? What’s missing from the usual transaction, and how can you respond to make it smoother? On the other end, shadow someone who is likely to receive a patient after you. Is there anything you can change to give your colleague more information and support? Designing transitions with the next user in mind will help bridge existing gaps.
  • Don’t just hand over the baton – Transitioning a patient shouldn’t be a relay race where you hand over the baton) and your part of the race is done. Instead, give some guidance to the next team member. What are the possibilities for something to “go bump in the night” after discharge and what would that look like? What steps would you recommend to address the problems to avoid a readmission to the ED? Take the extra step to make those anticipations known.
  • Put the patient in the driver’s seat – Instead of keeping a patient in the passenger seat, provide them with the information they need to help assist their own care, bringing them into the part of the transition. Coach them to administer the correct dosage of medication at home or recognize signs that a home visit or phone consultation might be appropriate. Engaging patients to take charge of their own care makes them more likely to stick to their treatment plan, which can prevent future care transitions.

We’ve got a long way to go in improving care transitions, and every organization, team and care setting is bound to have different needs. As we move to population health, the industry should learn from each other to bridge the gaps in care. Are there any other practices that have worked for you?

Leave a Reply

Your email address will not be published. Required fields are marked *