Health care stakeholders collaborate on the elderly

Coalition addresses transition of care issues

As the baby boomers age, creating a huge influx of Medicare recipients, health care providers are going to be challenged to provide coordinated care for the elderly as they move through the fragmented health care system.

The National Transitions of Care Coalition, an organization representing 23 groups from throughout the health care spectrum, was formed in 2006 to address gaps that occur when patients leave one care setting and move to another.

"Our health system often fails to meet the needs of the elderly patient population during these transitions of care because there is little communication across care settings or multiple providers. We firmly believe that case managers are essential in establishing effective communication for coordination of care between health care participants," says Connie Commander, RN, BS, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp. and immediate past president of the Case Management Society of America (CMSA).

CMSA initiated the coalition and solicited support from the other health care stakeholders. Commander and Nancy Skinner, RN, CCM, president of Riverside Healthcare Consulting, represent CMSA on the coalition.

In addition to case managers, the coalition includes physicians, social workers, health care executives, representatives from The Joint Commission, URAC, The National Business Coalition on Health, organizations that advocate for the aging, and representatives from the pharmaceutical industry.

"As patients transition from one part of the health care system to another, barriers can impede communication or result in redundant or conflicting information that can create serious issues for patients, their caregivers, and their families. We are trying to put together an orchestrated plan to reach across all venues of care so patients can make a seamless transition," Commander says.

The coalition has developed workgroups to address numerous serious health care issues that occur when patients move from primary care to specialty physicians; from the emergency department to intensive care or surgery; or when patients are discharged from the hospital to home, assisted living arrangements, or skilled nursing facilities, Commander says.

The overriding goal of the collaboration is to facilitate a seamless transition from one treatment environment to another for informed patients, whether it's acute care, rehabilitation, long-term care, skilled nursing care, or home, Skinner adds.

"To me, transition of care is a big, big problem that we face in America. Health care truly operates in silos. Patients see a hospitalist in acute care, then go back to their primary care provider or a specialist and they don't do a good job of communicating with each other. Care is fragmented and that's why transitions of care are so important," Skinner says.

One workgroup is focusing on awareness and education to increase the general knowledge of problems associated with transitions of care and to provide information to critical stakeholders, including patients, caregivers, health care professionals, and government officials.

Another group is focusing on health policy issues and ways to improve care including the possibility of enhanced reimbursement for transitional care support and medical information sharing between care settings.

The third workgroup is developing tools and resources that can be used by health care professionals to improve communication between care settings and reduce the risks associated with care transitions.