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Special Report: New models in care transitions
Transition in care plans should include strong DP support
HC trends indicate greater need for DP
The 21st century model for health care includes patient-centered care, focusing on quality, efficiency, and actions that have a long-term positive impact.
Hospitals that embrace this model will survive and, perhaps, thrive, experts say.
Even if the model has no short-term economic benefits, it's the right thing to do because of the problems patients and health systems face due to a disjointed system in which a single patient might see more than a dozen physicians to treat multiple chronic illnesses, experts say.
Recent health care projections predict that the number of people with multiple chronic conditions will increase to 81 million by 2020.1
"If you keep the old model, the patient loses, so we're interested in coalescing around patient-centered care," says Elizabeth J. Clark, PhD, ACSW, MPH, executive director of the National Association of Social Workers in Washington, DC. Clark is a member of the National Transitions of Care Coalition (NTOCC) advisory task force.
The NTOCC is a group of organizations working to improve care transitions and place the focus on patient-centered care. The organization provides a variety of educational material and tools for patients, caregivers, and providers on its web site at www.ntocc.org.
The pressures that bear down on families and health care providers will continue, so they need to be addressed or care transitions won't function as they should, experts say.
American demographics are causing some of the changes.
For example, Americans are living longer, so family caregivers often are quite old as well, notes Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America in Little Rock, AR. Lattimer also is a member of the NTOCC advisory task force.
"Where we've had three generations still living, we now have five and six generations of a family," Lattimer says. "That means there's a mother living to 101, and she has a daughter in her 80s and grandchildren in their 60s."
These elderly multi-generations can lead to care breakdowns when a frail and sick relative is sent home with little health system support.
"How do we restructure how we deliver health care long-term?" Lattimer says. "Think about the individual who is severely ill and how the family member is going to deal with all of the person's needs."
Hospital discharge planners might see a new trend in coming months as the recession takes its toll on how people manage their health, suggests Lanis Hicks, PhD, a professor in the department of health management and informatics at the University of Missouri in Columbia, MO.
"With an economic downturn, what we begin to see is fewer patients admitted for any kind of elective procedures," Hicks says. "As people lose insurance coverage because they're unemployed or their employers decrease benefits on insurance packages, then people wait longer to access health care."
So hospitals' patient populations will continue the trend of being sicker and more frail, which means better care transitions will be crucial for reducing repeated emergency department (ED) visits and improving patients' long-term health.
One discharge planning area that all hospitals should focus on and improve is medication management, says H. Edward Davidson, PharmD, MPH, a partner with Insight Therapeutics, a medication management and research firm in Norfolk, VA. Davidson also is an assistant professor at the Glennan Center for Geriatrics and Gerontology at Eastern Virginia Medical School in Norfolk. Davidson also is a member of the National Transitions of Care Coalition advisory task force.
"The quality of medication review, in my experience, is still pretty poor in some instances," Davidson says. "This is a key transition of care issue, whether the patient's going home or to a nursing facility or to an assisted living facility or transitional care hospital."
For instance, the transition of care team needs to keep a patient's spouse, family member, or other caregiver in the loop with regard to discharge planning and medication needs, he says.
"Hospitals need to involve family members and personal care advocates to a greater degree," Davidson says.
"There needs to be an advocate," Davidson explains. "There needs to be someone else who knows when these transitions occur for the older patients who are more likely to have functional or cognitive deficits that impair their ability to speak up for themselves about their medication."
Patients on medication regimens for chronic diseases sometimes are hospitalized with an acute illness, and then their medication is changed significantly, he notes.
"Then they go home, and the family has new marching orders that are discordant with what they were doing previously, so the prescriptions in their old bottles don't match up," Davidson says.
So the patients and families will adjust to the changes as well as they can, and then the patient is rehospitalized, and the medications change again, further confusing them, he adds.
Patients, caregivers, and medical providers need help with monitoring all medications patients are on and any changes made to these, he says.
A tool that will help with this is a personal medication list.
"We feel like this needs to be an accurate, dynamic document that patients have access to," Davidson says.
Ideally, the document would be updated each time the patient has a change to his or her medication regimen, he adds.
The nation's health care providers and advocacy organizations are focusing on transitions of care issues, which many see as a crucial element of health care, Lattimer says.
Research has shown that transitions can have adverse outcomes for patients and lead to dissatisfaction among providers, Lattimer says.
Several groups are highlighting care coordination this year, including The Joint Commission On Accreditation of Healthcare Organizations of Oakbrook Terrace, IL, which has published on its web site at www.jointcommission.org, its 2009 National Patient Safety Goals for a variety of health care settings, including ambulatory health care, behavioral health care, critical access hospital, disease-specific care, home care, hospital, laboratory, long-term care & Medicare/Medicaid certification-based long term care, and office-based surgery.
Also, the National Quality Forum (NQF) endorsed in 2006 a definition and framework for care coordination and now is seeking nominations for a steering committee and technical advisory panels for a project to endorse a set of preferred practices and performance measures in care coordination.
Also, the Centers for Medicare & Medicaid Services (CMS) has been pushing for greater care coordination. In January 2009, CMS announced sites for an Acute Care Episode demonstration that has the goal of using a bundled payment to align hospital and physician incentives and lead to better quality and efficiency in care delivery.
"There's a push for organizations to improve transition in care coordination and to provide resources to patients, case managers, and all providers, and identify performance measures that support that," Lattimer says.
"Case managers, nurses, and social workers often are assigned to medically-complex patients, who bring all of the issues of care coordination, because they require more resources," she says. "That's why you're hearing we'll need more case managers."
An example of care coordination that might serve as a model for the future is a community program called Kentucky Homeplace in Hazard, KY, Clark says.
Kentucky Homeplace is a program of the University of Kentucky's Center for Rural Health. With staff hired from the communities the program serves, its goal is to help people with chronic illnesses find health care services to prevent their conditions from becoming life-threatening.
"They don't assume people have the resources - they find the resources," Clark says. "It's gotten great funding from state government, because they see how valuable it is."
For every dollar spent for Kentucky Homeplace's program, the community benefits three- or four-fold, she adds.
"They work with hospital discharge [planners]," Clark says.
If a patient doesn't have the money to make a co-pay on medications, then the program will get the patient the drugs. The program's family health care advisors also help educate patients about their diseases and provide reinforcement in patients' homes, she says.
"If they can do that kind of program in Appalachia, then why can't we do it?" Clark adds.
1. Anderson, G. "Better Lives for People with Chronic Conditions," Partnership for Solutions. 2001. Available at http://www.partnershipforsolutions.org/statistics/prevalence.html. Last accessed November 17, 2008.
For more information, contact:
Elizabeth J. Clark, PhD, ACSW, MPH, Executive Director, National Association of Social Workers, 750 First Street, NE, Suite 700, Washington, DC 20002-4241. Telephone: (202) 408-8600. Web site: www.naswdc.org.
H. Edward Davidson, PharmD, MPH, Partner, Insight Therapeutics; Assistant Professor, Glennan Center for Geriatrics and Gerontology, Eastern Virginia Medical School, 825 Fairfax Avenue, Hofheimer Hall, Suite 201, Norfolk, VA 23501. Telephone: (757) 625-6040.
Lanis Hicks, PhD, Professor, Department of Health Management and Informatics, University of Missouri, Columbia, MO. Telephone: (573) 882-7423. Email: hicksL@health.missouri.edu.
Cheri Lattimer, RN, BSN, Executive Director, Case Management Society of America, 6301 Ranch Drive, Little Rock, AR 72223. Telephone: (501) 225-2229. Email: firstname.lastname@example.org.