Special Report: Improving care transition communication

Communication during care transitions should be training priority in hospitals

Variety of models exist for improving communication

[Editor's note: In this issue of Discharge Planning Advisor, there is a special report about how health care systems and discharge teams can improve communication between providers and patients/families. Federal agencies hold hospitals responsible for poor care transition outcomes, and often the chief culprit is a breakdown in communication. Various articles in this issue will focus on the existing communication issues and what hospital care transition teams can do to prevent or improve these areas.]

Health care systems have a few years to improve care transition communication and processes before health care reform changes make concise and clear communication essential, experts say.

The Centers for Medicare & Medicaid Services (CMS) will hold providers responsible for medical errors that result from poor transitions. Improved communication and provider-to-provider instructions at hospital discharge will be crucial to preventing these mistakes.

"I think there's a recognition that failure to communicate about patients at points of transfer, whether between care providers or settings, could result in serious harm to patients," says Ann S. O'Malley, MD, MPH, a senior researcher at the Center for Studying Health System Change in Washington, DC.

"It's an issue of coming up with systematic processes to make sure the person taking care of the patient communicates to the person to whom the patient is going," O'Malley says.

"With the development of new health information technologies and the efforts to get them to communicate with one another, we have the opportunity to use these tools to enhance the exchange of data and important clinical information about patients," she adds.

For example, hospitals could use electronic data sets or checklists to assist with the care transition process and hand-offs.

"Like pilots have a checklist before they take off, hospitals need checklists to bring efficiency into the health care system," says Diane Feeney Mahoney, PhD, ARNP, BC, FGSA, FAAN, a Jacques Mohr professor of geriatric nursing research at the MGH Institute of Health Professions in Boston.

Mahoney and co-investigators studied the use of a minimum data set to improve communication between emergency departments and nursing homes. Their study found that a transitional minimum data set could result in an improved transfer of essential clinical information, but there needs to be greater consistency of usage.1

The key is to create standardized questions that will work for a particular health care setting. Also, these should be honed to the most critical elements, Mahoney says.

"You don't want information overload," she adds. "If you send 20 pages of information, and a critical item is on the 18th page, it might be overlooked."

The chief drawback to improved communication between providers is that there's no payment for coordinating care, O'Malley says.

"There are few financial incentives for having a thorough discussion of patient information at the point of transfer," she explains. "We have disincentives for effective communication built into our current payment system because communication is not a reimbursable task."

Every time a clinician takes time to communicate with a provider, that's time not being spent on reimbursable activities, she adds.

The other issues are that support systems need to be put in place to improve care transition, and clinicians still are not trained to think outside of their silos of care, O'Malley says.

"We think about what happens in the hospital, but not what happens when patients leave the hospital," she says. "So we need some kind of increased emphasis in our training as nurses and physicians on the fact that patient care includes everything we've done and what happens when the patient leaves the hospital."

One strategy for improving care transition communication is to have a point person to work with the hospital and community providers to improve care transition communication and follow-up. This person could be a designated hospital discharge planner, case manager, nurse practitioner, or some other discipline.

The Mount Sinai Visiting Doctors Program of New York developed a nurse practitioner-led model as part of a pilot transitional care program, says Theresa Soriano, MD, MPH, director of the Mount Sinai Visiting Doctors Program and director of the Mount Sinai Chelsea-Village House Call Program.

"We started the program because of a realization that as our primary care program was getting bigger, there was a need of communication between our program's physicians and nurse practitioners and inpatient hospitals," Soriano says. "We hoped this would streamline the flow of patients as they came into the hospital and communicate their medical conditions and reasons for being admitted."

The purpose of the Mount Sinai Visiting Doctors Program is to make care transitions as smooth as possible and improve the flow of information, says Maria Tereza Lopez-Cantor, MA, ANP-BC, CCRN, a nurse practitioner with Internal Medicine Associates — PACT at Mount Sinai Medical Center. Lopez-Cantor and Soriano were among the authors of a study on the program.

Their research showed that this model is feasible for enhancing inpatient management and transitional care for a population of patients at high risk of readmission.1

This type of model can be a way to address high 30-day readmission rates for the same medical problem. This issue is targeted by CMS, which will penalize hospitals that fail to improve.

"The three big issues that CMS is looking at are heart failure, pneumonia, and acute myocardial infarction," Lopez-Cantor says. "We don't limit our work to those medical issues."

Hospital transition care staff need to concentrate on communication between the hospital team and community providers, but there also are deficits that should be addressed in how the discharge plan is communicated to patients' informal caregivers.

Informal caregivers are not always aware of the discharge process details and would like more information, says Janice B. Foust, PhD, RN, an assistant professor in the College of Nursing and Health Science at the University of Massachusetts Boston and a nurse research associate at the Visiting Nurse Service in New York.

"As we look at where we need to move to improve transitions from hospital to the home care setting, there could be proactive involvement of informal caregivers or family caregivers during hospitalization and at discharge," Foust says.

Another finding in Foust's study was that patients do not recall much detail about discharge instructions, which suggests different teaching methods need to be employed, she adds.

Written discharge instructions are an important way to communicate the care transition process to patients and their caregivers. But they're also a way to communicate with community clinicians about what took place in the hospital, Foust notes.

"It is important to recognize that they are very versatile as a way to communicate to patients, family caregivers, and clinicians alike," she adds.

Communication between hospital clinicians and patients' family members or caregivers can be turbulent at times, says Lori L. Popejoy, PhD, APRN, GNS-BC, John A. Harford Foundation Fellow and assistant professor in the Sinclair School of Nursing at the University of Missouri in Columbia.

Popejoy interviewed patients, their family members, and health care team members to learn how their perceptions of the discharge process were alike and how they were different.

"I wanted to find out how they achieved congruence between these three different groups," Popejoy says. "How did they arrive at an agreement about where the patient was going to leave when he left the hospital?"

The findings surprised her.

"Older adults don't tell their children everything," Popejoy says. "They tell them what they want them to know and what they think they should know."

This can be problematic when the older spouse of a patient is unable to handle the patient's care at home, but he or she is reluctant to let other family members help change a discharge plan for a safer transition.

Popejoy's study of the family and clinician dynamics at hospital discharge has implications for how hospitals might improve communication during this process.

For instance, hospital discharge staff should know many of their patients' interpersonal dynamics because often the people they see have been in the hospital previously, and they should communicate this information to community providers, such as home health agencies, Popejoy suggests.

"Communicate the patient's degree of risk at home," she says. "This risk is why patients are readmitted, and we should stop the cycle."


1. Ornstein K, Smith KL, Foer DH, et al. To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people. J Am Geriatr Soc. 2011;59(3):544-551.


• Janice B. Foust, PhD, RN, Assistant Professor, College of Nursing and Health Science, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125. Telephone: (617) 287-7535.

• Maria Tereza Lopez-Cantor, MA, ANP-BC, CCRN, Nurse Practitioner, Internal Medicine Associates – PACT, Mount Sinai Medical Center, 1 Gustave Levy Place, Box 1087, New York, NY 10029. Telephone: (212) 824-7228. Email: maria.lopez-cantor@mountsinai.org.

• Diane Feeney Mahoney, PhD, ARNP, BC, FGSA, FAAN, Jacques Mohr Professor of Geriatric Nursing Research, MGH Institute of Health Professions in the graduate program in nursing, Charlestown Navy Yard, 36 1st Ave., Boston, MA 02129-4557. Telephone: (617) 643-2745.

• Ann S. O'Malley, MD, MPH, Senior Researcher, Center for Studying Health System Change, Washington, DC. Telephone: (202) 554-7569. Email: aomalley@hschange.org.

• Lori Popejoy, PhD, APRN, GNS-BC, John A. Hartford Foundation Fellow, Assistant Professor, Sinclair School of Nursing, University of Missouri, Columbia, MO 65211. Telephone: (573) 884-9538.

• Theresa Soriano, MD, MPH, Director, The Mount Sinai Visiting Doctors Program, Director, The Mount Sinai Chelsea-Village House Call Program, One Gustave Levy Place, Box 1216, New York, NY 10029-6574. Telephone: (212) 241-4141.