Communicate to ensure a safe transition

With the emphasis on preventing readmissions and emergency department visits following a discharge, it's more important than ever before for hospitals to ensure that patients transition safely and successfully between levels of care. In this issue, we'll tell you why good transitions are so important and how to improve communication as patients move to another venue. We'll look at how one hospital facilitates transfers to a long-term acute care facility for appropriate patients and how a health system has improved communication with skilled nursing facilities. You'll learn how a transition coach cuts down on readmissions and the value of teaching heart failure patients to recognize when they need to seek medical attention. It's all in this issue of Hospital Case Management.

To succeed, hospitals improve transitions of care

Case managers should communicate throughout continuum

Healthcare reform mandates, new reimbursement requirements from the Centers for Medicare and Medicaid Services (CMS), and pressure from payers to keep patients out of the hospital and emergency department all mean that hospitals need to do a better job of transitioning patients to another level of care.

The words "transitions of care" are peppered throughout the Patient Protection and Affordable Care Act (PPACA), says Cheri A. Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA) in Little Rock, AK. "There's no doubt in anybody's mind that we, as providers, are charged with doing a much better job," Lattimer says. This job is not only to prevent readmissions, "but to put patients and family members in the center of everything we do," she says, "also providing them with good quality care and the information they need for making good decisions in conjunction with the clinical team."

The recommendations coming out of the PPACA are what case managers already know about the importance of coordination of care and transitions between levels of care, Lattimer says. "We recognize the need for hospitals and post-acute providers to work together to manage the care of patients and improve transitions," she says.

Beginning with readmissions on or after Oct. 1, 2012, hospitals will receive reduced payments from CMS if they have excess readmissions for acute myocardial infarction, heart failure, or pneumonia. In the Inpatient Prospective Payment System (IPPS) final rule for fiscal 2012, CMS announced that it is considering adding other conditions to the reimbursement reduction initiative in 2015. CMS also announced a new quality measure that assesses Part A and Part B Medicare spending for beneficiaries from three days before a hospital admission through 30 days after discharge. The measure will be used for the Hospital Inpatient Value-Based Purchasing program and the Hospital Inpatient Quality Reporting program.

All of these initiatives mean that planning for transitions must extend far beyond just moving the patients out of the hospital, says Carolyn Holder, MSN, RN, GCNS-BC, manager, transitional care, Summa Health System in Akron, OH. In addition to creating a discharge plan, case managers also must ensure a smooth transition to the next level of care. Sending patients to another level of care without a good hand-off not only increases the risk of readmissions that could affect the hospital's bottom line, but also increases risks for the patients, Holder points out. Lack of information between levels of care can impede a patient's recovery at home or in a post-acute facility and, in some cases, can put patients in danger of losing their ability to care for themselves, she adds.

"It's so important that we develop communications between levels of care as well as increasing our efforts to help patients and families manage better during transitions from one level of care to the next," Holder says.

With all the reimbursement changes coming down the pike, hospitals are going to have to focus more on making it a successful transition when patients move to the next level of care, says Maryanne P. Dixon, RN, BSN, CPUR, long-term acute care hospital (LTACH) liaison at Hershey (PA) Medical Center. This focus means case managers need to start proactively thinking about the next step for their patients and begin working on transitions early in the stay, Dixon says. "Case managers should identify what patients are likely to need after discharge and advocate for that level of care," she says.

The patient should not be someone you work for but someone you are working with, Lattimer says. This shift means involving patients and family members in developing a care plan and in transitions of care. "The healthcare system has given lip service to patient-centered care for years," Lattimer says. "Now it's time for them to walk the walk and truly deliver care that is patient centered."

If you work under the case management standards of practice, have the education of a nurse or social worker, and are looking at obtaining certification as a case manager, you already have the baseline skills for ensuring a smooth transition of care, she says. "Beyond that, case managers need interpersonal skills such as listening, creating trust and respect, and making the patient and caregivers a part of the clinical team in planning the transition," she says.

Data from several studies show what providers need to do when patients transition from one level of care to another, Lattimer says. These pieces include managing medication, reconciling medications, sending detailed information to the next level of care, and ensuring that the patient and family are involved. (For details on how to improve communication as patient's transition through the continuum, see related article at right.)

"We have all the tools and resources and a number of transition improvement models showing good return on investments. The hardest challenge is going to be to change the work flow and processes, the culture of the healthcare system, and individual behavior," Lattimer says. "Those need to go hand in hand with transition improvement initiatives. If we can't change the culture and move to patient-centered, collaborative care, we're going to continue to have problems with transitions."

For this reason, Lattimer encourages the executives who work with case management to conduct an assessment of the tasks for which the case management department is responsible to determine what resources the department needs to do the best job possible. "Unfortunately, case managers have, in many cases, become checklist task masters and documenters," Lattimer says. "They would rather be professionals who practice what they are trained to do — being patient advocates, providing transitions of care planning and coordination, and building education and awareness in helping patients and their caregivers manage their health."

Collect data so you can demonstrate the value of taking time up front to work with patients to improve transitions. "If hospitals don't ensure that patients and caregivers understand what they're supposed to do in the next level of care, hospital personnel will, in many instances, spend a lot of time on readmissions and medical errors," Lattimer says.

CMSA was instrumental in organizing the National Transitions of Care Consortium in 2006 in partnership with Sanofi-aventis U.S. to address gaps that affect safety and quality of care as patients transition from one level of care to another. The coalition of 32 organizations has developed tools and resources to help with transitions of care. They are available to healthcare professionals, consumers, and policymakers at


For more information, contact:

  • Maryanne P. Dixon, RN, BSN, CPUR, Long-term Acute Care Hospital Liaison, Hershey (PA) Medical Center. E-mail:
  • Carolyn Holder, MSN, RN, GCNS-BC, Manager, Transitional Care, Summa Health System, Akron, OH. E-mail:
  • Cheri A. Lattimer, RN, BSN, Executive Director of the Case Management Society of America, Little Rock, AR. E-mail:

Communication is key to successful transitions

Make sure patients, providers understand

Case managers do a good job of telling patients what they should do after discharge, and patients do a good job of nodding and saying "yes." However, the transition falls apart when case managers don't make sure the information resonated with the patients and family members, that they understand what to do and have voiced their questions, says Cheri A. Lattimer, RN, BSN, executive director of the Case Management Society of America in Little Rock, AR.

Case management guidance is essential to help patients obtain the resources they need to make good decisions and work with the treatment team, Lattimer adds. "We can talk about patient engagement, education, and activation, but if patients don't understand and feel comfortable with what they are supposed to do, it will be difficult to get their participation," she says. "Until they understand the expectations about their behavior and care, the next steps to be taken, and even the language healthcare providers use, they can't be accused of being non-adherent."

Case managers are in such a hurry to take care of all the tasks they are assigned that they often fail to make sure both parties, the patient and the case manager, understand what the other is saying. Case managers should go beyond just telling patients what they should do. They must make sure the patient understands what to do and how to do it, and they should make sure the patient is comfortable with it. "It's taking those few minutes to make sure patients can repeat their instructions and clarify any misinformation that reduces medication errors, ensures that patients will make a follow-up appointment, and improves the healthcare experience and quality of care for the patient and caregiver," Lattimer says.

It's difficult for patients and family members to absorb all the discharge instructions when they are preparing to go home, says Carolyn Holder, MSN, RN, GCNS-BC, manager, transitional care, Summa Health System with headquarters in Akron, OH. "Patients and family members may not fully understand what they need to do after discharge, and their recovery may fall apart," Holder says. For example, a sizeable number of patients fail to make a follow-up appointment with their primary care physician because they don't understand the importance. Patients might not understand the need to get their prescriptions. Another possibility is that they may take the medication they were taking before they were hospitalized as well as those prescribed at discharge, and they end up back in the hospital.

Case managers need to take more than a just few minutes to plan transitions and educate the patient and family, Holder says. "The information we glean in the hospital, the skilled nursing facility, the physician's office, all needs to be shared when the patient transfers to the next level of care," she says.

Maryanne P. Dixon, RN, BSN, CPUR, long-term acute care hospital (LTACH) liaison at Hershey (PA) Medical Center, suggests that case managers go beyond just sending information to post-acute facilities along with the patient's discharge orders. Once the post-acute providers receive information from the hospital, make sure they are comfortable with it and that they have everything they need, Dixon adds. "A hospital's responsibility doesn't end with sending the medical records and reports," she says. "It ends when the accepting facility has reviewed the information and has no remaining questions regarding the care to be rendered at the LTACH."

When Hershey Medical Center began working on its LTACH transition program, improving communication between the hospital and the LTACH was one of the biggest challenges, Dixon says. "When we improved the types and detail level of information we were sending with the patients, our return rate from LTACHs dropped," she says.

Holder recommends that case managers make sure information on the patient's stay is forwarded to the primary care physician. Because many patients are managed by hospitalists, if the hospital doesn't forward discharge information to the primary care physician, he or she may not have all the information they need to manage the patient's care in the future, Holder adds.

According to Lattimer, as part of their job description, case managers are charged with advocating for patients, helping patients understand their illness and how to self-manage their condition, and communicating with providers at the next level of care. All of these steps translate into better transitional care, she says. "I've seen many statements by physicians, advanced practice nurses, and pharmacists saying that case managers are the key to ensuring continuity from one level of care and one provider to the next," Lattimer says. "The changing healthcare arena give us new challenges and opportunities to be recognized for the value we bring to the healthcare system."