Provide information to ensure patients safely transition through the continuum

Breakdown in following plan of care can lead to rehospitalization

Everyone in the health care field has heard horror stories about patients' needs falling through the cracks when they transition from one level of care to another.

It may be that a patient's wheelchair isn't delivered to the home or home health doesn't show up to provide care. In some instances, staff at the receiving facility don't have complete information and perform the same scans and tests the patient had in the acute care hospital or give the patient medication that duplicates what he or she already is taking.

When patients go home from the acute care hospital, they may be confused about their medication regimen and treatment plan or fail to recognize symptoms that indicate they are in trouble.

"As patients transition from one level of care to another, we have been seeing a breakdown in the treatment plans. They are being readmitted to the hospital because there are gaps in care or they don't adhere to their treatment plan. All of this increases the cost of health care," says Connie Commander, RN, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp. in Pearland, TX, and a member of the National Transitions of Care Coalition, an association of 29 organizations in the health care field formed to address the gaps in care that occur when patients move between care settings.

Studies have shown that when patients leave the acute care facility, more than half don't remember their discharge instructions because of the stress of being hospitalized, says Nancy Skinner, RN-BC, CCM, principal consultant for Riverside Healthcare Consulting in Whitwell, TN, and a member of the National Transitions of Care Coalition.

"Other studies have indicated that one in five patients going home from an acute care facility experiences an adverse event, not because of the disease but because they didn't know what to do, why to do it, and when to do it," Skinner says.

This presents a lot of opportunities for lapses in continuity of care and transition of care, Skinner points out.

"Case managers are the key members of the transition-of-care team that focuses on bringing together all the players and helping everyone understand their responsibility and accountability," Skinner says.

Jolynne "Jo" Carter, BSN, RN, CCM, knows first hand the problems that occur when patients move from one setting to another.

Carter, director of network services for Paradigm Management Services LLC of Concord, CA, which contracts with workers' compensation insurers to manage the care of catastrophically injured patients, supervises 130 nurses who provide on-site case management.

Her company has the expectation that a case manager sees patients in person when patients change physical locations — whether they're going from the intensive care unit to a medical/surgical floor or the acute care hospital to home or a rehabilitation facility.

"We saw patients being discharged to home whose equipment wasn't delivered and occasions when the home care nurse didn't show up. One spinal cord-injured patient developed pressure ulcers because he lay in one position for hours in the emergency room," Carter recalls.

Many times, complete information about the patient and his or her needs doesn't reach the receiving facility, she adds.

"Everybody who has worked inside a hospital can tell you that there is a lot of information about the patient that's not in the medical record. That's why it's so important for hospital case managers to communicate verbally and in writing with the people at the next level of care and make sure that there is written documentation to support what is going on with the patient," Carter says.

It can be something as simple as making a follow-up telephone call to make sure there aren't outstanding questions or that information hasn't gotten lost in transit, she adds.

"Case managers must plan for the fact that transition takes extra time and effort. They should allow a little extra time to make sure the information that goes along with the patient is clear and complete. When patients are leaving the facility, it is incumbent on case managers to make sure that the people on the receiving end get the information they need to take care of the patient," Carter says.

Think about what could go wrong at the next level of care and take steps to avoid it, she adds.

Medicare's value-based purchasing initiative
is moving toward making providers financially accountable for patient outcomes, and commercial insurers are following suit, Skinner says.

"Everybody is going to have some responsibility in giving patients the tools they need to be successful in the next environment they go to, whether it's home or a post-acute facility. Whether patients go from the hospital to home or hospital to a skilled nursing facility or rehabilitation facility, the case manager's role will be the coordination of care through every transition of care," Skinner says.

Most importantly, case managers need to look at whether patients understand their role as they move to the next treatment level, she says.

"We are so busy getting patients up and moving them out that we may not give them the tools they need to be successful in the next level of care," Skinner says.

As patients are moving across the continuum more rapidly than ever before, case managers should be looking at all the options available to transition patients to the next level of care, adds Jackie Birmingham, RN, BSN, MS, CMAC, vice president of professional services at Curaspan Health Group in Newton, PA.

Assessing the patient

Case managers should identify patients early in the hospital stay who need coordination of services to transition across the continuum, and the case manager must be able to assess them to determine their continuing care needs to identify the most appropriate level of care of post-acute care, Birmingham points out.

"An assessment of the patient is a foundation of anything that case managers do in care coordinating or discharge planning. Case managers can't come up with an appropriate discharge plan unless they know the patient's status from a psychosocial, functional, and health standpoint," she says.

Case managers also should be cognizant of what community resources are available for their patients, particularly what kind of care post-acute providers can provide, Carter adds.

"Case managers should stay aware of what the capabilities of the post-acute resources are so they are assured that the patients will get the care they need," she says.

Part of the problems that occur when patients transition to post-acute providers is documentation is not consistent across settings of care, often creating confusion, Carter says.

The current health care system creates an opportunity for each hospital to vary the details for each step in the discharge planning process, leading to inconsistencies in practices across institutions, says Diane E. Holland, PhD, RN, clinical nurse researcher, department of nursing at the Mayo Clinic and assistant professor of nursing at the College of Medicine in Rochester, MN.

Lack of consistency also creates a barrier to determining best practices and evaluating the impact that the hospital discharge planning process has on patient outcomes, Holland adds.

"Currently, there is not standardized information on patient health or function status throughout the entire episode of care. It's difficult to identify similar patients because of the lack of standardization. At the end of the day, we have difficulty understanding the end result of the episode of care and we can't determine what our best practices are," Holland says.

Holland served as a technical expert for development of the Medicare Continuity Assessment Record and Evaluation (CARE) tool being pilot tested in facilities across the country. The tool is designed to provide consistency in documentation and information provided across the continuum.

(For more information on transition-of-care issues, contact:

  • Jackie Birmingham, RN, BSN, MS, CMAC, vice president of professional services, Curaspan Health Group, e-mail:;
  • Jolynne "Jo" Carter, BSN, RN, CCM, director of network services, Paradigm Management Service, e-mail:;
  • Connie Commander, RN, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp., e-mail:;
  • Diane E. Holland, PhD, RN, clinical nurse researcher, department of nursing at the Mayo Clinic and assistant professor of nursing at the College of Medicine, Rochester, MN, e-mail:;
  • Nancy Skinner, RN-BC, CCM, principal consultant for River-side Healthcare Consulting, e-mail: