How to achieve successful care transitions from hospital to community

When a patient is discharged from a hospital setting, continuation of the high-quality care delivered in the hospital is a recognized challenge across many health delivery systems within Canadian provinces and internationally. The 30-day readmission rates, especially for patients with complex chronic disease, are a recognized measurement of the success of hospital community integration and of community care coordination.

Recent studies in Canada have shown that 30-day readmission rates are as high as 18% for some key conditions such as congestive heart failure and are as high as 11% for mental illness. We recognize that not all hospitalizations are preventable. However, having appropriate coordinated community services built around the primary care medical home is key to reducing readmission rates and improving long-term clinical outcomes.

Providing information and the means to equip patients at home and in the community, both social and medical, is the most important key to reducing readmission rates. Reducing readmission rates is essential to improving long-term clinical outcomes. Achieving high quality community and home care will be an invaluable component to improving the overall healthcare system across Canada, helping to provide better solutions, services, treatment, and overall health outcomes for every step along the patient’s healthcare journey on both the patient and health system sides.

Let’s take for example a typical case: an 82-year-old male patient with diabetes, hypertension and depression who has been prescribed to take five or six daily medications to keep most of his clinical indicators under control. In this scenario, the patient is admitted to hospital with an acute myocardial infarction and he subsequently develops congestive heart failure which requires the addition of further medications and the adjustment of some of the medications he is currently prescribed to be taking. As a result, by the time of his discharge, his clinical needs are now significantly more complex and his need for additional help at home has greatly increased. To manage his care correctly and responsibly, he will require a new care plan that includes his multidisciplinary care team and further information to be shared with his primary physician and community care team.

For the actual care of the patient, it would be more helpful if all members of the care team were informed that the patient had been discharged and wouldn’t it be even better if the entire care team had been informed of the latest care plan devised for his treatment, including medications reconciled, plans for follow up care and recommendations for help at home? If this level of care integration were applied, it would enable a near seamless transition of care.

Currently, we see from real-life examples that is very difficult to achieve this level of care coordination with traditional methods, which include paper-based processes and perhaps a hurried phone call. It is no wonder that information can easily slip between the two sides of a care transition and it is not surprising, as a consequence, that care within our existing system is not always seamless.

Ideas on how to improve care coordination and delivery integration are supported by the research into causes and controls for hospital readmission. Studies show that the key elements that will lead to success in reducing readmissions include: enhancing patient-centered discharge processes; focusing on medication reconciliation; improving coordination with community-based care teams; and effective patient self-management of their conditions. What each of these elements indicate is that for patients to personally manage their conditions, he or she naturally needs direct access to their personal care plans. Undoubtedly, patients are key participants in their multi-disciplinary care team and should have plans that are uniquely tailored to their medical condition, medications, medical history, personal situation, the community in which he or she is living, and level of understanding of their medical condition.

Fortunately, technological advancements can provide significantly improved access to health information. Progress continues to advance at a rapid pace. Staying abreast of the latest technology can help the current situation significantly, while advancement in health technology is underway, more can be done in the interim to optimize technology currently in the field. In the past, integration of health information has been confined to linking data and information within the walls of a hospital organization. Today, hospital and healthcare leaders across Canada recognize that it is vitally important to integrate information that spans the continuum of care, beyond the walls of the hospital into communities and even into individuals’ homes. Many jurisdictions in Canada have achieved province-wide shared electronic health records that hold valuable complete information about patients sourced from hospitals and clinics across the province. How do we best leverage that information to achieve successful care transitions?

Faster delivery of information to the medical home is one important step that can be improved. We can now move the ball forward by focusing on key information such as (1) an immediate notification that a patient has been discharged to the members of that patient’s care team; (2) a comprehensive coordinated care plan; (3) medication reconciliation tools that enable reconciliation in the hospital and in the community; (4) details of all care providers involved for each patient (the “circle of care”) with clear tasks for each to perform as necessary and appropriate; and (5) details of follow up appointments with specialists and other providers.

It is important to remind ourselves that technology cannot solve all of the problems of care transitions. Technology needs to work alongside and enable further improvements in care processes and workflow within the hospital and especially across the community. As patients are discharged from hospital, the community needs to be fully prepared and able to accept them. To this end, I would recommend a re-examination of all community care giver roles to embrace the concept of care integration with shared responsibility for patient care. The patient centered medical home, (now often termed more broadly as the patient centered health home) concept which includes clear attachment of the patient to that home is essential to the improving the health delivery model.