Transitions of Care: The need for collaboration across entire care continuum

The Joint Commission enterprise is in the first year of a three-year initiative to define methods to achieve improvement in the effectiveness of the transitions of patients between health care organizations and provide for the continuation of safe, quality care for patients in all settings. All three components of The Joint Commission enterprise will offer various interventions and resources that are designed collectively to improve transitions of care. The interventions will apply to six accreditation programs: hospital, critical access hospital, behavioral health care, home care, nursing and rehabilitation center, and ambulatory care. As part of this work, The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another.

Developing ways to assure safe transitions of care requires collaboration among providers all along the care continuum. The Joint Commission recently organized a series of learning visits and focus groups to better understand the progress providers are making and the challenges they still face.

The brief identifies that organizations in all settings must establish seven “foundations” to assure safe transitions from one health care setting to another:
 • Leadership support
• Multidisciplinary collaboration
• Early identification of patients/clients at risk
• Transitional planning
• Medication management
• Patient and family action/engagement
• Transfer of information

INQRI grantees have contributed much to this field of research. Led by Barbara Roberge and Ken Minaker, a team at Massachusetts General Hospital tested the impact of identifying and communicating a pre-hospital preventive patient risk profile on nurse-sensitive outcomes for hospitalized older adults. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. They identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. Cynthia Corbett, Stephen Setter and their team at Washington State University used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. Researchers at the University Pennsylvania, led by Nancy Hanrahan and Phyllis Solomon, are working on a translation of the Transitional Care Model for use with people with serious mental illness as they transition in an out of psychiatric hospitals and emergency services.

Click here for the second issue of "Transitions of Care: The need for collaboration across entire care continuum" from the Joint Commission. 

Click here to access research from INQRI grantees related to transitions of care