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TransitionsofCareintheLong-TermCareContinuumPRACTICEGUIDELINE WorkgroupMembersJamesE.LettMDCMDChairNancyA.IstenesDOHaroldBobMDCMDSarahA.JerroMARNCDONALTCGwendolenGwenBuhrMDCMDCheriLattimerCharlesACefaluMDMSRhondaRichardsH.EdwardDavidsonPharmDMPHJoanneSchwartzbergMDJoAnnFisherARNPKeithVanMeterMDSandraGoodin-HicksRNCCALNGaryWinzelbergMDMPHMariannaGrachekMSNCNHACALAJamesJimR.YatesEricHowellMDSteeringCommitteeMemberAdditionalContributorsCathleenA.BergeronRNCDONALTCMSHARichardW.MilesMDEricA.ColemanMDMPHJosephG.OuslanderMDCMDAliceBonnerPhDRNNaurshiaPandyaMDCMDSandraFitzlerRNThomasPriceMDCMDMurthyGokulaMDCMDLarryWelliksonMDFHMKarynP.LeibleRNMDCMDTechnicalWriterEleanorMayfieldAMDAStaffJacquelineVanceRNC.CDONALTCCPGProjectManagerDirectorofClinicalAffairsThisclinicalpracticeguidelineisprovidedfordiscussionandeducationalpurposesonlyandshouldnotbeusedorinanywayrelieduponwithoutconsultationwithandsuper-visionofaqualifiedphysicianbasedonthecasehistoryandmedicalconditionofapar-ticularpatient.TheAmericanMedicalDirectorsAssociationitsheirsexecutorsadmin-istratorssuccessorsandassignsherebydisclaimanyandallliabilityfordamagesofwhateverkindresultingfromtheusenegligentorotherwiseofthisclinicalpracticeguideline.TheutilizationoftheAmericanMedicalDirectorsAssociationsClinicalPracticeGuidelinedoesnotprecludecompliancewithStateandFederalregulationaswellasfacil-itypoliciesandprocedures.Theyarenotsubstitutesfortheexperienceandjudgmentofcliniciansandcaregivers.TheClinicalPracticeGuidelinesarenottobeconsideredasstan-dardsofcarebutaredevelopedtoenhancethecliniciansabilitytopractice.Thecorporatesupportersofthisguidelineprovidedfundingwithoutconditionofprod-uctuseformularystatusorpurchasingcommitment.FormoreinformationabouttheAMDAguidelinesortoordercopiesoftheseclinicalprac-ticeguidelinescall800876-2632or410740-9743orvisitourwebsiteatwww.amda.com.Forguidelineupdatesvisitwww.CPGNews.org.TocitethisguidelineuseAmericanMedicalDirectorsAssociation.TransitionsofCareintheLong-TermCareContinuumClinicalPracticeGuideline.ColumbiaMDAMDA2010 iPrefaceThisclinicalpracticeguidelineCPGhasbeendevelopedunderaprojectconductedbytheAmericanMedicalDirectorsAssociationAMDAthenationalprofessionalorganizationrep-resentingmedicaldirectorsattendingphysiciansandotherpractitionerswhocareforpatientsinthelong-termcaresetting.Thisisoneofanumberofguidelinesundertakenaspartoftheassoci-ationsmissiontoimprovethequalityofcaredeliveredtopatientsinthesesettings.Originalguidelinesaredevelopedbyinterdisciplinaryworkgroupsusingaprocessthatcom-binesevidenceandconsensus-basedapproaches.Workgroupsincludepractitionersandothersinvolvedinpatientcareinlong-termcarefacilities.BeginningwithageneralguidelinedevelopedbyanagencyassociationororganizationsuchastheAgencyforHealthcareResearchandQualityAHRQpertinentarticlesandinformationandadraftoutlineeachgroupworkstomakeaconciseusableguidelinethatistailoredtothelong-termcaresetting.Becausescientificresearchinthelong-termcarepopulationislimitedmanyrecommendationsarebasedontheexpertopinionofpracti-tionersinthefield.Abibliographyisprovidedforindividualswhodesiremoredetailedinformation.GuidelinerevisionsarecompletedunderthedirectionoftheClinicalPracticeGuidelineSteeringCommittee.Thecommitteeincorporatesinformationpublishedinpeer-reviewedjournalsaftertheoriginalguidelinesappearedaswellascommentsandrecommendationsnotonlyfromexpertsinthefieldaddressedbytheguidelinebutalsofromhands-onlong-termcarepractitionersandstaff.PurposeAMDAseekstodevelopandreviseguidelinesthatfocusonspecificconcernsandcommonproblemsinthelong-termcaresetting.AlthoughAHRQandotheragenciesorganizationsandassociationshavedevelopedanumberofguidelinesforconditionsthatoccurinelderlyandchronicallyillindi-vidualsmanyoftheseguidelineslimitoromitconsiderationsthatareuniquetothelong-termcarepopulation.AMDAguidelinesemphasizekeycareprocessesandareorganizedforreadyincorporationintofacility-specificpoliciesandprocedurestoguidestaffandpractitionerpracticesandperformance.Theyaremeanttobeusedinamannerappropriatetothepopulationandpracticeofaparticularfacility.Guidelineimplementationwillbeaffectedbyresourcesavailableinthefacilityincludingstaffingandwillrequiretheinvolvementofallthoseinthefacilitywhohavearoleinpatientcare.AudienceThisguidelineisintendedforthemembersoftheinterdisciplinaryteaminlong-termcarefacilitiesincludingthemedicaldirectordirectorofnursingpractitionersnursingstaffconsultantpharmacistandotherprofessionalssuchastherapistssocialworkersdietitiansandnursingassistantswhocareforresidentsoflong-termcarefacilities.AMDACPGsincludemanyfunctionsandtasksrelatedtorecognizingclarifyingmanagingandmonitoringvariousconditionsandsituations.Buttheguidelinesonlysometimesspecifywhoshoulddothesetasks.Forexamplemanydisciplinesincludingnursingassistantslicensednursesdieti-ciansandsocialworkersmaymakeanddocumentobservationse.g.thatsomeonedoesnotsleepatnightismorewithdrawnorhasachangeinusualeatingpatterns.ButonlysomeofthemmayTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM PRACTICEGUIDELINEiibequalifiedtodeterminethesignificanceofthoseobservationsforexamplewhatiscausingthesleeplessnessorchangeineatingpatterns.Incontrastphysiciansandnursepractitionersmaynotbepresenttomakeobservationsbutaretrainedtoanalyzethesignificanceandcausesofsymptoms.Thuseachfacilityshouldensurethattasksaredonecorrectlyandbyappropriateinterdisciplinaryteammembers.Itisimportantforobserverstomakeanddocumentfindingseffectivelybuttheyshouldgetappropriatesupportforinterpretingthefindingswhenthisisnotwithinthescopeoftheirtrainingorpractice.AssumptionsGuidelinesinthelong-termcaresettingshouldbeconsistentwithfundamentalgoalsofdesirablelong-termcarepractice.Operationallythisrequirementmeansthatthenursingfacilitycareteamsys-tematicallyaddresses1eachindividualsriskfactorsforanumberofdiseasesandconditionsand2theadverseconsequencesofthediseasesandconditionsonthepatientsfunctioningandqualityoflife.Howeverwhennursingfacilitypatientsareatorneartheendoflifecaregoalswillshiftfromfunctionalimprovementorphysicalstabilitytopalliationorcomfortcare.AMDAguidelinesaddressthistransitionandprovidesuggestionsforappropriatemodificationofthepatientscareplan.Long-termcarefacilitiescareforavarietyofindividualsincludingyoungerpatientswithchron-icdiseasesanddisabilitiesshort-staypatientsneedingpostacutecareandveryoldandfrailindi-vidualssufferingfrommultiplecomorbidities.Whenaworkuportreatmentissuggesteditiscrucialtoconsiderifsuchastepisappropriateforaspecificindividual.Aworkupmaynotbeindicatedifthepatienthasaterminalorend-stageconditionifitwouldnotchangethemanagementcourseiftheburdenoftheworkupisgreaterthanthepotentialbenefitorifthepatientorhisorherproxywouldrefusetreatment.Itisimportanttocarefullydocumentinthepatientsmedicalrecordtherea-sonsfordecisionsnottotreatorperformaworkuporforchoosingonetreatmentapproachoveranother.HowtoUseTheseGuidelinesEachguidelineincludesanarrativeportionthatcoversdefinitionrecognitionassessmenttreatmentandmonitoringoftheconditionbeingaddressed.Recognitionmeansidentifyingthepresenceofariskorcondition.Assessmentmeansclarifyingthenatureandcausesofaconditionorsituationandidentifyingitsimpactontheindividual.Treatmentmeansselectingandprovidingappropri-ateinterventionsforthatindividual.Monitoringmeansreviewingthecourseofaconditionorsit-uationasthebasisfordecidingtocontinuechangeorstopinterventions.Eachguidelinealsoincludesanalgorithmthatsummarizesthestepsinvolvedinaddressingthecondition.Inthealgorithmrectanglessignifypointswhereactionistobetakendiamondsindicatepointswhereadecisionmustbemade.TerminologyWerecognizethatpeoplewhoresideinlong-termcarefacilitiesareresidents.Howeverwehaveusedthetermpatientsthroughouttheseguidelinesbecauseweareaddressingindividualswith-inthecontextoftreatingamedicalcondition.Inadditiontheseguidelinesapplysubstantiallytoindividualswhocometolong-termcarefacilitiesforshort-termcare.Whenreferringtopharmaceu-ticalproductswehaveavoidedtheuseofbrandnamesandrefertoclassesofdrugswheneverpossible. TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUMiiiTABLEOFCONTENTSTerminology....................................................................................................................................................1DEFINITIONS..................................................................................................................................................1TABLE1.SitesofCareWithintheLong-TermCareContinuum..............................................................................2INTRODUCTION............................................................................................................................4ScopeoftheProblem......................................................................................................................................4HospitalReadmissionsMedicationErrorsandAdverseEvents..........................................................................4CommunicationDeficiencies..........................................................................................................................5SegmentationofPrimaryMedicalCareServices..............................................................................................6BarrierstoEffectiveCareTransitions..................................................................................................................7Delivery-System-LevelBarriers................................................................................................................................7Clinician-LevelBarriers..........................................................................................................................................7Patient-LevelBarriers............................................................................................................................................8BenefitsofContinuityofCare............................................................................................................................8PurposeandScopeofThisClinicalPracticeGuideline........................................................................................9GuidingPrinciples..........................................................................................................................................9ImportanceofAccountability......................................................................................................................10Relationship-CenteredCare........................................................................................................................10ImportanceofDocumentation......................................................................................................................11OutcomesExpectedfromImplementationofThisClinicalPracticeGuideline........................................................11PART1CROSS-CUTTINGISSUESINTRANSITIONSOFCARE........................................................12ScopeoftheLong-TermCareContinuum..........................................................................................................12ToolsToFacilitateTransitionsofCareintheLong-TermCareContinuum..............................................................12InstitutionalCommitment................................................................................................................................12AccountabilityforCareTransitions..............................................................................................................13InserviceTraining......................................................................................................................................13InteractionsWithOtherFacilities..................................................................................................................14RoleofthePatientandofFamilyCaregiversinTransitionsofCare....................................................................14TheHIPAAPrivacyRuleandTransitionsofCare................................................................................................15TABLE2.ExamplesofMythsandFactsAbouttheHIPAAPrivacyRule................................................................15MedicationReconciliation..............................................................................................................................16TABLE3.SummaryofSuggestedCommonorEssentialElementsforMedicationReconciliation..............................17ElectronicHealthRecords..............................................................................................................................18FinancialIssues..............................................................................................................................................18PART2IMPLEMENTATIONOFACARETRANSITIONPROGRAM....................................................19STEP1..........................................................................................................................................................19STEP2..........................................................................................................................................................20 TABLE4.FacilityPre-TransitionChecklistIssuesThatShouldBeAddressedBeforeaPlannedPatientTransfertoAnotherSettingorLevelofCare......................................................................21STEP3..........................................................................................................................................................21TABLE5.EssentialInformationThatShouldAccompanyEveryTransitioningPatient..............................................24TABLE6.AMDAUniversalTransferForm..........................................................................................................23TABLE7.RecommendedElementsofaDischargeorCourse-of-TreatmentSummary..............................................27TABLE8.PractitionerRequestforNotificationofMedicationChange..................................................................27STEP3A......................................................................................................................................................28TABLE9.ExampleofaSkilledNursingFacility-to-EmergencyDepartmentTransferForm........................................28STEP3B........................................................................................................................................................30TABLE10.PatientInformationThatMayBeRequestedByanEmergencyMedicalServiceDispatcher....................31TABLE11.SummaryofCMSMedicalNecessityGuidelinesforAmbulanceTransportationofMedicarePatients......31TABLE12.InformationExchangeBetweenEMSPersonnelandSendingFacility....................................................32STEP3C......................................................................................................................................................32TABLE13.PurposesandPrinciplesofCaregiverAssessment..............................................................................33STEP3D......................................................................................................................................................34TABLE14.DeterminingAPatientsWishesRegardingEnd-of-LifeCare................................................................34STEP4..........................................................................................................................................................34STEP4A......................................................................................................................................................34STEP5..........................................................................................................................................................35STEP6..........................................................................................................................................................35TABLE15.FacilityPost-TransitionChecklists......................................................................................................36STEP7..........................................................................................................................................................37FIGURE1.AConceptualModelforTransitionsofCare....................................................................................38TABLE16.SamplePerformanceMeasurementIndicators....................................................................................39SUMMARY..................................................................................................................................37RESOURCES................................................................................................................................40APPENDIX1.SummaryofResultsofThreeRandomizedControlledTrialsofTransitionalCareTeams......................50APPENDIX2.PrinciplesforManagingTransitionsinCareBetweentheInpatientandOutpatientSettingsFromtheACPSGIMSHMAGSACEPandSAEM..............................51APPENDIX3.TransitionsofCareTwoContrastingScenarios............................................................................52APPENDIX4.ExamplesofServicesProvidedintheLong-TermCareContinuum....................................................54APPENDIX5.ExamplesofHealthCareandSupportProfessionalsFoundintheLong-TermCareContinuum............56APPENDIX6.SamplePolicyandProcedureforCareTransition..........................................................................57APPENDIX7.ExtractsfromJointCommissionNationalPatientSafetyGoals2009................................................58APPENDIX8.SuggestedCommonorEssentialElementsforMedicationReconciliation..........................................60APPENDIX9.IdealDischargeoftheElderlyPatientAHospitalistChecklist..........................................................64ivPRACTICEGUIDELINE APPENDIX10.ExampleofaPost-AcuteCaretoEmergencyDepartmentHospitalTransferForm............................65APPENDIX11.QualityIndicatorsforTransitionsBetweenNursingFacilitiesandEmergencyDepartments..............66APPENDIX12.RecommendedDomainsandConstructsforCaregiverAssessment................................................67APPENDIX13.InterventionsforImprovingComprehensionAmongPatientswithLowHealthLiteracyandImpairedCognitiveFunction............................................................................69APPENDIX14.SelectedPerformanceMeasurementIndicatorsforTransitionalCareFromExistingTools..................70vTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM TherewasanimportantjobtobedoneandEverybodywassurethatSomebodywoulddoit.AnybodycouldhavedoneitbutNobodydidit.EverybodyblamedSomebodywhenNobodydidwhatAnybodycouldhavedone.AnonymousFromasystemperspectiveasafetransitionfromahospitaltothecommunityoranursinghomerequirescarethatcentersonthepatientandtranscendsorganizationalboundaries.JencksetalNewEnglandJournalofMedicineApril2009 TerminologyPeoplewhoresideinfacilitieswithinthelong-termcarecontinuummaybereferredtobyavarietyoftermsincludingresidentsclientsandpatients.Wehaveelectedtousethetermpatientsintheseguidelinesbecausewearegenerallyaddressingindividualswithinthecontextofthecareofamedicalcondition.Wehavealsousedthetermfamilywhichisintendedtoincludeotherdecisionmakersandproxieswhomayadvocateforthepatientoractonthepatientsbehalf.WerecognizethatalthoughsomeindividualsaretransientresidentsoftheLTCCformanyoth-ersanLTCCfacilityistheirhome.Wehavethereforeusedthetermcommunityhomewhendis-cussingtransitionstoahomeinthecommunitythatisnotpartofafacilitywithintheLTCC.Wehaveusedthetermmedicalpointofcontacttorefertothepractitionerwhoisdesignatedbythepatientorfamilytobenotifiedoftransitionsandwhoisresponsibleforcoordinatingthepatientscareinthecommunity.Throughouttheguidelinewespeakofthefacilityashavingresponsibilityforcontactingthepractitionerorsiteofcaretowhichthepatientisbeingtransferred.Wedonotprescribeexactlywhichcategoriesoffacilitystaffshouldhavethisresponsibilityasthiswillvarybyfacility.Wealsodonotintendtoimplythattheseresponsibilitiesfallsolelyonfacilitystaff.Attimesitmaybemoreappropriatefortheattendingphysiciannursepractitionerorphysicianassistanttocontactthenextsiteofcare.Finallywhenreferringtopharmaceuticalproductswehaveavoidedtheuseofbrandnamesandrefertoclassesofdrugswheneverpossible.DefinitionsManydefinitionsexistastotheterminologyandconceptsrelatedtotransitionsofcare.RecognizingthatallexistingdefinitionshaveshortcomingstheAMDAconsensuspanelhaschosentousethefol-lowingdefinitions.Transitionofcarereferstothemovementofpatientsbetweenhealthcarelocationsprovidersordifferentlevelsofcarewithinthesamelocation1astheirconditionsandcareneedschange.Specificallyatransitionofcarecanoccur2uWithinsettingse.g.primarycaretospecialtycareintensivecareunittowarduBetweensettingse.g.hospitaltosubacutecareambulatoryclinictoseniorday-carecenter1TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUMTransitionsofCareintheLong-TermCareContinuum uAcrosshealthstatese.g.curativecaretopalliativecareorhospicepersonalresidencetoassistedlivingoruBetweenproviderse.g.generalisttospecialistpractitioneracute-careprovidertopalliativecarespecialisthospitalisttoprimarycarepractitionerPCP.Transitionalcareisasetofactionsdesignedtoensurecoordinationandcontinuityofcare.Itshouldbebasedonacomprehensivecareplanandtheavailabilityofwell-trainedpractitionerswhohavecurrentinformationaboutthepatientstreatmentgoalspreferencesandhealthorclinicalsta-tus.Itincludeslogisticalarrangementsandeducationofpatientandfamilyaswellascoordinationamongthehealthprofessionalsinvolvedinthetransition.12Carecoordinationisthedeliberateorganizationofpatientcareactivitiesamongtwoormorepar-ticipantsincludingthepatientandorfamilyinvolvedinapatientscaretofacilitatetheappropri-atedeliveryofhealthcareservices.Organizingcareinvolvesthemarshallingofpersonnelandotherresourcestocarryoutallrequiredpatientcareactivities.Thisisoftenmanagedbytheexchangeofinformationamongparticipantsresponsiblefordifferentaspectsofthecare.2Thelong-termcarecontinuumLTCCisacomprehensivelongitudinalpatient-centeredsystemofformalandinformalhealthandsupportservicesintendedtoimprovemaximizeorstabilizewhenpossiblethefunctionofpatientswithchronicdiseaseacrossvarioussettingsoveranextend-edperiodoftimeandtoprovidecompassionatecareattheendoflife.TheLTCCencompassesabroadrangeofsitesofcareTable1.TABLE1SitesofCareWithintheLong-TermCareContinuumTypeDescriptionNursingHomeSkilledNursingFacilityAnSNFalsoknownasanursinghomeisaplaceofcareforpeoplewhorequire24-hSNFnursingandrehabilitationforchronicmedicalconditionsorimpairedmentalcapacityandwhohavesignificantdeficienciesinactivitiesofdailyliving.Thegoalofcareistoassisttheindividualinachievinghisorherhighestleveloffunctionandwell-being.BothSNFsandNFscareforfrailelderlypatientsandyoungeradultswithphysicaldisabilitiesalthoughpediatricandotherspecializedSNFsalsoexist.ManySNFsandNFsofferspecialcareunitse.g.dialysisventilatorunits.SubacuteStep-DownCareFacilitySubacuteorstep-downcarecanbethebridgebetweenanacutehospitalstayandareturntoacommunityhome.ItcombinesaspectsofboththehospitalandtheSNFtoreducethecostofserviceswhilemaintainingqualityofcare.Thistypeofcarerequiresfrequentpatientreassessmentandreviewoftheclinicalcourseandtreatmentplanforalimitedtimeperioduntilthepatientsconditionhasstabilizedorapredeterminedtreatmentcourseiscompleted.Long-TermAcute-CareHospitalLTACHPatientswhorequirelong-termusuallylongerthan25daysclinicallycomplexacutemedicalcarequalifyforadmissiontoanLTACHwhichistypicallyafree-standingunitalthoughitmaybelocatedwithinanacute-carehospitali.e.hospitalwithinhospital.LTACHsoftenspecializeinrespiratoryventilatorcareandacceptpatientsfromintensivecareunits.Theymayalsoprovideotherspecializedservicessuchaspost-strokerehabilitationwiththegoalofpreparingthepatienttoreturntohisorhercommunityhome.PRACTICEGUIDELINE2 TABLE1continuedSitesofCareWithintheLong-TermCareContinuumTypeDescriptionIntermediate-CareFacilityfortheAnICFMRprovidescareforindividualswithmentalretardationordevelopmentalMentallyRetardedICFMRdisabilities.Servicesprovidedarebasedonclientneedswhichvaryaccordingtoageandlevelofdisability.Individualsmayresideinthefacilityfromyouthuntiloldagethusthefacilitybecomesapermanenthomeanditsstaffasecondfamily.CommongoalsofICFMRsaretoassesseachindividualsleveloffunctioningandhelpeachpersonachievehisorherpotentialthrougheducationandtraining.AssistedLivingCommunityALCAnALCprovidescareforindividualswhoneedsomehelpwithactivitiesofdailylivingADLsyetwishtoremainasindependentaspossible.AmiddlegroundbetweenindependentlivingandnursinghomesALCsaimtofosterasmuchautonomyastheresidentiscapableof.Mostfacilitiesoffer24-hsupervisionmostoftenbynonlicensedstaffandanarrayofsupportservicesthatmayincludemedicationmanagementanddementiacareservices.ContinuingCareRetirementCommunityCCRCsofferaccommodationsatmanylevelsincludingindependentandassistedlivingasCCRCorLifeCareFacilitywellasmedicalandnursingservicesuptoandincludingSNFcare.SomeCCRCsalsoofferspecial-careunitse.g.forpatientswithAlzheimersdisease.Residentsarecaredforastheyageandtheirhealthstatuschanges.SeniorhousingUndertheFairHousingActhousingforolderpersonsishousingthatuIsspecificallydesignedforoccupationbyelderlypersonsunderaFederalStateorlocalgovernmentprogramuIsoccupiedsolelybypersonswhoare62orolderoruHousesatleastonepersonwhois55orolderinatleast80oftheoccupiedunitsandadherestoapolicythatdemonstratesintenttohousepersonswhoare55orolder.TheHousingforOlderPersonsActof1995HOPAeliminatedtheinitialrequirementsforsignificantservicesandfacilitieswithindesignatedseniorhousingunitsorareas.Benefitstoseniorhousingmayincludelocationnearshoppingormedicalfacilitiessecurityfeaturessafety-equippedhandrailspullcordsunitsandcommunityactivitiesortransportation.Housingoptionsmayincludeluxuryretirementlivingmoderateapartment-stylelivingorrent-assistedlow-incomehousing.AdultDayCareFamilieswhoareunabletoprovidesupervisionforafamilymemberduringthedayduetojobresponsibilitiesorotherobligationsmayuseadultdaycare.Adultday-carecenterscanoffersupervisionsocialandrecreationalactivitieslunchandpossiblyhealth-relatedoversightduringthedayforadultswhomayneedcareoutsideofthehomeorresidentialcarefacility.Adultdaycarealsooffersrespiteforthosewhomightnormallycareforafamilymemberathome.HomeCareHomeHealthCareManyeldersdisabledadultsandchildrenwithspecialneedsreceivehealthcareathome.ServicesaredeliveredathometorecoveringdisabledandchronicallyorterminallyillpersonswhoneedmedicalnursingsocialortherapeutictreatmentorassistancewithessentialADLs.Theseservicesmayincludeskillednursingcarehomehealthcarehousekeepingsocialservicesphysicaloccupationalrespiratoryandspeechtherapyemergencyresponsenutritioncounselingandcasemanagement.HospiceHospiceisaconceptofcaredesignedtoprovidecomfortandsupporttopatientsandtheirfamilieswhenalife-limitingillnessisnolongerappropriateforcure-orientedtreatment.Thefocusofcareisonrelievingsymptomsandsupportingpatientsastheyapproachthelaststagesoflife.Hospicecareinvolvesateam-orientedapproachthatincorporatesexpertmedicalcarepainmanagementandemotionalandspiritualsupportexpresslytailoredtothepatientsneedsandwishes.AlthoughmanyhospicepatientsarediagnosedwithcancerhospiceservicesarealsoavailabletopatientswithAIDSAlzheimersdiseaseheartdiseaseneurologicaldisorderspulmonarydiseaseandotherterminalillnesses.Hospicecarecanbeprovidedinanycaresetting.PalliativeCarePalliativecareisbestunderstoodasasystemofcarebasedonapatient-centeredquality-of-lifemodelthatvaluespatientautonomyandfocusesonanticipatingpreventingandtreatingthesufferingofpatientsandfamiliesregardlessofdiagnosisorstageofillness.Althoughthepalliativeparadigmdiffersfromthemoretraditionalillness-centeredcurativemodelpalliativecarecanbeintegratedintocurativeandrestorativetreatmentplans.Thusnospecifictherapyshouldbeexcludedfromconsiderationasapalliativetreatmentifitcanenhancecomfortorimprovethepatientsqualityoflife.Palliativecareisusuallydeliveredbyaninterdisciplinaryteam.Multipledisciplinesareneededtoaddressmedicalnursingandothertherapeuticaspectsofcareandtomeetthepatientsorfamilysneedsforsocialemotionalandspiritualsupport.Reference-AmericanMedicalDirectorsAssociation.PalliativeCareintheLong-TermCareSetting.AMDAColumbiaMD20073TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM INTRODUCTIONScopeoftheProblemItiscommonforpatientsintheLTCCtobetransferredfromonecaresettinglevelofcareorcare-giverteamtoanother.ForexamplearesidentofafacilitywithintheLTCCwhoexperiencesanacutechangeofconditionmaybetransferredtotheemergencydepartmentEDadmittedtothehospitalandultimatelydischargedfromthehospitalbacktotheoriginalcaresetting.AresidentofaseniorapartmentcomplexmaybehospitalizedforasurgicalproceduretransferredtoaskillednursingfacilitySNFforrehabilitationandsubsequentlytransferredeitherbacktohisorhersen-iorapartmentorifunabletoresumelivingindependentlytoanassistedlivingcommunityALC.Itisalsoalltoocommonforadverseeventsandavoidablecomplicationstooccurasaresultofpoorcommunicationandcoordinationamongcaregivershealthcareprofessionalsandthepatientduringsuchtransitions.Poorlyexecutedcaretransitionsincreasehospitalreadmissions3duplicationofservicesandwasteofresources.4Poortransitionsaretheleadingcauseofmedicationerrorswhichfrequentlyresultfromlackofcoordinationbetweenprescribersacrosssettings.5-8Itisoftenunclearwhichpractitionerisresponsibleforthepatientintheintervalbetweendischargefromonesettingandadmissiontoanother.9SeeMedicationReconciliation.Someolderadultsareatparticularriskfortransitionproblemsfollowingahospitalization.Thosewithmultiplemedicalproblemscognitivedeficitsordepressionorothermentalhealthproblemsisolatedseniorsnon-Englishspeakersimmigrantsandrefugeesandthosewithfewfinancialassetsareespeciallyvulnerable.10HospitalReadmissionsMedicationErrorsandAdverseEventsTransfersfromnursingfacilitiesconstitute8.5ofallMedicareadmissionstoacute-carehospitalsabout40ofthesehospitalizationsoccurwithin90daysofnursingfacilityadmission.Eighty-fourpercentofthesepatientsaredischargedfromthehospitalbacktotheiroriginalcaresetting.11Jencksetal3recentlyestimatedthatclosetoonefifthofallMedicarebeneficiariesdischargedfromthehospitalarereadmittedwithin30daysthat90ofthesereadmissionsareunplannedandthatthecosttoMedicareofunplannedrehospitalizationsamountedto17.4billionin2004.Patientswithheartfailureaccountedfor26.9ofallreadmissionswithin30dayspatientswithpneumonia20.9.Whentheresearcherscomparedtheirdatawiththoseofasimilarstudypublishedin198412theyfoundthattherehospitalizationrateat60dayshadincreasedfrom22.5to31.Theycon-cludedthatthislargerdifferencewasmorelikelytoindicateanactualincreaseinrehospitaliza-tionratesovertimeperhapsowingtoashorterdurationofindexhospitalizationortotheincreaseinambulatorysurgeryoverthepast30years.InananalysisoftheuseofpostacuteandSNFsettingsovera2-yearperiodbyanationallyrep-resentativecohortofeldersalmost5millionpatientsagedover65mademorethan15milliontran-sitionsand1.1millionofthesepatients22.4hadsubsequenthealthcareusesuggestingapoten-tialtransitionproblem.Subsequenthealthcareuseincludedemergencyroomvisitspotentiallyavoidablehospitalstaysandreturntoaninstitutionalsettingfollowingdischargetothecommuni-ty.13TheCentersforMedicareandMedicaidServicesCMSinitsproposedinpatientprospectivepaymentsystemruleforfiscalyear2009estimatedthatnearly18ofMedicarepatientsarerehos-pitalizedwithin30daysofdischargeandthat13ofallreadmissionscostingapproximately12PRACTICEGUIDELINE4 billionarepotentiallyavoidable.14In2007theInspectorGeneraloftheDepartmentofHealthandHumanServicesestimatedthatconsecutivestaysequencesthreeormoresuccessiveadmissionstoahospitalorSNFeachwithinonedayoftheprecedingdischargedateassociatedwithquality-of-careproblemsandfragmentationofservicescosttheMedicareprogram4.5billionin2004.15Studieshaveshownthatmedicationchangesuponhospitaladmissionordischargeareafre-quentreasonforadverseevents.Aprospectivestudyof151patientsadmittedtogeneralinternalmedicineunitsatateachinghospitalfoundthataregularlyusedmedicationwasdiscontinuedin46.4ofcases38.6oftheseomissionswereconsideredtohavethepotentialtocausemoderateorseverediscomfortorclinicaldeterioration.16Inaprospectivecohortstudyinvolving400patientsdischargedfromatertiarycarehospitalnearlyoneinfivepatientsexperiencedanadverseeventdefinedasaninjuryoccurringasaresultofmedicalmanagementduringthetransitionfromhospitaltohome.Oftheseadverseevents66wereadversemedicationevents.Theinvestigatorsconsideredthatonethirdofalladverseeventswerepreventablethatiscausedbyanerrorandanotheronethirdwereameliorablethatisearli-ercorrectiveactionwouldhavedecreasedtheirseverity.7Boockvaretal6foundthatadversedrugeventsattributabletomedicationchangesoccurredin20oftransfersbetweennursinghomesandacute-carehospitals.Mooreetal17foundahighprevalenceofmedicalerrorsrelatingtolossofcontinuitywhenpatientsweredischargedfromahospitalsettingtothecommunity.Inaretrospectivereviewofpatientsmedicalrecordstheinvestigatorsfoundthatpatientsexperiencingawork-uperrordefinedasthePCPnotadequatelyfollowinguponawork-uprecommendationbytheinpatientproviderweresixtimesmorelikelytoberehospitalizedwithin3monthsofthepatientsfirstpost-dischargeoutpatientvisit.CommunicationDeficienciesCommunicationbetweenpractitionersindifferentcaresettingsduringtransitionsofcareisfre-quentlydeficient.Forexampletheauthorsofasystematicreviewfoundthatduringthedischargeprocesshospitalandprimarycarephysiciansrarelycommunicatedwitheachotherdirectly.Hospitaldischargesummariesoftendidnotidentifytheresponsiblehospitalphysicianmaindiag-nosisphysicalfindingsdischargemedicationsorfollow-upcareplansandrarelyprovidedinfor-mationabouttestspendingatdischargeorcounselingprovidedtothepatientorfamily.Approximately11ofdischargelettersand25ofdischargesummariesneverreachedthepatientsprimarycarephysician.5Inaretrospectivereviewofdischargesummariesformorethan600patientswhoweredis-chargedfromthehospitalwithtestresultspendingWereetal18foundthatonly25ofdischargesummariesmentionedanypendingtestsandonly13documentedallpendingtests.Seventy-twopercentofpendingtestresultsrequiringatreatmentchangewerenotmentionedindischargesum-mariesandonly67ofdischargesummariesidentifiedthehealthcareprovidersresponsibleforthepatientsfollow-upcare.Eachyearmorethan25ofnursinghomeresidentsaretransferredatleastoncetoanEDforevaluation19howeveressentialinformationisfrequentlynotconveyedwiththepatient.TenpercentofpatientsaretransportedtotheEDwithoutanydocumentationintheremaining90oftransfersessentialpatientinformationiscommonlymissing.20TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM5 Practitionersindifferentcaresettingsoftenfailtoensurethat8uTheessentialelementsofthepatientscareplanthatweredevelopedinonesettingarecommuni-catedtothenextteamofcliniciansuThenecessarystepse.g.preparationforthegoalsofcaredeliveredinthenextsettingarrange-mentsforfollow-upappointmentsandlaboratorytestingandreviewingthecurrentmedicationregimenbeforeandafterapatientstransferareproperlyandfullyexecutedanduThattherequisiteinformationaboutthecarethepatientreceivedfromthesendingcareteamiscommunicatedtothereceivingcareteam.Careprocessesmaybreakdownatmultiplepointsduringatransitionincluding8uThepreparationofthepatientandcaregiveruThecommunicationofvitalelementsofthecareplanuThereconciliationofthemedicationregimenthatwasprescribedbeforetheinitialtransitionwiththecurrentregimenuThetransportationofthepatientuThecompletionoffollow-upcarewithapractitioneruDiagnosticimagingorlaboratorytestinganduTheavailabilityofadvancecaredirectivesacrosssettings.Manypractitionersinvolvedintransitionalcarehavenotpracticedinthesettingstowhichtheyaresendingpatientsareunfamiliarwiththecare-deliverycapacityofthesesettingsandmaytrans-ferpatientsinappropriately.21SegmentationofPrimaryMedicalCareServicesEffectivemovementofpatientsthroughthecarecontinuumisfurthercomplicatedbythedifficultyofdefiningwhatprimarycarecomprisesaswellasbyadwindlingsupplyofPCPs.Atthesametimethereisincreasingsegmentationamongpractitionerswhoprovidehands-onmedicalservic-esincludingtheemergenceofnewmodelsofcaresuchasconciergeorretainerpractices.Hospitalistsphysicianswhopracticeonlywithinahospitalprovideavaluableservicehow-everahospitalistmaybereluctanttowriteordersorprescriptionsforapatientwhoismovingintothecommunity.Anoutsideentitysuchasahospicecareprogrammaybeunwillingtoacceptordersfromaphysicianwhowillnotfollowthepatientinthecommunityorbeavailableforlaterconsulta-tion.SkillednursingfacilityspecialistsSNFistsphysicianswholimittheirpracticetoSNFsmayhavesimilardifficultiesconnectingpatientswithcommunity-basedservicesbecausetheythemselvesdonotpracticeinthecommunityandwillnotfollowthepatientonceheorshehasbeentransferredthere.AsaresultofthissegmentationofservicesPCPsinatraditionalpracticesettingfrequentlysuf-ferfromaseriousinformationandcommunicationgap.ForexampleapatientmaybehospitalizedunderthecareofahospitalistandsubsequentlyadmittedtoanSNFunderthecareofanSNFist.UponthepatientsreturntothecommunitythePCPisoftenaskedtoresumecareandapprovemul-tipleservicesandprescriptionsrequiredasaresultoftheepisodeofillnessanillnessaboutwhichthePCPmayhavelittleornoknowledge.Inadditionthepatientmayhavebeenidentifiedashav-ingoneormoresignificantpreviouslyunrecognizeddisordersofwhichthePCPisunaware.ApprovaltoimplementnecessaryservicesmedicationsortreatmentmaybedelayeduntilthepatientcanreturntothePCPsofficeforafollow-upvisitleavingagapduringwhichnopractition-erisoverseeingthepatientscare.6PRACTICEGUIDELINE Acrucialsubsetofpatientswhosufferfromthisdiscontinuityarethosetransferredfromahos-pitaltoSNFcareandparticularlytohospicecarewholeavethehospitalwithoutwrittenprescrip-tionsfornarcoticstocontroltheirpain.Thisomissioncanpresentaparticularproblembecauseopi-oidanalgesicscannotbedispensedwithoutawrittenprescriptionfromanauthorizedprescriber.Ifthehospitalphysiciandoesnotprovidethepatientwithsuchaprescriptionitmaytake24to48hoursorlongertoobtainappropriatepainmedicationforthepatientanunacceptabledelayforapatientwhoisexperiencingpain.BarrierstoEffectiveCareTransitionsColeman821hascharacterizedbarrierstoeffectivecaretransitionsasoccurringatthreelevelsthedeliverysystemtheclinicianandthepatient.Delivery-System-LevelBarriersuEachcaresettingfunctionsasasilothatlacksformalrelationshipswithothercaresettings.Independentproviderscannoteasilyaccesspatientinformationmaintainedbyotherindependentprovidersmakingcarecoordinationmoredifficult.22Evenwithinapatient-centeredmedicalhome23providersmayhavedifficultyaccessingpatientinformation.uInformationsystemse.g.interoperablecomputerizedrecordsdesignedtofacilitatethetimelytransferofpatientinformationacrosscaresettingsdonotexist.Existingcomputerizedrecordsys-temsareoftenincompatiblewithoneanother.uFinancialincentivestopromotetransitionalcarecollaborationacrosssitesandaccountabilityarelacking.Forexamplepaymentpoliciesrarelyincludereimbursementforcarecoordinationandotheractivitiesthatfacilitatethesendingandreceivingofatransitioningpatient.uHealthcarefacilitieswithintheLTCCaswellashealthplansandgovernmentprogramsservingspecificpatientswithinthoseentitieshaveincentivestoprescribeorsubstitutemedicationsaccordingtotheirownformularies.Theconstantturmoilofmedicationswitchesandgenericsub-stitutionscreatesconfusionforthepatientcaregiversandreceivingclinicians.Eachhospitaliza-tionresultsinmodificationofthepatientsdrugregimenwhichisfollowedbyanotherroundoftherapeuticsubstitutionswhenthepatientreturnstohisorheroriginalcaresetting.uInsurancecoverageissuesfrequentlydriveservicedelivery.Forexampleachangeinapatientsinsurancemaynecessitateachangeofdoctor.InsurancecriteriaoftendeterminethelengthofahospitalorSNFstaywhichcanresultinanabruptchaoticdischarge.Insurance-drivenchangesinservicedeliveryfrequentlyoccurwithoutinformation-sharingwithprimarycareproviders.uThelackofconsistentsafehigh-qualitytransitionalcareisanunder-recognizedissuethathasreceivedtoolittleattentionfromhealthpolicymakers.Themassivescopeofactualandpotentialpatientharmresultingfrompoortransitionsandtheconsequentexcesshealthcarecostsarelike-wiseunappreciated.Clinician-LevelBarriersuAsingleclinicianrarelyprovidescontinuouscareforapatientacrosscaresettings.Exacerbatingtheproblemclinicianscaringforthesamepatientindifferentcaresettingsdonotcommunicatepatientinformationtooneanother.uCliniciansandhospitalistsmayconsultmultiplespecialistsabouteachpatientwitheachoftheseencounterspotentiallyleadingtoadditionaltestsandmedicationsthatmaybeunnecessaryortoTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM7 changesinexistingmedications.Astringoffollow-upappointmentsmayalsobegeneratedwith-outconsiderationoftheirrelevancetothepatientsoverallcaregoals.uCaremanagersandsocialworkerswhoonceprovidedlongitudinalcareoversightacrosssettingsnowarepredominantlyassignedtospecificcaresettings.Olderpatientswithmultipleproblemsmaybeassignedtomorethanonecaremanager.Withoutformalmechanismsforongoingcom-municationandcoordinationmultiplecaremanagersmaycontributetoratherthanalleviatecarefragmentation.Patient-LevelBarriersuPatientsandfamiliesrarelyadvocateforimprovedtransitionalcareuntilconfrontedwiththeproblemfirsthand.Theypresumethattheirhealthcareprofessionalswilltakecareoftheirneedsacrossthecontinuumofcareandoftenassumeincorrectlythattheprovidersinvolvedintheircarearesharingadequateinformation.uOlderpatientsandtheircaregiversareoftennotadequatelyinformedabouttheirdiseaseprocessandthenextstepsintheircaresothattheyareabletooptimizethecarethepatientreceivesinthenextsetting.uPatientsandcaregiversmaynotfeelempoweredtoexpresstheirpreferencesorprovideinputtothepatientscareplan.uThelevelofinformationprovidedtopatientshasnotescalatedproportionatelywiththecom-plexityofthecurrentmedicalmodel.uTake-homeinformationthatpatientsreceiveindifferentcaresettingsmayprovideconflictinginformationandleavepatientsandtheircaregiversconfused.uDifferingculturalorientationsexpectationsandbarrierssuchascognitiveimpairmentlimitedEnglishfluencyandlowliteracymaypreventpatientsandcareprovidersfromcommunicatingclearly.BenefitsofContinuityofCareEvidenceismountingthateffortstoensurecontinuityofcareforolderpatientsduringcaretransi-tionscanimprovepatientoutcomes.Byimprovingcoredischargeplanningandtransitionprocessesoutofthehospitalimprovingtransitionsandcarecoordinationattheinterfacesbetweencareset-tingsandenhancingcoachingeducationandsupportforpatientself-managementtherateofavoidablerehospitalizationcanbereduced.24InarandomizedcontrolledtrialRCTconductedatanurbanacademicmedicalcenterapack-ageofdischargeservicesincludingarrangingfollow-upappointmentsreconcilingmedicationsandeducatingpatientsdecreasedEDvisitsandreadmissionswithin30daysofdischargeby30.25IntheCareTransitionsInterventionalsoanRCTatransitioncoachwasusedtoencouragethepatientandcaregivertoassertamoreactiveroleduringcaretransitionsprovidecontinuityacrosssettingsandensurethatthepatientsneedswerebeingmetirrespectiveofthecaresetting.Thisinter-ventionreducedratesofrehospitalizationasfaras6monthsoutinapopulationofchronicallyillcommunity-dwellingadultsaged65andolder.26Atrialthatemployedadvancedpracticenursestoplayacentralroleincoordinatingcareacrosssitesandhealthcarepractitionersdemonstratedreductionsinbothhospitalreadmissionsandhealth-carecostsforelderswithcongestiveheartfailure27aswellasamongseniorsconsideredtobeathighriskforhospitalreadmission.2829SeeAppendix1forasummaryofresultsfromthreeofthesetrials.8PRACTICEGUIDELINE Qualitativeinvestigationhasidentifiedfourfactorsconsideredbypatientsandcaregiverstobemostvaluabletothemduringcaretransitions.ThesefactorswhichwerethebasisoftheCareTransitionsInterventionare26uAssistancewithmedicationself-managementuApatient-centeredrecordownedandmaintainedbythepatienttofacilitatecross-siteinformationtransferuTimelyfollow-upwithprimaryorspecialtycareanduAlistofredflagsindicativeofaworseningconditionandinstructionsonhowtorespondtothem.Theimportanceofcaretransitionstobothoverallcarequalityandpatientoutcomesisnowrec-ognizedbynumerousnationalhealthcareorganizationsincludingtheAgencyforHealthcareResearchandQualitytheJointCommissiontheNationalQualityForumandtheNationalTransitionsofCareCoalition.Theseorganizationsamongothersareleadingavarietyofinitiativesintendedtoimprovethegeneralqualityofcaretransitions.AcoalitionofsixmedicalprofessionalsocietieshaspublishedrecommendationsonprinciplesandstandardsformanagingtransitionsofcarebetweeninpatientandoutpatientsettingsAppendix2.30InadditionCMSispilot-testingaContinuityAssessmentRecordandEvaluationCAREtoolforuseinpost-acutecaresettings31andMedicaresQualityImprovementOrganizationProgramisworkingin14statestocoordinatecarepromoteseamlesstransitionsacrosssettingsandreduceunnecessaryhospitalreadmissions.3233ItisanopportunetimethereforeforAMDAtoofferthispracticeguidelinewhichisintendedtoprovidefacilitieswithintheLTCCwithpracticalguidanceonimprovingcaretransitions.Appendix3presentstwoscenariosthatillustrateboththeconsequencesofpoortransitionsofcareandthebenefitsofmanagingtransitionstoensurecontinuityofcareforthepatient.PurposeandScopeofThisPracticeGuidelineThisguidelinefocusesontransitionsofcarebetweensettingswithintheLTCCbetweenLTCCandacute-caresettingse.g.EDhospitalandbetweenanLTCCsettinge.g.SNFandthepatientscommunityhome.Activeinvolvementofthepatientandfamilyinthesetransitionsistobeencour-agedhoweverthisguidelineisprimarilydirectedatthehealthcareprofessionalsinvolvedincaretransitions.ItoutlinesaprocessthatiffollowedwillcontributetoensuringthatuNecessarycaretransitionsareconductedsmoothlyuEssentialpatientinformationistransmittedsuccessfullytothepatientsnextcaresettinganduHealthcareprofessionalsinvolvedinthecareofthetransitioningpatientcommunicateappropri-atelyaboutthepatientscareneedsresultinginasafermoresatisfyingtransitionforthepatient.GuidingPrinciplesAguidingprincipleunderlyingthisguidelineisthereplacementoftheconceptofdischargefromahealthcarefacilitywiththatoftransition.Dischargebyimplyingthatthepatientisnolongerourresponsibilityafterheorsheleavesthefacilityortheprovidersofficeisanoutmodedconceptthatcontributestoalackofcontinuityofcare.Transitionbycontrastextendsmedicalprovidersrespon-sibilityforapatientnotonlyintothewhitespacebetweenonelevelorsettingofcareandthenextbutactuallyintothenextsiteorlevelofcare.ThisresponsibilitypersistsuntilthenewcaregiversacknowledgetheassumptionofcareandanycarequestionsonthepartofthenewcaregiversareFormerlytheJointCommissiononAccreditationofHealthcareOrganizationsAlabamaColoradoFloridaGeorgiaIndianaLouisianaMichiganNebraskaNewJerseyNewYorkPennsylvaniaRhodeIslandTexasandWashington9TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM resolved.Inanytransitionitisessentialthatthepartiessendingandreceivingpatientinformationvalidatethetransferaccepttheinformationclarifyanydiscrepanciesandactontheinformationinatimelyfashion.Asecondguidingprincipleisthatunnecessarycaretransitionsshouldbeavoidedandnecessarytransitionsmanagedtoensurecontinuityofcareforthepatient.InaCMS-fundedspecialstudyexaminingthefactorscontributingtopotentiallyavoidablehospitalizationsamongresidentsofGeorgianursingfacilitiesexpertreviewersconcludedthat68of200hospitalizationsfrom20nurs-ingfacilitieswereprobablyordefinitelyavoidable.34Beforeanydecisionismadetotransferapatientthepotentialforharmfromimposinganadditionaltransfertoanewcaresettingmustbeweighedagainstthepotentialforbenefit.Basethedecisiontotransferontheappropriatenessofthematchbetweentheproposedcaresettingandthepatientsmedicalnursingandfunctionalneeds.8ForguidanceonavoidingunnecessarytransitionspleaserefertoAMDAsAcuteChangeofConditionintheLong-TermCareSettingaclinicalpracticeguidelineProtocolsforPractitionerNotificationinthenursingfacilitysettingbandCaregiversCommunicationGuidefortheassistedlivingcommunities.cImportanceofAccountabilityThispracticeguidelinedelineatesessentialstepsandactionsrequiredforsafemovementacrosscaresettings.Itdoesnothoweverdictatewhoshouldberesponsibleforperformingspecifictasksasso-ciatedwithcaretransitionsasthiswillvarybycaresetting.Withineachcaresiteeverytransitiontaskmustbeassignedtoadesignatedpersonconsistentlywiththeorganizationalstructure.Itisessentialthatthespecificresponsibilitiesofeachpersonwithregardtotransitionsbeidentifiedalongwithaccountabilityandclearfeedback.Specificityandaccountabilityareessentialforgoodoutcomes.Equallyimportantindividualaccountabilityforspecifictasksmustbesupportedbyafacility-wideculturethatplacesahighpriorityonsafetransitionsandconsidersthemtobeeveryonesresponsibility.Forexampletheprocessesrecommendedinthisguidelineforensuringthatessentialinformationistransmittedwiththepatientduringcaretransitionswillbeeffectiveonlyifthecareprovidersreceivingthepatientreadthemcarefullyandactonthemincludingrequestingclarifica-tionfromthesendingcareproviderswheninformationismissingorunclear.Furthermorethesam-pleformsprovidedinthisguidelinewillbehelpfulinconveyinginformationonlywhenprocessesareinplacewithinthefacilitytoensurethattheformsareusedasintended.Whenassigningindividualresponsibilitiesforcaretransitionsfacilitymanagersshouldkeepinmindthatsomeproviderstowhominformationaboutatransitioningpatientisbeingconveyedmaybemorereceptivetothatinformationwhenitisconveyedbyaproviderofequivalentlicensuree.g.physiciantophysiciandirectorofnursingtodirectorofnursing.Seniorfacilitystaffandconsultantsshouldbepreparedtoparticipateincommunicationsconcerningatransitioningpatientwhennec-essary.Relationship-CenteredCareTheconceptofrelationship-centeredcarefocusedonthepatientandfamilywhoconstitutetheunitofcareisessentialtothisguideline.ForpurposesofthisCPGfamilyorsupportsystemisdefinedaAmericanMedicalDirectorsAssociation.AcuteChangeofConditionintheLong-TermCareSetting.ClinicalPracticeGuideline.ColumbiaMD.bAmericanMedicalDirectorsAssociation.ProtocolsforPhysicianNotificationAssessingandCollectingDataonNursingFacilityPatients-AGuideforNursesonEffectiveCommunicationwithPhysicians.ColumbiaMD.cAmericanMedicalDirectorsAssociation.CaregiversCommunicationGuideCaringfortheOlderAdult.ProtocolsforChangeofCondition.ColumbiaMD10PRACTICEGUIDELINE asagroupofpersonsofmultipleagesbondedbyaffectionbiologychoiceconveniencenecessityorlawforthepurposeofmeetingtheindividualneedsofitsmembers.35Theseindividualsareselectedbythepatienttoreceivepersonalmedicalandsocialinformationandtoeitherassistindeci-sion-makingoractuallymakedecisionsasdesiredbythepatient.Itisimportanttorelationship-centeredcarethathealthcareprovidersrecognizeandhonorthisheterogeneousconceptoffamilybyrespectingtherightofthoseindividualswhomthepatienthasidentifiedashisorherfamilyorsupportsystemtoreceiveinformationorassistwithdecision-mak-inginaccordancewiththepatientswishes.ImportanceofDocumentationAcrosstheLTCCcontinuumclearcommunicationofappropriatepatientinformationisthefounda-tionofpatientsafetyandofgoodcaretransitions.BecausetheLTCCencompassesadiverserangeofcaresettingsboththeextentofpatientinformationthatisdocumentedandthemannerinwhichitismaintainedvarywidely.SomesitesmostnotablySNFsandhospitalsmustadheretorigiddocu-mentationstandards.InotherLTCCsettingspatientinformationisdocumentedandstoredbaseduponfunctionalneedcustomandpaymentrequirements.Anequallyacceptedfundamentalneedisthatofrespectforpatientautonomy.PrivacyconcernswhetherinregardtoethicalissuesorHealthInsurancePortabilityandAccountabilityActHIPAAcompliancerequirementsmustalsobeconsidered.Thiscomplexmixofautonomyprivacyandreg-ulationmustbenegotiatedinthepatientsbestinterest.MindfuloftheseissuesLTCCfacilitiesshouldmaintaindocumentationthatsupportsthecareofthepatientsinvolvedandprovidessubsequentcaresiteswithadequateinformationtoenableasmoothtransferwhetherinaplannedorunplannedtransition.Insomecircumstancese.g.whenapatientistransitioningtoacommunityhomethemostimportantroleforfacilitiesandpractitionersmaybetoencourageandempowerpatientsorfamiliesthemselvestomaintaintheirhealthinforma-tionsothatitcanbesharedwiththehealthcaresystemwhennecessary.PractitionersworkingwithintheLTCCshouldcomplywithapplicabledocumentationstandardsinthebestinterestoftheirpatients.Documentationwillneedtosatisfyfacility-specificstandardsinadditiontothoseofregulatorylicensureandreimbursemententities.OutcomesExpectedfromImplementationofThisPracticeGuidelineThisguidelinerecommendsprocessesthatifimplementedshouldhelpLTCCfacilitiestoappropri-atelycoordinatetransitionalcareforpatientsenteringandleavingtheircare.Potentialbenefitsasso-ciatedwiththeimplementationofthisguidelineincludethefollowinguReductionsinuAvoidablecaretransitionsthroughapatient-centeredreviewoftherisksandbenefitstothepatientfromanychangeincaresiteuCostsassociatedwithreadmissionstohigher-acuitylevelsofcareuDuplicativeuseofdiagnosticservicese.g.electrocardiogramslaboratorytestsuExtendedhospitalstaysforobservationuHospitalreadmissionsresultingfromavoidablepost-dischargecomplicationsandadverseeventsanduMedication-relatedadverseevents.11TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM uIncreasesinuPatientandfamilyinvestmentinparticipationinthecareprocessuPatientandfamilysatisfactionwithcareuPatientsafetyanduQualityoflifeforpatientswithcomplexhealthcareneeds.uImprovedcommunicationbetweencareproviders.PART1CROSS-CUTTINGISSUESINTRANSITIONSOFCAREThissectionconsidersimportantsystemicissuesthataffecttheenvironmentinwhichtransitionsofcaretakeplace.ScopeoftheLong-TermCareContinuumTheLTCCencompassesabroadrangeofsitesofcareseeTable1thatprovideabroadrangeofserv-icesAppendix4andemployawidevarietyofhealthcareandsupportprofessionalsAppendix5.ItisimportanttonotethatalthoughtheserviceslistedinAppendix3areallprovidedwithintheLTCCeveryfacilitywithintheLTCCdoesnotprovidethisrangeofservices.Furthermoreafacili-tysdesignatedlevelofcaredoesnotdictateitspreciserangeormixofservices.ThustheprocessofselectinganappropriatefacilitywithintheLTCCforatransferringpatientmustconsiderthatpatientsspecificserviceneeds.Ifapatientrequiresaspecificservicee.g.hemodialysisintravenousinfusiontherapytracheotomycareitisessentialtoensurethatafacilityiscapableofprovidingthatservicebeforearrangingtotransferthepatienttothatfacility.FacilitieswithintheLTCCaresubjecttovaryinglevelsofregulationbylocalstateandfederalauthorities.ForexampleSNFsareextensivelyregulatedbybothfederalandstategovernments.BycontrastnofederalregulationsapplytoassistedlivingcommunitiesALCswhichareentirelyreg-ulatedbythestates.InadditionmanyLTCCfacilitiesmayberequiredtocomplywithlawsandordi-nancesenactedbylocalgovernments.ThetopicofLTCCregulationistoocomplextobeadequatelyaddressedinthisguidelinepleaseconsulttheseResourcesformoreinformationabouttheregula-tionofnursinghomesandassistedlivingcommunitiesinparticular.ToolsToFacilitateTransitionsofCareintheLong-TermCareContinuumManytoolshavebeendevelopedtofacilitatetransitionsofcareincludingsomethathavebeendevisedspecificallyforuseintransitionsthatinvolvetheLTCCseeResources.Somestatese.g.RhodeIslandNewJerseyhaveimplementeduniversaltransferformsorcontinuityofcaredocu-mentsthatarerequiredbylawtobefilledoutatanytimeapatientistransferredfromanyinstitu-tionalsetting.36InstitutionalCommitmentInstitutionalcommitmenttotheimportanceofmanagingcaretransitionsisessentialtoovercomingbarrierstoeffectivetransitions.Facilitiesmaywishtoadoptpoliciesandprocedurestoguidespecif-ictransitionssuchasthatofanursinghomeresidenttotheEDorhospital.SeeAppendix6foranexampleofsuchapolicyandprocedure.12PRACTICEGUIDELINE Institutionalcommitmentincludesensuringthebestfitbetweenthepatientscareneedsandthecapabilitiesofhisorhernextcaresetting.Efficientinformationtransferwillnotsafeguardthepatientinanenvironmentthatisunabletomeethisorhersocialandmedicalneeds.Effectivecommunicationnotonlybetweenmembersoftheinterdisciplinarycareteambutalsobetweenproviderscaringforthesamepatientindifferentsettingsiscrucialtowell-managedcaretransitions.ManyofthestepsinPart2ofthisguidelineaddressprocessesforfacilitatingeffectivecommunicationduringcaretransitions.AccountabilityforCareTransitionsFacilitiesshoulddesignatestaffpositionswhoseresponsibilitiesincludemanagementofcaretransi-tions.Individualsinthesepositionsshouldbeappropriatelytrainedandempoweredtodeveloprela-tionshipswiththeircounterpartsi.e.staffwithresponsibilityformanagingcaretransitionsatsitestowhichthefacilitytransferspatientsorfromwhichitreceivestransferredpatients.Forexampleifasocialworkeratanursingfacilityistaskedwithmanagingcaretransitionsheorsheshouldbeempoweredtocontactthetransitionteame.g.dischargeplannersocialworkeratentitiessuchasbutnotlimitedtothefollowinguThelocalhospitaltowhichnursingfacilitypatientsaresentwheninneedofacutecareuOtherLTCCfacilitiesinvolvedintransfersuHomehealthagenciescaringforpatientswhoarebeingdischargedbacktotheircommunityhomesoruCommunityserviceagenciesthatmaybeinvolvedinthecareoftransitioningpatients.Asinglecaretransitioninvolvesmultiplestepsthatwillbeperformedbycaregiversfrommulti-pledisciplinese.g.writingordersreconcilingmedicationscopyingrecordsforthepatientorforforwardingtothereceivingprovidercleaningthepatientsroomcontactingthepatientsfamilyarrangingtransportation.Atransitionmaybethoughtofasaballetandtheparticipatingdisciplinesasperformerseachdancermustnotonlyperformhisorherownmovementsproperlybutmustdosowithintheframeworkandtimingofalltheotherdancers.Anyill-timedactione.g.leapinginsteadofcatchinganotherperformerpirouettinginsteadofremainingstillrenderstheballetuglyandunsaferegardlessofhowwelltheindividualactionisperformed.Thusalthoughitisessentialthatspecificresponsibilitieswithregardtotransitionsbeidentifiedforeachindividualanddisciplineitiscoordinationofthoseactionsthatdeterminessuccess.Asin-gleindividualshouldbearoverallresponsibilityforensuringthatallstepsrelatingtoacaretransi-tionarecarriedoutinthecorrectsequenceandinsynergywithalltheotherperformersintheprocess.Thisminimizesthelikelihoodthatstepswillfallthroughthecracksbecauseonestaffmemberassumedanotherwasresponsibleforthatstep.InserviceTrainingFacilitiesshouldprovideinservicetrainingandeducationprogramsforhealthcareprofessionalsatalllevelsonthemanagementofcaretransitions.Inadditiontoaddressingthebenefitsofgoodcaretransitionse.g.betterpatientoutcomesbetterresourceutilizationimprovedregulatorycompli-ancesuchprogramsshouldalsooffertrainingonprovidingpatientinformationthatisappropriateandusefultoprovidersinthecaresettingtowhichapatientisbeingtransferredanddealwithdif-ferencesinhowcareisorganizedandprovidedinothersettings.Hospital-basedphysiciansand13TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM medicaltraineesshouldknowforexamplethatfewfacilitieswithintheLTCChavearound-the-clockon-sitediagnosticserviceslaboratorytestingfacilitiesorpharmaceuticalservicesnorarephysiciansorotherclinicalprofessionalsonsiteatalltimes.InteractionsWithOtherFacilitiesInteractionsandcollaborativerelationshipswithlocalhospitalsandotherLTCCcaresettingswhichpatientsmaybetransferredtoorfromcanbeveryuseful.Facilitiesmayuseavarietyofstrategiestobuildsuchrelationships.ConsiderestablishingajointqualitycommitteewithparticipationbyhospitalsSNFsALCshomehealthagenciesandanyotherfacilitiesthatareinvolvedinpatienttransitionstoandfromeachotherscareorinviteotherentitiestoparticipateinaqualityimprovementinitiativetoensurethattherightinformationisbeingsentwithtransferringpatientsandisbeingreceivedbyprovidersatthenextcaresetting.Alsoconsidervisitingotherfacilitiesorinvitingotherstovisityourfacility.Facilitiesmayfindithelpfultoemployacasemanagertypicallywithabackgroundinnursingorsocialworkwhoseroleistovisitothercaresettingstoscreenpatientswhoarecandidatesfortransfer.Theinformationobtainedduringthisevaluationcangoalongwaytowardassuringasmoothpatienttransition.Visitscanaugmentknowledgeofhowtobestprepareapatientforatransfertoanothersiteofcare.Preparingpatientsandfamiliesforthenextsiteofcaredemonstratesreassuringcompetencetothepatientandfamilyshowsprofessionalismtoothercaresitesanddevelopsasenseofprideinfacilitycaregivers.Whenyourfacilityispubliclyexhibitedinapositivelightitwillbeperceivedasadesirableplacetolive.Thusthedevelopmentofgoodrelationshipswithotherentitiesmaybeasuccessfulcensus-buildingstrategy.Anadditionalroleforthecasemanageristoserveasabidirectionallinkbetweenthefacilityandtheothercaresettingstoorfromwhichpatientsaretransferred.Havinganidentifiablepersoninthisrolehelpstoclosetheloopandaddspersonalresponsibilityandaccountabilitytotheprocess.RoleofthePatientandofFamilyCaregiversinTransitionsofCarePatientsintheLTCCvarywidelyintheirabilitytobeactivepartnersintheirhealthcare.Mostpatientshavesomedegreeofphysicalormentalimpairmentandarelikelytohavedifficultynavi-gatingcaretransitionswithoutassistance.Mostpatientswillhaveformalandinformalcaregiverswhoparticipateincareanddecision-making.Inadditiontoadvisingfacilitiesoftheirexpectationsforthepatientsplanofcareprovidingahistoryofthepatientspastandpresentproblemaswellastotheextentpossibletherationaleforprevioustherapiesordecisionsnottotreatmaybethecaregiversmostimportantrole.Familycaregivershavebeencharacterizedasthesilentpartnersinhealthcaredeliveryfunc-tioningasdefactocarecoordinatorswhennocareproviderfillsthisrole.Duringcaretransitionsfam-ilycaregiversmakeimportantyetoftenunrecognizedandunsupportedcontributionstoensuringqualitysafetyandadherencetopatientpreferences.37Familycaregiversprovidemostlong-termcareintheUnitedStatestheannualeconomicvalueofallsuchcarewasestimatedat354billionin2006.38AlthoughintheaggregatefamiliesclearlymakeanenormouscontributiontocaregivingattheindividuallevelthereisawidespectrumoffamilyinvolvementinthecareofpatientswithintheLTCC.Familiesarediverseandcomplexandvarywidelyintheirdesireorabilitytobedeeplyinvolvedincaregiving.14PRACTICEGUIDELINE Familymembersmaybedistantfromthepatientgeographicallyemotionallyorboth.Familycaregivingmayinvolvepersonssuchasdomesticpartnersofeitherthesameoroppositesexfriendsneighborsoracourt-appointedguardianaswellasorinsteadofmembersofthepatientsfamily.Thisheterogeneitymustberecognizedandrespected.Transitionsbetweensitesorlevelsofcareshouldengageempowerandinvolvefamilymembersbutshouldnotplacetheresponsibilityforcaretransitionsonthem.Inthecaseofapatientwhosuffersfromdementiaorothercognitiveimpairmentsitisimportantthatthefacilityidentifyhisorherlegallyrecognizedhealthcareagentordecisionmakerwhomayormaynotbeafamilymember.TheHIPAAPrivacyRuleandTransitionsofCareSince2002healthcarefacilitieshavebeenrequiredtocomplywiththeHIPAAPrivacyRulewhichrestrictstheuseanddisclosureofindividualshealthinformation.AlthoughthePrivacyRulespecif-icallystatesthatitisnotintendedtointerrupttheflowofnecessaryinformationbetweencliniciansandsitesofcarefacilitiesinterpretationsofwhatcompliancewiththePrivacyRuleentailscanerro-neouslyimpaircommunication.Table2presentssomeexamplesofmythsandfactsabouttheHIPAAPrivacyRule.Anumberofwebsitesofferreliableinformationtoclarifycommonmisconceptionsaboutcom-pliancewiththeHIPAAPrivacyRule.SeeResourcesforanon-comprehensivelistofsitesthatfacil-itiesmaywishtoconsultforguidance.TABLE2ExamplesofMythsandFactsAbouttheHIPAAPrivacyRuleMythFactPractitionersmaynotemailcolleaguesaboutpatients.Theprivacyruledoesnotforbidcommunicationaboutpatientsbyemail.PractitionersmustrefertopatientsbytheirmedicalTheprivacyruledoesnotforbidtheuseofpatientnamesrecordnumbernotbynameine-mailmessages.ine-mailmessages.AproviderorhospitalmusthaveareleasesignedProvidersinvolvedinapatientscarearepermittedtofreelybythepatientinordertoprovidetestresultstoanothershareinformationfortreatmentpurposeswithoutasignedproviderorhospitalthatistreatingthepatient.patientauthorization.PrescriptionsorinsuranceauthorizationformsmayTheprivacyruledoesnotforbidthefaxingofprescriptionornotbesentbyfax.insuranceinformation.PractitionerscannotprovideanypatientinformationAslongasapatientdoesnotobjecttheprivacyruletoapatientsfamily.permitspractitionerstoshareneededinformationwithanyonethepatientidentifiesasinvolvedinhisorhercare.SourcesLoetalJAMA200539FastFactsforCoveredEntitieshttpwww.hhs.govocrprivacyhipaaunderstand-ingcoveredentitiescefastfacts.html40HealthInsurancePortabilityandAccountabilityActStandardsforPrivacyofIndividuallyIdentifiableHealthInformation15TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM MedicationReconciliationMedicationreconciliationistheprocessofcreatingthemostcurrentcompleteandaccuratelistpos-sibleofapatientsmedicationscomparingthatlistagainstmedicationordersateachstageofthepatientsstayinthefacilityandresolvinganydiscrepancies.41InananalysisofmedicationerrorsreportedtotheU.S.PharmacopeiasMEDMARXprogram66ofreconciliation-relatederrorsoccurredduringtransitiontoanotherlevelofcare22duringadmissionand12atdischarge.Mostoftheseerrorsinvolvedomissionsorprescribingmistakes.42BecauseeachfacilitymayuseauniqueformularyandtheexternalrestrictionsofsuchentitiesasMedicarePartDMedicaidandmanaged-caredrugprogramsmayfurthermodifydrugregimensmedicationchangesanddiscontinuationsfrequentlyoccurwhenapatienttransferstoanewserviceorcaresetting.Unintendeddrugomissionscanplacepatientsatriskforsignificanttherapyinter-ruptions.Furthermoreabruptdiscontinuationofmanymedicationsmayresultinadversehealthconsequences.43Atanytimeachangeismadetoapatientsmedicationregimenpractitionersmustensurethatthechangeismadecarefullyisdocumentedandaccordswithprescribinginstructionsfortherelevantmedications.Medicationreconciliationshouldbeperformedanddocumentedeverytimeapatientisadmittedtoafacilityortransferredtoanothersettingorlevelofcareincludingandespeciallywhenapatientistransferredtoacommunityhome.TheJointCommissionhasmademedicationreconciliationatcaretransitionsaNationalPatientSafetyGoalforbothhospitalsandnursingfacilitiesAppendix7.44ThisisahigherstandardthantheCMSguidelinefornursingfacilitieswhichrequiresamedicationregimenreviewbyaconsultantpharmacistatleastmonthlyormorefrequentlywhenanacutechangeofconditionhasoccurred.InthecaseofapatientwhoisadmittedtoanSNFforashortstayhoweveramedicationreviewwithinonemonthmaynotoccurintimetopreventadverseeffectsfromamedicationerrormadeatthetimeofadmissionorthepatientmayhavebeendischargedbeforethemedicationreviewisperformed.MedicationreviewshouldoccuruponSNFadmissionandmayreducetheincidenceofcomplicationsoradverseeventsresultingfrommedicationerrors.IfpossibletheSNFshouldobtainacopyofthemedicalreconciliationperformedatthetimeofthepatientsdischargefromhisorherpriorcaresite.Itiscommonforchangestobemadetoapatientsmedicationswhenheorsheishospitalized.UponthepatientstransitionbacktotheSNFmedicationreconciliationshouldbeperformedagainandthepatientscurrentmedicationscheckedagainstthoseheorshewastakingbeforebeinghospitalized.Nursingstaffshouldnotifythepracti-tionerofchangestooromissionsfromthepatientsmedicationregimenandverifywhethertheprac-titionerwishestoreorderanymedicationsthatwerestoppedduringthepatientshospitalization.Ideallyapharmacistshouldparticipateinthemedicationreconciliationprocessalthoughanoth-erhealthcareprofessionalmayconducttheinitialmedrec.Inadditiontoprescriptiondrugsthemedrecshouldincludeallover-the-countermedicationsandcomplementaryoralternativereme-diese.g.vitaminsherbalproductsthatapatientmayhavebeentakingbeforeadmissiontothefacilityandmayresumetakingoncedischargedbacktoacommunityhome.Informationaboutanydrugallergiesthepatienthasandaboutmedicationsthatweretriedandfoundtobeineffectiveorwerediscontinuedbecauseofadverseeffectsshouldalsobepartofthemedicationreconciliation.Askquestionstotrytodistinguishamongadversedrugeventstruedrugallergiesandineffectivetherapies.Patient-centeredengagementrequiresapractitionerwhoprovidesareconciledmedicationlisttothepatientfamilyandamotivatedpatientfamilywhomaintainsit.Thispartnershipinvolvesopencommunicationaboutmedicationproblemsnonprescriptiondrugusageandadherencetothepre-scriptiondrugprogram.Anexampleofausefultoolforhelpingpatientsandfamiliestokeeptrack16PRACTICEGUIDELINE ofmedicationsisNTOCCsMyMedicineList.httpwww.ntocc.orgHomeConsumersWWS_C_Tools.aspxTable3summarizesthecommonoressentialdataelementsformedicationreconciliationsug-gestedbytheNationalTransitionsofCareCoalition.Forthecompletelistofsuggesteddataele-mentsseeAppendix8.TABLE3SummaryofSuggestedCommonorEssentialElementsforMedicationReconciliationCategoryEssentialOptionalAssessmentonaccesstocaree.g.admissiontohospitalornursingfacilityDemographicinformationPatientnamePrimarylanguageDateofbirthReligiousculturalfactorsIDnumberGenderContactinformationCaregivernameandcontactinformationAllergiesintolerancesDateofassessmentMedicationsRoutineMedicationnamegenerictradeNameofprescriberDoseCompliancelevelFormFrequencyReasonforuseOtherOTCproductsHerbalremediesNutritionalsupplementsTime-limitedmedicationsPatientaccesstomedicationsPrescriptionbenefitsOut-of-pocketcostsPublicprivateassistanceprogramsAccesstoapharmacyOtherPrescribersNPIKnownconditionsinpatientsmedicalhistoryAssessmentreconciliationontransferofcareContinuingmedicationsMedicationnamegenerictradeMonitoringparametersDosefrequencyFormFrequencyReasonforuseExpecteddurationofusechronictime-limitedPatientaccesstomedicationsPrescriptionbenefitsOut-of-pocketcostsPublicprivateassistanceprogramsAccesstoapharmacyValidationoftransferinformationNameDateSignaturePointofcontactattransferringfacilityNameDepartmentContactinformationSourceNTOCC2008c4517TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM ElectronicHealthRecordsThetransmissionofpatientinformationismoreaccurateandcompletewhenthesendingandreceiv-ingentitiesshareasystemofelectroniccommunicatione.g.commonelectronichealthrecordEHRoronethatisinteroperablewiththeotherentitiesinvolvedinthepatientscare.AspreviouslynotedhowevermostentitieswithintheLTCCorthatinteractwiththeLTCCdonotpossesssuchinteroperablecomputerizedrecordswhichcouldfacilitatethetimelytransferofpatientinformationacrosscaresettings.AlthoughharddataarelackingwithregardtoLTCCfacilitieslevelsofconnec-tivitytoelectronicresourcesanecdotalinformationsuggeststhatmanyfacilitieshaveextremelylim-itedaccesstoelectronicresourcesofanykind.AsageneralprincipletheCareTransitionsworkgroupendorsestheadoptionofaninteropera-bleeasilyaccessiblesecureEHRasakeycomponentofsafercaretransitions.CurrentlypatientsmaybeassessedortreatedatmultiplehospitalsorLTCCfacilitiesbutinmanycasesinformationfromonesettingaboutproceduresnewfindingsorthepatientsresponsetotreatmentdoesnottrav-elwiththepatienttothenextcaresetting.Theformsandchecklistspresentedinthisguidelineareintendedtohelpfacilitiesandpractitionersimprovethequalityandconsistencyofinformationthatistransferredwiththepatientintheabsenceofinteroperablecomputerizedrecords.FinancialIssuesEvidencesuggeststhatunplannedrehospitalizationsofMedicarepatientsarebothcommonandcostlytotheMedicareprogram.3estimatedthataboutonefifthofMedicarebeneficiarieswhoaredis-chargedfromthehospitalarerehospitalizedwithin30daysthat90ofthesereadmissionsareunplannedandthatthetotalcosttoMedicareofunplannedrehospitalizationsin2004was17.4bil-lion.InitsownanalysisofthisproblemtheMedicarePaymentAdvisoryCommissionMedPACestimatedthatnearly18ofbeneficiarieswhoaredischargedfromthehospitalarereadmittedwith-in30days.MedPACconcludedthatover13of30-dayhospitalreadmissionsandanassociated12billioninspendingfourfifthsofallMedicarespendingforreadmissionsarepotentiallyavoidablethroughtheapplicationofevidence-basedbestpractices.14Forfiscalyear2010CMSisadoptingthestandardizedmeasureofreadmissionswithin30daysduetoheartfailureasaqualityrequirementforhospitalsundertheInpatientProspectivePaymentSystem.Additionalstandardizedmeasuresforreadmissionsduetoheartattackpneumoniaandotherconditionsarelikelytobeadoptedinfutureyears.14ThisnewCMSpolicyoffershospitalsandLTCCfacilitiesbothincentivesandopportunitytoimprovecommunicationandcollaborationintheinterestofimprovingpatientsafetyandavoidingunreimbursedreadmissionsofMedicarepatients.Agrowingbodyofresearchsuggeststhatcomprehensivetransitionalcareforhospitalizedeld-erscanreducereadmissionsimprovepatientqualityoflifeandsatisfactionwithcareandreduceper-patientcostsbyasmuchas37overa12-monthperiod.24-29Smoothwell-coordinatedcaretran-sitionscanproducecostsavingsbyenablinghospitalstouEfficientlymovepatientstothenextlevelofcaremakingbedsavailablefornewadmissionsuReducethelikelihoodthatdischargedpatientswillneedtobereadmitteduAvoidrevenuelossesstemmingfromnewMedicarepaymentpoliciesdesignedtoeliminatepay-menttohospitalsforcertainreadmissionswithin30daysmanaged-careandinsurancecompa-nieswillalmostcertainlyimplementsimilarpoliciesinduecourseanduMaximizeutilizationoffixedreimbursementprograms.18PRACTICEGUIDELINE Althoughevidence-baseddatalinkingcomprehensivetransitionalcarewithimprovedoutcomesandcostsavingsintheLTCCsettingarescantLTCCfacilitiesmayfindthatwell-executedcaretran-sitionsresultinbenefitssuchasuImprovedcustomerandfamilysatisfactionuAttentiontopatientneedsandadvancedirectivesuRepeatcustomersaspatientsfamiliesandpayersrecognizethefacilitysprofessionalismandcompassionuNewbusinessassatisfiedcustomerstellothersuReducedliabilityrisksasaresultofadecreaseinerrorsduringtransfersuBetterresourceutilizationthroughtheimplementationofaconsistentprocesstoadministerpatientadmissionsandtransferswhetherplannedoremergentanduWhereapplicableimprovedabilitytomeetregulatorystandards.PART2IMPLEMENTATIONOFACARETRANSITIONPROGRAMThissectionbreaksthecaretransitionprocessdownintoasequenceofsteps.Certainstepsandsub-stepsareparticularlyrelevantinthecontextofaplannedtransitionwhereasothersaremostappli-cabletoanunplannedtransitioni.e.anurgentoremergentsituation.Thisdistinctionisindicatedinthetextasfollowsplannedtransitionunplannedtransitionbothplannedandunplannedtransitions.STEP1BOTHPLANNEDANDUNPLANNEDTRANSITIONSThepatienthasarecognizedstatuschange.Managementofacaretransitiongenerallybeginswhenapatientisidentifiedashavingastatuschangei.e.deteriorationorimprovementthatmakesitappropriatetoevaluatehimorherforanothersettingorlevelofcare.Insomecasesthestatuschangeandtheneedforacaretransitioncanbeanticipatedandplannedforinadvance.Forexampleitcanbeanticipatedthatapatientwhoishospitalizedforsur-gerywilltransferfromthehospitaltoanotherlevelofcaree.g.rehabilitationfacilitycommunityhomewithinareasonablypredictableperiodoftime.Otherchangesofstatusareunanticipatede.g.apatientfallssustainingaheadinjurywhichnecessitatesatransfertotheED.Unanticipatedtransitionsaremorelikelytobeproblematicespe-ciallywhentheyoccuratnightoronaweekendorholiday.Bydefinitionsuchtransferscannotbeplannedinadvanceandoftenoccurattimeswhenthepractitionerwhoismostfamiliarwiththepatientisunavailable.Thebestpreparationisanticipatingthattheunexpectedwilloccurandestablishingaprocessforthateventuality.FacilitiesareadvisedtofollowtheprocessdescribedinAMDAsclinicalpracticeguidelineAcuteChangeofConditionintheLong-TermCareSettingdforrecognizingandassessinganunanticipatedstatuschange.Inparticularasystemshouldbeinplacetoenablethecaregiverwhoobservesanunanticipatedstatuschangetocommunicateitpromptlytoamemberofthecareteamwhoisinadecision-makingposition.Secondlyasystemshouldbeinplacetoidentifythepatientsmedicalpointofcontactassoonaspossibleuponadmissionandtonotifythepointofcontactpromptlywhenthepatientistrans-dAmericanMedicalDirectorsAssociation.AcuteChangeofConditionintheLong-TermCareSetting.ClinicalPracticeGuideline.ColumbiaMD2003.19TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM ferredtoanothersettingorlevelofcare.IdeallythemedicalpointofcontactwillbethepatientsPCP.Manycommunity-dwellingpatientshoweverdonothaveaPCP.Elderswithmultiplehealthcon-ditionsoftenseemanydifferentdoctorsaccordingtoonestudyolderpersonswithoneormorechronicillnessessawanaverageofeightphysiciansannually.8SeeSegmentationofPrimaryCareServices.Page6.Incaseswhereapatientisreceivingcarefrommultipleprovidersinthecommunitythebestapproachmaybetoaskthepatientorfamilywhichprovidertheywishtobethepatientsmedicalpointofcontact.Uponfacilityadmissionestablishthemostappropriatemethodofnotifyingthemedicalpointofcontacte.g.phonecallfaxe-mailandifthecommunicationmethoddiffersdur-ingandoutsideofofficehours.Ataminimumthemedicalpointofcontactshouldbenotifiedwhenthepatientisadmittedtoordischargedfromanyhealthcarefacilityandwhenthepatientdies.STEP2BOTHPLANNEDANDUNPLANNEDTRANSITIONSInterdisciplinaryteammemberscommunicatewitheachotherandwiththepatientfamilyunitofcaretodeterminethemostappropriatecaretransition.Thenumberandidentitiesofcareteammembersinvolvedinthisinitialcommunicationwilldependonthenatureandurgencyoftheissue.Forexampleinanemergencytheinitialcommunicationmayinvolveonlytwoorthreekeyteammemberswiththepatientsfamilynotifiedassoonasconsistentwithpatientsafety.Inaplannedtransitionthepatientandfamilyshouldbefullyinvolvedinthediscussionabouttheproposedcaretransition.Identificationofthemostappropriatecaretransitionmayalsoincludemakingadetermi-nationthatfinancialresourcesareavailabletopayfortheproperserviceorlevelofcare.Itisimportantthatmembersofthecareteamcommunicatewithfamiliesabouttheprosandconsofaproposedtransition.ForexampleafamilymayassumethatapatientwithAlzheimersdiseasewhodevelopsafeverorinfectionwillbebettertreatediftransferredtoanED.Howeveratransitionmaybesodisorientingtoacognitivelyimpairedpatientthatheorshemaybecomeagitatedandrequirerestraintorsedationbeforetreatmentfortheconditionthatwasthereasonforthetransfercanbegin.Insuchcasesitmaybeinthepatientsbestinterestforthefeverorinfectiontobetreatedinplace.Decisionsabouttransitionsshouldalsobeguidedbythepatientsadvancedirectivesifthepatientsowishesnotransitionmaybethebestdecision.Table4listsissuesthatthesendingfacilityshouldensureareaddressedbeforeaplannedpatienttransfertoanothersettingorlevelofcare.20PRACTICEGUIDELINE STEP3PLANNEDTRANSITIONThesendingfacilityorcareentitycommunicateswiththereceivingentity.Patientinformationreceivedbyentitypriortopatientarrival.Thisstepiscrucialtoensuringthattheentityreceivingthepatienthastheinformationnecessarytoprovideappropriatecareortreatmentuponthepatientsarrival.Althoughoralcommunicationisideali.e.apractitionerorothercareteammemberatthesendingfacilityspeaksdirectlytoapractitionerorothercareteammemberatthereceivingentitywrittencommunicationisthetypicalmeansbywhichpatientinformationisconveyed.AsharedEHRgreatlyenhancesthetransmissionofpatientinformation.Manytransitionshow-everarelikelytooccurbetweenentitiesthatdonotsharesuchacommunicationsystem.InthesecasesthesendingfacilitymaytransmitpatientinformationtothereceivingentitybyfaxorbymeansTABLE4FacilityPre-TransitionChecklistIssuesThatShouldBeAddressedBeforeaPlannedPatientTransfertoAnotherSettingorLevelofCareuDiscusstransitionwiththepatientandorfamilyorsignificantotherswellinadvanceuHaveadischargeappointmentwiththepatientandothersasappropriatetoplanasmoothtransferuEnsurethatmedicationreconciliationhasbeenperformedthatthemedicationlistisgiventothepatientandthatmedicationquestionsareanswereduExplaintothepatientandorfamilythatafterthetransferheorsheshouldtakeonlythemedicationsonthecurrentlistandshouldnotresumetakinganypriormedicationsthatarenotonthecurrentlistuHaveafacilitypolicyonwhatmedicalinformationistobesentwiththepatienttoinsureasmoothtransitionofcareuDesignateoneormorespecificfacilitystaffmemberswhoareresponsibleforarrangingtransitionsgatheringinformationtoensureasmoothtransferandwhoareavailableforquestionsandcallsbeforeandafterthepatientsdepartureuHaveaprocessforcopyingandassemblingmedicalinformationthattransferswiththepatientanddesignateastaffmemberwhoisaccountableforimplementingthisprocessuDefinenextstepsinthepatientscareuClarifywhereappropriatethatthefamilyorsignificantothershavethenecessaryinformationtomakearrangementsforuDurablemedicalequipmentuFollow-upphysicianappointmentsuFollow-upappointmentsfortestsuSupportservicese.g.homehealthcareMealsonWheelsuEnsurethatthepatientisstablefortransferuContactthenextsiteofcaretocommunicatespecialpatientneedsandconfirmthenextsitesreadinesstoreceivethepatientandabilitytodeliverthenecessarycareuReviewadvancedirectiveswiththepatientandothersasappropriateanddesiredbythepatientuIfthepatientistransitioningtoacommunityhomeuIdentifywhowillcareforthepatientathomeuDeterminepatientsabilitytoacquireneededmedicationsincludingcostandtransportationuProvidethepatientandfamilywithalistofcommunitycareresourcese.g.homehealthcareMealsonWheelsuEstablishwhenthepatientshouldseehisorherprimarycarephysicianorprimarymedicalpointofcontactuEnsurethatrelevantmedicalinformationissenttothepatientsprimarycarephysicianormedicalpointofcontact21TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM ofapaperformorsetofpaperdocumentsthataresentwiththetransitioningpatient.Verbalcom-municationbetweenproviderssupplementedbywrittendocumentationshouldbeencouragedtoenrichdataexchangeandpatientsafety.Itiscrucialthattheinformationtransmittedwiththepatientincludecontactinformationforthesendingprovidersothatthereceivingproviderknowswhomtocontactwithquestionsincludingwhocanbecontactedoutsideofnormalofficehoursandhow.Table5liststheessentialpatientinformationelementsthatshouldbetransmittedfromthesendingtothereceivingentityduringanycaretransition.Table6presentsasampleuniversaltransferformdevelopedbyAMDA.Inaplannedtransitionitisrecommendedthattheseessentialpatientinformationelementsbesupplementedbyacourse-of-treatmentsummarythatprovidesadditionalinformationaboutthepatientsmedicalhistoryprognosisandtreatmentcourse.Inhospitalsandnursingfacilitiessuchasummaryistraditionallycalledadischargesummary.Theinformationinthedischargeorcourse-of-treatmentsummarygivesprovidersatthereceiv-ingfacilityamuchfullerunderstandingofthepatientbeingtransferredintotheircare.Table7liststherecommendedelementsofadischargeorcourse-of-treatmentsummary.SeeAppendix9forachecklistforthedischargeofanelderlypatientfromthehospital.Medicationdiscontinuationsorchangescommonlyoccurduringtransitionsofcareandfre-quentlyresultinadverseeffectsandcomplications.ThepractitionerintheLTCCsettingwhoistrans-ferringapatienttoanacutecaresettingmaywishtouseaformsuchasthatshowninTable8toencouragecommunicationwithpractitionersatthereceivingfacilityconcerninganyproposedchangesinthepatientsmedicationregimen.22PRACTICEGUIDELINE TABLE5EssentialInformationThatShouldAccompanyEveryTransitioningPatientuPatientnameuPrimarydiagnosisforadmissiontosendingfacilityuAccuratemedicationlistwithprescriptionandnon-prescriptiondrugswithdosesandfrequencyuAllergiesandmedicationintolerancesuVitalsignsuCopiesofadvancedirectivesincludingANDDNRstatusuNameandspecificcontactinformationforuSendingfacilityincludingphonenumberoffacilitywingoffacilityandnursenameuResponsiblepractitioneratsendingandreceivingsitesofcareuResponsiblefamilymemberdecision-makeruBarrierstocommunicationuEnglishcomprehensionispoorprovideprimarylanguagespokenbythepatientuVisionrequiresglassestoappropriatelyseeblindetc.uHearingimpairmentrequireshearingaidtohearspokencommunicationetc.uCognitiveissuesthatimpairdecision-makingwhoshouldbecontactedfordecision-makinguHealthliteracyorculturalissuesthatmayinhibitcommunicationuReasonfortransferi.e.theacutechangeinconditionorproblemprecipitatingthetransferalongwithanyacutechangesfrombaselineassociatedwiththistransfere.g.confusionunabletowalkunresponsiveuMedicaldeviceslinese.g.centrallinedialysissitepacemakerorwoundsuPatientsabilitytofeedselfspecialdietaryneedse.g.pureedfoodslow-saltdietuSignificanttestresultsuTestswithresultspendingconsultsorproceduresorderedbutnotyetperformeduPrognosisandgoalsofcareANDDNRAllowNaturalDeathDoNotResuscitateInsomesettingsthepatientsmedicationadministrationrecordcouldserveasthemedicationlist.23TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUMAnexampleofatransferformandtransferchecklistaswellasatemplateforanursingprogressnoteforsendingnursingfacilityresidentstotheacutehospitalcanbefoundathttpinteract.geriu.orgClickonGettingStartedtoviewalistofthetools PRACTICEGUIDELINE24TABLE6AMDAUniversalTransferForm TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM25TABLE6continuedAMDAUniversalTransferForm PRACTICEGUIDELINE26TABLE6continuedAMDAUniversalTransferForm TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM27TABLE7RecommendedElementsofaDischargeorCourse-of-TreatmentSummaryuReasonforcourseoftreatmenti.e.diseaseprocessuNewdiagnosesarisingduringcourseoftreatmentuSurgeryorotherproceduresperformedduringcourseoftreatmentuConsultantsutilizedduringcourseoftreatmentuComplicationsencounteredduringcourseoftreatmente.g.fallsiatrogenicinfectionspatientharmuChangesfrompre-admissionbaselinee.g.changeinabilitytocommunicatecognitiveissuesfunctionaldeclineuTreatmentgoalsandadvancedirectivesdiscussedwithpatientfamilyuAnticipatedtreatmentgoalsattimeoftransitionuReturntoprevioussiteoflivingvs.stayatalevelofcaredifferentfrompre-admissionstatusuTotalrecoveryvs.partialrecoveryvs.recoverynotlikelyi.e.rehabilitationpotentialuPalliativecarehospiceuTestresultspendingattimeoftransitione.g.biopsieslabtestsradiologystudiesuNextstepsplannedinpatientscareplanwithspecificsastowhyandwhenandwhichpractitionersneedtobeinvolvedTABLE8PractitionerRequestforNotificationofMedicationChangesDearReceivingPhysicianIamthepractitionerfornameofpatient_______________________________________Beforediscontinuingorchangingthefollowingmedicationspleasecontactme.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dr.________________________________________Facility____________________________________Phone____________________________________Pager______________________________________Yourcooperationisgreatlyappreciated. Step3AUNPLANNEDTRANSITIONThepatienthasanacutechangeofconditionandtransfertoanemergencydepartmentisappro-priate.PatienttransfersbetweenanLTCCfacilityandanEDcanbeespeciallyproblematic.46PatientsarefrequentlytransferredtotheEDfromLTCCfacilitieswithoutessentialpatientinformation20mak-ingitdifficultforEDstafftoevendeterminethereasonforthetransfer.SomeEDscompoundtheinformationbarrierbyrefusingtoacceptoralcommunicationaboutapatientunlessthetransferringphysicianspeakstoanEDphysician.SuchpoliciescanpresentparticularproblemsfortransfersfromLTCCfacilitiesbecausetheattendingphysicianisoftennotatthefacilityatthetimeapatientstrans-fertotheEDisdeemednecessary.TheuseofastandardtransferformTable9Appendix10mayimprovecommunicationbetweenanursingfacilityandanED.2046Standardizationofpatientrecordsfacilitatescommunicationbetweencaresettingsandassistsprovidersinefficientlyreviewingrecords.47AdditionallycaregivingstaffmayfindithelpfultouseAMDAsprotocolsforpractitionercommunicationeefbothtostandardizethepatientevaluationthatdeterminestheneedforanEDtransferandtoobtainthedatathatshouldbetransferredwiththepatientifatransferisdeemedappropriate.FacilitiesmayalsowishtoconsiderplacinganidentificationarmbandonapatientwhoisbeingtransferredtotheED.InadditiontothepatientsnamedateofbirthandcontactinformationforthenursingfacilitythearmbandshouldalsoprovidecriticalinformationsuchasthepatientsDNRANDstatusanddrugstowhichthepatientisallergic.Suchinformationisparticularlyhelp-fulifthepatientisbeingtransferredtotheEDwithoutanaccompanyingcaregiverhascognitiveproblemsorhasadecreasedlevelofconsciousness.Appendix11providesalistofqualityindicatorsfortransitionsbetweennursingfacilitiesandEDs.TABLE9ExampleofaSkilledNursingFacility-to-EmergencyDepartmentSourceDavisetal200546SeenextpageNOTEThisisanexampleofaformthatfacilitiesmaywishtomodifyoradapttomeettheirownneeds.Shadedareasoftheformcanbecompletedatanytimeafterthepatientsadmissiontothenursinghomei.e.beforeanemergencyoccurswithmultiplecopiesmade.Theformcanthenbereadilyavailableandplacedinadesignatedlocationinthepatientschartorotherknownsitewithinthefacility.PractitionersatsomeLTCCfacilitiesupdatetheseformswhilemak-ingtheirrounds.Inanemergencyanursecantakeacopyoftheformandcompletethenon-shadedareas.Thefilled-outcopygoeswiththepatienttotheEDandtheoriginalformremainsinthepatientschart.eAmericanMedicalDirectorsAssociation.ProtocolsforPhysicianNotificationAssessingandCollectingDataonNursingFacilityPatients-AGuideforNursesonEffectiveCommunicationwithPhysicians.ColumbiaMD.fAmericanMedicalDirectorsAssociation.CaregiversCommunicationGuideCaringfortheOlderAdultProtocolsforChangeofCondition.ColumbiaMD.DoNotResuscitateAllowNaturalDeath28PRACTICEGUIDELINE 29TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUMAnotherexampleofatransferformandtransferchecklistforsendingnursingfacilityresidentstotheacutehospitalcanbefoundathttpinteract.geriu. Step3BBOTHPLANNEDANDUNPLANNEDTRANSITIONSThepatientisbeingtransferredtoanothercaresitebyemergencymedicalservices.EmergencymedicalservicesEMSmaybeinvolvedinbothemergentpatienttransferse.g.totheEDandnon-emergenttransfersbetweencaresettings.ClearcommunicationbetweenthesendingfacilityandtheEMSpersonnelisessentialtoensuringasmoothpatienttransfer.ItmaybehelpfultoregardtheEMStransferasapatienttransitioninitselfandtheEMSpersonnelasareceivingfacility.WhentheEMSreceivesacallrequestingpatienttransportationtheservicedispatcherwillaskforcertainpatientinformationTable10.Thetransferwillproceedmoresmoothlyifthefacilitystaffmembermakingtherequesthasthisinformationreadilyavailable.Forexamplethedispatchermayaskforthepatientsweightbecausethishelpstodeterminewhetherthepatientmayneedspecialhandlinge.g.anextremelyheavypatientmayrequireaspecialstretcher.InformationaboutthepatientsinsurancecoverageisnecessarytoestablishwhetherMedicareorotherinsurancewillreim-burseforthetransportationservice.AmbulancetransportationofMedicarepatientsisreimbursedonlyifitmeetsCMSsmedicalnecessityguidelinesTable11.MedicareAdvantageplansandotherinsurersmayhavedifferentcoverageguidelinesforambulancetransportation.EMSpersonnelwillrequestcertaininformationwhentheyarrivetocollectapatientthesendingfacilitymaysupplementthisinformationwithfurtherrelevantdatathatitconsidersimportantforEMSpersonneltoknowTable12.IfatransferringpatienthasrequestedDNRANDstatusEMSpersonnelmustreceivewrittendocumentationofthisstatus.Intheabsenceofwrittendocumenta-tionofDNRANDstatusEMSpersonnelaregenerallylegallyrequiredtoattempttoresuscitateapatient.FacilitiesshouldconsiderdevelopingrelationshipswithEMSprovidersandsharinginformationabouteachothersinformationneedsthroughinservicetrainingsessions.Facilitynursingstaffshouldbetrainedtoknowwhenambulancetransportationisappropriateandwhatpatientinforma-tiontoprovidetoEMSpersonnelwhenmakingatransportationrequest.EMSpersonnelshouldunderstandthespecialneedsoffrailelderlypatientswhomaybecognitivelyimpairedandmustbefamiliarwithstate-specificregulationsconcerningtherequirementforresuscitation.AsinanytransitionofcarecarefulattentionisessentialtoensureasafehandoffbetweenEMSpersonnelandtheLTCCfacility.ForexampleEMSpersonnelshouldverballynotifyfacilitynursesandcaregiversofthepatientsarrivalordeparture.ThesendingfacilitymustensurethatEMSper-sonnelhaveallthepertinentinformationthatistobetransferredwiththepatientandunderstandthatthisinformationistobedeliveredwiththepatienttothecaregiversatthereceivingsiteofcare.IfatallpossibleaftertransportingapatienttothenextsiteofcareEMSpersonnelshouldmakeafollow-upcalltothesendingfacilitytoverifythatthetransferhasbeencompletedandcommuni-cateanyinformationthatthesendingfacilitymayneedforitsrecords.ForexampleifthenearestEDwasondiversionthesendingfacilityneedstoknowtowhichalternateEDthepatientwastaken.PRACTICEGUIDELINE30 TABLE10PatientInformationThatMayBeRequestedByanEmergencyMedicalServiceDispatcheruNamedateofbirthsocialsecuritynumberuPrimaryconditionpatientisbeingtreatedforuWeightuInsurancecoverageTABLE11SummaryofCMSMedicalNecessityGuidelinesforAmbulanceTransportationofMedicarePatientsAmbulancetransportationofaMedicarepatientiscoveredwhensatisfactorydocumentationcanbeprovidedthatthepatientsillnessorinjurycontraindicatedtransportationbyothermeans.GenerallydocumentationmustshowthatthepatientuWastransportedinanemergencysituatione.g.asaresultofanaccidentinjuryoracuteillnessoruNeededtoberestrainedtopreventinjurytohimherselforothersoruWasunconsciousorinshockoruRequiredoxygenorotheremergencytreatmentduringtransporttothenearestappropriatefacilityoruExhibitedsignsandsymptomsofacuterespiratoryorcardiacdistresse.g.chestpainshortnessofbreathoruExhibitedsignsandsymptomsindicatingthepossibilityofacutestrokeoruHadtoremainimmobilebecauseofafracturethathadnotbeensetorthepossibilityofafractureoruWasexperiencingseverehemorrhageoruCouldbemovedonlybystretcheroruWasbed-confinedbeforeandaftertheambulancetrip.SourceCMS20074TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM31 STEP3CPLANNEDTRANSITIONPatientsconditionhasimprovedtotheextentthattransfertohisorhercommunityhomeisappro-priate.Whenapatientistransferringtoacommunityhomethefamilymembersorothercaregiverswhowillbesupportingthepatientathomeconstitutethereceivingfacility.Becausethesuccessoftheplanforthepatientscontinuingcaredependsonthesecaregivers49itisessentialthattheybepre-paredforthepatientstransitionbeforeitoccurs.ManyreadmissionstoacuteorSNFcaresettingsoccurbecausefamilycaregiversarepoorlypreparedtomeetthepatientsneedsandprovidersaregiveninadequateinformationtosuccessfullycontinuetheplanofcareafterthetransitiontoacom-munityhome.Facilitystaffmustdiscusswithfamilycaregiversthelevelofcarethepatientwillrequireathomeanddeterminewhethertheyareabletoprovidethatlevelofcare.Offerfamilycaregiverstrainingifnecessarytoperformcaregivingtaskssuchaschangingdressingsadministeringmedicationsormaintainingmedicaldevicese.g.dialysisaccesssitesFoleycatheterssuprapubiccatheters.Educatefamilycaregiversaboutwarningsignsforwhichtheyshouldseekmedicalattentione.g.medicationsideeffectssymptomsindicatingaworseningofdisease.Discussoptionssuchashomehealthcareandmealdeliveryservicesthatcanofferadditionalsupportorfillgapsinthepatientscare.TABLE12InformationExchangeBetweenEMSPersonnelandSendingFacilityWhenpickingupatransferringpatientfromanursingfacilityEMSpersonnelmayrequestthefollowinginfor-mationuPatientsdiagnosisonadmissiontofacilityuIdentityofpatientsnextofkinuReportofpatientsacutechangeofconditionincludingwhenitoccurreduListofpatientsmedicationsuWrittendocumentationofDNRANDstatusWhenpickingupatransferringpatientfromahospitalEMSpersonnelmayrequestthefollowingadditionalinformationuReportofhistoryandphysicaluOthernotesregardingthepatientsconditionortreatmentuDocumentationofmedicalnecessityuWrittendocumentationofDNRANDstatusOtherpatientinformationthatthesendingfacilitymayconsiderimportanttoconveytoEMSpersonnelmayincludethefollowinguPrimarylanguageandneedforinterpreteruSensoryimpairmentsuAllergiesDNRANDDoNotResuscitateAllowNaturalDeath32PRACTICEGUIDELINE Caregiverassessmentisanimportanttoolforunderstandingfamilycaregiversneedsandcapac-itiesandimprovingqualityofcareforthepatient.Ithasbeendefinedasasystematicprocessofgatheringinformationthatdescribesacaregivingsituationandidentifiestheparticularproblemsneedsresourcesandstrengthsofthefamilycaregiver.Itapproachesissuesfromthecaregiversper-spectiveandculturefocusesonwhatassistancethecaregivermayneedandtheoutcomesthefami-lymemberwantsforsupportandseekstomaintainthecaregiversownhealthandwell-being.49PurposesandprinciplesofcaregiverassessmentarepresentedinTable13.SeeAppendix12forrec-ommendeddomainsandconstructsforcaregiverassessment.Evaluationofcaregiversabilitytounderstandandactonhealthinformationisacrucialaspectofcaregiverassessment.Healthliteracyincludestheabilitytounderstandinstructionsonpre-scriptiondrugbottlesappointmentslipsmedicaleducationbrochuresdoctorsdirectionsandcon-sentformsandtheabilitytonegotiatecomplexhealthcaresystems.50TheInstituteofMedicinehasestimatedthatnearlyhalfofAmericanadults90millionpeoplehavedifficultyunderstandingandactinguponhealthinformation.51Appendix13presentsinterventionsthathavebeenshowntoimprovecomprehensionamongpatientswithlowhealthliteracyandimpairedcognitivefunction.SeeResourcesforsourcesofguidancethatmaybehelpfulonpresentinghealthinformationtopatientsandcaregiversinanunderstandablefashion.TABLE13PurposesandPrinciplesofCaregiverAssessmentPurposesuIdentifyingtheprimarycaregiverandotherinformalcaregivers.uImprovingcaregiversunderstandingoftheirroleandtheabilitiesneededtocarryouttherequiredtasks.uUnderstandingthecaregivingsituationincludingserviceneedsunresolvedproblemsandpotentialriskssothatthecaregiversneedscanbemet.uIdentifyingservicesavailableforthecaregiversandprovideappropriateandtimelyreferralforservices.uDeterminingthepatientseligibilityforservicesthatalsohelpthecaregiver.PrinciplesuBecausefamilycaregiversareacorepartofhealthcareandlong-termcareitisimportanttorecognizerespectassessandaddresstheirneeds.uCaregiverassessmentshouldembraceafamily-centeredperspectiveinclusiveoftheneedsandpreferencesofbothpatientandcaregivers.uCaregiverassessmentshouldresultinaplanofcaredevelopedcollaborativelywiththeprimarycaregiverthatindi-catestheprovisionofservicesandintendedmeasurableoutcomes.uCaregiverassessmentshouldbemultidimensionalinapproachshouldbeperiodicallyupdatedandshouldreflectculturallycompetentpractice.uThoseassessingfamilycaregiversmusthavespecializedknowledgeandskills.Practitionersandserviceproviderseducationandtrainingshouldequipthemwithanunderstandingofthecaregivingprocessanditsimpactsaswellasofthebenefitsandelementsofaneffectivecaregiverassessment.SourceCaregiverAssessmentPrinciplesGuidelinesandStrategiesforChange.ReportfromaNationalConsensusDevelopmentConference.5233TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM TABLE14DeterminingAPatientsWishesRegardingEnd-of-LifeCareuDeterminewhospeaksforthepatient.Manypatientswhoareapproachingtheendoflifecanspeakforthem-selvesabouttheirwishes.Howeverifapatientlacksthecapacitytounderstandormakecaredecisionsanappro-priatedesigneemustbeidentifiedpromptly.uDiscussthepatientswishesconcerningend-of-lifecare.Anunwantedtransfermustneveroccurbecausenooneaskedthepatientorhisorherdesigneetospecifyend-of-lifecarewishes.uDeterminethepatientsprimarygoals.DoesthepatientdesirelongevityfunctionalindependenceorsimplycomfortuProvideadequateunbiasedinformation.Appropriatepatientdecisionsmustbebasedonfulldisclosurecon-cerningtheconditiontreatmentoptionsandlikelihoodoftreatmentsuccessamongotherissues.uRevisitadvancedirectivesateverystagethroughouttheLTCC.Goalsofcaremayradicallyalterashealthstatuschanges.STEP3DPLANNEDTRANSITIONPatientisapproachingtheendoflifeandcomfortcareonlyisappropriate.Transfersaslifedrawstoacloseareintrusiveandcandiminishlifequality.Anytransfershouldoccurinthecontextofthepatientsexpressedwishes.AlthougheverypatientssituationisuniquetheapproachoutlinedinTable14mayprovideaguide.Discussionsaboutwithholdingaggressivetreatmentattheendoflifemaymeetwithresistancefrommembersofapatientsfamily.ThetermAllowNaturalDeathmaybemoreacceptabletofam-iliesthanDoNotResuscitate.PleaserefertoAMDAsinformationseriesPalliativeCareintheLong-TermCareSettinggwhichprovidesextensiveresourcesfordecision-makingforpalliativecare.STEP4PLANNEDTRANSITIONThepatientisphysicallyhandedovertothereceivinglevelorsettingofcare.Theissuestobeaddressedwhenapatientisphysicallyhandedovertoanotherlevelorsettingofcarewilldependonthenatureofthetransition.Routinelyastandardformmustbecompletedwhenapatientistrans-ferredtoanursingfacilityALForhomehealthagencyfromanyothercaresetting.Manyothersitesofcarerequirethatapractitionercompleteadmissionforms.Thekeytoasuccessfultransitioniscom-municationwiththenextsiteofcareandtransmissionofbothrequiredinformationandanyaddi-tionaldataconsideredessentialtotheprovisionofqualitycare.Step4APLANNEDTRANSITIONPatientisbeingdischargedtohisorhercommunityhome.AsdiscussedinStep3Bapatientwhoisdischargedhomeisbeingtransitionedintothecareoffamilyandcommunitycaregivers.WhenthisgAmericanMedicalDirectorsAssociation.LTCInformationSeriesPalliativeCareintheLong-TermCareSetting.ColumbiaMD.34PRACTICEGUIDELINE transitionoccursthefacilitymustensurethatthesecaregivershavetheinformationandresourcestheyneedtosuccessfullyassumethepatientscare.Ataminimumadesignatedfacilitystaffmem-bershouldensurethatalltaskslistedinTable4havebeencarriedoutbeforethepatientisdischargedhome.Althoughnoteverypatientwillbeusinghomehealthcareservicesfacilitiesshouldanticipatethispotentialneedandmakearrangementsinadvancetoavoidalast-minuteoftenflawedrushtocompletethenecessarydocumentationandobtaintherequiredsignatures.Asnotedpreviouslythefacilityshouldensurethatthepatientisconnectedwithhisorherprimarycareprovidersandthatthepatientandfamilyunderstandwhatthenextstepinthepatientscareiswhereitwilltakeplaceandthereasonsitisnecessary.STEP5BOTHPLANNEDANDUNPLANNEDTRANSITIONSBothsendingandreceivingentitiesverifythatthepatienthasbeenhandedoverandthatessen-tialpatientinformationhasbeenreceived.Thetransitionisnotcompleteuntilbothsideshavever-ifiedthatthehandoffhasoccurredandtheprovidersatthereceivingfacilityhaveassumedrespon-sibilityforthepatientscare.Thereceivingfacilitymustreviewtheinformationsentwiththepatienttoensureitsclarityandcompletenessandfollowupwiththesendingfacilitytoobtainanymissinginformationornecessaryclarifications.Whenapatienthasbeentransferredfromahospitaltoanurs-ingfacilityforexamplethefacilitymaywishtorequestcopiesofanylabtestresultsradiologystud-iesornotesfromspecialtyconsultationsconductedduringthepatientshospitalstaythatwerenottransmittedwiththepatient.Table15listsissuesthatthesendingfacilityshouldensureareaddressedintheperiodimmedi-atelyfollowingapatientstransitiontoacommunityhomeortoanotherlevelorsiteofcare.STEP6BOTHPLANNEDANDUNPLANNEDTRANSITIONSSendingfacilityfollowsuptoconfirmthatthepatienthasbeensuccessfullytransitionedtothenewlevelorsettingofcare.Itisrecommendedthatthesendingfacilitycontactthereceivingfacili-tywithin24hoursafterapatienttransitionhasoccurredtoconfirmthatthetransitionhasbeencom-pletedandthatprovidersatthereceivingfacilityhavealltheinformationtheyneedtocareforthepatientappropriately.Duringtheintervalbetweenthepatientsdepartureforthenextsiteofcareandconfirmationthatthereceivingcaresitehasacceptedresponsibilityforthepatientthesendingfacilityandpractition-ershouldbepreparedtorespondtotheextentpossibletopatientrequestsforhelporinformation.Thesendingpractitionerswillingnesstoberesponsiveduringthisbriefintervalshouldnotbeinter-pretedasacommitmenttoprovideongoingpost-transitioncareunlesssuchacommitmenthasbeenexplicitlyagreedtobybothpatientandpractitioner.Insomecaseslabtestsmayhavebeenorderedatthesendingfacilitybeforethetransitionoccurredbuttheresultsnotobtaineduntilafterthepatienthasbeentransferred.Theseresultsshouldbeconveyedtothereceivingfacilityinatimelyfashion.Thesendingfacilityshouldalsover-ifythatanynecessaryappointmentsforfollow-upcarehavebeenmadeoratleastclearlyrequestedinthetransferdocumentation.35TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM TABLE15FacilityPost-TransitionChecklistsA.IssuesThatShouldBeAddressedUponorShortlyAfteraPlannedPatientTransfertoaCommunityHome1.EnsurethatpatientsPCPorothermedicalpointofcontacthasbeennotifiedofthefollowinguThatthepatienthasbeendischargeduWhenthepatienthasbeenadvisedtoarrangeafollow-upappointmentuWhatinformationaboutthepatienthasbeensenttothePCPwhenandhowuNameandcontactinformationofattendingpractitionerintheLTCCfacilitywhomaybecontactedifthePCPconsidersthisappropriateuNameandcontactinformationforafacilitystaffmemberthatthePCPmaycontactforfurtherinformationIfthepatientdoesnothaveaPCPormedicalpointofcontactreaffirmtheneedtoacquireoneuReaffirmthatthefacilitycannotbethepatientsPCPuAdvisethepatientfamilythatthefacilityiswillingandabletosendinformationtothenewcaregiver2.Callthepatientfamily24-48hafterdischargeforfollow-upwiththefollowinguConfirmthatpreviouslyarrangedsupportservicese.g.homehealthcareMealsonWheelshavemadecontactandinitiatedservices.Ifnotprovidecontactinformationfortheseservicestothepatientfamilyagain.Inexceptionalinstancesthefacilitymayassistthepatientincontactingsupportservices.uReviewthelistofmedicationsgiventothepatientatdischargefromthefacilityandtheschedulefortakingthem.ReinforcetheimportanceofadheringtothisnewmedicationscheduleandnotresumingpriormedicationsuntilthepatientisseenbyhisorherPCP.uVerifythatthepatientfamilyhascontactedthepatientsPCPtomakeafollow-upappointment.uVerifythatthepatientfamilyhasmadeappointmentsforfollow-uptestsasnecessaryorhaskeptpreviouslymadeappointments.uVerifythatthepatientfamilyunderstandsthenextstepsinthepatientscare.3.Documentalloftheabovecontactsinthepatientsrecordnotingthedatetimeandasummaryoftheinformationexchanged.B.IssuesThatShouldBeAddressedUponorShortlyAfteraPlannedPatientTransfertoAnotherFacilityorLevelofCare1.EnsurethatpatientsPCPorothermedicalpointofcontacthasbeennotifiedofthefollowinguThatthepatienthasbeendischargeduNameandcontactinformationofattendingpractitionerintheLTCCfacilitywhomaybecontactedifthePCPconsidersthisappropriateuNameandcontactinformationforafacilitystaffmemberthatthePCPmaycontactforfurtherinformationDocumentthecalltothemedicalpointofcontactinthepatientrecordnotingthedatetimeandasummaryoftheinformationexchanged.uAdvisethepatientfamilyandreceivingfacilitythatthesendingfacilityiswillingandabletosendinformationtothepatientsnewcaregivers.Providecontactinformationforthepersonatthesendingfacilitywhocanprovidethisinformation.uCallboththereceivingfacilityandthepatientfamily24-48haftertransfertoconfirmthepatientsarrivalatthenewfacilityandobtainclosureofanyunresolvedquestionsorissues.36PRACTICEGUIDELINE AsuccessfultransitionmaybeenvisionedasaclosedloopFigure1.Toensurethattheloopisclosedthesendingandreceivingfacilitiesmustinteractverifyandclarifythatkeypatientinforma-tionisbothtransmittedandacteduponinatimelyfashion.STEP7BOTHPLANNEDANDUNPLANNEDTRANSITIONSMonitorthefacilitysperformanceinmanagingcaretransitions.Reviewthemanagementofcaretransitionsthroughthefacilitysqualityimprovementprocess.Table16suggestsindicatorsthatafacilitymaywishtousetomeasurethesuccessofcaretransitions.Appendix14presentsselectedper-formancemeasurementindicatorsfortransitionalcarefromexistingtoolsthatfacilitiesmaywishtoincorporateormodifytomeettheirneeds.SUMMARYCaretransitionshaveemergedasacriticalhealthcareissue.Patienttransfersacrosssitesofcarewereonceaninfrequenteventthattypicallyoccurredduringtheresolvingstageofanacutedefinedill-ness.Todaybycontrastachronic-diseasemodelofcareischaracterizedbyanagingpopulationsus-tainedbymedicationsandinterventionsunimaginableevenadecadeago.Inthisparadigmpatientsexperienceyearsofdiseaseanddisabilitymarkedbyrepeatedadmissionstohealthcarefacilities.Whereashealthcarefacilityoncemeanthospitalnumerousnon-hospitalfacilitiesnowprovidemanyelementsofthecarereceivedbyolderadults.Apartiallistofsuchinstitutionsincludesskillednursingfacilitiesassistedlivingfacilitiesseniorhousingfacilitiesadultdaycarefacilitieshospiceprogramsandeventhecommunityhomesetting.Giventhepanoplyofspecialistsfrequentlyinvolvedinchronicdiseasecareandtheconsequentnumerousmedicationsthatareprescribedtoolderadultsitisclearthatabewilderingamountofinformationmustbetransmittedatanytimeapatienttransferstoanotherlevelorsettingofcare.Unfortunatelytheabilityofhealthcareprofes-sionalsandsystemstoorganizeandcoordinatecareacrosssettingshasnotkeptpacewiththeincreasedquantityandcomplexityofdatathatmustbetransmittedtoassurequalityofpatientcarefollowingatransition.Uncoordinatedtransitionsofcarealltoooftenresultinduplicationofservicesandwasteofresourcesaswellasadverseeventsandavoidablecomplicationssuchashospitalreadmissionsextendedstaysintheemergencydepartmentforobservationmedicalerrorsandmostimportant-lypotentialandrealpatientharm.Evidenceismountinghoweverthateffortstoensurecontinu-ityofcareforallpatientsandespeciallyolderpatientsduringcaretransitionscanimprovepatientoutcomes.Thescienceofcaretransitionsisstillemerging.Defininggoodoutcomesisdifficultgiventhehet-erogeneousnatureofthepopulationtransitioningthroughthelong-termcarecontinuum.Forapatientwithmetastaticcanceragoodoutcomemaywellbeapeacefuldeathortheavoidanceofatransition.Forapatientwhohasjusthadahipreplacementagoodoutcomemaybeareturntoinde-pendenceathomeorassurancethatthepatientandfamilyknowthenextstepincareafterheorsheleavesthenursinghome.Bothintheliteratureandinpracticehoweversomeconceptsappeartobeconsistentlyassociatedwithperceivedgoodoutcomesforpatients.Firstcaretransitionsareapatient-centeredactivity.InformationmoveswiththepatienttheTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM37 FIGURE1AConceptualModelforTransitionsofCareThecaretransitionprocessinvolvesboththesenderandthereceiverofcriticalmedicalandhealth-relatedinformation.uThesenderisaccountableforensuringthatthekeyinformationtransferredtothereceiveriscompleteandtimely.Inthiscasethesendermustverifythattheinformationwasreceivedbytheintendedrecipient.uThereceiverisalsoaccountableandmustrespondaswellasacknowledgethereceiptofcompleteinformationfromthesenderinatimelymanner.uThesenderisavailabletoansweranyquestionsthatthereceivermayhaveregardingtheinformationreceivedthatistoclarify.uThereceiveractsupontheinformationreceivedi.e.evaluatestheinformationreceivedanddetermineswhethertheplanofcareforthepatientneedstobealteredbeforecontinuingitsimplementationandifsoinwhatway.uMeasuringboththesenderandreceiverpromotessharedaccountabilityacrosscaresettingsandproviders.SourceNTOCC2008a2TransitionsofCareTransitionsofCareProviderAccountabilityActivePatientFamilyEngagementCareCoordinationHubSendSenderVerifyClarifyACTKeyInformationReceiveReceiverssPRACTICEGUIDELINE38 patientandfamilyparticipateindecisionsafterbeingprovidedwithadequateinformationandtheneedsofthepatientpredominateindecision-making.Healthcareprovidersshoulddetermineandrespectthepatientswishesasexpressedinadvancedirectives.Secondmedicationreconciliationmustoccurwitheverytransitionatboththesendingandreceivingcaresites.Thirdcaretransitionsaretheultimateinterdisciplinaryteamactivity.Everymemberofthecareteammustbeinvolvedaccountableandresponsivetoensurethetimelyandappropriatetransferofinformationtothenextlevelorsettingofcare.Fourthcaregiversfromthesendingsiteofcaremustmaintainresponsibilityoratleastavailabilityforpatientsuntilthecaregiversatthereceivingsiteassumeclinicalresponsi-bility.Finallycommunicationofadequateclinicaldataisinstrumentaltosafetransitions.Informationmustbeappropriateinamountitshouldbecommunicatedbyamethodusefultothereceivingsiteofcareandwiththeurgencynecessarytoensuretimelydelivery.Achievingtheseobjectivesmayinvolvetheuseofstandardizedformsphonecallsfaxtransmissionelectronictransferorothermethodsasappropriatetothenatureofthetransfer.TABLE16SamplePerformanceMeasurementIndicatorsProcessindicatorsuFacilityhasadoptedandimplementedpoliciesandprocedurestoguidecaretransitionstothehospitalemergencydepartmentcommunityhomeandotherLTCCfacilitiesuAppropriatelytrainedstaffmembersaredesignatedasresponsibleformanagingcaretransitionsuFacilityprovidesappropriateinservicetrainingandeducationprogramsforhealthcareprofessionalsatalllevelsonthemanagementofcaretransitionsuFacilityutilizesastandardformtoprovideessentialpatientinformationtoreceivingentitiesincaretransitionsuDocumentationofDNRANDstatusisroutinelysentwithanypatientwhoistransferredtoanemergencydepartmentuPatientswishesconcerningend-of-lifecarearedocumentedandadvancedirectivesarerevisitedatregularintervalsashealthstatusandcaregoalschangeuDesignatedstaffmembersfollowupasamatterofcoursetoensurethatatransferredpatienthassuccessfullytransi-tionedtothenewsettingorlevelofcareOutcomeindicatorsDecreasesinuAvoidablecaretransitionsuReadmissionsresultingfromavoidablepost-dischargecomplicationsandadverseeventsuCostsassociatedwithreadmissionsuDuplicativeuseofdiagnosticservicesuMedication-relatedadverseeventsuPatientharmresultingfromerrorsinthetransitionprocessIncreasesinuPatientsafetyuQualityoflifeforpatientswithcomplexhealthcareneedsuPatientandfamilysatisfactionwithcareTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM39 ThisCPGdevelopedbyamultidisciplinaryexpertconsensuspaneldelineatesessentialstepsandactionsrequiredforsafepatienttransitionsacrosslevelsandsettingsofcare.Theprocessesout-linedinthisCPGwilliffollowedcontributetoensuringthatnecessarycaretransitionsarecon-ductedsmoothlyessentialpatientinformationistransmittedsuccessfullytothepatientsnextcaresettingandhealthcareprofessionalsinvolvedinthecareofthetransitioningpatientcommunicateappropriatelyaboutthepatientscarerequirements.Thiswillresultinatransitionthatmeetsthepatientsneedsandissaferandmoresatisfyingforthepatientandfamily.RESOURCESEvidence-BasedModelsofTransitionalCareCareTransitionsInterventionhttpwww.caretransitions.orgTheCareTransitionsInterventionisarandomizedcontrolledtrialconductedwithinalargeintegrat-edhealthcaredeliverysysteminColoradoanddesignedtoaddresspotentialthreatstoqualityandsafetyduringcaretransitionsbyprovidingpatientsandcaregiverswithtoolsandsupport.Publicationstoolsdevelopedtofacilitatetheinterventionandotherresourcesareavailableontheprojectwebsite.GuidedCarehttpwww.guidedcare.orgInthistransitionalcaremodeldevelopedbyresearchersatJohnsHopkinsUniversityaguidedcarenursebasedinaprimarycareofficeworkswithpatientsandfamiliestoimprovetheirqualityoflifeandmakemoreefficientuseofhealthservices.Inapilotstudypatientswhoreceivedguidedcareratedtheirqualityofcaresignificantlyhigherthanpatientswhoreceivedusualcareandaverageinsurancecostsforguided-carepatientswere25lowerovera6-monthperiod.Theprogramiscur-rentlybeingtestedinarandomizedtrialateightprimarycaresitesintheBaltimoreWashingtonD.C.area.ProjectREDRe-EngineeredDischargehttpwww.bu.edufammedprojectredindex.htmlProjectREDisarandomizedcontrolledtrialatBostonMedicalCentertore-engineerthedischargeprocessforpatientsfromanetworkofcommunityhealthcenterswhoaredischargedfromageneralmedicalserviceatanurbanhospital.Publicationstoolsdevelopedtofacilitatetheinterventionandotherresourcesareavailableontheprojectwebsite.OtherCareTransitionsResourcesforHealthCareProfessionalsHealthLiteracyThefollowingresourcesaresomeexamplesofsourcesofguidanceonpresentinghealthinformationtopatientsandcaregiversinanunderstandablefashionPRACTICEGUIDELINE40 HealthLiteracyHealthResourcesandServicesAdministrationU.S.DepartmentofHealthandHumanServiceshttpwww.hrsa.govhealthliteracyQuickGuidetoHealthLiteracyOfficeofDiseasePreventionandHealthPromotionU.S.DepartmentofHealthandHumanServiceshttpwww.health.govcommunicationliteracyquickguideClearCommunicationAnNIHHealthLiteracyInitiativeNationalLibraryofMedicineNationalInstitutesofHealthhttpwww.nih.govicdodocplresourcesclearcommunicationhealthliteracy.htmHIPAAPrivacyRuleThefollowingisanon-comprehensivelistofwebsitesthatofferreliableinformationtoclarifycom-monmisconceptionsaboutcompliancewiththeHIPAAPrivacyRule.FastFactsforCoveredEntitieshttpwww.hhs.govocrprivacyhipaaunderstandingcoveredentitiescefastfacts.htmlDebunkingsomecommonmythsabouttheHIPAAprivacyrulehttpwww.acpinternist.orgarchives200309privacy.htmmythsFAQsregardingHIPAAhttpwww.ifsmed.comhipaa.html10MythsAboutHIPAAPatientsandMedicalRecordsPrivacyhttppatients.about.comodyourmedicalrecordssshipaamyths.htmTheListSixHIPAAMythsDebunkedhttpwww.physicianspractice.comindexfuseactionarticles.detailsarticleID1270.htmHIPAAMythsandFactshttpwww.ahima.orgpdf_filesHIPS_Mythsfootnotes.pdfMythsandFactsabouttheHIPAAPrivacyRulehttpwww.healthprivacy.orgnewsletter-url2306newsletter-url_show.htmdoc_id173459NationalPatientSafetyGoalshttpwww.jointcommission.orgpatientsafetynationalpatientsafetygoalsAlsoseeAppendix6ThisprogramoftheJointCommissionformerlytheJointCommissiononAccreditationofHealthCareOrganizationshelpsaccreditedorganizationsaddresspatientsafetyconcerns.Thegoalsaredevelopedandregularlyupdatedbyapanelofpatientsafetyexpertsandprofessionalswithhands-onexperienceaddressingpatientsafetyissuesinavarietyofhealthcaresettings.41TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM PhysicianOrdersforLife-SustainingTreatmentParadigmwww.polst.orgThisprogramisintendedtoimprovethequalityofend-of-lifecare.Healthcareprovidersuseastan-dardizedmedicalorderformtoindicatewhichtypesoflife-sustainingtreatmentaseriouslyillpatientwantsordoesnotwantifhisorherconditionworsens.Signedbyboththephysicianandthepatienttheformrequireshealthcareproviderstoengagepatientswithseriouslife-limitingillness-esinadiscussionabouttheirpreferencesforend-of-lifemedicalinterventionsandintensityofcare.Theformmoveswiththepatientandmustbehonoredacrossallcaresettings.ProjectBOOSTBetterOutcomesforOlderadultsthroughSafeTransitionsSocietyofHospitalMedicinehttpwww.hospitalmedicine.orgResourceRoomRedesignRR_CareTransitionsCT_Home.cfmAninitiativetoimprovecaretransitionsoutofthehospitalbyusingateamapproach.Anonlineresourceroomprovidesawealthofmaterialstoassistwithoptimizingthedischargeprocess.RegulationoftheLong-TermCareContinuumNHRegulationsPlushttpwww.hpm.umn.edunhregsPlusThissitecontainsfederalnursinghomeregulationsandnursinghomeregulationsforallstatesandtheDistrictofColumbiaupdatedasofJuly2007comparativeanalysesofmorethan70topicsdeal-ingwithnursinghomeregulationandresourcesandpublicationsrelevanttonursinghomeregula-tion.AssistedLivingStateRegulatoryReviewhttpwww.ncal.orgaboutstate_review.cfmThisreportpublishedannuallybytheNationalCenterforAssistedLivingprovidesastate-by-statesummaryofassistedlivingregulationscovering21categoriesprovidescontactinformationforstateagenciesthatoverseeassistedlivingactivitiesandincludeseachagencysWebsiteaddress.ResourcesforFindingandComparingHealthCareFacilitiesandServicesCentersforMedicareandMedicaidServicesResourcesCMSprovidesseveraltoolsthatmayhelpconsumerstofindandcomparehealthcarefacilitiesandservices.HomeHealthComparehttpwww.medicare.govHHCompareHospitalComparehttpwww.hospitalcompare.hhs.gov42PRACTICEGUIDELINE NursingHomeComparehttpwww.medicare.govNHCompareEldercareLocatorhttpwww.eldercare.govEldercarePublicHome.asp800677-1116weekdays900a.m.-800p.m.EasternTimeAserviceoftheU.S.AdministrationonAgingthiswebsitelinksolderadultsinneedofassistancewithstateandlocalagenciesonagingandcommunity-basedorganizationsthatserveolderadultsandtheircaregivers.OtherResourcesforOlderAdultsandFamilyCaregiversCMSSupportforCaregivershttpwww.cms.hhs.govpartnershipsdownloadsCMSCaregivers91907.pdfThispaperdescribesCMSlegalauthoritytosupportcaregiversandHIPAArulespertainingtothedisclosureofinformationtocaregivers.FamilyCaregiverAlliance-NationalCenteronCaregivinghttpwww.caregiver.org800445-8106FCAoffersanarrayofservicesandpublicationsbasedoncaregiverneedsaswellaslocalstateandnationalprogramsofeducationandsupportforcaregivers.NationalClearinghouseforLong-TermCareInformationhttpwww.longtermcare.govThiswebsitewasdevelopedbytheU.S.DepartmentofHealthandHumanServicestoprovideinfor-mationandresourcesthathelpindividualsandfamiliesplanforfuturelong-termcareneeds.Itincludesacomprehensiveglossaryoflong-termcaretermsandextensiveinformationonresourcestoassistwithlong-termcarefinancialplanningetc.NationalFamilyCaregiversAssociationhttpwww.nfcacares.orgNFCAisanonprofitorganizationthatofferseducationsupportservicesandresourcesforfamilycaregivers.NextStepinCarehttpwww.nextstepincare.orgNextStepinCareprovidesinformationandadvicetohelpfamilycaregiversandhealthcareprovidersplansafeandsmoothtransitionsforpatients.TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM43 NationalTransitionsofCareCoalitionhttpwww.ntocc.orgNTOCCwasformedin2006toaddressproblemsassociatedwithtransitionsofcareanddefinesolu-tionsthatimprovesafetyandqualityofcarefortransitioningpatients.TheNTOCCwebsiteoffersinformationandtoolsforpatientsandcaregiversaswellasforhealthprofessionals.ResourcesforpatientsandcaregiversincludeTakingCareofMYHealthCarehttpwww.ntocc.orgPortals0Taking_Care_Of_My_Health_Care.pdfAguideforpatientsandcaregiverstohelpthembeactiveparticipantsintheircare.MyMedicineListhttpwww.ntocc.orgHomeConsumersWWS_C_Tools.aspxAtooltohelppatientsandcaregiverskeeptrackofmedications.ProductsPleasenotethatinclusionofanyproductinthislistisforinformationalpurposesonlyandimpliesnoendorsementbytheAmericanMedicalDirectorsAssociation.ClockworkEDBestPracticeReportsTheAdvisoryBoardCompanyClinicalInitiativesCenter202672-5600www.advisoryboardcompany.comThisthree-volumeseriesexaminesbestpracticesdesignedtoaddressbottlenecksinhospitalemer-gencydepartmentsandstrategiesforminimizingdelaysandreducinglengthsofstay.eMPOWERxwww.empowerx.comThiswirelessdevicesimilartoapersonaldigitalassistantoffersclinicalinformationanddecisionsupporttoolsincludinganelectronicprescribingtoolthatenablestheusertoaccessthepatientspre-scriptionhistorycheckformedicationinteractionsandsecurelytransmitaprescriptiondirectlytothepharmacy.ePOCRATESwww.epocrates.comThislineofclinicalinformationanddecisionsupporttoolsisavailableonlineandfordownloadtoasmartphoneorotherwirelessdevice.Thecontentisdevelopedbyphysiciansandpharmacistsandiscontinuouslyupdated.PRACTICEGUIDELINE44 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APPENDIX1SummaryofResultsofThreeRandomizedControlledTrialsofTransitionalCareTeamsAuthorsSettingClinicalSubjectsYearsDurationIntensitySavingsPub.DateFocusGroupPatientNayloret2universityVaried180199219966monthsHigh3301al199928hospitalsNayloret6urbanHeartfailure1201997200112monthsHigh4845al200427hospitalsColemanetHMO1Varied360200220036monthsLow488al200626hospital8NHs1HHAHHAhomehealthagencyHMOhealthmaintenanceorganizationNHsnursinghomes.NaylorMDBrootenDCampbellRetal.Comprehensivedischargeplanningandhomefollow-upofhospitalizedeld-ers.Arandomizedclinicaltrial.JAMA1999281613-620.NaylorMDBrootenDACampbellRLetal.TransitionalcareofolderadultshospitalizedwithheartfailureArandom-izedcontrolledtrial.JAmGeriatrSoc200452675-684.ColemanEAParryCChalmersSMinS.TheCareTransitionsInterventionResultsofarandomizedcontrolledtrial.ArchInternMed20061661822-1828.AdaptedfromBolingPA.Caretransitionsandhomehealthcare.ClinGeriatrMed2009251135-148viii.50PRACTICEGUIDELINE APPENDIX2PrinciplesforManagingTransitionsinCareBetweentheInpatientandOutpatientSettingsFromtheACPSGIMSHMAGSACEPandSAEMuAccountabilityuCommunicationClearanddirectcommunicationoftreatmentplansandfollow-upexpectationsuTimelyfeedbackandfeed-forwardofinformationuInvolvementofthepatientandfamilymemberunlessinappropriateinallstepsuRespectforthehubofcoordinationofcareuAllpatientsandtheirfamilycaregiversshouldhaveandbeabletoidentifyamedicalhomeorcoordinatingcliniciani.e.practiceorpractitioneruAteverytransitionpointthepatientandorfamilycaregiversneedtoknowwhoisresponsibleforthepatientscarewhotocontactandhowuNationalstandardsfortransitionsincareshouldbeadoptedandimplementedatthenationalandcommunitylevelsthroughpublichealthinstitutionsnationalaccreditationbodiesmedicalsocietiesmedicalinstitutionsetc.inordertoimprovepatientoutcomesandpatientsafetyuTobringaboutqualityimprovementandaccountabilitystandardizedmetricsrelatedtothenationalstandardsrec-ommendedaboveshouldbeusedtomonitorandimprovetransitionsACPAmericanCollegeofPhysiciansSGIMSocietyofGeneralInternalMedicineSHMSocietyofHospitalMedicineAGSAmericanGeriatricsSocietyACEPAmericanCollegeofEmergencyMedicineSAEMSocietyofAcademicEmergencyMedicineAdaptedfromSnowVBeckDBudnitzTetal.TransitionsofCareConsensusPolicyStatementAmericanCollegeofPhysicians-SocietyofGeneralInternalMedicine-SocietyofHospitalMedicine-AmericanGeriatricsSociety-AmericanCollegeofEmergencyPhysicians-SocietyofAcademicEmergencyMedicine.JGenInternMed.2009Aug248971-6jointlypublishedinJHospMed51TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM BackgroundHelenisa79-year-oldwomanwholiveswithherhusbandintheirownhome.Shehasahistoryofarenaltransplant7yearsagoforwhichshenowtakesimmunosuppressantsandsteroids.Shealsotakesmorethanadozenmedicationsdailyforhermultipleillnesseswhichincludeessentialhypertensionandpulmonaryhypertension.Hermedication-inducedosteoporosishasresultedinspinaldeformity.Gaitinstabilityandfallshaveproducedseveralfracturesdespiteherintermittentuseofacane.Shecontinuestodrivemuchtothedismayofherfamilyandactsascaregiverforher80-year-oldhusbandwhoisnowlegallyblindfrommaculardegenerationandsufferingfromearlycognitivedeficits.Helenandherhusbandbothdevelopedaflu-likeillnesseatinganddrinkinglittlewithresultingdehydrationandweakness.Helenfellonthewaytothebathroomandcouldnotgetupevenwiththehelpofherhusband.ScenarioAPoorCareTransitionHelenshusbandremainedathersidewithoutcallingforhelp.Finallyaneighborcheckedonthemandfoundbothonthebedroomfloor.UponarrivalattheemergencydepartmentHelenwasdiagnosedwithcongestiveheartfailurepneumoniaanddehydrationandsubsequentlyadmittedtothehospital.Additionalfindingsinthehospitalincludeddeliriumandele-vatedbloodglucoserequiringmultiplebloodglucosereadingsandinsulinadministration.AlthoughHelensconditionimprovedandshegainedstrengthshewasnotabletowalksafely.At1100a.m.onthefourthdayofHelenshospitalizationsomeoneappearedtotellHelenshewouldbedischargedat2or3p.m.todayonereasonbeingthatshewasnotmakingprogressintherapy.Thiswasthefirstindicationthatdischargewasbeingconsidered.Helenhadreceivednoexplanationforherelevatedbloodglucoseexceptthatnowshewasadiabetic.Shehadreceivednotrainingincheckingherbloodglucoseoradministeringinsulinathome.Althoughtheworstofherdeliriumhadresolvedhermemorywasstillsuspect.MultiplefrenziedphonecallstoasoninCaliforniaageriatricphysicianlocalgranddaughtersandaformerdaughter-in-lawresultedinadecisionthatHelencouldnotreturnhomesafely.Thefamilysrefusaltoallowhertobedis-chargedhomeresultedinthehospitalproducingalistoflong-termcarefacilitiestowhichshemightgo.AfacilitywaschosenfollowingfurthercallstoapersonalfriendofthesonandHelenwastransferredthatdayforrehabilitationunderthecareofthesonsphysician-friend.EvaluationatthenursinghomerevealedthatHelencouldnotwalkbecauseherfoothurtwithbearingweightacom-plaintthatshehadmaderepeatedlyatthehospital.Anx-rayrevealedtwofootfracturessufferedintheinitialfallathome.Helenshusbandwascaredforbyaninformalcommitteeoffriendsneighborsandfamilymemberswhotookcareofhousekeepingfoodandsafety.TheyrotateddrivinghimtothenursingfacilitydailyasabsencesfromHelenwereunsettlingforhim.Helenselevatedbloodglucoseacommontemporaryoccurrenceinthefaceofcombinedstressinfectionandsteroidsresolvedassheimprovedclinically.AsthefractureshealedHelenwasabletowalkagain.Shereturnedtoherhometoresumecareofherhusband.ScenarioBExcellentCareTransitionFortunatelyafterHelenslastfallherdoctorhadconvincedhertocarryanemergencyalertdeviceatalltimes.Activationofthedevicepromptlysummonedemergencypersonneltotakehertothehospital.IntheemergencydepartmentEDtheadmittingnursenotedthatHelenandherhusbandbothseemedtohavecog-nitivedeficits.AquicksearchofpersonaleffectsdisclosedthepersonalhealthrecordPHRthatHelenalwayscarriedinherpurse.Theemergencyphysicianwasabletodeterminehermedicationshealthproblemsandmedicationaller-giesaswellasthenamesofhernephrologistcardiologistrenaltransplantsurgeonandfamilydoctor.ThePHRalsocontainedcontactinformationforthepeoplewhohadagreedtocareforHelenshusbandinjustsuchanemergency.ThehoursinvestedbythetransitioncoachfromthepriorhospitalizationinconvincingthecoupletomakearrangementsforthehusbandscareandcompletethePHRwereinvaluabletotheEDtreatmentteam.ThealertEDstaffAPPENDIX3TransitionsofCareTwoContrastingScenarios52PRACTICEGUIDELINE notingconfusioninboththepatientandthehusbandnotifiedthedischargeplanningdepartmentthatadifficultdischargewasanticipatedandthatcareissuesforthehusbandneededtobeaddressed.WhencontactedthenextdayHelensfamilydoctoraccessedherelectronicmedicalrecord.HewarnedtheattendinghospitalphysicianthatHelensbloodglucosehadrisenbeforewithacuteillnessbutresolvedwithmedicalstabilization.ThefamilydoctorconfirmedthatHelensconfusionwasnewandthuslikelytobedeliriumandthatbeforeadmissionshecouldambulateeasilywithacane.ThehospitaldoctorreassuredHelenthatshedidnothavediabetesandwouldneedbloodglucosetreatmentforashorttimeonly.Thefamilywasreassuredthathermilddeliriumwouldresolve.Theinabili-tytoambulatewasimmediatelynotedasachangeinstatusbasedupontheinformationprovidedbythefamilydoctor.Helenspainfulswollenfootwasx-rayedandtwofractureswerefound.Physicaltherapyfollowedorthopedicconsulta-tionstrengtheningherupperbody.Dischargeplanningfeltthattheinvolvementofatransitioncoachwasappropriate.ThecoachcalledHelensfamilytofindthatseveralmemberslivedlocallyandwerewillingtoassistinpost-dischargecare.Dailydiscussionsbetweenthecareteammembersthetransitioncoachandthefamilyresultedinaplanthatservedeveryonewell.Helenmadeenoughprogresswiththeearlyphysicaltherapyanddiagnosisofherfracturethatshecouldstayonemoredaythanplannedinthehospitalandreturnhomewithwalkerambulationwithoutinsulintreatmentwithhomephysicaltherapyandhomehealthfollow-up.ThetransitioncoachcoordinatedthehomecareforHelen.HealsoarrangedforthehusbandsinformalcaregiverstospendlesstimeatthehomesinceHelencouldnowreturndirectlyhome.DailycallsfromthetransitioncoachassuredhimthatHelenwastakinghermedicationsproperlyafterthemultiplechangesmadeinthehospital.Follow-upappointmentsweremadewithHelensdoctorsandtransportationwasarrangedforthedoctorvisits.Helenreturnedhometoresumecareofherhusbandunderthewatchfuleyesofhercareteam.APPENDIX3continuedTransitionsofCareTwoContrastingScenariosTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM53 APPENDIX4ExamplesofServicesProvidedintheLong-TermCareContinuumNOTEThislistillustratestherangeofservicesthatmaybefoundwithintheLTCC.NotalloftheserviceslistedwillbeavailableateveryLTCCfacilityorcaresite.WhenconsideringtransferringapatienttoanLTCCfacilitypleasedeterminewhethertherangeofservicesprovidedatthatfacilitywillmeetthepatientsneeds.CategoryExamplesofServicesActivitiesBingoCognitivetherapyExerciseclassesLibraryMoviesMusictherapyPettherapyTherapeuticoutingsAdministrationAdmissionsmarketingCentralsupplyFoodservicesFinancialmanagementsupportHousekeepingMedicalrecordshealthinformationtechnologyTransportationservicesConsultantservicesDentalcareHearingevaluationcareMedicalspecialtyservicese.g.endocrinologynephrologyMentalhealthcarecounselingPodiatriccareVisioncareWoundstomacareDiagnosticservicesLaboratorytestingEKGultrasoundX-raysDialysisHemodialysisPeritonealdialysisDietaryservicesGastrostomyassessmentsMealdietaryplanningNutritionalneedsassessmente.g.forapatientwhoislosingweightHospicepalliativecareCareofpatientswhohaveseriousmedicalconditionsandusuallylimitedlifeexpectancyMedicalOversightofpatientsmedicalcareneedsNursingCareplanningPatientassessmentDirectpatientcareSupervisionofcaregivingstaffPharmacyservicesMedicationreviewsMonitoringofintravenousmedicationswarfarindosingetc.RehabilitationservicesDurablemedicalequipmentassessmentandtrainingOccupationaltherapyPhysicaltherapySpeechtherapySupervisionofrestorativecareRespiratorytherapyNebulizertreatmentOxygentherapyTracheotomycareandsuctioningPRACTICEGUIDELINE54 CategoryExamplesofServicesSocialservicesCasemanagementChaplaincyCounselingDischargeplanningFamilysupportLiaisonwithcommunityservicese.g.homehealthcaresupportgroupsLiaisonwithotherdepartmentsandlevelsofcareEKGelectrocardiogram.APPENDIX4continuedExamplesofServicesProvidedintheLong-TermCareContinuumTRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM55 APPENDIX5ExamplesofHealthCareandSupportProfessionalsFoundintheLong-TermCareContinuumNOTEThislistillustratestherangeofhealthcareandsupportprofessionalsthatmaybefoundwithintheLTCC.NotalloftheseprofessionalswillbeavailableateveryLTCCfacilityorcaresite.WhenconsideringtransferringapatienttoanLTCCfacilitypleasedeterminewhethertherangeofprofessionalstaffavailableatthatfacilitywillmeetthepatientsneeds.uActivitiesdirectorandassistantsuAdministratoruAdmissionscoordinatoruAdvancedpracticenursesuAttendingphysiciansuCateringmanageruChaplainuConsultantpharmacistuConsultantphysiatristuDietitiansuDirectorofnursinguDirectorofsocialworkuFinancialofficersuHospicecareconsultantuHousekeeperuLicensedpracticalnursesuMedicaldirectoruMedicaltechniciansuNursingassistantsuOccupationaltherapistsuPhysicaltherapistsuPhysicianassistantsuRegisterednursesuRespiratorytherapistsuSocialworkerssocialworkassistantsuSpecialistconsultantse.g.dentistsoptometristsphysicianspecialistswoundcarespecialistsuSpeechtherapistsuTherapyaidesPRACTICEGUIDELINE56 APPENDIX6SamplePolicyandProcedureforCareTransitionPolicyandProcedureforNursingHomeResidentTransfertoEDHospitalTitleAppropriateandpatient-centeredtransferApprovedbyofaresidenttotheemergencydepartmentorhospitalApprovedbyEffectivedateJune12008RevisedPurposeuTomakecleartheappropriateinformationthatshouldbeincludedwitharesidentwhoistransferredtoanemer-gencydepartmenthospitalorotherfacilityforcareuTosetresponsibilityamongtheprofessionalstaffandsupportserviceswithrespecttotransfersuTomaintainpatient-centeredcarebyinvolvingtheresidentandhisherfamilymembersorlegallyauthorizedrep-resentativewheneverpossibleProcedureOnekeyindividualinvolvedinthecareofthepatiente.g.theunitnursewillberesponsibleforcoordinatingthetrans-ferprocess.ThisindividualwillensurethatallnecessaryactionhasbeentakentoafacilitatetransporttothereceivingfacilitybgatherallnecessarydocumentsandinformationforcommunicationwiththereceivingfacilityincludethelisthereccommunicatedirectlywiththereceivingfacilityabouttheresidentbeingtransferreddcommunicatewiththeresidentsprimarycarephysicianecommunicatewiththeresidentsfamilyorlegallyauthorizedrepresentativefdocumentallcommunicationandactivitiesintheresidentsmedicalchartUsetheapprovedchecklisttodocumentthatalloftheaboveprocedureshavebeencarriedout.TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM57 APPENDIX7ExtractsfromJointCommissionNationalPatientSafetyGoals2009TheNationalPatientSafetyGoalsmaybeaccessedintheirentiretyathttpwww.jointcommission.orgPatientSafetyNationalPatientSafetyGoals09_hap_npsgs.htmGOAL2ImprovetheeffectivenessofcommunicationamongcaregiversNPSG.02.05.01Theorganizationimplementsastandardizedapproachtohand-offcommunicationsincludinganopportunitytoaskandrespondtoquestions.RationaleforNPSG.02.05.01Healthcarehasnumeroustypesofpatienthand-offsincludingbutnotlimitedtonursingshiftchangesphysiciantrans-ferofcompleteresponsibilityforapatientphysiciantransferofon-callresponsibilityacceptanceoftemporaryrespon-sibilityforstaffleavingtheunitforashorttimeanesthesiologistreporttopost-anesthesiarecoveryroomnursenursingandphysicianhand-offfromtheemergencydepartmenttoinpatientunitsdifferenthospitalsnursinghomesandhomehealthcareandcriticallaboratoryandradiologyresultssenttophysicianoffices.Theprimaryobjectiveofahand-offistoprovideaccurateinformationaboutapatientscaretreatmentandservicescurrentconditionandanyrecentoranticipatedchanges.Theinformationcommunicatedduringahand-offmustbeaccurateinordertomeetpatientsafetygoals.ElementsofPerformanceforNPSG.02.05.011.Thehospitalsprocessforeffectivehand-offcommunicationincludesthefollowingInteractivecommunicationsthatallowsfortheopportunityforquestioningbetweenthegiverandreceiverofpatientinformation.2.Thehospitalsprocessforeffectivehand-offcommunicationincludesthefollowingUp-to-dateinformationregardingthepatientsconditioncaretreatmentmedicationsservicesandanyrecentoranticipatedchanges.SeealsoNPSG.08.01.01EP43.Thehospitalsprocessforeffectivehand-offcommunicationincludesthefollowingAmethodtoverifythereceivedinformationincludingrepeat-backorread-backtechniques.4.Thehospitalsprocessforeffectivehand-offcommunicationincludesthefollowingAnopportunityforthereceiverofthehand-offinformationtoreviewrelevantpatienthistoricaldatawhichmayincludepreviouscaretreatmentandservices.5.Interruptionsduringhand-offsarelimitedtominimizethepossibilitythatinformationfailstobeconveyedorisforgot-ten.GOAL8AccuratelyandcompletelyreconcilemedicationsacrossthecontinuumofcareNPSG.08.01.01Aprocessexistsforcomparingthepatientscurrentmedicationswiththoseorderedforthepatientwhileunderthecareoftheorganization.RationaleforNPSG.08.01.01Patientsareathighriskforharmfromadversedrugeventswhencommunicationaboutmedicationsisnotclear.Thechanceforcommunicationerrorsincreaseswheneverindividualsinvolvedinapatientscarechange.CommunicatingPRACTICEGUIDELINE58 aboutthemedicationlistmakingsureitisaccurateandreconcilinganydiscrepancieswhenevernewmedicationsareorderedorcurrentmedicationsareadjustedareessentialtoreducingtheriskoftransition-relatedadversedrugevents.ElementsofPerformanceforNPSG.08.01.01Atthetimethepatiententersthehospitalorisadmittedacompletelistofthemedicationsthepatientistakingathomeincludingdoserouteandfrequencyiscreatedanddocumented.Thepatientandfamilyasneededareinvolvedincre-atingthislist.uThemedicationsorderedforthepatientwhileunderthecareofthehospitalarecomparedtothoseonthelistcreatedatthetimeofentrytothehospitaloradmission.uAnydiscrepanciesthatisomissionsduplicationsadjustmentsdeletionsadditionsarereconciledanddocumentedwhilethepatientisunderthecareofthehospital.uWhenthepatientscareistransferredwithinthehospitale.g.fromtheICUtoafloorthecurrentprovidersinformthereceivingprovidersabouttheup-to-datereconciledmedicationlistanddocumentthecommunication.SeealsoNPSG.02.05.01EP2NoteUpdatingthestatusofapatientsmedicationsisalsoanimportantcomponentofallpatientcarehand-offs.NPSG.08.02.01Whenapatientisreferredtoortransferredfromoneorganizationtoanotherthecompleteandreconciledlistofmed-icationsiscommunicatedtothenextproviderofserviceandthecommunicationisdocumented.Alternativelywhenapatientleavestheorganizationscaredirectlytohisorherhomethecompleteandreconciledlistofmedicationsispro-videdtothepatientsknownprimarycareproviderortheoriginalreferringprovideroraknownnextproviderofserv-ice.NoteWhenthenextproviderofserviceisunknownorwhennoknownformalrelationshipisplannedwithanextprovidergivingthepatientandfamilyasneededthelistofreconciledmedicationsissufficient.Theaccuratecommu-nicationofapatientsreconciledmedicationlisttothenextproviderofservicereducestheriskoftransition-relatedadversedrugevents.Thecommunicationenablesthenextproviderofservicetoreceivethoroughknowledgeofthepatientsmedicationsandtosafelyorderprescribeothermedicationsthatmaybeneeded.Thiscommunicationisespe-ciallyimportantattransitionsincarewhenapatientisreferredortransferredfromoneorganizationtoanother.RationaleforNPSG.08.02.01Theaccuratecommunicationofapatientsreconciledmedicationlisttothenextproviderofservicereducestheriskoftransition-relatedadversedrugevents.Thecommunicationenablesthenextproviderofservicetoreceivethoroughknowl-edgeofthepatientsmedicationsandtosafelyorderprescribeothermedicationsthatmaybeneeded.Thiscommuni-cationisespeciallyimportantattransitionsincarewhenapatientisreferredortransferredfromoneorganizationtoanother.ElementsofPerformanceforNPSG.08.02.01uThepatientsmostcurrentreconciledmedicationlistiscommunicatedtothenextproviderofserviceeitherwithinoroutsidethehospital.Thecommunicationbetweenprovidersisdocumented.uAtthetimeoftransferthetransferringhospitalinformsthenextproviderofservicehowtoobtainclarificationonthelistofreconciledmedications.NPSG.08.03.01Whenapatientleavestheorganizationscareacompleteandreconciledlistofthepatientsmedicationsisprovid-eddirectlytothepatientandthepatientsfamilyasneededandthelistisexplainedtothepatientandorfamily.APPENDIX7continuedExtractsfromJointCommissionNationalPatientSafetyGoals200959TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM APPENDIX8SuggestedCommonorEssentialElementsforMedicationReconciliationSourceNTOCC2008cavailableathttpwww.ntocc.orgPortals0Medication_Reconciliation.pdf.Reproducedwithpermission.NOTEUsersmaycreatetheirownmedicationreconciliationformsbyselectingfromtheelementsinthefollowingtablethosethataremostrelevantintheirownenvironments.NTOCCtableappearsonnext3pagesSourceHalasyamaniLKripalaniSColemanEetal.TransitionofcareforhospitalizedelderlypatientsDevelopmentofadischargechecklistforhospitalists.JHospMed20061254-360.Reproducedwithpermission.RationaleforNPSG.08.03.01Theaccuratecommunicationofthepatientsmedicationlisttothepatientandtothepatientsfamilyifneededreducestheriskoftransition-relatedadversedrugevents.Athoroughknowledgeofthepatientsmedicationsisessentialforthepatientsprimarycareproviderornextproviderofservicetomanagethesubsequentstagesofcareforthepatient.ElementsofPerformanceforNPSG.08.03.011.Whenthepatientleavesthehospitalscarethecurrentlistofreconciledmedicationsisprovidedandexplainedtothepatientandtheirfamilyasneeded.Thisinteractionisdocumented.NotePatientsandfamiliesareremindedtodiscardoldlistsandtoupdateanyrecordswithallmedicationprovidersorretailpharmacies.APPENDIX7continuedExtractsfromJointCommissionNationalPatientSafetyGoals200960PRACTICEGUIDELINE TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM61APPENDIX8continuedSuggestedCommonorEssentialElementsforMedicationReconciliation APPENDIX8continuedSuggestedCommonorEssentialElementsforMedicationReconciliation62PRACTICEGUIDELINE TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM63APPENDIX8continuedSuggestedCommonorEssentialElementsforMedicationReconciliation PRACTICEGUIDELINE64APPENDIX9IdealDischargeoftheElderlyPatientAHospitalistChecklistSourceHalasyamaniLKripalaniSColemanEetal.TransitionofcareforhospitalizedelderlypatientsDevelopmentofadischargechecklistforhospitalists.JHospMed20061254-360.Reproducedwithpermission. TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM65APPENDIX10ExampleofaPost-AcuteCaretoEmergencyDepartmentHospitalTransferFormSourceAkronRegionalHospitalAssociation.Reproducedwithpermission. PRACTICEGUIDELINE66APPENDIX11QualityIndicatorsforTransitionsBetweenNursingFacilitiesandEmergencyDepartmentsIfanursinghomeresidentistransferredtoanEDthenursinghomeshouldprovidethefollowingwritteninformationinthetransferpaperwork1.Reasonfortransfer.2.Resuscitationstatus.3.Medicationallergies.4.Contactinformationforthenursinghomeprimarycareoron-callphysicianandtheresidentslegalhealthcarerepresentativeorclosestfamilymember.5.Medicationlist.6.IfanursinghomeproviderrequeststhatspecifictestsbeperformedintheEDtheemergencyphysicianshoulddocumentperformanceoftherequestedtestsordocumentinthemedicalrecordwhythetestswerenotperformed.7.IfthenursinghomeresidentwillbereleasedfromtheEDbacktothenursinghometheemergencyphysicianshoulddocumentcommunicationwithanursinghomeprovideroron-callphysicianpriortotheresidentsdischargefromtheEDordocumentattemptstodoso.8.IfanursinghomeresidentisdischargedfromtheEDbacktothenursinghometheEDshouldprovidethefollowingwritteninformationinthetransferpaperwork9.EDdiagnosis.10.Testsperformedwithresultsandtestswithpendingresults.11.IfanursinghomeresidentisdischargedfromtheEDbacktothenursinghomeandphysicianfollow-upisrecommendedthepatientshouldreceivethefollow-uporthemedicalrecordshouldindicatewhythefollow-updidnotoccur.12.IfanursinghomeresidentisdischargedfromtheEDbacktothenursinghomeandtheEDproviderprescribesorrecommendsamedicationthenursinghomeshouldadministerthemedicationordocumentinthemedicalrecordwhythemedicationwasnotadministered.AdaptedfromTerrellKMHusteyFMHwangUetal.Qualityindicatorsforgeriatricemergencycare.AcadEmergMed200916441-449. TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM67APPENDIX12RecommendedDomainsandConstructsforCaregiverAssessmentSeenextpageSourceFamilyCaregiverAllianceNationalCenteronCaregiving.CaregiverAssessmentPrinciplesGuidelinesandStrategiesforChange.ReportfromaNationalConsensusDevelopmentConferenceVol.I.SanFrancisco2006.Availableathttpwww.caregiver.orgcaregiverjspcontentpdfsv1_consensus.pdf.Accessed91509.Reproducedwithpermission.Thesedomainsandconstructsareapplicableacrosssettingse.g.homehospitalbutneednotbemeasuredateveryassessment.DomainsandspecificquestionsmaydifferforuInitialassessmentscomparedtoreassessmentsthelatterfocusonwhathaschangedovertimeuNewversuscontinuingcaresituationsuAnacuteepisodepromptingachangeincaregivingversusanongoingneedanduTypeofsettingandfocusofservices. PRACTICEGUIDELINE68APPENDIX12continuedRecommendedDomainsandConstructsforCaregiverAssessment TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM69APPENDIX13InterventionsforImprovingComprehensionAmongPatientswithLowHealthLiteracyandImpairedCognitiveFunctionSourceChughAWilliamsMVGrigsbyJColemanEA.Bettertransitionsimprovingcomprehensionofdischargeinstruc-tions.FrontHealthServManage200925311-32.Reproducedwithpermission PRACTICEGUIDELINE70APPENDIX14SelectedPerformanceMeasurementIndicatorsforTransitionalCareFromExistingToolsSourceHMOWorkgrouponCareManagement.OnePatientManyPlacesManagingHealthCareTransitions.February2004.WashingtonDCAAHP-HIAAFoundation.Facilitiesmaywishtoincorporateormodifytheseindicatorswhenutilizingqualityimprovementprocessestoreviewtheirmanagementofcaretransitions.CitationsCaliforniaHealthCareFoundation.ResultsfromthePatientsEvaluationofPerformancePEP-CSurvey.2003.Availableathttpwww.chcf.orgdocumentsqualityPEPCTechReport.pdf.ColemanEAParryCChalmersSAetal.Thecentralroleofperformancemeasurementinimprovingthequalityoftran-sitionalcare.HomeHealthCareServicesQuarterly200726493-104.WengerNSYoungRT.Qualityindicatorsforcontinuityandcoordinationofcareinvulnerableelders.ACOVE-3qualityindicators.JAmerGeriatrSoc200755S285S292. TRANSITIONSOFCAREINTHELONGTERMCARECONTINUUM71APPENDIX14continuedSelectedPerformanceMeasurementIndicatorsforTransitionalCareFromExistingTools TheAmericanMedicalDirectorsAssociationdevelopedthisguidelinewiththesupportandcooperationofthefollowingindividualsandcompaniesCharlesCefaluMDMSClinicalPracticeCommitteeChairJamesELettMDCMDCPGChairSteeringCommitteeMembersCharlesCefaluMDMSChairSherrieDornbergerRNCCDONAFDONASandraFitzlerRNMariannaGrachekMSNCNHACALAJosephGruberRPhFASCPCGPSusanM.LevyMDCMDEvvieF.MunleyJonathanMusherMDCMDBarbaraResnickPhDCRNPWilliamSimonsonPharm.D.FASCPCGPCorporateSupporterssanofi-aventisU.S.LLCOrganizationalandAssociationParticipantsAmericanAssociationofHomesandServicesfortheAgingAmericanAssociationofRetiredPersonsAmericanCollegeofHealthCareAdministratorsAmericanMedicalAssociationAmericanGeriatricsSocietyAmericanHealthCareAssociationAmericanSocietyofConsultantPharmacistsCaseManagementSocietyofAmericaGerontologicalAdvancedPracticeNursesAssociationNationalAssociationofDirectorsofNursingAdministrationinLong-TermCareNationalAssociationofHealthCareAssistantsNationalTransitionsofCareCoalitionSocietyofHospitalMedicineCopyright2010AmericanMedicalDirectorsAssociation