SPECIAL ARTICLES

JAGS 51:556–557, 2003© 2003 by the American Geriatrics Society 0002-8614/03/$15.00

Improving the Quality of Transitional Care for Personswith Complex Care Needs

Position Statement of The American Geriatrics Society Health Care Systems CommitteeEric A. Coleman, MD, MPH,* and Chad Boult, MD, MPH, MBA

†

Key words: systems of care, care transitions, care integration

Background

For the purpose of this position statement, transitionalcare is defined as a set of actions designed to ensure the co-ordination and continuity of healthcare as patients trans-fer between different locations or different levels of carewithin the same location. Representative locations include(but are not limited to) hospitals, subacute and postacutenursing facilities, the patient’s home, primary and spe-cialty care offices, and assisted living and long-term carefacilities. Ideally, transitional care is based on a compre-hensive plan of care and the availability of healthcarepractitioners who are well trained in chronic care andhave current information about the patient’s goals, prefer-ences, and clinical status. It should include logistical ar-rangements, education of the patient and family, and coor-dination among the health professionals involved in thetransition. Transitional care, which encompasses the send-ing and the receiving aspects of the transfer, is essential forpersons with complex care needs and their caregivers.

Persons whose conditions require complex, continu-ous care frequently require services from different practi-tioners in multiple settings, but practitioners in each set-ting often operate independently, without knowledge ofthe problems addressed, services provided, informationobtained, medications prescribed, or preferences expressedin previous settings.

1

The growing national trend for phy-sicians and other clinicians to restrict their practices to sin-gle settings (e.g., hospitals, skilled nursing facilities, or am-bulatory clinics) and not to follow complex patients asthey move between settings heightens this potential forfragmentation of care.

2,3

During transitions, these patientsare at risk for medical errors, service duplication, inappro-priate care, and critical elements of the care plan “falling

through the cracks.”

1,4,5

Ultimately, poorly executed caretransitions may lead to poor clinical outcomes; dissatisfac-tion among patients; and inappropriate use of hospital,emergency, postacute, and ambulatory services.

1,6,7

Positions

Position 1. Clinical professionals must prepare patientsand their caregivers to receive care in the next setting andactively involve them in decisions related to the formula-tion and execution of the transitional care plan.

Rationale: During a care transition, patients withcomplex care needs and their caregivers require prepara-tion for what to expect at the next care site and the oppor-tunity to provide input into the plan of care regardingtheir values and preferences.

8–11

An important componentof this preparation is to ensure that these patients andtheir caregivers have clear advice on how to manage theirconditions, how to recognize warning symptoms that mayindicate that their condition has worsened, how to contacta health professional who is familiar with their plan ofcare, and how to seek care in the setting to which theyhave moved.

Position 2. Bidirectional communication between clin-ical professionals is essential to ensuring high-quality tran-sitional care.

Rationale: During a care transition, the “sending” and“receiving” healthcare professionals require a uniformplan of care to facilitate communication and continuityacross settings and an accessible record that contains a cur-rent problem list, medication regimen, allergies, advancedirectives, baseline physical and cognitive function, andcontact information for caregivers and healthcare profes-sionals. This communication can be telephonic, electronic,or through a paper medical record. Barriers need to be re-moved and incentives created to develop electronic com-munication systems that facilitate the appropriate transferof essential clinical data between providers with hetero-geneous information systems.

In addition, the opportunity to collaborate with a “co-ordinating” health professional functioning across health-care settings to reduce care fragmentation may enhancethe care that these professionals deliver. This professionalshould be skilled in the identification of changes in healthstatus, assessment and management of multiple chronic

From the *Divisions of Geriatric Medicine and Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, Colorado; and

†

Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.

Address correspondence to Eric A. Coleman, MD, MPH, Divisions of Geriatric Medicine and, Health Care Policy and Research, University of Colorado Health Sciences Center, 3570 East 12th Ave, Suite 300, Denver, Colorado 80206. E-mail: Eric.Coleman@uchsc.edu

JAGS APRIL 2003–VOL. 51, NO. 4

IMPROVING THE QUALITY OF TRANSITIONAL CARE

557

conditions, managing medications, and collaboration withinterdisciplinary healthcare professionals and caregivers.

12–15

Position 3. Policies should be developed that promotehigh-quality transitional care.

Rationale: Policymakers need to recognize the criticalrole of transitional care in the quality and outcomes ofcare experienced by persons with complex care needs andcommit to implementing new quality-improvement strate-gies. Performance indicators designed to measure the effec-tiveness of transitional care across different delivery set-tings are needed to ensure that both the “sending” and“receiving” providers of care are held accountable for thesuccess or failure of a patient’s transition. Whenever pos-sible, quality improvement entities such as the NationalCommittee for Quality Assurance, Quality ImprovementOrganizations (formerly known as Peer Review Organiza-tions), the Joint Commission on Accreditation of Health-care Organizations, state health departments, or a newquality improvement entity should monitor transitionalcare performance in fee-for-service and capitated practiceenvironments. Finally, greater financial incentives areneeded to improve transitional care. Essential elements oftransitional care should become Medicare benefits (e.g.,interinstitutional and interprofessional communication tocoordinate their execution of each patient’s care plan).

Position 4. Education in transitional care should beprovided to all healthcare professionals involved in thetransfer of patients across settings.

Rationale: Professional educational institutions, spe-cialty certification boards, licensing boards, and qualityimprovement programs should seek to improve, evaluate,and monitor health professionals’ ability to collaborateacross settings to execute a common plan of care. Corecompetencies include the incorporation of patients’ andcaregivers’ preferences into a plan of care, active commu-nication (telephonic, electronic, or printed paper) withhealth professionals across settings, attention to and coor-dination of individual elements of the plan of care, and en-suring timely transfer to the next level of care or follow-upin the ambulatory setting.

Position 5. Research should be conducted to improvethe process of transitional care.

Rationale: To advance the understanding and practiceof high-quality transitional care, research is needed to bet-ter understand how to empower persons with complexcare needs and their caregivers to express their preferencesand manage their care needs across healthcare settings.

9–11

This line of inquiry further necessitates attention to theneeds of persons from various ethnic and racial groups.

Research is also needed to determine how to improvethe effectiveness of training healthcare professionals in

transitional care and the most-effective incentive strategiesfor encouraging clinicians and institutions to improvetransitional care.

In addition, systems of care designed to optimize tran-sitional care need to be developed and tested. Such inter-ventions should be patient centered and be designed to fa-cilitate external adoption in different delivery systems andunder different payment mechanisms. Similarly, perfor-mance indicators and quality-improvement technologiesthat focus on the quality of transitional care need to be de-veloped and tested. Finally, research is needed to advanceand disseminate state-of-the-art information technologysystems that facilitate interinstitutional and interpracti-tioner communication and collaboration (with appropriatesafeguards in place to ensure patient confidentiality).

REFERENCES

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System ofthe 21st Century. Washington, DC: National Academy Press, 2001, pp. 1–22.

2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA2002;287:487–494.

3. Katz TF, Walke LM, Jacobs LG. A geriatric hospitalist program for nursinghome residents. Ann Long Term Care 2000;8:51–56.

4. Beers M, Sliwkowski J, Brooks J. Compliance with medication ordersamong the elderly after hospital discharge. Hospital Formul 1992;27:720–724.

5. Agency for Health Care Quality Research. Medical Errors. The Scope of theProblem. Rockville, MD: Department Health Human Services, 2000.

6. Ellers B, Walker J

.

Facilitating the transition out of the hospital. In: GerteisM, Edgman-Levitan S, Daley J, eds. Through the Patient’s Eyes: Understand-ing and Promoting Patient-Centered Care. San Francisco: Jossey Bass, 1993,pp. 204–223.

7. Murtaugh CM, Litke A. Transitions through postacute and long-term caresettings: Patterns of use and outcomes for a national cohort of elders. MedCare 2002;40:227–236.

8. Coulton CJ, Dunkle RE, Chow JC et al. Dimensions of post-hospital caredecision-making: A factor analytic study. Gerontologist 1988;28:218–223.

9. Levine C. Rough Crossings: Family Caregivers’ Odysseys Through theHealth Care System. New York: United Hospital Fund of New York,1998.

10. Coleman E, Smith JD, Frank J et al. Development and testing of a measuredesigned to assess the quality of care transitions [On-line]. Int J Integr Care2002:2. Available at www.ijic.org/index2.html Accessed December 11, 2002.

11. Weaver FM, Perloff L, Waters T. Patients’ and caregivers’ transition fromhospital to home. Needs and recommendations. Home Health Care Serv Q1998;17:27–48.

12. Naylor M, Brooten D, Campbell R et al. Comprehensive discharge planningand home follow-up of hospitalized elders: A randomized clinical trial.JAMA 1999;281:613–620.

13. Naylor M, Bowles K, Brooten D. Patient problems and advanced practicenurse interventions during transitional care. Public Health Nurs 2000;17:94–102.

14. Rich M, Beckham V, Wittenberg C et al. A multidisciplinary intervention toprevent the readmission of elderly patients with congestive heart failure. NEngl J Med 1995;333:1190–1195.

15. Stewart S, Pearson S, Horowitz J. Effects of a home-based interventionamong patients with congestive heart failure discharged from acute hospitalcare. Arch Intern Med 2000;158:1067–1072.