AdvisaCare

Continuum of Care: What Do I Need to Know?

National Transitions of Care Coalition 2009

National Transition of Care Coalition (NTOCC) was formed in 2006 to address a serious U.S. health care issue: problematic situations which can occur when patients leave one care setting and move to another care setting. The U.S. healthcare system often fails to meet the needs of elderly patient populations during these transitions because care is rushed and responsibility is fragmented with little communication across care settings and multiple providers. These failures lead to undue burdens on patients and their families and negatively impact patient safety, quality of care and outcomes. The focus of NTOCC is to bring together leaders and health care experts from various settings to address this critical issue, define solutions and develop tools to address the gaps impacting patient care. Tools and resources developed by NTOCC will be made available to everyone in the health care industry including providers, payers, patients and consumers.

Transitions of care include situations in which a patient moves from primary care to specialty physicians or moves within the hospital including moves from the emergency department to other various departments, such as surgery or intensive care; or when a patient is discharged from the hospital and goes home or to an assisted living or skilled nursing facility. Patients, especially older persons, face significant challenges when moving from one level of care or practice setting to another in the healthcare system. During these transitions, lack of communication can result in redundant or conflicting information that often creates serious issues for patients, their caregivers and their families.

Steps to Improve communication during transitions between providers, patients, and caregivers:
• Implement electronic medical records that include standardized medication reconciliation elements;
• Establish points of accountability for sending and receiving care, particularly for hospitalists, SNFists (physicians practicing in skilled nursing facilities), primary care physicians, and specialists;
• Increase the use of case management and professional care coordination;
• Expand the role of the pharmacist in transitions of care;
• Implement payment systems that align incentives; and
• Develop performance measures to encourage better transitions of care.

The last concern most individuals have when they or their loved ones are dealing with a health situation is ensuring effective communication between their doctors, nurses, social workers and other health care providers. However, it is poor communication between well-intentioned professionals and an expectation that patients themselves will remember and relate critical information that can lead to dangerous and even life-threatening situations. NTOCC believes that patients are at the center of care and can play an active role in improving communications and use tools to ensure effective transitions. We have brought together industry leaders who have created resources to help you better understand transitional challenges and empower you as part of the care giving team.

NTOCC.ORG (2009)