The Evolution of a Transitions of Care Program

Executive Summary

Since the passage of the Affordable Care Act in 2010, healthcare has undergone a paradigm shift from a volume-based fee-for-service to an outcomes-based payment model. For Jefferson Health and other providers employing a continuum of care model (a cohesive care system that guides and tracks patients over time through a comprehensive array of services spanning all levels of care), this transformation has placed an outsized focus on improving an integral part of the patient journey: the transition from one service level of care to the next. Strategic communication is a key driver in effectual and proficient patient care across the healthcare continuum, particularly in transitions of care, with numerous studies demonstrating that effective communication increases patient safety, saves costs, and reduces duplicative work.  And so, in autumn 2018, Jefferson Health launched a multidisciplinary effort to develop a comprehensive transitions of care program that would be both replicable and sustainable, address communication challenges, and mitigate fragmentation through the patients’ acute care journey. Emphasis was also placed on establishing goals to ensure our program fostered accountability and collaboration in a multidisciplinary service delivery structure that provides the right care, to the right patients, at the right time—to treat each person holistically. While initial improvements in outcomes for patients with ambulatory sensitive conditions were impacted by the COVID-19 pandemic, the team is confident that the comprehensive transitions of care program will rapidly return to pre-pandemic levels of success. The health system now has tools to identify patients discharged from all locations in a timely manner without our nurse team sifting through spreadsheets and risk scores to locate them. Custom templates were developed in our EHR to guide our staff in consistent evidence-based scripted calls during our transition of care connection. Disease-specific questions and care plans were built to direct our attention to a patients’ ambulatory sensitive conditions which included self-management plans, and barriers to follow up care. As members of comprehensive primary care (CPC+), we are tasked with attempting to contact 75% of patients transitioned out of an inpatient, or post-acute setting. As a result of our efforts, our patient population is successfully engaged 78% of the time and we have seen a significant reduction in our Hospital Readmissions Reduction Program (HRRP) year over year with a savings of 18%.

Lessons learned include:

A high-quality transition is achieved when all patient referrals and transitions meet the six Institute of Medicine aims of high-quality health care. From this perspective, referrals and transitions should be:

• Timely: Patients receive needed transitions and consultative services without unnecessary delays.
• Safe: Referrals and transitions are planned and managed to prevent harm to patients from medical or administrative errors. Care coordination has been defined as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”
• Effective: Referrals and transitions are based on scientific knowledge and executed well to maximize their benefit.
• Patient-centered: Referrals and transitions are responsive to patient and family needs and preferences.
• Efficient: Referrals and transitions are limited to those that are likely to benefit patients and avoid unnecessary duplication of services.
• Equitable: The availability and quality of referrals and transitions does not vary by the personal characteristics of patients.

The journey through our transition of care program has shown there are numerous steps to success as well as a great many patient outcomes to measure. Initial focus was on identification of patients to outreach. We quickly learned that it is the quality of the outreach and defining a successful outreach that adds impact.