The American Geriatrics Society - Position Statements

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American Geriatrics Society (AGS) Position Statement

Improving the Quality of Transitional Care for Persons with Complex Care Needs

AGS Health Care Systems Committee

Definition
For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

Rationale
Persons whose conditions require complex continuous care frequently require services from different practitioners in multiple settings. Practitioners in each setting often operate independently, however, without knowledge of the problems addressed, services provided, information obtained, medications prescribed, knowledge of informal support, or preferences expressed in previous settings. This potential for fragmentation of care is heightened by the growing national trend for physicians and other clinicians to restrict their practices to single settings (e.g., hospitals, skilled nursing facilities, or ambulatory clinics) and to not follow complex patients as they move between settings. During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan "falling through the cracks". These risks are especially threatening for frail older patients with multiple co-morbid conditions. Ultimately, poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and inappropriate use of hospital, emergency, post-acute, and ambulatory services.

The rationale for this position statement is consistent with the release of the timely and compelling Institute of Medicine Report, Crossing the Quality Chasm: A New Health System for the 21st Century, which states, "Care for the chronically ill needs to be a collaborative, multidisciplinary process. Effective methods of communication, both among caregivers and between caregivers and patients, are critical to providing high-quality care. Personal health information must accompany patients as they transition from home to clinical office setting to hospital to nursing home and back" (Washington D.C.: National Academy Press, 2001, page 9).

Position 1. Clinical Care Needs
During a care transition, older patients require:

Preparation for what to expect at the next care site.
The opportunity to provide input about their values and preferences into the plan of care.
Clear advice on how to manage their conditions, how to recognize warning symptoms that may indicate their condition has worsened, how to contact a health professional who is familiar with their plan of care, and how to seek immediate care in the setting to which they have transitioned.
Arrangements for the next level of care (e.g., admission to a rehabilitation facility or a home health agency or an appointment and arrangements for transportation to a follow-up ambulatory visit).
Stronger adherence to the practice standard that requires timely evaluation by the receiving clinician to identify or verify areas of concern and ensure implementation of the care plan.

During a care transition, the "sending" and "receiving" health care professionals require:

A uniform plan of care to facilitate communication and continuity across settings.
An accessible record that contains a current problem list, medication regimen, allergies, advance directives, baseline physical and cognitive function, and contact information for all professional care providers as well as informal care providers.
Input from informal care providers who are involved in the execution of the plan of care.
The opportunity to coordinate care with a "coordinating" health professional who oversees both the sending and receiving aspects of the transition. This professional should be skilled in identification of changes in health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with members of the interdisciplinary care team and informal care providers.

Position 2. Policy Needs
Policymakers need to recognize the critical role of transitional care in the quality and outcomes of care experienced by persons with complex care needs and commit to improving care by:

Developing new performance indicators designed to measure the effectiveness of transitional care across different delivery settings.
Launching new quality improvement efforts to address transitions between care settings. Both the "sending" and "receiving" providers of care would be accountable for the success or failure of the patient's transition. Whenever possible, transitional care performance in both fee-for-service and capitated practice environments should be monitored by quality
Removing barriers and creating incentives to develop electronic communication systems that facilitate the appropriate transfer of essential clinical data between providers with heterogeneous information systems.
Creating financial incentives for providing transitional care. Essential elements of transitional care should become Medicare benefits (e.g., inter-institutional and inter-professional communication to coordinate their execution of each patient's care plan).
Discussing the opportunity to link payment to the quality of care delivered, including transitional care, in the formulation of Medicare+Choice capitation.

Position 3. Education Needs
Professional educational institutions, specialty certification boards, licensing boards, and quality improvement programs should seek to improve, evaluate, and monitor health professionals' ability to collaborate across settings in order to execute a common plan of care. Core competencies include the incorporation of patients' and informal care providers' preferences into a plan of care, active communication (telephonic, electronic, or printed paper) with health care professionals across settings, attention to and coordination of individual elements of the plan of care, and ensuring timely transfer to the next level of care or follow-up in the ambulatory setting.

Position 4. Research Needs
In order to advance the understanding and practice of high-quality transitional care, research is needed to:

Develop and test systems of care designed to optimize transitional care. Such interventions need to be patient-centered and be designed to facilitate external adoption in different delivery systems and under different payment mechanisms.
Better understand how to empower persons with complex care needs and their informal care providers to express their preferences and manage their care needs across health care settings. This line of inquiry further necessitates attention to the needs of persons from various ethnic and racial groups.
Develop and test performance indicators and quality improvement technologies that focus on the quality of transitional care.
Determine the most effective incentive strategies for encouraging clinicians and institutions to improve transitional care.
Improve the effectiveness of training health care professionals in transitional care.
Advance and disseminate state-of-the-art information technology systems that facilitate inter-institutional and inter-practitioner communication and collaboration (with appropriate safeguards in place to ensure patient confidentiality).

Credits
Developed by Eric A. Coleman, MD, MPH and Chad Boult, MD, MPH, MBA on behalf of the AGS Health Care Systems Committee and approved by the AGS Board of Directors in May 2002. AGS, The Empire State Building, 350 Fifth Avenue, Suite 801 New York, NY 10118.