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An Introduction to Transitional Care

By Dr. Veronica LoFaso
Dr. Veronica LoFaso is a physician at the Irving Sherwood Wright Center on Aging at New York-Presbyterian/Weill Cornell Medical Center. Dr. LoFaso spoke at the April 8, 2010 ESCOTA general membership meeting.
Dr. Veronica LoFaso
What is Transitional Care?
Transitional Care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different health care settings.

Why Does it Matter?
  • Patients get "lost in transition"
  • Adverse events are common
  • Medical errors are newsworthy
  • 1 in 10 results in death

Handoffs and Transfers
  • Patients undergo an average of 3.5 "relocations" following hip fracture
  • Between Thursday and Monday morning, patients are subjected to 6-7 transfers

Show Me the Numbers
  • Almost 1 in 5 patients suffers an adverse event during the transition from hospital to home
  • One-third of adverse events are preventable
  • Two-thirds of adverse events are medication-related
  • One-quarter of patients are readmitted to the hospital

Types of Adverse Events
  • Medication-related
  • Procedure-related
  • Nosocomial infection
  • Falls
  • Other

What Were the Identified Deficits in the System?
  • The most common deficit was poor communication, including inadequate patient education, poor communication between patient and the doctor, and poor communication between hospital and community providers.

Other Deficits That Lead to System Failure
  • Inadequate monitoring
  • No emergency contact information
  • Difficulty obtaining prescriptions
  • Inadequate home services
  • Delayed follow-up care
  • Premature discharge

What are the Key Components of Good Transitional Care?
  • A comprehensive care plan
  • Medication reconciliation
  • Patient preparation
  • Patient education
  • Communication of the plan to receiving professionals

"Side Effects" of Poor Transitional Care
  • Inappropriate plan
  • Conflicting recommendations
  • Incorrect medication regimen
  • Inadequate follow-up
  • Insufficient patient education
  • Patient frustration and dissatisfaction
  • Increased health care utilization

Challenges To Improving Transitional Care
  • Lack of provider awareness
  • Unprepared patients
  • Isolated institutions
  • Lack of financial incentives to collaborate

Interventions Work!
  • Can be patient or provider centered
  • Decrease readmission rates
  • Decrease costs
  • Decrease mortality
  • One intervention for CHF patients results in a 30% reduction in mortality and re-admission—equal to the effect of being on a beta blocker!

  • 73% of seniors with chronic illnesses take 5+ medications daily

Medication Non-Adherence
A study of seniors with chronic illness showed that:
  • 20% skipped doses or stopped a medication because of side effects
  • 20% stopped medications they believed were not helping
  • 25% did not fill a prescription due to cost
  • Age itself is not predictive of non-adherence

Health Literacy
  • 50% of adults in the United States lack the reading and numerical skills necessary to understand and act on health information.

Transitional Care is complex and will require a multifactorial approach including changes in the:
  • Health Care Delivery System
  • Technology
  • Health Policy
  • Research

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