Rocky Transitions, And How To Fix Them

April Seligman & Georgia Maheras, of the advocacy group Health Care For All, explore various ways to deal with problems that arise from patient "transitions," between health care facilities and from unnecessary hospital readmissions:

Last week, the Health Care Quality and Cost Council met to discuss a new initiative aimed at keeping patients healthy and out of the hospital. The plan is focused on improving “transitions to care” and preventing repeated and unnecessary hospital stays.

Care transitions are when a patient is transferred from the hospital to a rehabilitation center, is moved from a nursing home to a hospital, or is readmitted to the hospital for something that could have possibly been prevented.

Massachusetts has a disproportionately high rate of hospital readmissions compared to other states. This new initiative is designed to improve post-discharge communication and coordination and reduce this rate.

At the HCQCC meeting, Alice Bonner PhD, RN from DPH, Craig Schneider from the Massachusetts Health Data Consortium and Dr. Joel Weissman from EOHHS identified barriers to effective care transitions; they are both structural and procedural and include a lack of integrated care and effective communication. Under use of clear performance measurers to indicate optimal transitions is also problematic. The result of these barriers is that patients are in the hospital repeatedly and unnecessarily.

Care transitions present a unique opportunity to improve the quality of health care for patients in Massachusetts. It should also result in cost savings as well. It is the opportunity to provide better care for all Massachusetts’ residents. The goal of this care transitions strategic plan is to have interdisciplinary teams delivering safe, effective, and timely care that is culturally and linguistically appropriate in various types of settings. Furthermore, there must be an alignment of clinical care, public health, and health policy.

Across the nation and in Massachusetts, there are pockets of successful programs where this is a reality.

At the recent launch of the Massachusetts Campaign for Better Care three vulnerable patients discussed their successful care transitions. For each, there is effective communication between them and their care team. Unfortunately, this is not true for all patients. But it should be.

Bonner, Schneider and Weissman discussed the principles around which the plan was created- principles which will guide the health care community so that quality is improved. The principles include: timely feedback between and among the primary care team, standardized processes and documents, a communications infrastructure, patient and family engagement, outcome measurers based on nationally endorsed measurements, and payment reform.

These principles also take into account the differences in health care delivery prevalent in different regions of the state. For example, some communities have the capacity to deliver meals, while others do not. As a result, the principles will be prioritized differently depending on the needs of the different communities. It is clear there is no ‘one size fits all’ process that can be implemented.

They noted that once the strategic plan is implemented, including payment reform, health status will be improved (fewer complications, fewer adverse events, and greater patient satisfaction), appropriate utilization of health care resources will occur in the form of fewer ER visits, fewer readmissions, fewer preventable admissions, and a lower incidence of unnecessary care. Things that we all want to see in our health care.

The QCC postponed its vote until next month so that it could have time to fully evaluate the proposal. The Massachusetts Campaign for Better Health Care is eager work with the state to make sure that all patients in Massachusetts can receive better care as soon as possible.