Care transitions, when patients are transferred from one care provider to another or from one care setting to another, have been associated with high rates of adverse events and a 20% re-hospitalization rate within 30 days of transfer.
While the Centers for Medicare and Medicaid Services, the National Quality Forum and other national organizations have undertaken major efforts to reduce re-hospitalizations due to poor care transitions from hospital to home, little attention has been paid to care transitions from hospital to nursing facility and nursing facility to home.
To help fill this void, the Massachusetts Senior Care Foundation formed a Care Transitions Task Force focused specifically on issues that occur during transfers. Later joined by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Health Data Consortium, the task force has now grown to include nearly 70 member organizations and has changed its name to the Care Transitions Forum.
In 2008, the Care Transitions Forum was asked to lead a work group on care transitions for the Massachusetts Health Care Quality and Cost Council, the entity mandated under the state’s health care reform law to forge quality and cost effective improvements across the health care system.
The work began in 2008 and includes the design and implementation of a statewide strategic plan for care transitions, participation in new demonstration projects led by partners such as the Institute for Healthcare Improvement, Partners HealthCare, Commonwealth Medicine, and others. The Care Transitions Forum also sponsors seminars on care transitions for health and informatics professionals.
Efforts to prevent the negative consequences associated with poor care transitions involve improving communication among providers, creating standardized tools and processes, encouraging patients and families to be more involved in and educated about their own health care, and measuring results.
More information on improving care transitions is available from the National Transitions of Care Coalition, and the Care Transitions Program.
If you would like to join the Massachusetts Care Transitions Forum, please contact Alissa Weintraub.
INTERACT II
Nursing facility residents who become acutely ill are often transferred to acute care hospitals for evaluation and treatment. Although often appropriate, studies have suggested that some residents could be cared for more cost effectively and with better clinical outcomes by remaining with trusted caregivers in a familiar nursing facility setting.
A Centers for Medicare and Medicaid Services (CMS) study conducted in three Georgia nursing facilities demonstrated a significant reduction in unnecessary hospital transfers using a tool kit developed through a project called INTERACT (Interventions to Reduce Acute Care Transfers).
Now in its second phase, the study was expanded to include 10 nursing facilities each in Massachusetts, New York, and Florida. The Massachusetts Senior Care Foundation took the lead in working with nursing facility staff in Massachusetts to tailor the INTERACT II tools and resources to enhance nursing assessment skills, improve communication, and promote the discussion of advance directives. The revised tool kit will be posted on this website at the conclusion of the study, July 2010.
The toolkit is now being disseminated to additional facilities in Massachusetts as part of the Massachusetts Strategic Plan for Care Transitions. The Practice Change Fellowship, awarded to Alice Bonner PhD, RN, Director of the Massachusetts Bureau of Health Care Safety and Quality partially funds the strategic plan and the dissemination of the INTERACT II toolkit.
The INTERACT II project is one of several care transitions initiatives that the Massachusetts Senior Care Foundation is leading. For more information, please contact our Director of Clinical Quality, Laurie Herndon.
STAAR (State Action on Avoidable Re-hospitalizations Initiative)
Recently, the Institute for Healthcare Improvement (IHI) launched the State Action on Avoidable Re-hospitalizations (STAAR) initiative — a multi-state, multi-stakeholder approach to dramatically improve the delivery of effective care at a regional scale. This initiative aims to reduce re-hospitalizations by working across organizational boundaries in three states, Massachusetts, Michigan, and Washington — by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces. Through supporting the strategy and leadership of state-level Steering Committees in the three states, IHI aims to help states reduce state-wide 30-day re-hospitalization rates by 30 percent and to increase patient and family satisfaction with transitions in care and with coordination of care.
The engagement with cross-continuum partners is integral to the core principle of co-creating the ideal communication processes between “senders” and “receivers” across care settings. The second phase of this work will consist of a collaborative learning network to improve the “reception” into the post-acute setting of care: the medical home and/or the skilled nursing facility. Many MA skilled nursing facilities are currently participating on these cross continuum care teams. For more information on this project, please contact our Director of Clinical Quality, Laurie Herndon.
Resources for preventing re-hospitalization