Care transitions are recognized as a time of significant vulnerability for children and adults with multiple chronic illnesses and complex health and social needs. Moving between settings or between providers requires comprehensive preparation and education of patients and families and accurate and timely flow of essential information. Lack of effective coordination on both sides of the transition leaves patients at risk for serious adverse outcomes influencing quality of life and function and substantial cost.This OJIN topic captures several important steps in the evolution of knowledge and practice of transitional care and care coordination. Together, the articles included in this topic reflect where we have been and where we still need to go to assure that patients and their families have safe and effective transitional care experiences. The articles range from a summary of over two decades of research on the nurse-led Transitional Care Model (TCM) to recent pilot studies developing new models and tools to expand transitional care and care coordination interventions to new settings and populations.
In Continuity of Care: The Transitional Care Model, Hirschman and members of the multiprofessional Transitional Care Model (TCM) team at the University of Pennsylvania detail the evidence supporting the impact of their nurse-led transitional care model on quality and cost outcomes for older adults with multiple chronic illnesses. The TCM has undergone rigorous testing over the past two decades and has consistently demonstrated reductions in hospitalizations and costs for Medicare beneficiaries at high risk for adverse outcomes. This well-recognized model has been implemented in hospitals and health systems including patient-centered medical homes across the United States. The nine core TCM interventions and tools developed to measure them are described in the paper. This latest summary of the body of TCM research and its translation into “real-world” health care systems is a testament to the importance of rigorous and continuous programs of research for defining and improving care coordination for vulnerable populations with complex care needs.
DelBoccio and colleagues describe one hospital’s experience in becoming a top performer in transitional care in Successes and Challenges in Patient Care Transition Programming. Spurred to improve transitional care by changes in the Affordable Care Act, Indiana University Health North Hospital launched new programs to enhance patient activation and health team performance in medication management and communication with post-acute providers. Their experience reinforces the importance of effective teamwork and continuous quality improvement in making meaningful improvements in the care transition experience and subsequent performance outcomes.
Nurses across academic and clinical settings in Minnesota describe the implementation of two models of care coordination for children with medical complexity (CMC) in their article Pediatric Care Coordination: Lessons Learned and Future Priorities. Cady and colleagues designed the TeleFamilies Model and PRoSPer models of pediatric care coordination to overcome current challenges of integrating complex care for children in healthcare homes (HCH) and to address key components of their state’s healthcare reform legislation. Examining the implementation of new care coordination models within the context of unfolding state healthcare reform is a critical aspect of this article. Both the TeleFamilies and PRoSPer models incorporate nurses as drivers of care coordination processes in concert with members of interprofessional teams. They involve different team members and the use of different technologies according to the needs of children and families in rural and urban HCHs. The results of initial model tests show improved family perceptions of their health care experience and provider communication. The authors suggest several opportunities for further evaluation of the use of telehealth and other distance modalities in care coordination.
In their article Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Multimorbidity, Scholtz and Minaudo summarize current definitions of care coordination and explore roles for registered nurses and health care teams. They review literature on competencies and key quality and cost outcomes. An example of one model of evidence-based care coordination is used to illustrate the significant potential for customizing care coordination models for older adults with multiple chronic illnesses.
And finally, Yeaman, Ko and Alvarez del Castillo describe a pilot study conducted as part of the Office of the National Coordinator for Health Information Technology Challenge Grant Program to examine the use of health information technology (HIT) to facilitate transitional care in long term care (LTC) settings. To date, LTC facilities have had limited access to HIT and the benefits of using electronic data transfer to assist with information flow between settings and providers. While most LTC facilities use HIT for billing, less than half use it to support clinical processes and communication. The pilot study detailed in this article, Care Transitions in Long-term Care and Acute Care: Health Information Exchange and Readmission Rates, capitalizes on a secure state-wide health information exchange to enhance sharing of information during patient transitions between LTC and acute care facilities. LTCs used standardized clinical tools, including a universal transfer form, to document and share important information about risk factors and changes in clinical condition. Early results are promising: completion of standardized information tools increased and both 30-day readmissions and return emergency room visits were reduced from baseline to 20 months following implementation of HIT to support transitional care. Lessons learned during the implementation suggest that implementation of HIT requires important cultural changes for LTC staff and that these changes can be managed effectively through planning and staff support.
These five articles reflect important developments in the history and growth of care coordination practice and research. While the concepts of transitional care and care coordination are certainly not new in healthcare – they have been studied and practiced for more than half a century in the United States – this group of articles demonstrates the value of long-term rigorous programs of research and rapid-cycle evaluation of new models and technologies for advancing care coordination practice. Both are needed to achieve state and national quality goals for better health and cost outcomes. The work detailed in these articles is a welcome sign of the much needed spread of transitional care and care coordination interventions across the care continuum and to very vulnerable groups of patients.
The journal editors invite you to share your response to this OJIN topic addressing Care Coordination either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Gerri Lamb, PhD, RN, FAAN
Gerri Lamb, PhD, RN, FAAN is a well-known author and speaker on care coordination. She is editor of Care Coordination: The Game Changer - How Nursing is Revolutionizing Quality Care published by the American Nurses Association. Dr. Lamb serves as the Director for the Center for Advancing Interprofessional Practice, Education and Research at Arizona State University's College of Nursing and Health Innovation.