Patient care delivery transitions can quickly develop complex issues... The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (Centers for Medicare and Medicaid Services, 2015); enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions, both internal to the hospital and between settings. Quality healthcare delivery is contingent upon a patient’s understanding and retention of education, involvement in care, and self-management activation. Patient care delivery transitions can quickly develop complex issues while clinicians focus on patient safety, satisfaction, and clinical outcomes within a hospital environment of cost containment, rising workloads, and increasing patient comorbidities.

The Context of Care Transitions

Patient transitions from the hospital to alternate settings (e.g., home, rehabilitation facility) and within-hospital transfers between units, or the emergency department and inpatient setting, are areas of increased national focus within healthcare. In 2013, the Institute for Healthcare Improvement (IHI) released a hospital how-to guide which included recommendations for transitions from the hospital setting, typical failures, and implementation resources; practical methods and resources for the adoption and testing of changes within the clinical setting; the inclusion of successful case studies; and suggested measures, resources, and references (Rutherford, Nielsen, Taylor, Bradke, & Coleman, 2013).

Organizations such as The Joint Commission have developed videos to help clinicians improve patient transfer communication skills (Joint Commission Resources, n.d.). A repository of information for healthcare individuals can be found at The Joint Commission Transition of Care portal that includes performance measures; articles and publications; links to other government and professional organization sites with transition programs; and recorded webinars and education offerings, all at no cost (The Joint Commission, 2014).

Seven elements that must be in place for a safe transition to occur from one health setting to another include: leadership support; multidisciplinary collaboration; early identification of patients/clients at risk; transitional planning; medication management; patient and family action/engagement; and the transfer of information (Figure 1, The Joint Commission, 2014). The Joint Commission has incorporated transition measures into their disease specific care certification programs as a component to ensure excellence in the delivery of healthcare services for several designated conditions. Their certification program began in 2012 as an additional designator of a higher level of service through evaluation of clinical programs across the continuum of care (The Joint Commission, 2014). Organizations that have the certification have undergone a rigorous review process.

Figure 1. The Seven Elements for a Safe Transition to Occur (adapted from The Joint Commission, 2014).

The HCAHPS survey was implemented in October 2006 by the Centers for Medicare and Medicaid Services (CMS) as a national, standardized method to evaluate patient perception of care received. Formal public reporting of HCAHPS results for hospitals began in March 2008. Until January 2013, the required questions for the HCAHPS survey had remained unchanged. Five additional questions were added to the HCAHPS Survey in 2013: three questions related to transitions to post-hospital care, one question about admission to the hospital through the emergency department, and one question related to mental and emotional health (HCAHPS Fact Sheet, 2013). The three questions that comprise the HCAHPS survey Care Transition Measures include (Coleman, n.d., Box 2):

• “The hospital staff took my preferences and those of my family or caregivers into account in deciding what my health care needs would be when I left the hospital” (focus on when the patient was in the hospital)
• “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” (focus on discharge preparedness)
• “When I left the hospital, I clearly understood the purpose for taking each of my medications” (focus on medication understanding at time of hospital discharge)

Data are emerging from the additional Care Transition Measures and benchmarks have been developed. Data are emerging from the additional Care Transition Measures and benchmarks have been developed. The remaining sections of this article describe the journey of Indiana University Health North Hospital to overcome patient care transition obstacles, ultimately achieving designation as a top performer. We will discuss our efforts to personalize patient outcomes and transition through activation and improve transitions for vulnerable populations, specifically in the bariatric and orthopedic patient populations. The article concludes with discussion of overcoming obstacles and continued focus on collaboration and improvement.

Data: Indiana University Health North Hospital as a Top Performer

Top performers among 568 hospitals were determined by examining Care Transition Measures scores from patients who returned HCAHPS surveys between January 1 and December 31, 2013. Based on this time frame, patients at Indiana University Health North Hospital reported an aggregate top box score of 61.5% (n=1,396) for the Care Transition Measures, which was one of the highest scores. CMS defines top box for the Care Transition Measures as the percentage of patients who answered “Strongly Agree” on the three Care Transition Measures out of the total number of responses (HCAHPS Hospital Survey, 2014). Further, a review of data for patients discharged between January 1 and December 31, 2013 was conducted to identify when improvements were implemented at Indiana University Health North Hospital, and when those changes were reflected in scores that measured patient experience.

Indiana University Health North Hospital performance scores on the Care Transition Measures have steadily increased since the third quarter of 2012 (Figure 2). The hospital’s top box scores of a “Strongly Agree” response on the HCAHPS survey has consistently shifted upward by quarter from 57.8% for patients discharged between July 1, 2012 and September 30, 2012 to 66.1% for patients discharged between October 1, 2013 and December 31, 2013. Aggregating quarters for all of 2012, the organization had an overall top box score of 61.5%

Figure 2. Hospital Care Transition Measures Top Box Scores

A concentration on care transitions and better coordination at Indiana University Health North Hospital improved the effectiveness of clinicians managing orthopedic patient pain levels during hospitalization (Figure 3). Two questions from the HCAHPS survey provided focus for improvement that resulted in substantial upward shifts. The question “During this hospital stay, how often was your pain well controlled?” top box scores increased from 78.3% to 83.2%. The question “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” top box scores increased from 84.8% to 91.7%. In the next sections, we will discuss some of the factors that may impact patient scores, and our unique experiences with these factors.

Figure 3. Percent Responding “Always” to HCAHPS Pain Questions Before and After Inpatient Pain Rounding

Personalizing Patient Outcomes and Transitions Through Activation

Patient activation is a concept that relates to an individual’s resolve to engage in health improvement. Patient activation is a concept that relates to an individual’s resolve to engage in health improvement. It is comprised of four components: believing an individual’s role is important; having the confidence and knowledge needed to take action; taking action to maintain and improve health; and sustaining health under stress (Hibbard, Stockard, Mahoney, & Tusler, 2004). The relationship between patient experience and activation goes beyond perception. Patients with higher levels of activation have been correlated with a more positive physician interaction experience. Further, this correlation also exists when individuals with either high or low activation scores interact with the same physician (Greene, Hibbard, Sacks, & Overton, 2012). Subsequently when communicating with patients, a provider should focus beyond the patient experience with strategies to involve patients at a deeper level in self-management of health and to understand the relationship equity being created within the interaction.

Medication Cards for Patient Activation

Patient understanding of medications can be a difficult process in the transition from the hospital to alternate settings. Medication reconciliation occurs at the time of discharge; however, there is a second medication reconciliation by patients when they arrive home (Volland, 2011). Any resources patients can acquire to assist their understanding and knowledge retention about newly prescribed and discontinued medications becomes invaluable upon arrival home. To facilitate patient understanding of medications at the time of hospital discharge, Indiana University Health North Hospital pharmacists identified specific populations with a need for additional communication.

Using the medication card approach for teaching increased the level of consistency across healthcare providers... Medication cards are now used with populations such as orthopedic and bariatric patients, who undergo substantial lifestyle changes in the post-hospitalization period. Cards enable better staff communication with patients about medications, including undesirable side effects should they occur (Figure 4). While medication cards are already commonly used in the inpatient setting, the improvement at Indiana University Health North Hospital allowed pharmacists and nursing staff to “speak the same language” across the team with the patient. Using the medication card approach for teaching increased the level of consistency across healthcare providers who educated patients on medications while also elevating the continuity in messaging each time education was done with a patient.

Figure 4. Medication Side Effect Quick Reference Card

Increasing Patient Activation in the Breast Program

Indiana University Health North Hospital’s breast program is another example of streamlining processes for more patient activation that supported an increase in an individual’s ability to engage in health improvement. Creating an environment of holistic care and providing convenient access to services resulted in an easier process for patients to understand their condition(s) and a more inclusive process of health management. For example, unification of services to one geographical location permitted patients to see all members of their care team during a visit. Physicians providing different components of care (e.g., surgery, radiation, chemotherapy support) became better aligned with a patient’s overall plan of care.

Patients noted a greater understanding of their condition(s) and the specifics of health management, and were better able to become an active participant in their health at a deeper level. Additionally, family involvement has increased since members of the care team can offer proactive outreach, such as the geneticist meeting with family members to offer education and breast cancer testing. This approach has increased the level of services provided to both patient and family.

Improving Transitions for Vulnerable Populations Through Inpatient Programs

The importance of improving care coordination for vulnerable populations led to innovations for two Indiana University Health North Hospital programs. In this section, we briefly explain challenges and solutions in our programs for two such populations, the elderly and bariatric patients.

Care Transitions and the Elderly

A case manager follows patients during the hospital stay and throughout their stay at the skilled nursing facility until their arrival to home. To support patients in their health journeys with partnering facilities, we created the “Transitional Care Program.” The purpose of this program is to ensure care continuity with safe handoffs (i.e., transfer of responsibility for a patient from one entity to another) from the hospital to other receiving facilities. This program is an example of a dedicated focus on the vulnerable elderly population. A case manager follows patients during the hospital stay and throughout their stay at the skilled nursing facility until their arrival to home. Additional oversight by the hospital case manager provides care continuity and a partner in care collaboration; supports a seamless process for communication of orders; and ensures additional services coordination, such as home care or transportation upon discharge from the skilled nursing facility. The case manager works not only with the patient, but also the family or guardian.

Improving Indiana University Health North Hospital’s external care transitions with partnering skilled nursing facilities has resulted in a readmission rate decrease to 11.7 % for these complex patients, with a Medicare cost avoidance of more than $239,000. Indiana University Health North Hospital received a Case in Point Platinum award in 2013 for the Transition of Care Program. The Case in Point Platinum award recognizes initiatives with successful case management and care coordination that improve a healthcare system.

Bariatric Patient Care Transitions Related to Medications

Vulnerable populations can also include patients who may have a significant learning curve with a high risk for readmission. We initiated a pilot project with bariatric patients after determining that the nursing education conducted was not sufficient for this specialized population, especially related to medications. This became evident when medications via pill form were too large or unable to be crushed for a nasogastric tube or medications were unavailable in liquid form.

Because the patient’s surgery date is a scheduled event, care coordination and communication processes within a hospital’s internal team can begin in advance of patient admission. Because the patient’s surgery date is a scheduled event, care coordination and communication processes within a hospital’s internal team can begin in advance of patient admission. At Indiana University Health North Hospital, an emphasis is placed on diet and medications changes. Patient education (e.g., an introduction to lifestyle changes that will be required upon discharge) is conducted during a required bariatric class completed prior to scheduling the surgery. While in the inpatient setting, diet and daily goals are reviewed between the nurse and patient. A pharmacist meets with the patient the day prior to discharge to conduct education about administration of prescribed medications. During this time, the pharmacist explains to the patient the rationale for modifications in medication dosage or route of administration due to change(s) in his or her disease condition. Education about medication and diet is also reinforced in the physician office after hospital discharge.

Refining Patient Transition Coordination Across Settings of Care

Population health management transcends the hospital stay and requires increased accountability by the hospital across the care continuum. Population health management transcends the hospital stay and requires increased accountability by the hospital across the care continuum. Following a patient across the care continuum involves not only primary, secondary, and tertiary care, but also care coordination between acute inpatient and post-acute outpatient environments, such as specialized facilities, long-term care settings, and home health services. Developing programs for patient populations that follow a consistent track of care, with a set of care needs that can be anticipated in advance, is part of the responsibility and awareness process that inpatient providers can bring to a population health approach. Indiana University Health North Hospital has developed specific programming for an orthopedic population that comprises 17.75% of their patient population base. The new approach offers better patient preparation for scheduled procedures and coordinates patient transition across inpatient and outpatient care settings.

Orthopedic Population Care Coordination with Improved Education

Patients are required to attend an educational session in advance of their procedure. Patients are required to attend an educational session in advance of their procedure. The target attendance level for pre-op patients to attend this mandatory education is 90%. Our results have exceeded this threshold, with 92% of hip surgery and 95% of knee surgery patients attending the required session. If a patient is a no-show, the orthopedic coordinator calls the patient to review in advance the information covered in the mandatory session.

Programmatic evaluation of this class suggested several changes. To ensure that content focused upon only the most pertinent post-discharge information, we restructured the class. There are now more opportunities for patients to ask questions of the respiratory therapist and nurse during the class. We reduced class time and increased emphasis on exercises needed to do in the home setting. Each patient scheduled for hip or knee surgery receives binders of material with standardized content, including information about what the patient needs to do before surgery, during the hospital stay, and upon hospital discharge. To ensure these exercises are conducted properly, pictures are provided to improve patient comprehension and information retention. With this education, patients understand how to actively manage their hospital journey, post-hospital stay, and how to enhance appropriate healing at home. We also work with patients to arrange purchase for cold therapy and durable medical equipment in advance of the surgery to avoid delays prior to hospital discharge.

The orthopedic interprofessional team meets weekly to discuss patients scheduled to arrive the following week. The orthopedic interprofessional team meets weekly to discuss patients scheduled to arrive the following week. The orthopedic coordinator leads the meeting, which includes case management, at least one bedside nurse, a member from the post anesthesia care unit (PACU), an individual from the perioperative care area, a wound care specialist, a pharmacist, a physical therapist, and a social worker.

Patients with comorbidities, or who are otherwise deemed high risk, are also evaluated by a hospitalist during the preadmission testing process. This initiates the discharge planning process prior to a patient’s admission to Indiana University Health North Hospital. If it is anticipated that a patient will have a specific need upon discharge (e.g., rehabilitation, durable medical equipment needs), these items are prearranged as part of this process. Program changes described above have made a difference. In April 2014, Indiana University Health North Hospital received The Joint Commission Gold Seal of Approval^® for its Joint (hip and knee) Replacement program.

Safe Patient Care Transitions Through Improved Communication

Additional steps in a process are opportunities to place a patient at risk through communication breakdown. Patient transitions create additional handoffs between healthcare providers. Additional steps in a process are opportunities to place a patient at risk through communication breakdown. In 2012, safe handoffs were a focused priority at Indiana University Health North Hospital. We created improved guidelines for nurse reporting of information to transferring facilities and a “safe handoff form” (Figure 5). Nurses, physicians, and pharmacists complete this handoff form included in the transfer packet that accompanies the patient to a different facility. This form is also used for ambulance transports from the hospital, which improves patient safety by providing transferring care providers rapid access to the most pertinent patient information.

Figure 5. Indiana University Health North Hospital Safe Handoff Form

[View full size]

Unifying Care Providers for Treatment Coordination and Handoffs

Interprofessional collaboration is a fundamental aspect of providing coordinated, patient-centered care. Interprofessional collaboration is a fundamental aspect of providing coordinated, patient-centered care. We implemented multiple internal care coordination initiatives during 2013 that had an impact on several departments. Handoffs and communication were improved between the PACU and post-operative surgical areas by having a registered nurse, rather than a transporter, transfer patients to their rooms to provide a face-to-face, safer handoff. Nurses adopted bedside reporting for shift-to-shift coordination and encouraged participation of patients and family members. Multidisciplinary rounding in the adult, neonatal, and pediatric intensive care units is another recent initiative. Within the medical surgical areas, there is a complete pharmacy review of a patient’s medications, in addition to the physician and nurse review, during the discharge process. A specific example of this unified approach to collaboration related to orthopedic pain management is described below.

A Unified Approach to Orthopedic Pain Management

An impactful test-of-change was conducted with the implementation of weekly team rounding by the orthopedic physician, orthopedic coordinator, nurse, and pharmacist at the patient bedside. If pain levels exceed a patient reported score of six or greater on a 1-10 scale, we initiate a process of case study and root cause analysis to improve pain management by modifying medication(s). The initiative has provided additional insight to support overall hospital changes. For example, between late November 2011 and June 2012, top box scores began to decline both for pain management questions and overall hospital rating scores on Indiana University Health North Hospital’s reported HCAHPS. An investigation suggested better use of team rounding within the hospital culture; HCAHPS scores increased after this process was more widely reinitiated in June 2012.

In addition to weekly pain rounds, bedside nurse education on multimodal pain management occurs in real-time as situations arise. Education and collaboration also contributed to unifying the approach to pain management. Some nurses within the organization attended a multi-modal pain management course offered by the hospital system. In addition to weekly pain rounds, bedside nurse education on multimodal pain management occurs in real-time as situations arise. For example, participants might have conversations about current methods of pain control, additional options using a multi-modal approach, what else the team could do differently, review of orders and discussion of any necessary changes (e.g. addition of medications, decreasing the interval between pain therapies).

The orthopedic program has adopted a similar approach to the unified care collaboration effort already achieved by our Breast Care Program tumor board. Each week, breast surgeons and related specialists (e.g., radiologists, medical oncologists, radiation oncologists, geneticists, pathologists) meet to discuss complex cases. Based on the successes in communication by the members of the tumor board, leaders in the orthopedic program initiated a centralized care model that schedules a patient to see multiple provider types in one location. This has decreased the number patient visits required for a before surgery and created a more efficient process for both the patient and clinicians.

Overcoming Obstacles: Lessons Learned

During the implementation of the improvements related to care coordination, it became evident that a singular approach to change would not lead to sustainable processes. The following section describes three important lessons learned during our journey to improve care coordination.

Interprofessional Approach

Focus on only nurses or physicians, or any single type of provider, was not broad enough to engage all of the process stakeholders. It was an interprofessional approach that ultimately led to synergy and organizational insight to support our initiatives. For example, once therapists became active participants in our improvement initiatives, patients received a higher quality of education and transition continuity than what we provided before inclusion of this critical segment of the hospital workforce.

Consistency Among Providers

Another lesson learned was the importance of interprofessional collaboration as an element of the improvement process. Ensuring that each provider understands his or her role and the consistent message and terminology for use is essential. This step provides continuity within the team and between team members, patients, and families as everyone is more likely to speak the same language and interpret information in the same way.

Data Collection and Timing Processes

Finally, data management and capturing the timing of improvements was an additional process barrier to overcome to make sustainable changes. As Indiana University Health North Hospital began to better understand processes, both measurement tracking and collecting specific metrics increased. The importance of knowing the baseline state of data, and the potential impact points within a process, became increasingly evident as a prerequisite for understanding changes. Baseline data was critical to accurately assess whether or not an improvement actually made a difference and/or if a further tweak to the process was effective.

Future Directions: A Continued Focus on Collaboration and Improvement

The CMS questions added to the HCAHPS survey that created the Care Transition Measures provide a method of evaluating performance as changes are adopted. Indiana University Health North Hospital has begun the journey of care transition improvements for patients. The CMS questions added to the HCAHPS survey that created the Care Transition Measures provide a method of evaluating performance as changes are adopted. The hospital also uses multiple other metrics for the evaluation of progress, such as pain management HCAHPS responses and readmission rates.

More changes are in process this year. One change already underway involves pairing hospitalists with case managers to create dyads. Although the initiative is relatively new, we anticipate that partnering of these healthcare professionals will lead to enhanced care coordination, more efficient case management, better communication, and improved patient satisfaction.

Physicians, therapists, and nurses continue to focus on a team approach that establishes both daily goals and discharge goals for each patient. Coordination of patient care between nurses and physicians continues as an area of emphasis. A recently implemented program features nurses and physicians rounding together in the patient room to review specific questions that relate directly to the patient plan of care. Physicians, therapists, and nurses continue to focus on a team approach that establishes both daily goals and discharge goals for each patient. Patient goals are individualized by disease condition, then further adjusted according to the level of patient progress. For example, the orthopedic surgery population requires effective pain control as part of recovery and parameters met for discharge. The targeted pain score is individualized to the patient, in addition to education about pain medications and management. A second set of goals target rehabilitation, since ambulation predicts whether or not a patient can return to the home setting. In contrast, the bariatric population also have specific ambulation distances required for hospital discharge; however, these individuals may often be relatively healthy, other than lacking an ideal weight upon hospital admission. Their unique goals include keeping fluids down without nausea and maintaining hydration without requiring intravenous fluids support.

Patient goals are reinforced by making them visible via the patient white board. The initiative of clinicians collaboratively rounding is helping patients to become more involved in understanding their plan of care and frequently includes the family. The nurse, patient, family (as appropriate) and full interdisciplinary care team work collaboratively to achieve the anticipated date of discharge.

In October 2014, Care Transition Measures became publically reported, which created increased transparency for consumers. Hospitals across the United States will continue to focus on the Care Transition Measures as a priority to provide care that creates a safe handoff. The ability to conduct successful transitions across settings requires the care coordination of multiple providers. During a time when hospitals look to cultivate best practices, the journey of Indiana University Health North Hospital as an example of a Care Transition Measures top performer will continue to set benchmarks in the industry.

Note: Figures 2, 3, 4, and 5 are reprinted with permission from Indiana University Health North Hospital.

Authors

Suzanne DelBoccio, MS, RN, CENP, FACHE
Email: sdelboccio@IUHealth.org

Susanne is employed in Patient Care Services at Indiana University Health in Patient Care Services at Indiana University Health in Indiana for IU Health North Hospital in Carmel, IN and IU Health Saxony Hospital in Fishers, IN. Suzanne ensures the quality of services through the design, development and documentation of a quality monitoring system and/or program evaluation reflected through key indicators. She leads the efforts at both IU Health North and IU Health Saxony Hospital in being recognized as a premiere quality organization.

Debra F Smith, MSW, LCSW, CCM
Email: debsmith@IUHealth.org

Debra is the Case Management & Social Work Manager at Indiana University Health North Hospital in Carmel, Indiana. Debra is currently serving as the manager for the Department of Throughput. She graduated from Juniata College, attained her MSW from Indiana University and has been a practicing medical social worker for over 30 years.

Melissa Hicks, MSN, RN-BC
Email: mhicks8@IUHealth.org

Melissa is the Clinical Nurse Manager of the Inpatient Adult Medical and Surgical Units at Indiana University Health North Hospital in Carmel, Indiana. She is also the value stream owner for lean process improvement in the medical-surgical units.

Pamela Voight Lowe, MSN, RN, CPHQ, NE-BC
Email: plowe@IUHealth.org

Pamela is the Director of Quality for the North Central Region at Indiana University Health in Indiana supporting IU Health North Hospital (Carmel), IU Health Saxony Hospital (Fishers), and IU Health Tipton Hospital (Tipton). Ms. Lowe has responsibility for quality, regulatory compliance, throughput, infection prevention, risk management and medical staff functions at IU Health North Hospital.

Joy E Graves-Rust
Email: jgravesr@IUHealth.org

Joy is the Coordinator, Patient Experience for the North Central Region at Indiana University Health in Indiana supporting IU Health North Hospital (Carmel), IU Health Saxony Hospital (Fishers) and IU Health Tipton Hospital (Tipton). Ms. Graves-Rust is responsible for actively monitoring patient satisfaction survey data and collaborating across the continuum to identify improvement opportunities, target key predictive indicators and provide data interpretation as it relates to organizational operations and behaviors.

Jennifer Volland, DHA, RN, MBB, CPHQ, NEA-BC, FACHE
Email: jvolland@nationalresearch.com

Jennifer is Vice President of Program Development at National Research Corporation in Lincoln, Nebraska. Dr. Volland has oversight of program development and educational outreach for the Patient Experience, Patient Outreach, Medical Groups, and Payer Solutions programs.

Sarah Fryda, BA, MS
Email: sfryda@nationalresearch.com

Sarah is a Senior Research Associate at National Research Corporation in Lincoln, Nebraska. She specializes in Survey Research and Methodology and examining patient experience trends throughout various National Research product lines.