Why are Transitions in Care so Difficult?

**  This article was originally posted  April 3, 2017 on HQO’s new Quality Forum called “Quorum“.   This is an online community for those interested in and doing quality improvement work in Ontario healthcare every day!

 

For patients, caregivers and providers alike, a transition in care is often a frustrating experience. When looking at why,  many problems are uncovered. A transition occurs when care is handed off from one environment to another (i.e.: hospital to home), one person to another (i.e.: specialist to primary care) or one program to another (i.e.addiction support to general mental health care). When the process is viewed through a quality lens, one sees huge opportunity for improvement.

Problems with transitions occur in every Quality domain.

Effectiveness – Transitions are often cumbersome, uncoordinated, and rarely automatic. Moving a patient along is like “passing the buck” rather than a seamless hand over. If patient information can be moved quickly and in a standard way, effectiveness improves dramatically

Efficiency – Transitions are often attended to after other urgent issues, when the patient has already left your care and sometimes as an afterthought. Creating a process for handover that is widely and consistently adopted, with as little prompting as possible, is important so that less time and energy is spent in making it happen.

Safety – Every time care is passed there is a chance that important information, knowledge, insight and context could be lost. This is largely due to fractured communication. Communication issues are relatively easy to fix when providers collectively own the problem. Solutions are as simple as a phone call or as technical as moving a complete electronic record from one provider to another.

Patient Centeredness – The healthcare system often puts responsibility for a transition onto the back of the patient (multiple pages printed out by the hospital on discharge, handed to the patient for their next doctor). There is no thought as to their capacity to follow through, especially if frail or sick. Some hand-offs happen without the patient at all, and this too can be a problem. The job is considered done when a summary is sent by regular mail to a doctor “on record”. This may not even be the correct physician for follow-up, and often it arrives too late. Looking at this from the perspective of a patient’s needs, both habits need to change.

Equity – Transitions in care are not consistent, equivalent or equitable across the province. Interestingly they work best in locations where there are tight provider relationships and there is a sense of shared responsibility. A great example of this is in rural towns where a small number of the same providers are doing the work in each environment: hospital, community and home. Patients move between local clinicians who all know each other, and where there is a sense of joint ownership in helping someone. In large urban centres providers are more disconnected and unknown to each other, so warm hand-offs are rare. This is a “reverse inequity” problem where care in the city, often with more resources, has a lower standard than remote communities. Standardized and automated processes for making a transition happen can correct this, and in Ontario were now seeing a move back to “local” with transformation initiatives.

Accessible – When patients arrive home after being in hospital they often experience problems with access to people and resources in follow-up. Their family doctor may not be aware of their hospitalization, for example, or there was no advice on when to see her. Access is improved if the patient’s primary care provider knows immediately that he has been admitted or discharged. Having complete information makes it is much easier to plan nursing care or home visits, and access is vastly improved.

Given all these barriers to an easy transition in care, what can we collectively do to remove them?

There are solutions at our fingertips right now. Most of these focus on maintaining key clinical relationships, with attention paid to direct communication. Integrated technology can address some of the issues related to standardization and ensuring that information is transferred automatically. For example, OntarioMD has deployed two products that bridge the information gap between layers in the system. HRM, or Health Report Manager, moves discharge summaries, test results, consultation notes and more from hospitals and health facilities directly into the EMRs of doctors and NPs in near real time. Often they have this information to work with even before their patient has arrived home. Nested in HRM is eNotifications, which tell us when our patient has been admitted, discharged or transferred, notifies us of Health Links status, and even activates CCAC, as case coordinators simultaneously receive the same alert.

The availability of accurate up-to-date information, and advanced technology that smooths communications between various levels of care goes far in ensuring that warmer hand offs occur. But technology is not a panacea. Nor should it be seen as a substitute for simple yet impactful relationship-based transitions like a hand over call to the family doctor on discharge. Institutions, providers and patients working together are the ultimate integrated transition team. It is our collective job to make this happen and create a culture of markedly improved quality in the process.

9 Comments

  1. Thx Darren… no question that e-notification and HRM are terrific resources for ensuring that acute care to primary care transitions are as safe and effective as possible. Thnx for your personal leadership and ONTMD leadership in this crucial area. Best wishes, Bob Bell

    • Thanks for the comments Bob! And happy to be part of something that provides a technical tool, and to talk about the decidedly human work of successful transitions . Appreciated!

  2. Thanks for sharing this Darren. A good reminder how simple modifications of our current practice go a long way to making our patients safer and our health care system that much better!

  3. Darren,

    A wonderful reminder of the importance of “shared responsibility” as we help guide our patients through care transitions.

    Thank you.

  4. Thanks for the post! Transitions are super important. The current common practice of asking the patient ” well what did they tell you” on discharge is not acceptable. As you mention in your post, What I thought of immediately is the dichotomy between transitions in big vs small institutions. How in large centres the task of discharge planning is usually delegated to the newest and most junior member of the team with little ownership from the MRP. Often, these tasks are done as a final task on a post call day by residents. This is made worse by the fact that residents often have little knowledge of community resources available and little to no accountability to community providers. I totally agree that electronic resources are a big help, but are limited by the quality of the planning and data put into them. This problem is largely solved in rural settings when you know you will be working in close contact with community providers and the sense of team work that come with it. I Iike the idea of bringing the hybrid electronic and community model to bigger centres.

  5. Thanks for the post Darren! The current common practice of asking the patient ” well what did they tell you” on discharge is not acceptable. As you mention in your post, What I thought of immediately is the dichotomy between transitions in big vs small institutions. How in large centres the task of discharge planning is usually delegated to the newest and most junior member of the team with little ownership from the MRP. Often, these tasks are done as a final task on a post call day by residents. This is made worse by the fact that residents often have little knowledge of community resources available and little to no accountability to community providers. I totally agree that electronic resources are a big help, but are limited by the quality of the planning and data put into them. This problem is largely solved in rural settings when you know you will be working in close contact with community providers and the sense of team work that come with it. I Iike the idea of bringing the hybrid electronic and community model to bigger centres. Thanks for the post!

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