Care transitions
Bridging the gap between acute and postacute care By Claire M. Zangerle, MBA, MSN, RN Editor’s note: Because care delivery doesn’t always start or end at the hospital, comprehending the value of care transitions is essential for excellent patient outcomes. This new bimonthly column will bring you best practices and creative approaches to transitioning the patient from one care setting to another.
N
urse leaders at all levels have a unique opportunity to provide significant leadership when it comes to bridging the gap between acute and postacute care, ensuring smooth transitions for the patient and family. The chasm that exists is no longer tolerable. Patients and their families are demanding better coordination, as are payers. By implementing employee strategies commonly used within the acute care setting across the continuum, the nurse leader will see the result of better outcomes, lower costs, and an improved patient experience.1 Until recently, there hasn’t been a significant focus on utilizing care coordination strategies beyond the internal coordination within the acute care setting, such as between hospital departments. With the implementation of financial penalties for hospital readmissions in 2013 for specific diagnoses and additional diagnoses added in 2015, more attention is focused on the importance of transitioning patients into the appropriate postacute care venue.2 However, the increased scrutiny has added to the stress of staff and nurse leaders as they strive to ensure that high-quality care is provided to hospitalized patients. Coordinating care has always been, and always will be, a great strength of the clinical nurse. It’s expanding those skills
8 February 2015 • Nursing Management
outside the walls of the hospital that will close the chasm. The identified root causes of ineffective care transitions—breakdowns in communication, patient education, and accountability—can be effectively addressed through the targeted efforts of nursing leaders.3 The role of nurse leaders The bridge to success between acute and postacute care begins with nursing leadership. Although nurse leaders continue to take on more responsibilities, employing strategies to keep patients from returning to the hospital and, ultimately, living well in their community is a solid foundation for positive outcomes. Nurse leaders play an essential role in promoting a culture of responsibility to the patient and family by creatively implementing care transition tactics. Embrace nurse leader roles beyond the hospital There are nurse leaders in all settings of the care continuum: acute care, long-term care, skilled nursing, home care, and hospice. The first step for hospital nurse leaders is the recognition of, and collaboration with, nurse leaders in all of these settings across the care continuum. This modeling behavior promotes a culture within the hospital of the significance of ensuring appropriate care outside the hospital. Furthermore, developing processes to support that culture will result in positive patient outcomes, closer collaboration of staff, and smoother transitions of care. Partnering with other nurse leaders, either internally or externally, expands horizons beyond the four walls of the unit or the hospital. Much like we want our politicians to reach www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Care transitions across the aisle, it should be a priority with colleagues in other care settings. Those relationships enrich the experience of patient care for the entire multidisciplinary team and, more important, for the patient and family. Expand nurse leader competencies to enhance knowledge of postacute care There are defined competencies for nurse leaders apropos to the setting in which the leader practices. However, to support care coordination across the continuum, the nurse leader should be knowledgeable about other settings that directly or indirectly impact his or her practice environment. Although the competencies aren’t considerably different, there are enough nuances in responsibilities that it warrants being highlighted. In 2014, the American Organization of Nurse Executives (AONE) board of directors recognized this need and commissioned a task force to address it. Members of the task force represented a variety of areas: acute care, ambulatory care, home care, hospice, academia, and consulting. Building on the already existing AONE system CNO competencies, members of the task force identified specific attributes of postacute care nurse leaders and acknowledged the differences between leader attributes.6 Understanding, embracing, and leveraging those differences is the key to bridging the gap between care delivery settings. Operationalize a transitions of care model that improves patient outcomes There are several evidencebased transitions of care models that have been developed that may be implemented in totality www.nursingmanagement.com
Table 1: Discharge begins on admission Collaborating with nursing case managers, the clinical nurse generally owns the discharge process. However, there’s little true evidence of this ownership because there are no specific measures to demonstrate that the clinical nurse has a significant effect on patient outcomes postdischarge.4 In the American Nurses Association’s Scope and Standards of Practice, it’s stated that care coordination—accountability for care of the patient across settings—is a core professional standard.5 It’s a collaborative process, with input from the clinical nurse, patient, and family. Recognizing that the clinical nurse possesses the most robust knowledge of the clinical, social, and behavioral information about the patient, being part of discharge planning makes absolute sense. Often, however, discharge planning is disconnected from the clinical nurse, either due to time constraints or lack of knowledge of what’s available to the patient upon discharge. To successfully bridge the gap, it’s essential that the clinical nurse engages in discharge planning and nurse leaders provide the tools to allow them to do so.
or cherry-picked to fit the culture of the setting. These include, but aren’t limited to, the Care Transitions Intervention, Transitional Care Model, and Project BOOST—Better Outcomes for Older Adults Through Safe Transitions.7-9 The common elements in each model aren’t foreign to clinical nurses, but must have the full support of nursing leadership to be successful. These elements include: • multidisciplinary communication • shared accountability • comprehensive planning and risk assessment • standardization of transition procedure • staff training on the elements of transition • solidification of the after-care plan before discharge. By operationalizing a transitions of care model in the acute setting, the awareness of the clinical nurse is heightened and the importance of care beyond the hospital becomes part of the care planning. Patient throughput is a rapid process in every hospital these days, but this isn’t justification to ignore appropriate transitions for the patient at hospital discharge. (See Table 1.) Because, in the end, not only is it better for the patient, it also saves
the hospital significant dollars from unnecessary readmission and improves the overall retention of patients as life-long partners in their own care. Provide supplemental educational opportunities related to transitions of care Encouraging and supporting nursing staff members in their endeavor to execute an appropriate transitions model will ensure success. The American Association of Ambulatory Care Nursing offers an evidence-based, patientcentered course on care coordination and transition management that supplements any transitions model focusing on the nurse as a member of the interprofessional team.10 Knowledge is power and the patient wins Nurse leaders can reshape the future of care coordination, thus having a significant impact on healthcare reform. By building relationships with colleagues in the postacute care space, educating themselves on the roles of those colleagues, and engaging staff in the adoption of a transitions of care model, outcomes will improve and, in the end, the patient wins. NM
Nursing Management • February 2015 9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Care transitions REFERENCES 1. Whitcomb W. Homecare will help you achieve the triple aim. http://www. the-hospitalist.org/homecare-will-helpyou-achieve-the-triple-aim/. 2. Alliance for Home Health Quality and Innovation. Hospital readmissions and admissions. http://www.ahhqi.org/images/ pdf/cacep-wp4-executive-summary.pdf. 3. Center for Improving Value in Health Care. Improving care transitions: a strategy for reducing readmissions. http://www.civhc. org/getmedia/475510fc-ff67-4655a915-c9539117eb2f/Care-TransitionsPolicy-Brief-FINAL_9.2012.pdf.aspx/. 4. American Nurses Association. Framework for measuring nurses’ contributions to care coordination. http://www. nursingworld.org/Framework-forMeasuring-Nurses-Contributions-toCare-Coordination.
5. American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: 2010. 6. American Organization of Nurse Executives. 2014 AONE post-acute care nurse leaders core competencies task force. http://www.aone.org/membership/ about/2014Committees/PostAcute_Care_ Nurse_Leaders_Core_Compentencies_ Roster2014w.pdf. 7. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828. 8. Naylor MD, Sochalski JA. Scaling up: bringing the Transitional Care Model into the mainstream. Issue Brief (Commonw Fund). 2010;103:1-12. 9. Society of Hospital Medicine. Project BOOST implementation toolkit. http:// www.hospitalmedicine.org/Web/Quality_
10 February 2015 • Nursing Management
Innovation/Implementation_Toolkits/ Project_BOOST/Web/Quality___ Innovation/Implementation_Toolkit/ Boost/Overview.aspx. 10. American Academy of Ambulatory Care Nursing. Care coordination and transition management. http://www.aaacn.org/ practice-resources/cctm. Claire M. Zangerle is the president and chief executive officer of the Visiting Nurse Association of Ohio in Cleveland, Ohio, a Nursing Management editorial board member, and the coordinator of the bimonthly Care Transitions column. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000460051.24804.48
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Bridging the gap between acute and postacute care By Claire M. Zangerle, MBA, MSN, RN Editor’s note: Because care delivery doesn’t always start or end at the hospital, comprehending the value of care transitions is essential for excellent patient outcomes. This new bimonthly column will bring you best practices and creative approaches to transitioning the patient from one care setting to another.
N
urse leaders at all levels have a unique opportunity to provide significant leadership when it comes to bridging the gap between acute and postacute care, ensuring smooth transitions for the patient and family. The chasm that exists is no longer tolerable. Patients and their families are demanding better coordination, as are payers. By implementing employee strategies commonly used within the acute care setting across the continuum, the nurse leader will see the result of better outcomes, lower costs, and an improved patient experience.1 Until recently, there hasn’t been a significant focus on utilizing care coordination strategies beyond the internal coordination within the acute care setting, such as between hospital departments. With the implementation of financial penalties for hospital readmissions in 2013 for specific diagnoses and additional diagnoses added in 2015, more attention is focused on the importance of transitioning patients into the appropriate postacute care venue.2 However, the increased scrutiny has added to the stress of staff and nurse leaders as they strive to ensure that high-quality care is provided to hospitalized patients. Coordinating care has always been, and always will be, a great strength of the clinical nurse. It’s expanding those skills
8 February 2015 • Nursing Management
outside the walls of the hospital that will close the chasm. The identified root causes of ineffective care transitions—breakdowns in communication, patient education, and accountability—can be effectively addressed through the targeted efforts of nursing leaders.3 The role of nurse leaders The bridge to success between acute and postacute care begins with nursing leadership. Although nurse leaders continue to take on more responsibilities, employing strategies to keep patients from returning to the hospital and, ultimately, living well in their community is a solid foundation for positive outcomes. Nurse leaders play an essential role in promoting a culture of responsibility to the patient and family by creatively implementing care transition tactics. Embrace nurse leader roles beyond the hospital There are nurse leaders in all settings of the care continuum: acute care, long-term care, skilled nursing, home care, and hospice. The first step for hospital nurse leaders is the recognition of, and collaboration with, nurse leaders in all of these settings across the care continuum. This modeling behavior promotes a culture within the hospital of the significance of ensuring appropriate care outside the hospital. Furthermore, developing processes to support that culture will result in positive patient outcomes, closer collaboration of staff, and smoother transitions of care. Partnering with other nurse leaders, either internally or externally, expands horizons beyond the four walls of the unit or the hospital. Much like we want our politicians to reach www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Care transitions across the aisle, it should be a priority with colleagues in other care settings. Those relationships enrich the experience of patient care for the entire multidisciplinary team and, more important, for the patient and family. Expand nurse leader competencies to enhance knowledge of postacute care There are defined competencies for nurse leaders apropos to the setting in which the leader practices. However, to support care coordination across the continuum, the nurse leader should be knowledgeable about other settings that directly or indirectly impact his or her practice environment. Although the competencies aren’t considerably different, there are enough nuances in responsibilities that it warrants being highlighted. In 2014, the American Organization of Nurse Executives (AONE) board of directors recognized this need and commissioned a task force to address it. Members of the task force represented a variety of areas: acute care, ambulatory care, home care, hospice, academia, and consulting. Building on the already existing AONE system CNO competencies, members of the task force identified specific attributes of postacute care nurse leaders and acknowledged the differences between leader attributes.6 Understanding, embracing, and leveraging those differences is the key to bridging the gap between care delivery settings. Operationalize a transitions of care model that improves patient outcomes There are several evidencebased transitions of care models that have been developed that may be implemented in totality www.nursingmanagement.com
Table 1: Discharge begins on admission Collaborating with nursing case managers, the clinical nurse generally owns the discharge process. However, there’s little true evidence of this ownership because there are no specific measures to demonstrate that the clinical nurse has a significant effect on patient outcomes postdischarge.4 In the American Nurses Association’s Scope and Standards of Practice, it’s stated that care coordination—accountability for care of the patient across settings—is a core professional standard.5 It’s a collaborative process, with input from the clinical nurse, patient, and family. Recognizing that the clinical nurse possesses the most robust knowledge of the clinical, social, and behavioral information about the patient, being part of discharge planning makes absolute sense. Often, however, discharge planning is disconnected from the clinical nurse, either due to time constraints or lack of knowledge of what’s available to the patient upon discharge. To successfully bridge the gap, it’s essential that the clinical nurse engages in discharge planning and nurse leaders provide the tools to allow them to do so.
or cherry-picked to fit the culture of the setting. These include, but aren’t limited to, the Care Transitions Intervention, Transitional Care Model, and Project BOOST—Better Outcomes for Older Adults Through Safe Transitions.7-9 The common elements in each model aren’t foreign to clinical nurses, but must have the full support of nursing leadership to be successful. These elements include: • multidisciplinary communication • shared accountability • comprehensive planning and risk assessment • standardization of transition procedure • staff training on the elements of transition • solidification of the after-care plan before discharge. By operationalizing a transitions of care model in the acute setting, the awareness of the clinical nurse is heightened and the importance of care beyond the hospital becomes part of the care planning. Patient throughput is a rapid process in every hospital these days, but this isn’t justification to ignore appropriate transitions for the patient at hospital discharge. (See Table 1.) Because, in the end, not only is it better for the patient, it also saves
the hospital significant dollars from unnecessary readmission and improves the overall retention of patients as life-long partners in their own care. Provide supplemental educational opportunities related to transitions of care Encouraging and supporting nursing staff members in their endeavor to execute an appropriate transitions model will ensure success. The American Association of Ambulatory Care Nursing offers an evidence-based, patientcentered course on care coordination and transition management that supplements any transitions model focusing on the nurse as a member of the interprofessional team.10 Knowledge is power and the patient wins Nurse leaders can reshape the future of care coordination, thus having a significant impact on healthcare reform. By building relationships with colleagues in the postacute care space, educating themselves on the roles of those colleagues, and engaging staff in the adoption of a transitions of care model, outcomes will improve and, in the end, the patient wins. NM
Nursing Management • February 2015 9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Care transitions REFERENCES 1. Whitcomb W. Homecare will help you achieve the triple aim. http://www. the-hospitalist.org/homecare-will-helpyou-achieve-the-triple-aim/. 2. Alliance for Home Health Quality and Innovation. Hospital readmissions and admissions. http://www.ahhqi.org/images/ pdf/cacep-wp4-executive-summary.pdf. 3. Center for Improving Value in Health Care. Improving care transitions: a strategy for reducing readmissions. http://www.civhc. org/getmedia/475510fc-ff67-4655a915-c9539117eb2f/Care-TransitionsPolicy-Brief-FINAL_9.2012.pdf.aspx/. 4. American Nurses Association. Framework for measuring nurses’ contributions to care coordination. http://www. nursingworld.org/Framework-forMeasuring-Nurses-Contributions-toCare-Coordination.
5. American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: 2010. 6. American Organization of Nurse Executives. 2014 AONE post-acute care nurse leaders core competencies task force. http://www.aone.org/membership/ about/2014Committees/PostAcute_Care_ Nurse_Leaders_Core_Compentencies_ Roster2014w.pdf. 7. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828. 8. Naylor MD, Sochalski JA. Scaling up: bringing the Transitional Care Model into the mainstream. Issue Brief (Commonw Fund). 2010;103:1-12. 9. Society of Hospital Medicine. Project BOOST implementation toolkit. http:// www.hospitalmedicine.org/Web/Quality_
10 February 2015 • Nursing Management
Innovation/Implementation_Toolkits/ Project_BOOST/Web/Quality___ Innovation/Implementation_Toolkit/ Boost/Overview.aspx. 10. American Academy of Ambulatory Care Nursing. Care coordination and transition management. http://www.aaacn.org/ practice-resources/cctm. Claire M. Zangerle is the president and chief executive officer of the Visiting Nurse Association of Ohio in Cleveland, Ohio, a Nursing Management editorial board member, and the coordinator of the bimonthly Care Transitions column. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000460051.24804.48
www.nursingmanagement.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
