Closing the Gap: Transitions of Care

Hopefully, as healthcare providers, we can recognize that our responsibility extends beyond the inpatient setting, and work together to open communication to ensure smooth transitions of care.

Clinical Scenario: Ms S is an 84-year-old female with multiple medical problems including mild dementia, HTN, Afib on coumadin, PVD s/p stent right lower extremity, h/o CVA, CKD III, and hypothyroidism. She was admitted to the hospital in July of 2007 for confusion and lethargy and found to have a UTI. She was started on Ciprofloxacin per urine sensitivities. Her INRs subsequently were supratherapeutic up to 7's while in the hospital, thus she was instructed to hold her coumadin until she completed the 7day course of antibiotics for her UTI. She was set up with home visiting nurse with instructions to forward any concerns to her primary care physician. The visiting nurse, who had been familiar with the patient from prior to hospitalization, noticed that coumadin was not included in her discharge medication list. After confirming with the primary care physician that the patient, in fact, was supposed to be on coumadin for her Afib, her previous coumadin dose was resumed. Three days later, on day 7 of her ciprofloxacin course, she developed melena and was readmitted to the hospitalist with hematocrit drop from 32 to 26 and and INR of 12.4. Given this occurrence of gastrointestinal bleeding as a complication of coumadin therapy, her anticoagulation was stopped as the risks were felt to outweigh the benefits. She now returns to the hospital in May of 2009 with slurred speech and right upper extremity weakness. MRI is consistent with embolic strokes.

When the field of hospital medicine was first surfacing, it seemed that the main purpose was to provide high quality and efficient inpatient care that would overall decrease length of stay without having any negative impact on morbidity and mortality. What was always known but taken for granted was the disruption to continuity of care that occurred with each admission. Lack of communication between hospital physicians and ambulatory physicians as well as any health care provider and patients can lead to serious adverse consequences and has gained increasing attention in the past few years. As our patients are getting older and living with a greater number of comorbities, ensuring continuity between inpatient and outpatient has become of paramount importance in terms of minimizing errors, ensuring proper follow up after hospitalization, readmission to hospital, and overall morbidity/mortality. One study interviewed 400 patients and found that 1 in 5 had experienced an adverse event related to the medical management (not the underlying disease) within 3 weeks of discharge. Of these, 66% were drug-related adverse events which could have been easily avoided1. Coleman, et al. noted in his study of 375 elderly patients, "Posthospital Medication discrepancies: prevelance and contributing factors", that 14% had 1 or more medication discrepancy after hospitalization. Of these, 14% were rehospitalized within 30 days2. Literature reviews regarding discharge summaries have shown that not only are they are frequently very late and unavailable at follow up visits, they are often lacking important information3. Another study addressing patient safety with respect to test results that are pending at time of discharge found that 40% of the 2644 patients had pending results at time of discharge, of which 10% required some action which the outpatient physicians were unaware of4.

I recently had the pleasure of attending the annual Society of Hospital Medicine (SHM) meeting in May 2009. I was very excited to go to this meeting because I was looking forward to brushing up on some key general topics as well as learning about any relevant new evidence based guidelines that I have not been exposed to. What came to my surprise, instead, was how much focus was placed on the issue of "safety" and "quality" in hospital medicine. What do I mean by this? Aside from the ensuring delivery of efficient and good medical care, focus has grown to encompass other aspects of the inpatient admission such as incorporation of electronic medical records systems, medication reconciliation, better inpatient signouts, better communication with and education for patients/families, optimization of the discharge process to minimize readmission (see BOOST project link below), and quality of discharge summaries. Not only were there an abundant of lectures and discussions dedicated to these topics, many of the keynote speakers also spoke on this very issue of transition of care. In fact, the Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core compentency for hospital physicians5. A quick glance at the topics published in a recent issue of Journal of Hospital Medicine (Volume 4, April 2009) also highlights this focus on care transitions. In July 2007, the ACP (American College of Physicians), SHM, and SGIM (Society of General Internal Medicine) convened a conference called Transitions of Care Consensus Conference (TOCCC), which included over 30 organizations, to address the quality gaps in the transitions between inpatient and outpt settings and to develop consensus standards for these transitions. This is detailed in an article in the latest issue of JHM (see below for link), "Transitions of Care Consensus Policy Statement: American College Of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine". As mentioned above, essentially the TOCCC is an an effort by the above-mentioned societies, in parallel with American Board of Internal Medicine (Stepping up to the Plate-STUPP) and Centers of Medicare and Medicaid Services (CMS) and National Quality Forum (NQF), to help identify key principles for effective transitions of care, and subsequently use these as a framework for establishing universal standards of care transitions both into and out of the hospital (JHM May 2009). Not only is the goal to improve the care transition process in terms of quality and safety, these standards will hopefully allow for more concrete and objective performance measures in the future.

The issue of ensuring continuity of care and safe transitions will soon become standard of care. Currently there are no good ways to measure this reliably accross various institutions and levels of care. Recently, there has been some talk about looking at readmission rates as a surrogate. This has gained even more attention as the CMS are now investigating ways to impose penalty on hospitals for readmissions within 30days for the same DRGs (diagnoses related groups). Essentially, this may mean that a hospital would get no additional reimbursement for a certain diagnosis (DRG) for 1 month after discharge so the cost of the entire readmission would fall upon them. Some private insurance companies already have something similar called "bridging" in place, where they do not reimburse for a particular DRG if the patient is readmitted for that same diagnosis within 7days. With this system, hospitals will have to come up with better strategies to minimize readmissions in order to avoid impending downfall. A multidisciplinary approach involving case managers, social workers, health care team (nurses and physicians), primary care physician, physical and occupation therapists, pharmacists would be ideal, but is again time-consuming and costly and difficult to develop in the present healthcare environment with their budget cuts, staff shortages, and resource limitations. The way I see it, hospitals will need to look at such efforts for efficient discharge planning and follow up systems more as investments, with high upfront costs which will hopefully pay for themselves at the end. Ideally, reimbursement policies will change to reward behaviors and clinical practices that promote safe discharges and transfers of care.

In the above clinical scenario, a number of simple measures, such as a brief and timely discharge summary sent to the primary care physician and/or the home visiting nurse, patient/family education prior to discharge, or a post-discharge follow up call by a member of the inpatient team, may have cleared up any confusion about when to start the coumadin. Needless to say, the complications of gastrointestinal bleeding and subsequent embolic strokes off coumadin are adverse events that could have been avoided. Hopefully, as health care providers, we can recognize that our responsibility extends beyond the inpatient setting, and work together to open communication to ensure smooth transitions of care.


1) Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003; 138( 3): 161-167.

2) Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005; 165( 16): 1842-1847.

3) Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007; 297( 8): 831-841.

4) Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005; 143( 2): 121-128.

5) Young A. A New Narrative for hospitalists. JHM. 2009; 207-208 Note: Some of the above references were borrowed from the JHM article provided below.

Links: BOOST project

TOCCC article in JHM