Components of Comprehensive and Effective Transitional Care

Abstract

Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve patients’ health outcomes and reduce preventable hospital readmissions. Yet little is known about the key elements of effective TC and how they relate to patients’ and caregivers’ needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Project ACHIEVE. A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multi-stakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components, then analyzed how well the set aligned with “real-world” patients’ and caregivers’ experiences. Through this process, the workgroup identified eight TC components: Patient Engagement, Caregiver Engagement, Complexity/Medication Management, Patient Education, Caregiver Education, Patient and Caregiver Well-Being, Care Continuity, and Accountability. While the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

“…Involving patients and families in care is a central tenet of healthcare policy globally [ 47 , 48 ] and may be key to enhancing safety at transitions [ 26 , 49 ]. However, the extant literature predominantly focuses on the need to provide patients and families with information and to communicate discharge plans [ 17 , 23 ].…”

Improving patient experience and safety at transitions of care through the Your Care Needs You (YCNY) intervention: a study protocol for a cluster randomised controlled feasibility trial

“…Transitions from hospital to home can be risky, particularly for older people who often have complex health and/or social care needs [ 3 ]. Although the evidence is equivocal, there is some suggestion that interventions that support patient involvement may improve transitional care outcomes [ 10 , 12 ]. The PACT programme of research, therefore, asks whether supported involvement of older patients and their families in their care improves patient experience and safety at transitions of care.…”

“…As a consequence, deciphering which components are the active ingredients is challenging [ 8 – 10 ]. There is some suggestion however that interventions which seek to enhance patient capacity to reliably access and enact post-discharge care are effective [ 11 , 12 ]. Supporting patient involvement aligns with the patient’s and carer’s position as the common denominator throughout the care pathway.…”

The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality

“…The transition of care in which patients transfer between different settings increases the risk for adverse health outcomes due to inadequate attention to patients’ healthcare needs [ 7 , 8 ]. For example, the failure to recognize geriatric conditions in older cardiac patients negatively impacts treatments post-discharge, e.g.…”