Improving Care Transitions to Drive Patient Outcomes

Abstract

Purpose: The purpose of this article is to examine how case managers can support positive outcomes during care transitions by focusing on the goals of the Triple Aim (D. Berwick, T. Nolan, & J. Whittington, 2008) and Coleman's Four Pillars (E. Coleman, C. Parry, S. Chalmers, & S. Min, 2006). Case managers can play a pivotal role to ensure high-quality transitions by assessing patients and identifying those who are at high risk; coordinating care and services among providers and settings; reconciling medications; and facilitating education of patients and their support systems to improve self-management. These activities are congruent with an underlying value of case management as defined by the Code of Professional Conduct for Case Managers: “improving client [i.e., patient] health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation” (Commission for Case Manager Certification [CCMC], Code, Rev. 2015). Case Management Primary Practice Settings: Case managers across health or human services must assess for, identify, and understand the vulnerability of patients during care transitions and must adopt best practices to support successful care transitions. This includes case managers in acute care, primary care, rehabilitation, home health, community-based, and other settings. Implications for Case Management Practice: Two frameworks that support care transitions are the Triple Aim of improving the individual's experience of care, advancing the health of populations, and reducing the costs of care (D. Berwick, T. Nolan, & J. Whittington, 2008), and Coleman's “Four Pillars” of care transition activities of medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (E. Coleman, C. Parry, S. Chalmers, & S. Min, 2006). From a case management perspective, these approaches and their goals are interrelated. As an advocate for the individual and at the hub of the care team, the professional case manager engages in important activities such as facilitating communication across multiple providers and care settings, arranging “warm handoffs,” undertaking medication reconciliation, and engaging in follow-up, particularly with high-risk patients. To support successful transitions of care, case managers must adopt best practices and advocate within their organizations for systematic approaches to care transitions to improve outcomes.

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

“…Ensure the flow of information across multidisciplinary teams in the same or different sectors [ 62 , 63 ]. Advise and share relevant information about the patient with other providers (eg, primary care provider) [ 64 - 67 ].…”

“…Make connections with community-based services and resources [ 68 , 69 ]. Communicate with patients and caregivers promptly [ 63 ]. Inform patients and caregivers and family when and how they will be contacted and whom to follow-up with if they do not receive follow-up [ 60 , 68 , 70 , 71 ]…”

“…Educate patients about condition, disease management, symptoms, adverse events or red flags, symptom management, dietary recommendations, medication instructions, general condition or health, explain care protocols [ 25 , 68 , 72 - 81 ], reinforce education (eg, teach-back strategies) [ 82 ], and provide verbal or written instructions and demonstrations [ 63 , 83 ]…”

“…Advocate for access and entry to appropriate health and social services across settings and providers to ensure that patients’ needs are met, and break down health system and communication barriers [ 58 , 63 , 94 ]…”

“…Have a comprehensive knowledge of the patients’ care needs (eg, “patient’s medical, functional, cognitive, affective, psychosocial, nutritional, and environmental status” [ 76 , 99 ]) and goals to inform care and discharge plan through assessment findings [ 58 , 63 , 100 ]. Assess patients’ needs for home care and community support and resources, and identify and address potential medication adherence issues to prevent readmission [ 63 , 67 , 76 , 78 , 83 , 95 , 101 , 102 ]…”