When It Comes to Transitions of Care, Are We There Yet?

AMDA and its members have long been working on improving care transitions between nursing homes and the hospital emergency room (ER). There have been dozens of articles, webinars, and program sessions on the topic. There is even a Transitions of Care (ToC) clinical practice guideline. At this point, physicians and others might ask, “Are we there yet?” According to a new AMDA On-The-Go podcast, Interventions to Improve SNF to ER Transitions, we’re getting closer but there’s still some work to do.

Cameron Gettel, MD, instructor of emergency medicine at Yale University School of Medicine, first recognized the challenges related to ToC early in his career. “I was seeing a fair amount of older adults with or without cognitive impairment from long-term care facilities. They often had inadequate or incomplete continuity of care forms and/or no family to corroborate baseline status, and facility staff were often lacking or unaware of reasons for the patient’s transfer,” he said. “This issue remains relevant. I’ve had patients on a recent shift with lack of information on transfer.”

With an interest in studying this issue, Dr. Gettel took on a project to analyze about 500 electronic health records (EHRs) of transfers from nursing homes to the ER. He assessed 15 core items based on the INTERACT transfer form.  In these transfers, he found that usual functional status and/or usual mental status was absent in the form about 75% of the time. “This suggested a significant opportunity for improvement,” Dr. Gettel said.

In another study, Dr. Gettel wanted to summarize the literature involving ToC. He reviewed 609 articles and identified 11 studies that met his criteria. Of those, eight studies reported improvement in critical information, such as patient’s medications, contact information, and/or functional status, as a result of interventions. Only three addressed more patient-oriented outcomes of health care utilization, particularly after the intervention implementation.

“The largest issue we identified was a focus on process measures and not on patient-oriented outcomes.,” said Dr. Gettel. “We need to evaluate in further detail health care utilization after the intervention implementation, especially regarding what matters to the patient,” he suggested.

 Dr. Gettel also talked about the value of soft handoffs, where there is verbal communication and the sharing of high-quality information between the nursing home and the ER. “This can help with high- quality information delivery and receipt,” he said.

Looking ahead at the “big picture,” Dr. Gettel suggested three focuses: building on opportunities for electronic transfers and looking at interoperability, seeking to make improvements on financial and reimbursement structures that can enable patients to be treated at the nursing facility when feasible, and improving the ability to measure for quality care and streamlining measures that really matter for the older adult population.

In the meantime, AMDA members and frontline practitioners have a key role to play. Dr. Gettel suggested, “One opportunity for physicians and others in the trenches is to identify a champion at each site and work in collaboration with local ER or EMS groups to address both ideal and suboptimal transfers.” Assessing transfers and conducting root cause analyses at the local level, he observed, can not only improve communication and outcomes but contribute to better relationships.

For more insights from Dr. Gettel, click here to hear the entire podcast. Go here for a list of all AMDA On-The-Go podcasts.