Section6.1 Optimize

Section 6 Optimize—Optimization Strategies for Transitions of Care and Care Coordination - 1

Optimization Strategies for Transitions of Care and Care Coordination

This tool can help you improve transitions from one care setting to another and coordination and information sharing between health care organizations and between clinicians.

Time needed: 2 hours
Suggested prior tools: NA

Introduction

The National Transitions of Care Coalition (NTOCC) has observed: “In spite of world-class clinical advancements and talent, the United States’ health and long term care system is plagued by suboptimal care quality. Problems of underuse, overuse, and misuse of health care all contribute to these quality issues. Care episodes often involve numerous settings and multiple highly-specialized professionals, with little or no communication between them.”[1]A study conducted for the National Partnership for Women & Families. ( found that 74 percent of those surveyed said that they wished their doctors talked and shared information with each other; 45 percent said that they have had to act as communicators between doctors who were not talking to each other.

Improving transitions of care and care coordination are essential to improving the quality of our care.

How to Use

  1. Distinguish between transitions of care and care coordination.
  2. Plan approaches to how your skilled nursing facility may be able to improve transitions of care and care coordination.
  3. Utilize electronic health records (EHRs), health information exchange (HIE), and other health information technology (HIT) to support transitions of care and care coordination.

Key resource:

Transitions of Care and Care Coordination

The NTOCC distinguishes between transitions of care and care coordination:

  • Transitions of care, “refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change” and “are a set of actions designed to ensure coordination and continuity of care. They should be based on a comprehensive care plan and the availability of practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status.”
  • Care coordination is a broader concept. NTOCC describes care coordination as “the deliberate organization of patient care activities among two or more participants (including the patient and/or the family) to facilitate the appropriate delivery of health care services.” The Agency for Healthcare Research and Quality (AHRQ)[2] has identified five key elements comprising care coordination:
  • Numerous participants are typically involved in care coordination.
  • Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care.
  • In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others’ roles, and available resources.
  • In order to manage all required patient care activities, participants rely on exchange of information.
  • Integration of care activities have the goals of facility-appropriate delivery of health care services.

The AHRQ study also notes some key attributes of care coordination. You can use these attributes as a checklist or springboard for discussion among the participants in care coordination to break down traditions and improve results:

  • Collaboration

Interactions based on shared power and authority and mutual respect for the unique abilities of each participant.

Cooperative problem-solving and decision making, where participants achieve better patient care by working together than would have been possible individually.

  • Teamwork

Individuals from different disciplines contribute specialized knowledge.

Nonhierarchical relationships.

Participants act according to situational demands rather than traditional organizational roles.

Mutual adjustments are made among participants to coordinate care, especially as the level of interdependence among participant’s separate activities increases.

  • Continuity of care, which is the extent to which the appropriate care is provided at the right time and in the right order by the right persons.

Informational continuity is use of information on past events and personal circumstances to make current care appropriate for each individual.

Interpersonal continuity is ongoing therapeutic relationships between a patient and one or more clinicians.

Management continuity is a consistent and coherent approach to managing a health condition that responds to the patient’s changing needs.

Approaches to Improving Transitions of Care and Care Coordination

The following table lists key considerations proposed by the NTOCC and others for contributing to successful transitions of care and care coordination. Also listed are the types of EHR functions, HIE services, and other HIT that may be needed for support. Determine the areas of potential progress for your skilled nursing facility and the type of technology you would strive to acquire.

Considerations for Improving Transitions of Care (Adapted from NTOCC) / Technology Suitable for Supporting Transitions of Care
Improve communications during transitions between providers, patients, and family caregivers. / Clinical summaries in CCD or C-CDA format
 Health information exchange organization (HIO) to support querying for additional needed information
 Personal health record
 ADT tool
Ensure medication reconciliation at every transition of care. / E-prescribing system with access to all prescribed medications
Medication list management from HIO
Medication reconciliation software in EHR
Expand the role of pharmacists in transitions of care with respect to medication reconciliation. / Tele-pharmacy consults
Drug knowledge database accessible to all stakeholders
Use of fill status notification in e-prescribing systems
Establish points of accountability for sending and receiving care, especially for physician oversight. / Provider portal to agency EHR
Workflow support in EHR
HIO support for tracking patient episodes of care
Increase the use of case management and professional care coordination. /  Directory of community services maintained by an HIO
 Directory of providers, care coordinator/case manager specific to each patient maintained by an HIO
Implement payment systems that align incentives. / Although this requires national health reform, on a local level an HIO could be a convener for accountability in care
Integrate clinical and financial information and use analytics tools at the local and community levels to promote the healthcare value proposition
Develop performance measures to encourage better transitions of care. / Embedded evidence-based knowledge in EHR
Adopt standardized way to exchange information to avoid adverse consequences for patient care. /  Ensure EHR and HIE follow technical, semantic, and process interoperability standards
Utilize clinical decision support to alert user that additional information is needed /  Inclusion of clinical decision support rules that look for necessary information and alert user to query HIO
Utilize clinical decision support to alert caregivers of signs or symptoms that could worsen and require re-hospitalization or emergency visit /  Inclusion of clinical decision support rules in EHR

Copyright © 2014 Updated 03-19-2014

Section 6 Optimize—Optimization Strategies for Transitions of Care and Care Coordination - 1

[1] National Transitions of Care Coalition, 2010. Position Paper: Improving Transitions of Care with Health Information Technology, available at:

[2]McDonald, KM et al. 2007 Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7 Care Coordination) Agency for Healthcare Research and Quality. Available at: