Are too many patients today “lost in transition?”

by Burl Stamp

Since 1983 when Medicare launched the prospective payment system (PPS), the average inpatient hospital stay has declined from 10.0 to 4.5 days. During this same period, Medicare discharges to skilled nursing increased four-fold.  Health care providers are well aware that patients are being discharged at a higher acuity and with far more significant needs for continuing care. What often is not recognized is how vulnerable patients are during transitions between care settings, especially older adults and those with multiple comorbidities.

Poor communication and coordination during care transitions can contribute to adverse events and preventable hospital readmissions.  As health care providers and systems are incentivized to manage episodes of care beyond the inpatient stay, hospitals increasingly are under pressure to transform the traditional discharge planning paradigm to more robust care transition management and coordination.

Patients Tell Us Better Discharge Instructions Is Not What They Want – or Need

A recent study published in the Annals of Family Medicine, “Care Transitions from Patient and Caregiver Perspectives,” looks closely at what matters most to patients and caregivers during care transitions. The need for and purpose of the study were clear:

Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them.

Patients and caregivers identified three primary desired outcomes of care transitions:

  • To feel cared for and cared about by medical providers,
  • To have unambiguous accountability from the healthcare system, and
  • To feel prepared and capable of implementing care plans.

And five key characteristics of the care transition experience were linked to achieving these outcomes:

  • Using empathetic language and gestures,
  • Anticipating the patient’s needs to support self-care at home,
  • Collaborative discharge planning,
  • Providing actionable information, and
  • Providing uninterrupted care with minimal handoffs.

The authors concluded that: “Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers.  When these outcomes are achieved, care is perceived as excellent and trustworthy.  Otherwise the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.”

What is not called for in this study – or in Stamp&Chase’s experience working with a variety of care providers – is the need for more detailed, standard discharge instructions without true collaboration with patients, family caregivers and/or post-acute care facilities.

For more information, download our free LeaderBriefing white paper: Lost in Transition.