Transitions of Care

Transitions of Care are a component of Care Coordination that occur when information or responsibility of a patient experiences movement between varying levels of care in the same location, across different entities of care, or longitudinally over time [1]. This includes the movement of information, both the sending and receiving of, between individuals and organizations that is essential in facilitating continuity of care.

When do Transitions of Care Occur?

There are a variety of settings where care transitions occur. While they often happen when individuals moves between different levels of care, notably between hospital and home, transitions in care are not limited to this and may also be seen between [2]:

• Different health care settings, e.g., inpatient to outpatient care

• Different health care systems, e.g., hospital transfers

• Care teams or team members, e.g., shift change, consult services

• Patients, families, and caregivers, e.g., AVS, caregiver teaching

• Separate episodes of care, e.g., separate hospitalizations for one patient

• Progression across the lifespan, e.g., aging out of pediatric care

• Progression of an illness/disease, e.g., chronic disease

Importance

A transition of care if often a period in care that is also tied with increased vulnerability, when a patient may be experiencing changes in their overall health. Patients may be learning about a new diagnosis, managing new or ongoing treatment, or experiencing decreased functional ability. By moving information along, across the continuum, the quality of care from one setting to another should be able to be maintained. This continuity has the benefit of passing along relevant details of care that has already been provided to minimize disruptions and bridge relationships. Strong transitions of care have the ability to improve clinical outcomes and increase cost savings, while poor transitions have been linked to worse outcomes for patients and healthcare organizations alike [3]:

• Patients: Increased adverse events and mortality/morbidity, delays in care, and emotional burden

• Health Systems: Increased ED utilization, duplication of care and diagnostic testing, and increased avoidable hospital readmissions

Role of Informatics

Informatics can assist with facilitating transitions of care through a variety of functions that bridge gaps between separated instances of care. Changes and improvements related to Meaningful Use, Health Information Exchange (HIE), Interoperability, and EHRs have all influenced separate health entities’ abilities to communicate and share information with one another. The ability to seamlessly move information between settings and individuals is driven by informatics-related tools, especially with the level of EHR utilization that has been constructed.

EHRs can assist with the relay of information between different health entities during care transitions by improving the ability to access, store, retrieve, and electronically exchange information. EHRs hold a variety of tools that allow for improved tracking of patients over time while also providing a centralized location for patient information to live. This allows for data to be collected, presented, and later moved during transitions in a format that should be easy to access and easy to read [4]. Some of the core objectives of Meaningful Use criteria promoted EHR requirements that affect transitions of care by providing patients with the ability to access their own health information and requiring a summary care record be given at each period of transition [5]. While there is some risk involved, by providing patients with access to their own health information, there is potential for patients, families, and their caregivers to become more knowledgeable about their own diagnoses and treatment, and be able to assist with continuity when working with clinicians at that next level of care. A summary of care ideally should facilitate a smoother introduction for clinicians taking over care of a patient as well as reduce waste and duplication of care.

The exchange of information during transitions of care is often limited by the individual HIE capabilities of each healthcare setting involved [6]. These barriers to communication may be a result of infrastructure or hardware limitations, but they may also be related to data standardization restrictions, sometimes resulting from the prevalence of disparate, competing EHR formats [7]. Information blocking has created restrictions in care transitions by hindering the ability of EHRs to access information that is stored on a different platform. This has led to a reliance on older methods of information transfer being utilized in order to facilitate handoff. If unable to view or receive data electronically from an EHR, patient information may need to be faxed, mailed, or given physically or verbally. While feasible, such methods may delay handoff and increase the likelihood of outdated information being given. If able to fully deliver, the 21st Century Cures Act Final Rule can potentially improve transitions of care by way of more uniform standards for data exchange, and the prevention of information blocking [8].

References

1. Medicaid, C. f. M. (2014). Eligible Professional Meaningful Use Menu Set Measures. CMS.gov: Centers for Medicare & Medicaid Retrieved from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/8_transition_of_care_summary.pdf

2. Quality, A. f. H. R. a. (2014). Care Coordination Measures Atlas Update. Agency for Healthcare Research and Quality. https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html

3. Organization, W. H. (2016). Transitions of Care. WHO.int: World Health Organization Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf

4. Medicaid, C. f. M. (2014). Eligible Professional Meaningful Use Table of Contents. CMS.gov: Centers for Medicare & Medicaid Retrieved from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/ep_mu_tableofcontents.pdf

5. Marie Krousel-Wood, A. B. M., Chad Ahia, Elizabeth W Holt, Donnalee N Trapani, Qingyang Luo, Eboni G Price-Haywood, Eric J Thomas, Dean F Sittig, Richard V Milani. (2017). Implementing electronic health records (EHRs): health care provider perceptions before and after transition from a local basic EHR to a commercial comprehensive EHR. Journal of the American Medical Informatics Association, 25(6), 618-626. https://doi.org/https://doi.org/10.1093/jamia/ocx094

6. Dori A. Cross, P., Jeffrey S. McCullough, PhD, Julia Adler-Milstein, PhD. (2019). Drivers of Health Information Exchange Use During Postacute Care Transitions. The American Journal of Managed Care, 25(1), 7-13. https://cdn.sanity.io/files/0vv8moc6/ajmc/484b93d0d65f1795ed4f4c76cec829d13695ea2e.pdf/AJMC_01_2019_Cross%2520final.pdf

7. Jordan Everson, V. P., Julia Adler-Milstein. (2021). Information blocking remains prevalent at the start of 21st Century Cures Act: results from a survey of health information exchange organizations. Journal of the American Medical Informatics Association, 28(4), 727-732. https://doi.org/10.1093/jamia/ocaa323

8. Services, D. o. H. a. H. (2020). 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. Federalregister.gov: Department of Health and Human Services Retrieved from https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-cures-act-interoperability-information-blocking-and-the-onc-health-it-certification

Submitted by Joshua Masters