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Ensuring Smooth Care Transitions Through Provider Accountability


Industry experts at the National Association for Healthcare Quality's National Quality Summit highlighted improving care through successful care transitions.

Industry experts at the National Association for Healthcare Quality (NAHQ)’s National Quality Summit highlighted improving care through successful care transitions.

Providers are increasingly important in assuring patients are transitioned properly from one clinical environment to another, both Cheri Lattimer, RN, executive director of the Case Management Society of American and National Transitions of Care Coalition, and Neil Kirschner, PhD, senior associate of regulatory and insurer affairs for the American College of Physicians, said when they spoke at the Summit.

“For too long, care transitions have been the weakest points in the chain of care, causing inefficiency, fragmentation, and poor outcomes,” Ms Lattimer said in a statement.

Lowering hospital readmissions through better care transitions has a 3-fold effect through improving quality and patient safety, while reducing healthcare costs, said Eric A. Coleman, MD, MPH, professor of medicine and director of the Care Transitions Program at the University of Colorado Anschutz Medical Campus.

According to Dr Kirschner, it is expected by health insurance providers that primary care and specialist physicians will be responsible for managing these care transitions. In reality, it should be a team effort involving the provider and the support staff, as well as administrators, patients, and caregivers.

Ms Lattimer stressed the importance of successful communication between the various providers and other parties involved in the care transition.

“Case managers should take the lead in coordinating care transitions and be the hub to which all involved parties are connected,” she said. “Case management has always been about patient-centered care.”

Dr Kirschner explained that the patient-centered medical home (PCMH) is designed to assure care transitions are managed properly and cost effective through a few core elements, such as:

  • Ongoing relationships between the patient and the PCMH team of clinical professionals
  • Providing care across all elements of the healthcare system by ensuring the patient can receive appropriate care when and where they need it
  • Optimizing quality and safety by having patients involved in decision making, using evidence-based medicine, and clinical support tools

“The effectiveness of the PCMH model for coordinating care by specialists requires the various providers to be aligned with the goals of the PCMH care model,” he said.

However, one challenge facing improvements to smooth care transitions is convincing policy makers and payers of the importance of coordinated care and engaging and educating patients and families, Ms Lattimer noted.

“We have to be united and active in the public policy arena in promoting the value of care transitions management and relating successful outcomes in patient and family engagement, medication management, and assuring seamless, coordinated care across the healthcare continuum,” she said.

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