Transitions of Care Challenges in Cardiology - Episode 8

Improving Transitions of Care: Dr May

To improve transitions of care for cardiology patients, David May, MD, PhD, FACC, suggests that a standardized approach is necessary. Dr May explains that the approach should take into account patient- and family-dependent factors and that standard protocols should be used whenever possible.

Additionally, Dr May states that communication efforts are very important. He suggests that the most effective communications with patients and their families involve personal, straightforward,

collaborative encounters. Communication is key to helping patients and their family members understand what medications do and what to expect from treatment. He adds that collaboration among all providers involved in a patient’s transition is important, and that the use of electronic medical records can allow providers access to the information they need throughout the course of a patient’s illness.

Dr May describes programs that help with the transitions of care process. He discusses the American College of Cardiology Hospital to Home program, including the 3 evidence-based areas targeted by this program for improvement: arranging for early follow-up, managing of discharge medications, and providing education to patients and families regarding signs and symptoms.

Dr May also discusses the care transition interventions popularized by Eric A. Coleman, MD, MPH, including the 4 pillars: adherence to medication self-management, creation of a patient-centered medical record, timely follow-up with clinicians, and education regarding red flags that indicate worsening of the condition and how to respond to them.