Posted June 21, 2017

Transitions of Care: Moving from Acute Care to Home with Comprehensive Care Plans

By Debbie Caskey, RN Diana Topjian, RN, MSN, DM, C-ENP

In "It's Not Just About Discharge: The Other Transitions of Care," we focused on critical transitions occurring within the hospital. In this Insight, we will focus on the transition from acute care to home, both with and without home health in place. Centers for Medicare and Medicaid Services (CMS) reports that the HCAHPS survey Transitions of Care domain is most highly correlated with Overall Rating of Hospital. Public reporting of this domain began in 2017, providing greater visibility into the issues of the discharge process that lead to avoidable readmissions with inclusion into Value Based Purchasing calculations as of FY18.

(Fire Starter Publishing offers two detailed resources, "The HCAHPS Handbook 2" and "OAS CAHPS Compendium" for more learning on CAHPS.)

The scale for responses in the Transitions of Care domain is Strongly Agree, Agree, Disagree and Strongly Disagree which differs from other HCAHPS survey domains that use Always, Usually, Sometimes, Never or a scale of 0 to 10. Additionally, the key words used in the Transitions of Care questions add a new urgency to our call to action. The HCAHPS Transition of Care questions are:

  • During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.
  • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • When I left the hospital, I clearly understood the purpose for taking each of my medications.

Having a comprehensive care plan in place is critical to safe transitions from acute care to home.

Components of the Comprehensive Care Plan

The success of the comprehensive care plan occurs when the interdisciplinary team is aligned in their plan, and ensures the inclusion of the patient and his/her family. Having care transition conversations with patients and families, answering their questions, and identifying clear plans for post discharge care (with arrangements made as necessary) are needed to optimize outcomes. In addition, it is a best practice to start the care plan at the beginning of the episode of care.

A truly comprehensive care plan is rooted in communication, coordination and collaboration. It demands that the care team fully assess the capacity and capability of the patient, family or caregiver to understand the plan, agree to the plan and perform the necessary post discharge care included in the plan.

The information obtained through a comprehensive nursing admission assessment, as well as input from team members, should inform our understanding of the capacity and capability of the patient and family/caregiver to perform the necessary care post discharge. This information should inform the creation of a care plan. The assessment should include the needs of the patient and the family/caregiver, including physical, psycho-social, emotional and financial needs.

Learn how a focus on care transitions can help reduce readmissions and improve financial pressures. This infographic includes 8 techniques you'll want to ensure are on your readmission prevention checklist. Read more.

The second component that adds further insight and knowledge into the patient's readiness for discharge can be obtained through multidisciplinary rounds. Key questions generated from the initial assessment noted above should be used to further understand the patient's current state and level of readiness for discharge when he/she is ready to leave the organization.

A sampling of the questions that will enhance a broader understanding of the patient's current state and needed steps for preparation of discharge include:

  • Who from your family (or caregivers) should we work with along with you to discuss your healthcare needs at home?
  • What are you and your family's specific preferences that we should consider when making follow-up and home care arrangements?
  • Is your primary care provider still Dr. Jones? We want to be sure to communicate your follow up care recommendations to him.
  • Is there a pharmacist you work with or case manager to assist with helping to manage your medications after discharge?

Timing the planning of transitions of care, particularly as length of stays become shorter and shorter, needs to occur as close to admission as possible. Use of length of stay data, available through case management, begins preparing the team early on to have key discussions for safe transitions. Discussing anticipated discharge, along with answers to questions from the family, will assist the healthcare team in frequently communicating the plan for transition.

Armed with information from the assessment and multidisciplinary rounds, caregivers can implement a series of best practices designed to ensure accurate execution of the plan developed. Such activities include:

  • Medication reconciliation
  • Interview and introduce post-discharge care team (as applicable)
  • Comprehensive discharge instruction counseling utilizing basic language and teach back methods for clarifying understanding, begin as soon as possible after admission
  • Seamless and timely communication between hospital providers and patient's Primary Care Provider (PCP)
  • Consistent communication and updating of the patient's discharge plan through inclusion of discussions done during Bedside Shift ReportSM, multi-disciplinary rounds and huddles
  • Timely post visit follow-up with patient's PCP; schedule appointment prior to discharge whenever possible
  • Patient awareness to expect transition of care call and confirmation of best phone number to reach patient

Transitioning from an environment where patients feel safe and well cared for to home can be scary and unsettling. A comprehensive plan utilizing best practices and the evidence based tactics above, plus involving patients and caregivers from the start greatly increases our ability to address preferences, purpose and responsibility.

Diana Topjian, RN, MSN, DM, C-ENP is a Studer Group coach with more than 30 years of experience ranging from direct line staff nurse to executive leadership roles in both academic and community-based hospitals.

Debbie Caskey, RN has been a registered nurse and healthcare leader for more than 40 years. In her role as a Studer Group coach and account manager she specializes in helping rural and community hospitals improve results.


  • Debbie Caskey

    Debbie Caskey, RN

  • Diana Topjian

    Diana Topjian, RN, MSN, DM, C-ENP

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