Posted May 15, 2018

COACHING MINUTE: Diagnosing Your Current Care Transitions Process

By Diana Topjian, RN, MSN, DM, C-ENP

Care transitions are top of mind for many of us in today’s healthcare industry. We know that the Care Transitions domain is one of the top corollaries to the HCAHPS “Overall Rating” driven by a heightened focus on safety during these critical times. When transitions (handovers) are done well, organizations find a reduction in serious medical errors and readmission rates in key patient populations.
What does the data tell us? A recent study by The Joint Commission (2017) reported that 80 percent of serious medical errors involve miscommunication when a patient is transitioning. Safe transitions of care require a multi-faceted, comprehensive treatment plan that is unique to the patient and considers his specific needs. The complexity of this tailored approach highlights the need for an increased focus on care transitions.   
Here are a few diagnostic questions that will assist you in determining the current state and reliability of your care transitions process. 

  1. What is the documented, standard process for how handovers occur between care units and/or individuals?  At what point during admission are the key transition concerns (new medications and help when going home) assessed and interventions planned based on findings?
  2. How well are you currently able to contact patients once discharged home or to home health from your facility?

If any of your answers to the above questions suggest you have opportunity to improve your care transitions, my best advice is to hardwire a post-discharge call process. Transitions of care are high-risk for our patients, and post-discharge calls allow us to ensure the patient is doing well and provide early intervention if needed. Discharge calls also help in gathering important information for improvement or recognition of high-performing staff.
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.

Add Value to Post-Discharge Calls
Already have a post-discharge call process in place? Here are a few tips to make calls even more impactful.

  1. Aim for a 100 percent attempt rate and a contact rate of at least 80 percent.
  2. Hardwire the use of AIDET® during the discharge process. For example: Mr. X, one of our nursing team members, will call you 1-2 days after your discharge to see how you are doing. What number should we use to reach you?
  3. Ask open-ended questions and repeat what patients heard to ensure accurate information is captured. Specific patient comments are critical to providing context.
  4. Share stories with staff about the benefits of these calls. For example, one partner organization uses their internal website to promote “lives saved”. The button links to a page where staff members detail how they have made a difference for patients with the post-discharge call process.
  5. If using a decentralized model (unit nurses making the calls), ensure that nurse callers are held to an objective expectation for outcomes. This should be measured regularly and discussed during performance reviews.


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