There has been a lot written about transitions of care / care transitions in the last few years. There are even organizations that have come into being centered around this topic. What is the concept and why is it so important?
The concept is a very simple one. Health care needs of individuals are dynamic and the resources necessary to deliver that health care change over time. This is especially true of seniors who suffer from chronic medical conditions or even multiple conditions – the “medically complex” senior.
Not only do those needs change, such that a senior with COPD and Congestive Heart Failure may transition from a hospital to a rehab or skilled nursing facility, but that recipient of care may be using the services of multiple health caregivers at the same time – a Primary Care Physician (PCP) and home health physical therapy and a wound nurse and non-clinical home care, for example.
The need for communication among the caregiving team, clinical, non-clinical and family, is absolutely critical to successful outcomes for the recipient of care, whether the patient is changing physical locations or simply receiving service from caregivers on “Tuesday’s” care plan.
The secret to success in care transitions is care coordination, provided, for example, by Geriatric Care Managers. Without that coordination, gaps in the plan will inevitably occur; medications prescribed by a hospitalist will not mesh with those from the PCP; changes in diet from the hospital do not get communicated to the non-clinical Home Care Aide supporting ADLs and providing meals at home.
There are a number of models for transitions of care / care transitions. The Care Transitions Program, headed by Eric A. Coleman, MD, is one. The Home-Based Chronic Care Model developed by Beth Hennessey and Paula Suter (both now at Sutter Care at Home in northern California) is one that makes a lot of sense to us. We recently talked about what Univita is doing is the care coordination space. On a local level here in the greater Sacramento area, we perform that function, as well. The bottom line is that coordination is literally vital to the wellbeing of the care recipient.