The complexity and fragmented nature of the health system makes effective care delivery during patient transitions between care providers and facilities vary significantly. The majority of transitions are not patient-centred and can lead to unsatisfactory patient experiences, poor adherence to and support for ongoing treatment, an increase in medication errors, and unnecessary hospital readmissions. This results in a poor experience, increased confusion, reduced health outcomes, and increases the burden on the health system in terms of additional clinician time and cost.

One of the negative outcomes of dealing with a complex and often fragmented healthcare system is ineffective communication between clinicians (care team) and patients. Poor communication can have a detrimental flow on effect for the patient’s recovery and their family. Unfortunately, this often results in a longer hospital stay and their readmission risk increases.

All participants suffer when there is inadequate information, instruction, and patient education, which can develop into confusion and insufficient support for the patient. This can hinder the patient’s ability to move along their care journey and can also impact whether the patient is discharged to a nursing facility or back to their own home. Implementing and following an effective patient-centred, coordinated transition of care model is essential to reducing a delay in a patient being discharged and curbing an increased avoidable hospital readmission rate.

The vital role of Transition Coordinators in patient-centred care

Coordination of care, transitions of care and patient navigation have all become integral terms in explaining how to deliver and communicate effective healthcare. How are healthcare organisations embracing and attempting to respond to the ever-increasing requirements they hold? Transition of care not only defines a role but also a means to capturing and delivering the coordinated approach required to support transfers.

The role of the Transition Coordinator, or Discharge Planner, Nurse Navigator and Case Manager has changed over the last decade. The Transition Coordinator role started performing utilisation reviews without any relationship to the direct delivery, coordination and communication of the patient’s ongoing care. This is required by each provider or multi-interdisciplinary care team that pick up the handover and care of the patient at these transition points.

From these early roots the transition role has evolved to incorporate utilisation management, transition and discharge planning, documentation improvements, education and communication of planned treatment and after care. This can be between the care team – both acute and ambulatory, auxiliary support services in the community, and the patient and their caregivers. The transition role acts as the patient’s advocate but also has a focus on enabling providers (the care team).

Vitally important in healthcare today, Transition Coordinators are playing an essential role in acute, ambulatory care and other types of health settings. It is important to provide them with the right tools to make their role transparent to the greater care team, they are becoming the face of care for the patient, in effect the care communicator. There are cases where hospitals provide a bonus or extract a penalty depending on the quality of care they deliver. Hospital and ambulatory care organisations know that the difference between getting more and getting less from these payments will depend on how well ‘the team’ performs, but they might not realise that perhaps the most critical team members in improving quality and patient experience are the Transition Coordinators.

Transition Coordinators are individually responsible for ensuring that patient care is delivered appropriately for their organisation to get reimbursed for their care delivery. With the right tools, the Transition Coordinators can bring together the clinical team’s essential functions to enhance the coordinated care approach. This can improve clinical and patient outcomes, care efficiency and decrease any adverse events prior to and post discharge, plus enabling the patient to become more engaged in their own care.

Ultimately, providing Transition Coordinators with the right tools helps to identify, track, collate, communicate and engage, and will have significant impacts to the bottom line in our hospitals, ambulatory and other health settings.

Making transition in care work

Implementing transition care models with the right tools is not only for patients with complex, chronic conditions, such as congestive heart failure – where these patients often rely on care from multiple clinicians, but so do patients who need transitional support. These patients are particularly susceptible to the effects of poorly coordinated transitions. It has been shown that deliberate transition planning and management has the potential to improve a patient’s discharge outcomes, reduce their rate of readmissions and simultaneously reduce costs.

An example I remember clearly is of a respiratory patient who kept coming back to the emergency department. The patient was in her early 50s, always engaging and bright, but her frequency of readmission was increasing, with only short stays at home after her last discharge. With each readmission she was presenting more unwell than the last.

It was noted that at each admission the patient was taught how to use her inhalers and other medications and was given detailed written instructions by the discharging doctor. These instructions described her diagnosis and what to do if she had any problems – an escalation plan.

During her last admission the patient was assigned a Transition Coordinator, a new role that ambulatory care was trialling in the acute hospital for patients due to be discharged. The purpose of this role was to help identify high risk patients transitioning back to the community after a hospitalisation. During the first contact session with the Transition Coordinator, they discussed the patient’s concerns. These were written up with corresponding risk assessments (which included an education plan and health literacy assessment) to evaluate the likelihood for another readmission. The Transition Coordinator also created a next contact schedule – best suited for the patient. This was also based off the acuity (risk) assessment. Most importantly this one-on-one session revealed a tightly held secret, one the patient had hidden from everyone. She couldn’t read.

This patient had navigated through her adult life without revealing this important fact to anyone. She could sign her name and do basic maths, but she could not read the instructions on her medication bottles or the printed instructions on the escalation plan. She was a highly functional illiterate but had missed post discharge appointments as no one took the time to explain when these were to be and the importance of these follow-ups.

In recording this information as part of the transition pathway the Transition Coordinator made sure that the patient’s care team were informed, who then implemented appropriate support systems for her needs prior to her discharge. The patient received her medications in colour-coded form, and any handouts or instructions were provided and explained verbally during specific teach back sessions prior to the patient going home.

Most importantly, as part of the transition in care model the Transition Coordinator had a task to follow-up with the patient by phone. This was scheduled as indicated by the acuity assessment to reiterate the importance of attending her post discharge appointment and to provide any further support if required. The Transition Coordinator continued to follow-up with the patient for the next 30 days, until both the patient and the Transition Coordinator were confident she would not be readmitted. This story illustrates the power of forging relationships with patients who are about to embark on one of the most perilous journeys in the healthcare system – the trip home after being in hospital.

Many healthcare organisations have improved patient transitions, but there is no silver bullet, and it remains a team effort for all involved in the patient’s circle of care. There is a corresponding relationship between the percentage of primary care physicians who receive a discharge summary about their patient within 24 – 48 hours and a decrease in the number of tests being ordered. But most importantly, patients reported a decrease in the amount of times they received conflicting information from the various care providers.

Having patients and care providers voice increased satisfaction with the quality of coordinated care during transitions increases both the safety and efficiency of transitions in care. Each step in care transition combines elements of both utilisation management and transition planning. In this role Transition Coordinators may find themselves circling back or repeating processes. They may even need to occasionally skip a step, or the step may not be necessary in a particular patient’s situation.

Designing a successful solution involves policy decisions that create new provider and patient expectations, incentives, and infrastructure to support patient-centred care. An integral feature of the programme is the development of a care coordination infrastructure at the central, regional, and local level.

Where does technology come in?

This is where technology becomes the enabler. Orion Health Coordinate, utilising the Transition of Care pathway has the ability to power effective care coordination across multiple care settings. This provides predictable, optimised workflows to support and manage programmes of care. It can be implemented across multiple hospitals and healthcare facilities and connect all the stakeholders in a patient’s circle of care to improve communication.

The Transition of Care pathway can help to reduce or prevent avoidable hospital readmissions by focusing on patients with chronic conditions or patients over 65 years old who have a high-risk of hospital readmission. With the right support and care coordination, hospital readmissions within two weeks of a high-risk patient being discharged can be avoided.

For example, when a high-risk patient is hospitalised for an event, such as a worsening or exacerbation of their heart failure or chronic obstructive pulmonary disease (COPD), the Transition Coordinators identify and start the patient on the Transition of Care pathway. Appointments can be made with a Primary Care Physician (PCP), Social Services and the Transition Pharmacist, to wrap the appropriate care around the patient to ensure they have the resources required to enable the highest level of health they can.

Orion Health Coordinate, utilising the Transition of Care pathway has the ability to power effective care coordination across multiple care settings. The pathway provides predictable, optimised workflows to support and manage programmes of care.