Journal of Gerontological Nursing

Guest Editorial 

Transitional Care: What Does It Mean for Nurses?

Marina Burke, MSN, ANP-C

Abstract

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Most of you probably know something about transitional care. But what you may not know is that it is one of the most exciting emerging areas of nursing and health care in the country. Transitional care includes actions ensuring the coordination and continuity of care between settings (e.g., hospitals, nursing homes, patients’ homes, physicians’ offices). It is based on a comprehensive plan of care and involves health care practitioners who have current information about the patient’s goals, preferences, and clinical status (Coleman & Boult, 2003).

Geriatric nurses may know it (on a bad day) as the frustration they experience after a patient they discharged from their unit or from their home health caseload is readmitted a few days later with a preventable problem. On a better day, they know it as the satisfaction they experience when the stars align and they are able to share the essentials of their patient’s hospitalization with the patient’s community physician, home health intake nurse, and maybe even a family member and a paid caregiver, thereby decreasing the likelihood of a preventable emergency department (ED) visit or readmission.

Consider the example of a 73-year-old African American man, Mr. W., brought into a major urban university teaching hospital with a blood sugar of 560, dehydration, and confusion. He improved with insulin and hydration and was able to give the hospital team his wife’s telephone number. After a discussion between the hospital team and his wife, Mr. W. was sent home with a referral for home care services and the same diabetic regimen he had before the hospital visit. His primary care physician was not contacted. Five days later, Mr. W. returned to the ED after police found him wandering the streets. Further testing revealed moderate vascular dementia, hyperglycemia, and dehydration. In addition, his wife is disabled, attends a day center, and cannot assist him with his diabetic regimen or diet. These discoveries easily require several ED visits and hospitalizations. The concerns of this patient point clearly to the need for improved transitions.

The facts that support what went wrong with Mr. W. are dramatic: As many as one fifth of all Medicare patients are readmitted within a month of being discharged, and a third are rehospitalized within 90 days. Half of the patients who returned to the hospital within 30 days of undergoing treatment other than surgery apparently did not see a physician before they went back. Cost estimates for these unplanned return trips have been projected at $17 billion in 2004 alone (Jencks, Williams, & Coleman, 2009).

What does this mean for nurses? One concrete way nurses have become involved in transitional care initiatives is through one of The Joint Commission’s (2009) mandated National Patient Safety Goals to “accurately and completely reconcile medications across the continuum of care” (p. 7). This initiative was created because of recent statistics showing that nearly one third of all patients age 65 and older admitted to home care had evidence of a potential medication problem (Meredith et al., 2001). The process requires physician and nurse practitioner accountability for medications prescribed at discharge (The Joint Commission, 2009), indicating a new focus on interdisciplinary processes.

Nurse practitioners have been at the forefront of transitional care initiatives for the past several years, with impressive results. Rehospitalization rates have been shown to decrease when nurse practitioners evaluate high-risk patients during their hospital stay and follow up with home visits and telephone interaction after discharge (Naylor, 2000;…

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Most of you probably know something about transitional care. But what you may not know is that it is one of the most exciting emerging areas of nursing and health care in the country. Transitional care includes actions ensuring the coordination and continuity of care between settings (e.g., hospitals, nursing homes, patients’ homes, physicians’ offices). It is based on a comprehensive plan of care and involves health care practitioners who have current information about the patient’s goals, preferences, and clinical status (Coleman & Boult, 2003).

Geriatric nurses may know it (on a bad day) as the frustration they experience after a patient they discharged from their unit or from their home health caseload is readmitted a few days later with a preventable problem. On a better day, they know it as the satisfaction they experience when the stars align and they are able to share the essentials of their patient’s hospitalization with the patient’s community physician, home health intake nurse, and maybe even a family member and a paid caregiver, thereby decreasing the likelihood of a preventable emergency department (ED) visit or readmission.

Consider the example of a 73-year-old African American man, Mr. W., brought into a major urban university teaching hospital with a blood sugar of 560, dehydration, and confusion. He improved with insulin and hydration and was able to give the hospital team his wife’s telephone number. After a discussion between the hospital team and his wife, Mr. W. was sent home with a referral for home care services and the same diabetic regimen he had before the hospital visit. His primary care physician was not contacted. Five days later, Mr. W. returned to the ED after police found him wandering the streets. Further testing revealed moderate vascular dementia, hyperglycemia, and dehydration. In addition, his wife is disabled, attends a day center, and cannot assist him with his diabetic regimen or diet. These discoveries easily require several ED visits and hospitalizations. The concerns of this patient point clearly to the need for improved transitions.

The facts that support what went wrong with Mr. W. are dramatic: As many as one fifth of all Medicare patients are readmitted within a month of being discharged, and a third are rehospitalized within 90 days. Half of the patients who returned to the hospital within 30 days of undergoing treatment other than surgery apparently did not see a physician before they went back. Cost estimates for these unplanned return trips have been projected at $17 billion in 2004 alone (Jencks, Williams, & Coleman, 2009).

What does this mean for nurses? One concrete way nurses have become involved in transitional care initiatives is through one of The Joint Commission’s (2009) mandated National Patient Safety Goals to “accurately and completely reconcile medications across the continuum of care” (p. 7). This initiative was created because of recent statistics showing that nearly one third of all patients age 65 and older admitted to home care had evidence of a potential medication problem (Meredith et al., 2001). The process requires physician and nurse practitioner accountability for medications prescribed at discharge (The Joint Commission, 2009), indicating a new focus on interdisciplinary processes.

Nurse practitioners have been at the forefront of transitional care initiatives for the past several years, with impressive results. Rehospitalization rates have been shown to decrease when nurse practitioners evaluate high-risk patients during their hospital stay and follow up with home visits and telephone interaction after discharge (Naylor, 2000; Naylor et al., 1999). More recently, the focus has been on RNs and trained non-nurses performing customized transitional care coaching to patients and families, with the underlying cause of unplanned hospitalizations being poor understanding of disease processes and symptom management (Parry, Kramer, & Coleman, 2006). The emergence of managed care companies provides nurses with an opportunity to align nurse-focused transitional care goals with the goals of the managed care companies. What nurses have been providing patients since the beginning of the profession is now gaining visibility in the larger health care arena: Care and communication have value! Providing nurses with the right process and structure to make their interventions more powerful could have revealed Mr. W.’s true social and medical problems before he was discharged and would have likely averted his episode of wandering and unplanned hospitalization.

A next step for transitional care is to strive to learn how nurses with different roles—as well as in different organizations—can work together most effectively. There is enormous promise in this vision, because, as we know, nurses are arguably the best suited to communicate what patients and families need to know when moved from one health setting to another. For additional information, visit http://www.transitionalcare.info/.

Marina Burke, MSN, ANP-C
Clinical Project Manager
Visiting Nurse Service of New York
New York, New York

References

  • Coleman, E.A. & Boult, C.E. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556–557. doi:10.1046/j.1532-5415.2003.51186.x [CrossRef]
  • Jencks, S.F., Williams, M.V. & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360, 1418–1428. doi:10.1056/NEJMsa0803563 [CrossRef]
  • The Joint Commission. (2009). Accreditation program: Medicare/Medicaid long term care national patient safety goals. Retrieved from http://www.jointcommission.org/NR/rdonlyres/028D69A3-591A-427E-897E-E19AF5DDDA9A/0/RevisedChapter_LT2_NPSG_20090924.pdf
  • Meredith, S., Feldman, P.H., Frey, D., Hall, K., Arnold, K. & Brown, N.J. et al. (2001). Possible medication errors in home healthcare patients. Journal of the American Geriatrics Society, 49, 719–724. doi:10.1046/j.1532-5415.2001.49147.x [CrossRef]
  • Naylor, M.D. (2000). A decade of transitional care research with vulnerable elders. Journal of Cardiovascular Nursing, 14(3), 1–14.
  • Naylor, M.D., Brooten, D., Campbell, R., Jacobsen, B.S., Mezey, M.D. & Pauly, M.V. et al. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 281, 613–620. doi:10.1001/jama.281.7.613 [CrossRef]
  • Parry, C., Kramer, H.M. & Coleman, E.A. (2006). A qualitative exploration of a patient-centered coaching intervention to improve care transitions in chronically ill older adults. Home Health Care Services Quarterly, 25(3–4), 39–53. doi:10.1300/J027v25n03_03 [CrossRef]
Authors

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

10.3928/00989134-20091103-05

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