In this chapter, the discussion centers on the identification and definition of key roles on the care coordination team, with emphasis on the value of these relationships and fostering collaboration to create a patient-centered care experience. We look at the difference between interdisciplinary and transdisciplinary teams and the need to eliminate silos.

We continue the discussion with a comparison between handoff and handover in transition management. Communication across the varied transitional points is vital to the success of the patient, both in sending and receiving information. This chapter features demonstrations of both good and poor examples of sending and receiving between care team members at a key transition point from acute to post-acute care.

Using the case study of Mr. Brown, we analyze the original what we know with the sending and receiving model. By digging deeper into both sides, we identify more information needed to ensure that Mr. Brown has a more complete and effective transitional experience.

In this chapter, the discussion centers on the potential barriers to effective communication, introducing concepts such as bidirectional communication, interoperability, and a provider’s understanding of the patient’s knowledge to support shared decision-making.

We continue to explore communication with a look at specific strategies that can enhance communication (and collaboration) across the care continuum. We also look at the patient-specific barriers related to communication that can impact the transitions of care.

Revisiting the case study of Mr. Brown, we follow the patient as he prepares to transition home, and we create a transition plan that supports him in his highest attainable level of health, based on his needs, preferences, and values. We note that home may be the ultimate destination but care is ongoing, and we explore the further care needs of this patient.

In this chapter, we will begin to look at how to close transitional care gaps, with a focus on assessment and communication. Utilizing the Swiss cheese model, we will explore how easy it is for transitional care gaps to occur. The essential elements of transitions of care are identified and defined.

One of the biggest risks among the transitions of care from setting to setting is ineffective communication. This chapter looks at the importance of the interdisciplinary handover and the roles/responsibilities of both the sender and receiver of information to ensure gaps are addressed/closed through the patient’s transitional experience.

Providing excellent healthcare relies on utilizing best practices. This chapter reviews several transitions-of-care best practices and recent research regarding implementation strategies. Outcome metrics, specifically focused on readmission reduction, are discussed.

We will travel along with Ms. Jones on her healthcare journey from acute care to rehabilitation facility to home. Looking at the critical points of transition, we will investigate and identify the gaps in her transitional planning, what could have been more effective, and how to best support this patient along the care continuum.

Based on our experience with Ms. Jones, we will delve into what exactly can be transitional care gaps, including reflection on the impact of the social determinants of health on a successful care transition. Topics include physical limitations, health literacy, family/caregiver support, and the impacts of psychosocial and financial issues.

In this chapter, we will define the concept of transitions of care and discuss the impact that transitional care has on the healthcare delivery system. The impact of good and poor transitions on healthcare outcomes, costs, and patient experience is explored.

Continuing the discussion on transitions of care, we study the metrics that are closely associated with transitions of care (readmissions, patient outcomes, patient satisfaction, financial outcomes). An in-depth discussion of the Medicare Hospital Readmissions Reduction Program features prominently. This chapter begins a discussion on defining transitional care gaps and the risks/effects of each on the transition plan.

We will continue the discussion of transitions in healthcare delivery with a review of the Transitions of Care Standards from the American Case Management Association. Following established standards of care can decrease the impact of the care gaps and create a better overall transitional experience. The standards are explored in detail in this section, and examples are used as illustration.

In previous sections, the concept of readmissions has been discussed. This chapter will introduce the readmission prevention concept. We will discuss the available tools and resources that clinicians can use with their patients to enable each patient to more effectively self-manage through the transition process. Examples from leading transitions-of-care organizations are highlighted.

In this chapter, we will define the key elements of quality and safety in healthcare delivery, referencing the seminal work Crossing the Quality Chasm from the Institute of Medicine. The discussion continues with a review of policy and regulatory mandates that advance quality of care across the care continuum. This also features an overview of the National Quality Initiative and the Triple Aim.

In this chapter, we continue the quality discussion, focusing on legislative actions that impact healthcare delivery along the care continuum. Legislative actions that feature prominently in this section include the Affordable Care Act (ACA) and the IMPACT Act.

We will wrap up the discussion of quality in healthcare delivery with the identification of key metrics that are used to evaluate the quality of provided care through each transition of patient care. The discussion includes regulatory, accreditation, and consumer assessment models, with discussion regarding the ramifications of negative outcomes (readmissions, mortality, morbidity) and the importance of patient experience perspective at the varied settings of patient care.

In this chapter, we explore the evolving role of the transitional team as the patient moves through the care continuum. We discuss the fundamental shifts from length of stay to effectiveness of the plan, from provision of discharge instructions to advancing an understanding and engagement in the information for patient self-management, and the balancing act of financial stewardship and patient advocacy.

We continue with a review of the shifting focus of healthcare from volume to value through a discussion of current alternative payment models and healthcare delivery systems. Concepts including value-based purchasing, bundled payment models, patient-centered medical homes, accountable care organizations, and transitional care management are examined.

Join us for a discussion between the instructors on key transitional care management topics reviewed in this series. The impact of each element is discussed within this lively Q&A.