• Define "care transition"
• Recognize risks involved in care transitions
• Identify ways to improve medication reconciliation in a care transition
• Describe several ongoing projects to improve care transitions

Angela R. Curtis, PhD
Managing Editor
Assistant Professor, Geriatric Education Manager
Division of Gerontology, Geriatrics and Palliative Care

Clare I. Hays, MD, CMD
Associate Professor of Medicine, Division of Gerontology, Geriatrics and Palliative Care

University of Alabama at Birmingham
Birmingham, Alabama

Dr. Hays has no commercial affiliations to disclose.

Because of the nature of preliminary studies, some products mentioned are unlabeled and investigational. Dosages, indications, and methods of use of drugs mentioned in this publication may reflect the experience of the authors, clinical literature, or other resources. Therefore, please see the full prescribing information before using any licensed product mentioned.

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

In an American Geriatrics Society Position Paper in 2003, transitional care was defined “as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.”[1] This would include such things as patients transferring from home or nursing home to hospital; patients discharging from hospital to home, nursing home or acute rehab; and patients transferring from home or nursing home to the emergency room. Because of the increasing tendency for health care providers to practice in only one setting (hospital, outpatient clinic, or nursing home), there often is a lack of coordination of care, duplication of tests, problems with medications, and lack of patient/family education.

Appropriate transitions are especially important for older persons who have complex chronic illness. They frequently receive care in multiple settings from multiple health care providers. For example, an elderly patient with congestive heart failure may be seen by a home health agency at home, his primary care physician in the office, a hospitalist when he is admitted to the hospital, and a nursing home attending physician if he requires subacute rehabilitation after his hospitalization. The average Medicare beneficiary sees seven different physicians and fills upwards of 20 different prescriptions per year. This increases with the number of chronic conditions and the amount of activity limitation.[2] Twenty-three percent of hospital patients aged 65 and older are discharged to another institution, and 11.6% are discharged with home health care. Studies of skilled nursing facility patients show that 19% are transferred back to the hospital within 30 days and as many as 42% are transferred within 24 months.[3] With chronic complex patients and our current health care system, a successful “handoff” at each point of transition between the health care professionals involved is critical to achieve optimal outcomes.

CASE:

Mr. H. is an 80 yo WM with a history of coronary artery disease, peripheral vascular disease, type II diabetes, hypertension, hyperlipidemia, and bullous pemphigoid maintained on chronic low-dose steroids. He had a stroke with residual right hemiparesis in 2007 and has been living at home with his wife with the aid of home health. He has had progressive difficulty with ischemic vascular ulcers on his right foot. He develops a fever and is transferred to the emergency room for further evaluation.