Usted Si Puede Vivir con Insuficiencia Cardiaca

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The Goal:
Improve quality and reduce the disparities associated with patient transitions in care between practitioners and health care settings.

Why It's Important:
Transitions in care for minority patients were closely tied to many of the disparities encountered during the Expecting Success program. Moving between the hospital and ambulatory care settings, minority patients were more likely to experience serious lapses in their path to recovery. Hospitals can make significant progress in reducing racial, ethnic and language disparities in health care by improving the transition process and providing patients with the resources to maintain good health.

How To Do It:
1. Assess the transition points in the hospital.
Step back and identify all the transition points in patient care, looking at every step to identify ways these transitions can be improved. Because of the size and pace of most hospitals, it is easy for hospital staff to lose sight of the many transition points patients faces in their care.

2. Ensure that existing transition procedures are being consistently followed.
Use existing data or generate new data to ensure that all existing, evidence-based transition procedures are being followed consistently. If not, identify if staff education can help increase compliance or if changes to the processes are needed to make it more routine.

3. Assess if other procedures or resources exist to improve transitions.
Many proven tools and intervention resources exist to improve the transition process. Some hospitals periodically bring together front-line staff and managers from different departments to share learnings about increasing quality during times of patient transition. These discussions help determine if the existing procedures and resources staff use for transitions are still the best available. Sometimes even simple updates to paperwork can have a huge impact.

4. Coordinate the transition with all relevant inpatient staff.
Expecting Success participants say that the most significant step they can take to improve quality and equity in care during transitions is to provide better patient care coordination. Some are bringing together all relevant staff such as pharmacists, counselors, charge nurses and the patient's primary care physician and/or caregiver to:

  • Reconcile care records
  • Develop a clear plan for discharge
  • Arrange for follow-up visits
  • Provide necessary medications and instructions for taking them
  • Discuss responsibilities for following up with the patient.

5. Discuss the transition and care plan with patients before discharge.
Leaders at some Expecting Success hospitals say they are now taking more time to talk with cardiac patients about their transition care plan long before discharge so that they can help identify any potential problems before they leave. This allows them to provide more patient-centered care and help the patient plan contingencies for potential problems after discharge so that they do not need to be readmitted. Sometimes it's as simple as finding out if patients have transportation to get to follow-up visits or the pharmacy, or if they can afford the medications.

6. Develop patient-centered take-home resources to provide support during transitions.
It is important to provide patients with take-home resources to help manage their disease and remain healthy during transitions in care. Examples include:

  • Disease educational materials, for both patients and caregivers
  • Tools for tracking progress such as a daily weight tracker
  • Dietary guidelines and sample menus
  • Information on local outpatient counseling services.

To reduce care disparities among minority patients, Expecting Success hospitals have found that it is often necessary to redevelop these resources to focus on particular racial, ethnic and language needs.

7. Proactively check on the status of patients after discharge and during transition.
Reaching out to patients after discharge and during transitions is a valuable way to make sure they are doing all right. This helps catch potential problems early and avoid future care issues that can lead to measurable disparities.