ReadmissionS and SAFE Transitions of Care

Studies show poor communication during transitions of care leads to increased rates of hospital readmissions and medical errors. In fact, nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days.

photo of patient and nurse

To address this problem, hospitals across Minnesota participate in SAFE Transitions of Care. This goal is to improve patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities, long-term care, assisted living, home health, and primary care. With implementation of safe transitions strategies, patients should experience improved care including fewer incidents of delayed care or redundant tests, fewer medication events or missed doses, and reduced readmissions to the hospital. The framework includes a road map of best practices to address patient safety gaps and a tool kit of resources to implement the recommendations.

Thirteen Minnesota hospitals participated in the pilot project; another 14 formed the first cohort early in 2011 and found this framework to be a template for smooth, safe transitions, which is one component of reducing readmissions. Participating hospitals also experienced fewer follow-up calls from community providers. Subsequent cohorts complete gap analyses using the Road Map to Safe Transitions.

Minnesota Hospital Association also participated in the Reducing Avoidable Readmissions Effectively (RARE) campaign, which aimed to prevent 4,000 avoidable hospital readmissions during a time period of July 1, 2011 and Dec. 31, 2013.

SAFE Transitions of Care toolkit

SAFE component	Specific action	Tools
SAFE SITE team	Provide support and expectations for SAFE TRANSITIONS champions Adopt an interdisciplinary team approach to SAFE TRANSITIONS with a designated coordinator Engage key stakeholders	Transitions team form
Access to information	Verify the completion of SAFE TRANSITIONS Audit the effective completion of SAFE TRANSITION Measure the outcomes of SAFE TRANSITIONS Evaluate the SAFE TRANSITIONS efforts for learning opportunities	Safe Transition Gap Analysis Sample Policies: Discharge transfer care planning process and implementation Discharge planning and referral Model transfer policy Discharge checklist and document envelope workflow Audit Tools MHA Safe Transitions facility feedback tool Essentia Health transition of care transfer form Sample audit tool discharge to TCU/LTC/SNF Sample audit tool discharge to home care Sample audit tool discharge to home - no services Medication reconciliation resources: ED communication form Recommended tools: National Transitions of Care Coalition (NTOCC), "Improving on Transitions of Care: How to Implement and Evaluating a Plan" National Transitions of Care Coalition (NTOCC), Elements of Excellence in Transitions of Care Checklist Dr. Eric Coleman's "Care Transitions, Discharge Checklist for Patient" Dr. Eric Coleman's "Care Transitions, Personal Health Record"
Facility expectations	Set expectations for implementation of SAFE TRANSITIONS for any transition Expect staff to "speak up" when they become aware of a patient safety issue related to transitions of care.	Discharge flowchart for nursing home transfers MHA Safe Transition of Care Core Elements Crosswalk High risk assessment for readmission and discharge flow Sample Forms: Transfer form with core safety elements Nursing home transfer back to hospital Patient transfer form, Lakewood Health Center, Baudette Multi-disciplinary hospital discharge plan Interagency transfer form Admission/discharge/transfer form Sample Discharge/Transition Checklists: Discharge checklists TCU/SNF, HealthEast; Fairview Care progression checklist Agency discharge checklist Discharge destination checklist Hospital to facility/Facility to hospital transfer packet checklist Nursing home transition form and checklist Assisted living transition form and checklist Sample care conference form Incorporating core elements into EHR, sample 1; sample 2 Hard Stop policies
Staff and patient education	Provide SAFE TRANSITIONS education for all staff involved in transitions, including practitioner. Educate patients and families on their role in SAFE TRANSITIONS. rd Stop policies	Staff Education Sample presentations: Olmsted, Northland Clinical education Patient Education and Checklists Discharge documentation After hospital care plan Discharge preparation checklist

Other resources

In 2013, the federal government began penalizing hospitals with higher than expected readmission rates. From HealthLeaders Media, the article "12 Ways to Reduce Hospital Readmissions" includes prevention strategies that national experts think might be worth implementing.
"BOOSTing Care Transitions": The Society of Hospital Medicine launched Project BOOST to improve care of older patients as they transition from the hospital to home or another care facility. The project uses a team approach to assess patients' risk for re-hospitalization and plan-and-execute risk-specific discharge planning activities. The site offers a comprehensive resource room covering planning, best practices, education resources and clinical tools.
Transitions of Care Consensus Policy Statement - American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians-Society of Academic Emergency Medicine. Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976. This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes (subscription required.) See also "Consensus on Care Transitions: Time for All of Us to Step Up to the Plate," Published in Journal Watch Hospital Medicine, Oct. 9, 2009.
National Transitions of Care Coalition has brought together thought leaders and representatives of different practice and professional settings studying the transitional challenges and identifying tools which can help improve transitions of care
Dr. Eric Coleman's Care Transitions Intervention(SM) addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home. Support is available for program adoption. A training manual and DVD are available on this site to prospective health systems at no charge. The Care Transitions InterventionSM and all of its materials are the property of the Care Transitions Program(SM).
Agency for Healthcare Research and Quality's (AHRQ) RED project: Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.
Next Steps in Care includes patient and caregiver resources/guides to help with the keys to smooth transitions: careful planning, clear communication, and ongoing coordination.
Missouri Long Term Care Best Practices Coalition Toolkit on Transitions Between Hospital and Long Term Care:
The Health Research & Educational Trust (HRET), 'Health Care Leader Action Guide to Reduce Readmissions.' Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.
CMS's CARE Tool: The Care Transitions Quality Improvement Organization Support Center (QIOSC) assists Medicare quality improvement organizations (QIOs) to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.
Consumers Advancing Patient Safety's toolkit: "Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient."

Quality & Patient Safety

Quality & Patient Safety

ReadmissionS and SAFE Transitions of Care

SAFE Transitions of Care toolkit

Other resources

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