1.  Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs

Author(s): Eric A. Coleman, MD, MPH

Source: Journal of American Geriatrics Society 2003 (NULL);51((NULL)):549-555.

Summary: 

Every day, patients with continuous, complex care needs make hundreds of thousands of transitions across different sites of care. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. The many adverse effects of poorly executed transitions on patients and their informal caregivers are potentially preventable with the implementation of evidence-based and clinically sound interventions; however, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.

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2.  Pediatric Aspects of Inpatient Health Information Technology Systems

Author(s): George R. Kim, MD, Christoph U. Lehmann, MD and the Council on Clinical Information Technology

Source: Pediatrics 2008 (NULL);122((NULL)):e1287-96.

Summary: 

US adoption of health information technology as a path to improved quality of patient care has been promoted by the medical community. Children and infants are at higher risk than are adults for medical errors and their consequences. However, development and adoption of health information technology tools and practices that promote pediatric quality and patient safety are lagging. Two inpatient clinical processes-medication delivery and patient care transitions-are discussed in terms of health information technology applications that support them and functions that are important to pediatric quality and safety. Pediatricians and their partners (pediatric nurses, pharmacists, etc) must develop awareness of technical and adaptive issues in adopting these tools and collaborate with organizational leaders and developers as advocates for the best interests and safety of pediatric patients. Pediatric health information technology adoption cannot be considered in terms of applications alone but must be considered globally in terms of technical, organizational, and cultural aspects of what is best.

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3.  Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists

Author(s): Sunil Kripalani, MD, MSc, Amy T. Jackson, PharmD, Jeffrey L. Schnipper, MD, MPH, Eric A. Coleman, MD, MPH

Source: Journal of Hospital Medicine 2007 (NULL);2(5):314-323.

Summary: 

The period following discharge from the hospital is a vulnerable time for patients. About half of adults experience a medical error after hospital discharge, and 19%-23% suffer an adverse event, most commonly an adverse drug event. This article reviews several important challenges to providing high-quality care as patients leave the hospital. These include the discontinuity between hospitalists and primary care physicians, changes to the medication regimen, new self-care responsibilities that may stress available resources, and complex discharge instructions. We also discuss approaches to promoting more effective transitions of care, including improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician-patient communication. By understanding the key challenges and adopting strategies to improve patient care in the transition from hospital to home, hospitalists could significantly reduce medical errors in the postdischarge period.

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4.  Using Information Technlogy to Improve the Health Care of Older Patients

Author(s): Michael Weiner, Christopher M. Callahan, William M. Tierney, Marc Overhage, Burke Mamlin, Paul R. Dexter, Clement J. McDonald

Source: Annals of Internal Medicine 2003 (NULL);139((NULL)):430-436.

Summary: 

The high burden of illness and frailty common among older adults often results in fragmentation of care across providers and health care systems, increasing the complexity and costs of caring for these patients. Scientists at the Regenstrief Institute have experience in using medical informatics to support clinicians in the day-to-day care of older adults. Their research has progressed through several evolutionary cycles, beginning with the acquisition of relevant data and moving to studies of the most efficient and effective mechanisms for sharing relevant information at time of clinical decision making. Information technology designed with the input of the end user has the greatest promise of changing provider behavior. One topic of active research is information technology to support transitions of care among sites and providers. These transitions place older adults at increased risk for avoidable illness, death, and health care costs. Information systems that improve communication among providers during these transitions have the potential to improve safety and reduce costs.