Change Concepts for Improving Care Transitions

Safely and effectively sending patients to the hospital and receiving patients from the hospital are fundamental to improving transitional care. Obtaining patient information from hospitals in a timely manner after patients are discharged and return to outpatient dialysis has always been a major area of concern. An effective communication process is essential to ensure safe patient hand-offs between all healthcare facilities whether it is between dialysis facilities, hospitals, nursing homes, or ambulatory care centers and should require the active participation of both a sending provider and a receiving provider.

Establishing a good system of communication between healthcare settings is the key to good care transitions. The Change Concepts listed below were developed by The Renal Network, Inc. by collecting information from a small number of dialysis facilities in the Network 9/10 area.   Every facility has different circumstances, faces different barriers and will have different processes. No process is right or wrong and may change over time. The Network has attempted to rank the most effective and efficient processes below as well as provide some resource material.

1. Gain access to hospital electronic healthcare systems or Health Information Exchange Systems.

  • Contact appropriate hospital personnel for permission to obtain access to their computer system. Designate dialysis staff to monitor hospitalization information on facility patients. The majority of necessary information can be obtained by the designated staff member. Missing information such as medications may need to be obtained by other means.
  • Access agreements are HIPAA compliant. Download sample confidentiality agreement. [PDF, 128Kb]

 

 

With electronic health records (EHRs), patient information is more readily available when needed.

 

1a. Contact state Health Information Exchange organization.   

Health Information Exchange (HIE) is the mobilization of health care information shared electronically between health providers who are giving care to an individual. People often visit different health care offices, physicians, and other providers when getting help with a medical condition. With an HIE, a patient’s information is accessible wherever the patient seeks medical care.

For more information on the development of HIE in the Network 9/10 area, go to the respective websites listed below. 

  • Indiana: Indiana Health Information Exchange. (http://www.ihie.org/)
    • ◊  Docs 4 Docs Service (DOCS4DOCS®) is an electronic results delivery service provided by the Indiana Health Information Exchange (IHIE). It offers a single source for clinical information such as lab results, radiology reports, transcriptions, pathology and hospital admissions reports, discharge and transfer reports from all participating Indiana hospitals, physician practices, labs and radiology centers. Results can be viewed through a web-based portal or delivered directly into an electronic medical record system at no cost to the provider. http://www.ihie.org/docs4docs

  • Illinoishtttp://www2. ILHIE.Illinois.gov
    • ◊  Metropolitan Chicago Health Information Exchange is the mobilization of health care information shared electronically across organizations within a region or community between health providers who are giving care to an individual. People often visit different health care offices, physicians, and other providers when getting help with a medical condition. With an HIE, a patient’s information is accessible wherever the patient seeks medical care. http://www.mchc.org

  • Ohio: http://www.healthbridge.org
  • Kentucky: http://khie.ky.gov

2. Communicate with the Nephrologists office.

  • Establish a relationship with the nephrology office staff. The nephrologist may have been sent patient hospitalization records that could be copied for the dialysis facility.
  • The office also may have access to the hospital computer system or may have a better opportunity to gain access. The office staff could then share hospitalization information with dialysis staff.

3. Utilize a clinical nurse, nurse practitioner etc (care transition liaison staff) to round on hospital patients and relay information to the dialysis staff.

  • Designate a person(s) to be responsible for communicating information to appropriate personnel.
  • Read an abstract [PDF, 29Kb] of the article on North Carolina nursing model. An excerpt [PDF, 100Kb] of this article is available from HighBeam. Neyhart, C.D., McCoy, L., Rodegast, B., Gilet, C.A., Roberts, C., & Downes, K. (2010). A new nursing model for the care of patients with chronic kidney disease: The UNC Kidney Center Nephrology Nursing Initiative. Nephrology Nursing Journal, 37(2), 121-131.

4. Utilize a care transitions form to communicate information between the hospital and dialysis facility.

5. Email /telephone/fax information between hospital staff and dialysis.

  • Establishing regular communication with hospital staff will improve information exchange.
  • Consider holding a conference call with appropriate staff to discuss patient.

6. Obtain discharge summaries and other hospital records from medical record departments.

  • Discharge summaries may be missing vital information. Missing information may need to be obtained or clarified by other means. 

7. Include the patient/and or family members in your communications!!!

  • The patient and/or family may be able to provide details on their hospitalization.
  • Regular communication with the patient or family/ caregiver may provide valuable information about the patient’s condition and keep the dialysis staff informed of their condition.

Articles

  1. Castner, Debra. Management of Patients On Hemodialysis Before, During, and After Hospitalization: Challenges and Suggestions for Improvements .Nephrology Nursing Journal, July-August 2011, Vol. 38, No.4. [PDF, 386KB]
  2. Coleman, Eric A, & Fox, Peter D. One Patient, Many Places: Managing Health Care Transitions, Part I: Introduction, Accountability, Information for Patients in Transition. Annals of Long-Term Care / Volume 12, Number 9 / September 2004. [PDF, 106KB]
  3. Hauser, N., Anderson, D. et al. A QIO-Renal Network Collaboration Experience: Addressing Care Transitions. The Remington Report, July-August 2011. [PDF, 614KB]
  4. Kripalani, S., Jackeon, A.T. et al. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Journal of Hospital Medicine, Vol 2, No. 5, Sept/Oct 2007. [PDF, 101KB]
  5. Neyhart, Clara D., McDoy, Lynn,et al.  A New Nursing Model for the Care of Patients with Chronic Kidney Disease: The UNC Kidney Center Nephrology Nursing Initiative. Nephrology Nursing Journal, March 2010, Vol. 37, No. 2. Read an abstract [PDF, 29Kb] of the article on North Carolina nursing model. An excerpt [PDF, 100Kb] of this article is available from HighBeam.

Links

  1. The following link will connect you to Care Transitions.org and multiple care transition resources. The program is led by Eric Coleman, MD, MPH  http://www.caretransitions.org/publications.asp
  2. The Colorado Foundation for Medical Care (CFMC) has a variety of resources and materials available for  care transitions improvement. http://www.cfmc.org/integratingcare/patient_resources.htm
  3. Click on the following link for a press release on the important role of family caregivers in reducing negative outcomes for patients. Family Caregiver Alliance Releases Two New Reports on Important Role of Family Caregivers in Reducing Negative Outcomes for Patients
  4. Link to Connecting the Care Continuum an article by Matthew Weinstock. Hospitals and Health Networks Daily, January 10, 2013.
  5. InTERACT is an acronym for Interventions to Reduce Acute Care Transfers. The interventions is a quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status.

    INTERACT was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS). The current quality improvement project is supported by a grant from the Commonwealth Fund, and will involve a total of 30 nursing homes in the states of Florida, New York and Massachusetts. Many nursing homes across the country are using INTERACT.

    The Interact II toolkit is a great resource to use to reduce and/or prevent acute care transfers. The toolkit was introduced during the presentation workshop "Using Adaptive vs. Technical Change to impact Quality: Reducing Re-hospitalizations and Antipsychotic Drug Use". The presentation was hosted by Kentucky Agency of Health Care Facilities (KAHCF)and presented by Senior Vice President and Vice President of Quality and Regulatory Affairs from the American Health Care Association. Link to their website: http://interact2.net/tools.html

  6. The New York Academy of Medicine (NYAM) is an organization that addresses the health challenges of urban populationswebsite. The NYAM website contains articles on care coordination including Randall Brown’s The Promise of Care Coordination. Link to their website: http://www.nyam.org/search.jsp?query=care+coordination&x=0&y=0

 

The Renal Network, Inc.
911 E. 86th Street, Suite 202
Indianapolis, IN 46240
Phone: (317) 257-8265
Fax: (317) 257-8291
Patient Line:
1 (800) 456-6919
Email: [email protected]

Last updated on: July 12, 2013