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90-day transition plans: a safer journey to living safely at home

(Original Source:

By David Baiada


Transitional care is complicated. For any patient, the journey from acute hospital stay to living safely at home is fraught with hundreds of complex and interdependent variables. Discharge is just the first step on this journey, yet the health care providers that participate in transitions are primarily focused on discharge plans (which are really a way to get someone “out of my care and into yours”). A better route is the 90-day transition plan, which provides a road map families can follow through the maze of post-acute chaos to independence at home.

A familiar story

Anyone who has spent time in the transitional care field knows a story like this one: A client is admitted to the hospital for the third time in a year—in this case for exacerbation of heart failure (HF). She wants to go home, so her case manager provides a list of home health agencies (HHAs) — which would be helpful, except that many are no longer in business and the list includes no information about each provider’s ability to manage a successful transition. Suddenly the family decides that the client will go to her daughter’s house, but that house isn’t ready yet. They agree instead that the client will regain strength in a sub-acute setting, so she is discharged to a skilled nursing facility (SNF) with a lot of confusing paperwork, pamphlets about HF, and a few new medications (despite some confusion about what pills she’s already taking).

After 10 days of rehab at the SNF, she receives a new list of HHAs from her social worker. The list is based only on the social worker’s personal relationships and experience, rather than proven outcomes and capabilities. The client picks a home health provider and is discharged to her daughter’s house.

Day 2: While the client is being bathed, the home health nurse (RN) shows up without an appointment. It’s not a convenient time for the family, so she leaves.

Day 3: The RN returns and engages the family in developing a care plan that includes continued teaching about HF risk factors. She also gathers all the medications from the client’s purse and the hospital bag, plus the new scripts from the SNF, and puts them on the kitchen table. (WOW, what a confusing pile of pills!) When the RN calls the client’s primary care physician (PCP) to discuss and reconcile the medications, she learns that the PCP hasn’t seen the client in 18 months and didn’t know the client had been in the hospital. The PCP and RN have a quick chat to determine appropriate medications and verify the RN’s care plan, which will include three visits per week for three weeks, and also continued physical therapy (PT) at home.

Day 4: The PT calls to tell the client he’ll be making a home visit on day six. This worries the daughter because her mom is starting to lose some of the strength she regained at the SNF. The daughter calls the SNF social worker and the hospital case manager for advice. They explain there’s not much they can do, as therapy staffing can be very difficult for home health agencies, even if they promise quick availability.

Day 5: Forgetting the RN’s advice, the client has a bowl of chicken soup for dinner. When she starts to experience some edema in her ankles, she calls the home health agency to talk to the RN, but gets their answering service. After 15 minutes no one has called her back. She calls her PCP, but can only talk to the physician on call (who isn’t familiar with her care). Given the status of her HF exacerbation, the on-call physician recommends that the client go to the emergency department. She is admitted for a hospital stay to get her heart failure symptoms back under control. And so the cycle continues…

A safer solution

As we collaborate with over 1,000 acute and sub-acute facilities from coast to coast, helping to facilitate transitions for more than 10,000 clients each week, BAYADA Home Health Care has a unique opportunity to view incidents of success and failure. What we see most often are great people with good intentions, who work hard to help clients and families during periods of crisis. But the multiple handoffs, along with unpredictable and changing environmental, social, and clinical variables, make it very difficult to achieve consistently successful transitions.

Recognizing these challenges, the Alliance for Home Health Quality and Innovation has compiled current research and best practices to identify the five core elements of an effective Care Transition model. Any transitional care plan should include these five components:

  1. Patient-centered focus
  2. Medication management
  3. Communication and care coordination
  4. Timely follow-up by the health care team (including the primary care physician and home health agency)
  5. Patient-activated education and coaching

We agree that these five elements are essential to any post-discharge care plan. Additionally, what BAYADA has learned in nearly four decades of home health care experience is that industry-wide change is needed to achieve optimal results in transitional care.

First, discharge plans must be replaced with 90-day transition plans. Handoffs from one provider to the next in the chain of care are often insufficient, and more importantly, they can be confusing to the patient and family. Providers must come together to develop an effective transition plan, initiated at the hospital bedside, that coordinates services from all players in the process. The plan must include:

  • Clear assignment and communication of each provider participating in the plan (i.e. hospital, SNF, skilled HHA, non-skilled HHA, and others as needed), and confirmation that the client/family were given a choice of providers consistent with all regulatory requirements
  • Clear and correct contact information for each participant in the plan, including the above providers, plus physicians, pharmacy, insurance company, and other community resources

Next, preferred providers should be established based on service level commitments and performance. Personal relationships are no longer enough; our shared clients and families expect high-quality services, and our outcomes are increasingly driving reimbursement. The following steps help ensure high-quality service:

  • Preferred providers meet quarterly to review data, process, and goals
  • Monthly reporting of clients re-hospitalized within 30 days
  • HHA services initiated within 24 hours for at least 90% of clients
  • HHA ensuring PCP appointment within 14 days after arriving at home

The future of health care requires that we reframe the transitional care experience. Successful collaboration between providers participating in the journey of transitional care is critical to producing great outcomes, reducing costs, and supporting clients and families throughout a very challenging time in their lives. At this important moment in time, we should work together to transform the transitional care experience by developing more integrated preferred relationships focused not on simple discharge handoffs, but on comprehensive transition plans that guide shared clients through the continuum.

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