Improving Transitions in the Care of Older, Hospitalized Patients

Funded by: Commonwealth Fund of New York
Project Period: 5/04 - 12/05

Improving the coordination of post-hospital care for elderly, chronically ill patients has proved difficult. A major reason is the dearth of quality-of-care measures to help pinpoint problems that occur during the transition from one site of care to another. This project will refine and test the Care Transitions Measure, a tool that assesses problems in care coordination from the patient’s perspective so that hospital systems can develop targeted solutions. An advisory committee representing organizations involved in furthering quality improvement at the health system and policy levels will provide guidance in the refinement and testing processes, and later will promote the measure’s use by health care providers.

Background: Care for patients who have been discharged from the hospital is seriously compromised by gaps in communication among patients’ multiple health care providers and between providers and patients. Poorly coordinated care—especially for elderly people with chronic conditions—jeopardizes patient safety, creates stress and uncertainty for patients and their families, and, too often results, in rehospitalization and higher costs. In the absence of reliable measures to assess problems related to transitional care, this critical aspect of health care delivery will continue to be ignored.

The Project: Under the direction of Eric Coleman, M.D., M.P.H., associate professor at the University of Colorado Denver, Divisions of Geriatric Medicine and Health Care Policy and Research, this project will refine and test the Care Transitions Measure, a tool developed by Coleman and colleagues to assess, from the patient’s perspective, problems that occur as patients transfer between different health care settings (e.g., from hospital to home, primary care office, or nursing facility) or different levels of care within the same facility. Project staff will seek to determine whether hospitals can use this tool, which currently exists only as a prototype, to characterize deficiencies in care for elderly, chronically ill patients following their discharge so that future interventions can be developed.
Coleman and colleagues will collaborate with a team of researchers and clinicians at PeaceHealth, an integrated health system with locations in Alaska, Oregon, and Washington. Project staff and PeaceHealth will pilot-test the Care Transitions Measure, then design and implement interventions based on the information the measure provides. An advisory committee representing regulatory agencies, credentialing and quality improvement organizations, policymakers, and hospital trade associations will provide guidance for the instrument refinement and testing processes and, later, will promote the measure’s use by other health care providers.
Project staff will develop a variety of written materials to guide hospitals in using the measure, calculating scores, and implementing targeted interventions. Papers will be submitted for publication by peer-reviewed journals and the Fund. Coleman and his team will also present their findings at national conferences.

Expected Outcomes and Risk: This project will help fill a void in provider performance measurement. With this tested and validated instrument, hospitals will be able to identify specific problems in the transitional care for elderly, chronically ill patients, allowing them to develop tailored interventions for improving care coordination.

Key Staff: Coleman, Parry, Min, Chalmers, Schoen