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New Perspectives on Improving Transitions in Care

An educational program developed by Joint Commission Resources, with financial support from Astellas Pharma US, Inc.

When patients transition from hospital to home or other care settings, they are at risk for communication breakdowns that can adversely affect their health and often result in their readmission to the hospital again. This educational program was developed to provide the latest information on solutions that health care organizations can adopt to improve the transition from hospital to home or other settings and prevent patient harm that results from breakdowns in the transitions process.

Program 1:  Transitions in Care:  Creating the Burning Platform


This presentation describes categories of adverse events that occur at the time of hospital discharge that can lead to avoidable hospital readmission using case-based scenarios and review of relevant published studies. National all-cause readmission rates are highlighted as well as federal initiatives to reduce avoidable readmissions. The essential elements and the impact of hospital-based and post-acute, community-based readmission reduction programs are reviewed. The importance of social factors that impact readmissions are discussed. Data describing important patient-centered outcomes and the emerging role of family caregivers in the transition from hospital to home is described. Finally, Dr. Jack will present an example of how information technology can be used to provide patients with information needed for successful care transitions.

Speaker:  Brian Jack, MD, Professor and Chair of the Department of Family Medicine, Boston University School of Medicine and Founder, Project Re-engineering Discharge (RED)


Program 2: Partnering with Patients & Families to Support Transitions of Care

This presentation will highlight broad and significant policy changes and structural changes which have affected health care in the recent past that have resulted in powerful impacts on transitions of care. Ms. Levine will describe what it means to patients, caregivers and providers when patients transition from hospital to home and will discuss techniques that can be adopted for everyday use to make transitions smoother and more effective for all involved parties. 

Speaker:  Carol Levine, Director of Families and Health Care Project at the United Hospital Fund, New York, NY


Program 3:  Getting It Right:  The Medication Challenge in Transitions of Care


Medication issues play a significant role in less than optimal care transitions. Failure to take medication, as directed, is a not uncommon occurrence, either due to a lack of understanding or a lack of motivation, and can result in a disruption of the find balance between a stable and unstable state of health. This presentation will describe the research which has demonstrated the significance of medication issues which can disrupt the transition from hospital to other care settings and the significant toll it has on the health of the patient. Medication reconciliation is an important strategy to improve communications about medications between health care provider and patient, but is complex and not always successfully performed. Dr. Kliethermes will present an important perspective, from her experience and research, how to communicate with patients more effectively about their medications and how to improve the medication reconciliation process.

Speakers:  Mary Ann Kliethermes BS, Pharm.D, Professor and Vice-Chair of Ambulatory Care , Chicago College of Pharmacy, Midwestern University  and Jeannell Mansur, Pharm.D., FASHP, FSMSO, Principal Consultant, Medication Management and Safety, Joint Commission Resources

For complimentary access to these three programs, please complete the information below and click the submit button.