Table of Contents
Introduction
Part 1: Issues in Transitions of Care
Chapter 1: Communication Challenges Between Caregivers
Between Primary Care Physicians and Other Physician Specialties
Between Primary Care Physicians and Hospital-Based Caregivers
Between Hospitalists and Other Physicians or Other Service Units
At Physicians’ Transfer of Complete or On-Call Responsibility
Between Anesthesiologists and Postanesthesia Recovery Room Nurses
At Nursing Shift Changes
Between Nurses and Physicians
Between the Emergency Department and Another Department or Unit Within the Hospital
Between Emergency Department Physicians and Internists
Between Emergency Department Nurses and Receiving Nurses
Between Two Separate Care Settings
Between Hospital and Home Care
Between Hospital and Long Term Care or Rehabilitation Facilities
Between Hospital Emergency Departments and Nursing Homes
Between Psychiatric Hospitals and Community Care Facilities
Within Specific Types of Nonhospital Settings
Behavioral Health Care
Long Term Care
Home Care
Throughout a Cycle in Which a Patient Makes Multiple Transitions Between Home and Health Care Organizations
References
Chapter 2: Patient Experience, Participation, and Understanding of Condition
Inadequate Patient and Family Preparation at Discharge
Low Health Literacy
Language Barriers
References
Chapter 3: Medication Errors
Medication Reconciliation Issues
Medication Administration Issues
Medication Adherence Issues
Medication Costs
Lack of Social or Other Outside Support
Ineffective Communication Between Provider and Patient
References
Part 2: Solutions for Coordinating and Standardizing Communication During Transitions of Care
Chapter 4: Tools Applicable to Communication at Any
Transition Point
Tracer Methodology
Ambulatory Care and Office-Based Surgery
Behavioral Health Care
Hospital and Critical Access Hospital
Home Care
Laboratory
Long Term Care
The Situation–Background–Assessment–Recommendation (SBAR) Technique
Implementing SBAR
Transition Scenarios Using the SBAR Technique
The Transitional Care Model
Transitions of Care Checklist
Standard Operating Protocol for Bedside Handover
Standard Operating Protocol for Whiteboard Communication
Use of Technology to Streamline Transition Processes
Solutions That Work in Paper-to-Technology Types of Transitions
Institute for Quality at DeKalb Medical Center, Decatur and Hillansdale, Georgia
Health First, Rockledge, Florida
Wan Fang Hospital, Taipei, Taiwan
Al Ain Hospital, United Arab Emirates
National Skin Centre, Singapore
Medication Reconciliation Policies and Procedures
Compiling the Medication List
Reconciling Medications with New Orders
Communicating the List at Discharge or Transfer
Contingency Planning
Educating Patients About Medications at Discharge
Patient Education Tool: Help Avoid Mistakes with Your Medicine
Ways to Address Health Literacy Issues
Appropriate Communication for Patients’ Age and Development
Communicating with Patients with Limited Comprehension and Reading Skills
Communicating with Patients with Limited English Proficiency
Patient Education Tool: Understanding Your Doctors and Other Caregivers
Tool for Improving Health Communication
References
Chapter 5: Communication in Specific Situations
Between Primary Care Physicians and Other Specialty Care Providers
Between Hospitalists and Other Physicians or Service Units
At Physicians’ Transfer of Complete or On-Call Responsibility
Between Anesthesiologists and Postanesthesia Recovery Room Nurses
At Nursing Shift Changes
Between Nurses and Physicians
Between the Emergency Department and Another Department or Unit Within the Hospital
Between Two Separate Specialty Care Facilities
Hospital and Long Term Care
Hospital and Home Care
Between Specialty Care Provider or Primary Care Physician and Pharmacy
At Discharge from Hospital
Patient Continuity of Care Questionnaire
Patient Education Tool: Planning Your Follow-Up Care
Within Specific Types of Nonhospital Settings
Behavioral Health Care
Long Term Care
Home Care
References
Chapter 6: Monitoring and Evaluating Transitions of Care
Conducting a Failure Mode and Effects Analysis (FMEA) on Transitions of Care
Studying Transition-of-Care Processes
Determining Root Causes
Implementing Improvement Initiatives
Sample FMEA: Psychosocial Assessments in Behavioral Health Care
What to Look for When Monitoring Transition-of-Care Processes
The Care Transitions Measure
Performance Improvement Methodologies
Six Sigma
Lean
Lean Six Sigma
Work Out
Change Management
References
Chapter 7: Case Studies on Transitions of Care
Project RED
Project BOOST
Oncology Care at the Interface Between Hospital and Community Care in Israel
U.S. Veterans Affairs Shift Handoff Tool
Putnam Hospital Center’s Anticoagulant Therapy Program
Improving Communication Between Home Health Agencies and Health Plans
University of California San Francisco’s Home Health Care Referral Process
Developing and Evaluating a Classroom-Based Intervention to Improve Communication Among Staff Members in a Danish Hospital
Transition from the Hospital to Home Health Services in Qatar
References
Index