The Care Transitions Intervention developed by Eric Coleman at the University of Colorado uses “transitions coaches,” primarily nurses and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls. Another proven transitional care model, developed by Mary Naylor and colleagues at the University of Pennsylvania, employs advanced-practice nurses to coach patients and their caregivers, coordinate follow-up care plans, and provide regular home visits and round-the-clock support by phone.
Although these models have been adopted by hundreds of hospitals, it is frustrating that they aren’t more widely utilized. Fortunately, one of the reform strategies in the Affordable Care Act, the formation of accountable care organizations, should spur health systems to adopt these models.
The Centers for Medicare and Medicaid Services has established 33 quality measures for accountable care organizations, some of which deal with the patient-caregiver experience. Earlier this month, Medicare announced that, starting in January, it will pay doctors for care coordination services when transferring patients to skilled nursing facilities.
But will these measures go far enough? I’m skeptical. For example, the patient/caregiver experience is a broad measure that includes how well doctors communicate; it implies a verbal exchange or discussion of information. In our case, technically, we were “communicated with,” but the communication was far from adequate.
Providing patients with written instructions before they’re discharged from a hospital is not a sufficient indication that a patient’s care has been “coordinated” or “managed.” True coordination and management requires ongoing communication between patient and provider and among multiple providers. Patients and their families need to participate actively in these processes at all stages, including needing to know what to do if conditions worsen when they are home.
A long-term relationship
Experiences such as my family’s offer guidance on what’s needed to get so-called patient-centered care right. We need to ensure that this care is part of a long-term relationship in which patients have a specific point of contact with a team of providers, and that this team is accountable to those patients and responsible for coordinating their care. Patients and their families need access to information and experts around the clock.
This could be accomplished in small practices with a designated on-call provider who has access to electronic health records, or by call centers staffed by registered nurses with access to the records. Registered nurses seem to me like the group with the right training for the job, but I also believe that getting it done properly is more important than which profession does it.
At the heart of this coordination is assessing patients’ and families’ capability. We should never assume that they can do it all on their own. When people are in hospitals, they’re sick and vulnerable. That doesn’t necessarily change on the day they’re discharged.
Swan is dean and professor at the Jefferson School of Nursing at Thomas Jefferson University in Philadelphia. This article was excerpted from the Narrative Matters section of the journal Health Affairs and can be read in full at