Empowering family caregivers assures successful acute care transitions

JHQ is the peer-reviewed publication of the National Association for Healthcare Quality (NAHQ). The current issue is devoted to an increasingly significant concern in healthcare quality management -- how to assure favorable outcomes when transitioning patients from one clinical environment to another or to the home.

According to JHQ Editor Maulik Joshi, DrPH, transitions in care can be broadly defined as practices implemented across the continuum of care, such as within a healthcare delivery organization, across settings (e.g. acute to post-acute) and within a community or population. "The critical benefits of successful care transitions are preventing hospital readmissions and reducing health care costs," said Joshi.

"Because family caregivers contributions often go unrecognized, there is relatively little attention to their needs and consequently even less guidance for how to best incorporate their voice and preferences to more formally engage them at times of care transitions," said lead author Eric A. Coleman, MD, MPH, professor of medicine and director of the Care Transitions Program at University of Colorado Anschutz Medical Campus.

In the JHQ study, 83 patient-family caregiver teams were studied following discharge from a Colorado acute-care hospital. They participated in an enhanced Care Transitions Intervention (CTI). The enhanced CTI is a four-week intervention by Transition Coaches (social workers or nurses) composed of a hospital visit, a home visit and three follow-up telephone calls.

"Transitions Coaches encourage patients and family caregivers to take a more active role in their care, better articulate their needs, and improve their ability to meet those needs," Coleman explained. "They also help patients and caregivers respond to common challenges in medications management, use of a patient centered personal health record, timely follow up with primary care providers, and ability to respond to red flags that may indicate a worsening condition."

Results of the study showed that using the enhanced CTI significantly improved medication safety, collaborations with transition coaches in resolving discrepancies and errors, and being confident in taking responsibility for implementing the discharge care plan.

"With high levels of satisfaction, the enhanced CTI model appears to have applications to local and national efforts aimed at improving the hospital transition experience," said Coleman.