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Healthcare Professionals Seek to Improve Transitions of Care, Reduce Avoidable Readmissions

More than 200 individuals representing various healthcare settings, including ambulatory care, acute care, home health, and long-term care, attended Transitions of Care: Improving Care Across Settings on Nov. 2. Based on the conference’s success, an additional event has been scheduled for next month to further the work of the group.

During his presentation, entitled, “Infusing True Person-Centered Care into Improving the Quality of Transitional Care,” keynote speaker Eric A. Coleman, MD, MPH, University of Colorado at Denver, identified seven key strategies for effective transitions of care:

• Foster greater patient engagement
• Elevate the status of family caregivers as essential members of the care team
• Appreciate the culture, strengths, and limitations of acute, post-acute, and long-term care settings
• Define accountability during transitions
• Build professional competency in care coordination
• Implement strategies to improve cross-setting communication
• Align financial incentives to promote cross-setting collaboration

Following his presentation, Coleman moderated a panel of regional providers as they discussed tactics they use to reduce heart failure readmissions and improve the transitions of care. Regional panelists included:

• Deborah Adams, BSN, MSO, Director, Community Services & Supports Department, Western Reserve Area Agency on Aging
• Jennifer Andrey, MSN, CNP, Director, Cardiac Program Development, Cleveland Clinic Western Region
• Lisa Kristosik, RN, BSN, MSN, Director, Home Health, Visiting Nurse Association of Ohio
• Sharon Mack, MSN, ACNP-BC, CHFN, IA, Nurse Practitioner, Certified Heart Failure Nurse, MetroHealth Medical Center.

During lunch, attendees participated in a facilitated discussion utilizing questions suggested by Dr. Coleman, with the objective of creating a dialog based on topics related to various stages of transitions of care.

Participants used their expertise to guide the table discussion on topics including:

• Effective teaching and enhanced learning
• Assessment of post-hospital care follow up
• Real-time handover communications
• Timely post-hospital care follow up

As the discussions concluded, each group recorded their top two priority areas that need to be addressed to improve transitions of care and reduce avoidable hospital readmissions.

By the end of the event, more than 80 attendees expressed interest in participating in multi-stakeholder workgroups to integrate effective strategies in care transitions across Northeast Ohio to reduce avoidable hospitalizations and rehospitalizations and improve care coordination across settings.

This event was sponsored by The Center for Health Affairs and Better Health Greater Cleveland, and funded by the Robert Wood Johnson Foundation - Aligning Forces for Quality.

A follow-up event is scheduled for Dec. 7, and will feature keynote speaker Mary Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology, Director of NewCourtland Center for Transitions & Health, University of Pennsylvania School of Nursing. At this event participants will identify the ten essential elements of the Transitional Care Model and describe the impact of evidence-based transitional care for chronically ill older adults. Attendees will also learn the role of home care in reducing readmission, as well as effective patient teaching and learning strategies to improve care transitions and reduce hospital readmissions.

For additional information on the Transitions of Care Collaborative, or the Dec. 7 follow-up event, please contact Linda Neiding at 216.255.3666 or linda.neiding@chanet.org, or Lisa Anderson at 216.255.3660 or lisa.anderson@chanet.org.

To a view a photo album from the event, visit NEONI’s Facebook page.