Table 1 Transitional Care Processes Assessed

Pre-discharge patient education

Patient given instructions by staff (nurses, physicians, pharmacists, social workers, etc.) about the reasons for their admission, their disease state, their medications, what they need to do at home, warning signs or red flags, who to call, follow-up, etc.

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain disease specific patient groups

3 = this process is done for all patients who meet criteria for receiving this process but is not disease dependent

Use of teach-back method with patients

The teach-back method involves having the patient or caregiver who received the teaching, explain back to the teacher what they understood in order to check comprehension of information learned.

0 = did not observe or mention in discussions

1 = mentioned in discussions or on template but not observed

2 = mentioned and observed but not consistently

3 = many patient-staff observations included teach-back

Increased emphasis on patient education about diagnoses, self-management and medications throughout hospitalization

Education delivered during hospital stay by video, group classes or one-on-one to patients in addition to standard discharge instructions.

0 = did not observe or mention in discussions

1 = mentioned in discussions but not observed

2 = mentioned and observed

3 = programs individualized to patient needs and observed consistently across multiple different staff roles

Communication of medical plans in front of patients during physician team rounds

Discussions held in patient rooms and preferably engaging patients themselves regarding diagnostic and treatment decision making and plans by inpatient staff including physician teams, nurses, and other team members. Note: In this study only physician team rounds were observed systematically.

0 = rounding in the team room

1 = bedside rounds but discussions occurring in hall way or team room

2 = almost all discussions in patient room but with physicians only

3 = multidisciplinary team discussions in patient room

Implementation of a discharge checklist

Checklist of items to be considered prior to discharging a patient such as living situation, need for prosthetic items, need for home health, availability of a caregiver, transportation needs to come back to appointments.

0 = facility does not have a checklist

1 = existence of checklist mentioned but not used consistently

2 = this process is performed consistently but only for certain patient groups such as palliative care

3 = checklist used for all patients being discharged

Assessment of readmission risk

Either calculating readmission risk with a risk calculator or assessing a list of risk factors prior to discharge if they exist (such as Project BOOST 8P)

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain disease specific patient groups

3 = this process is done for all patients and is not disease dependent.

Implementation of discharge planning rounds

Multidisciplinary meetings with physicians, nurses, case managers, social workers,

0 = facility does not perform this process

1 = inconsistently done (either frequency or coverage of only a portion of patients)

2 = done for most pts. with an emphasis on high risk

3 = done for all patients 5 days a week with a multidisciplinary team

Medication reconciliation prior to discharge

Medications are reviewed prior to discharge to insure that all medication changes (new drugs, dose change on previously prescribed drugs and elimination of drugs) are accurate in medical record..

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain disease specific patient groups

3 = this process is done for all patients who meet criteria for receiving this process but is not disease dependent.

Assignment of medication reconciliation to pharmacist

Pharmacist rather than physician or other staff member performs the above reconciliation

0 = facility does not use pharmacists to complete med rec

1 = this process is performed inconsistently by pharmacists

2 = this process is performed consistently by pharmacists but only for certain disease specific patient groups

3 = this process is done for all patients by pharmacists

Utilization of discharge/care transitions case manager

Logistical inpatient care coordination to insure that pt. leaves with equipment needed in the home, that appointments are made, that home health is ordered, that transportation to home is available. If pt. to go to SNF or NH, then additional work on funding, acceptance, and orders must be done.

0 = facility does not have discharge or care transitions case managers

1 = has case managers but not available consistently or for all patients

2 = case manager for all patients

3 = has case managers for all patients plus transitional care managers for high risk groups

Printed follow-up instructions which might include medication reconciliation, follow-up appointments, self-care tasks or action plan for management of symptoms

Pt given a printed set of discharge instructions that includes the new medication list, their follow-up appointments, self-care tasks and action plan for symptom deterioration. Presented by nurse and/or pharmacist with verbal instructions prior to leaving hospital.

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = has standardized discharge package for all patients

3 = has additional patient-centered discharge instructions for patients

Post discharge follow-up appointments to PCP and for diagnostic testing made prior to discharge

Appointments made and given to patient prior to patient leaving to go home. These could be for primary or specialty care or for diagnostic tests. Could even include appts for post-discharge telephone calls.

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain disease specific patient groups

3 = this process is done for all patients who meet criteria for receiving this process but is not disease dependent.

Direct communication with PCP or other PACT team members

Direct communication could be through “warm” hand-offs such as phone calls, secure emails, SKYPE/LYNC instant messaging or “cold” hand-offs such as notes or portions of notes designed to proactively address exactly what the PCP needs to address in follow-up

0 = discharge summary only

1 = deliberate hand offs done inconsistently

2 = deliberate hand offs done for certain patient populations

3 = deliberate hand offs done consistently across patients

Need for rehabilitation services routinely assessed during discharge planning

Inpatient physicians, case managers, nurses or pharmacists assess pts. for their potential need for rehabilitation services (PT/OT at home, PT/OT outpatient, inpatient rehabilitation or SNF). This could be done by individuals or in IDTs or medical team rounds.

0 = did not observe in IDT or mention in interviews,

1 = mentioned in interviews but not observed in IDTs

2 = mentioned and observed infrequently in IDTs and/or PTs inconsistently present

3 = PT present or calls in to IDTs and gives input

Assessment for advanced care planning (palliative / hospice)

Patients assessed for quality of life/goals of care and need for palliative care and/or hospice. Applies to patients with severe chronic illnesses such as CHF, COPD, cirrhosis, metastatic cancer, or just complex disease burden.

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain disease specific patient groups or palliative care in IDTs

3 = this process is done for all patients who meet criteria for receiving this process but is not disease dependent.

Enlisting social and community supports (home health services, Meals-on-Wheels, day care services, housing, etc.) for post-discharge care

Assessing patients’ needs at home as they recover from hospitalization and then referring to community services available to fill those gaps. Most often performed by social work. What is available varies by community.

0 = did not observe in IDT or mention in interviews,

1 = mentioned in interviews but not observed in IDTs

2 = mentioned and observed in IDTs but mostly home health and transportation but not other community services

3 = mentioned and observed both home health and other community services

Post-discharge patient hotline available?

Providing number to patient to call 24 hours a day with questions or concerns post-discharge. Usually manned by nurses.

0 = no hotline

1 = hotline but not staffed by nurses

2 = hotline staffed by nurses and put in every discharge instruction notes

3 = hotline staffed by nurses with physician back-up

Post-discharge home visit available?

Facility offers transitional care programs that can, when deemed appropriate for high risk patients, provide home visits by a VA provider (NP, PA or MD). This is different from contracting for home health care.

0 = not available at this facility

1 = availability inconsistently or low capacity to do home visits

2 = home visits performed consistently but only for certain high risk patient groups (Ex.: age > 75, 3 or more admissions in last year)

3 = home visits available on referral with less restrictive criteria (larger capacity)

Post-discharge phone call from hospital (who, time frame)

Staff member associated with the discharging specialty calls the patient regarding their status, questions, concerns post-discharge.

0 = facility does not perform this process

1 = this process is performed inconsistently

2 = this process is performed consistently but only for certain patient groups (such as moderate to high risk for admission)

3 = this process is done for all patients who meet criteria for receiving this process but is not disease dependent.

Post-discharge phone call from PACT team

Phone call from PACT team member (usually nurse) regarding their status, questions, concerns post-discharge. VA performance measures include need to have patient’s PACT team or surrogate call NOT just any primary care staff and that it occur within 2 business days after discharge.

0 = facility does not perform this process

1 = < 60% completion rate

2 = 60- < 70% completion

3 = greater than or equal to 70%