When I first started in the field of transitional care several years ago, I was curious what the world saw as transitional care in healthcare. So what better way to find that out than a Google search right? Can you guess what my Google search returned? In healthcare and medicine ‘transitional care’ was typically thought of as taking care of a patient from childhood, through adolescence to adulthood, with a focus on the adolescent stage. A transitional care specialist was then, essentially, a late puberty physician specialist. My children are 11, 14, 16, and 19 years old, so I think I qualify.
Things have certainly evolved in the past 5 years. A Google search on ‘transitional care’ now produces a completely different set of results. Transitional care is now recognized as healthcare delivery across the continuum, between locations, such as from an acute care hospital to home. Sounds simple enough, right?
If ‘transitional care’ is assisting patients or more appropriately caring for patients in between locations, what is that really? What does that mean for patients, doctors, hospitals, healthcare systems?
As I contemplated this and reflected what I have seen, I realized the market does not have a grasp on this yet, far from it.
Is transitional care:
- A committee?
- An institutional ‘program’?
- Data collection?
- Data sharing?
- A marketer renamed?
- A call center?
- Care coordinators pieced together from those representing their own organization’s interest?
- Providers talking to providers?
Part of the problem I see is the market doesn’t even really know what ‘transitional care’ is. It appears organizations, doctors, healthcare systems, payers all view this differently through their own ‘transitional care’ goggles. This has resulted in just as many approaches to tackling the problem.
What is the problem? Again, depends who you ask.
For the patient this means, spotty communication on what their path to recovery will look like. Who, what, when, why and how that will that take place? This also means disjointed care and complex systems with multiple people ‘looking out’ for the patient, still unable to coordinate effectively.
For physicians this means trying to ‘know’ everything about your patient across systems that don’t communicate with each other and working within healthcare systems who are trying to figure this out themselves. This also means receiving a reimbursement penalty for not being able to do this effectively when we don’t have the tools or structure in place.
For healthcare systems this means readmission penalties and bottom line headaches with one foot still in ‘fee for service’ and the other in ‘alternative payment models’ and working to survive within both of these two completely different worlds.
So it is no surprise the ‘solutions’ are as varied as the views of the problem. Solutions are coming from all angles: Administrative, entrepreneurial, technology based, marketing, and clinically to some degree.
I picture each of these areas in the market standing in line at a birthday party waiting to take their swing at the transitional care pinata. The physician in this analogy is being told how, when, where and why to swing by all of his friends shouting in his ear resulting in the dreaded complete miss, total air swing, and probably accidentally hitting his grandma watching innocently on the sideline.
Imagine the effectiveness and force of the swing with a coordinated effort. Candy for all, but the real winner is the patient.
To compound this, the problem is so severe that most measures taken right now are billed as ‘effective’ because they do make things better than they were, in some ways, but create new problems in others. Much work remains in providing effective transitional care for patients.
Here are what I feel are essential features of successful transitional care:
- It is actually care. Patient care. This means the patient comes first and it is clinical in nature. This means providers, people, not institutions are the means of delivery. This means physicians, yes, physicians need to be involved, as well as nurses, therapists, and others. It is not an institutional concept of committees, quality improvement and data sharing. These facilitate, and provide a framework for transitional care, but should never be billed or thought of as transitional care.
- Communication. There is no replacement for providers communicating with providers. There are tools, programs, clerical positions that can facilitate this, but will never replace a provider communicating with another provider. Even more effective, I’ve found, is actually setting aside the time to speak with providers face to face. An astute provider will immediately recognize…”I don’t get paid to do that.” There are two problems here that warrant a more in depth discussion and I will go into more detail in other writings: 1. Systems, again, are not designed for this. 2. Providers are not trained to think this way.
- Community based collaboration. Providers and institutions, including and especially post-acute businesses and providers have to collaborate. Post-acute markets vary widely. However, no matter the market, clinicallycollaborating is essential. Administrative meetings and data sharing are valiant efforts, but until we collaborate clinically, the patient fares no better and providers will remain functioning in their individual silos. I have seen the care and passion of providers and organizations within communities. It is invaluable and irreplaceable for this to happen at the community level.
While improving transitional care may appear complex and reflect the pitfalls of our current system, it has to be tackled for the sake of patients and providers. Programs such as LePont’s Bridge transitional care program tackles each of these essentials head on. I love seeing innovative technology, but it will never replace and should always be designed to facilitate the patient-physician relationship and support a clinical program. In addition, patients need to be educated appropriately. They deserve this! Finally, providers need to be trained to think differently. Training curriculum and inservice training needs to be geared and structured with these principles in mind. Together we can improve transitions of care for patients so patients heal faster with fewer complications and get back to function. Providers again feel they are making a difference and institutions satisfy fiscal obligations. We will be providing better care for less cost, true value-based care.