Transitions of Care: It's All About the Patient

Michael Sequeira , MD, FACEP

Director of Quality and Performance for Risk

Published November 09, 2013

I call them the "gray zone" patients.

Often they're medically frail, elderly, living alone. They come to the emergency department (ED) because they've gotten weaker and weaker — maybe from dementia, maybe from dehydration.

As we do the workup, we look for a severe electrolyte abnormality or other indicators that would allow Medicare to cover their admission. Sometimes we don't find them. They're not sick enough to be admitted, but we hate to send them home.

Would a nursing home help? Probably. But under current regulations, Medicare won't pay for that either unless the patient's been in the hospital for three days.

It's during cases like these where I fully appreciate the hospice philosophy. What gray zone patients need is personalized care and advocacy that follows them from setting to setting. I can't put my dehydrated patient in hospice, but I'd love to find a similar program that can fill in the gaps in our fragmented system.

The ACA set out to address this problem, but with a focus on venues rather than patients. One thrust of healthcare reform is to create integrated, multi-specialty groups based around disease processes (heart attack, pneumonia and so on). In theory, this will help patients get appropriate care faster and facilitate transitions between settings.

And it isn't happening overnight. The ACA does little to address the very real regulatory barriers to integration. What's more, hospitals and physician groups don't always see integration as worth the effort — or even in their best interests. Thorny issues remain around competition, culture and payment.

Meanwhile, at one of the hospitals where I practice, we have four different medical groups admitting. Dealing with all of them, plus the radiologist and the sub-specialists requires a lot of time and energy. And for now, I'd say that's more or less the norm.

So what's the alternative? How can we overcome system fragmentation to deliver the right care at the right time?

Turns out Palo Alto Medical Foundation is doing just that. They've developed a transitional care program that assigns each patient an advocate (generally a physician or advanced practitioner). The advocate follows the patient across the entire continuum of care — from the emergency department to the hospital to the nursing home and then home again — coordinating appropriate care.

The idea of patient-focused transitional care appears to be slowly catching on. Similar programs are currently being piloted at Vituity sites. The University of Pennsylvania School of Nursing is working to disseminate the Transitional Care Model, a similar program for older adults with chronic conditions. And the State of Oregon's Coordinated Care Organizations have done a great job helping ED "frequent flyers" access more appropriate care.

Under these models, an advocate would meet my fragile patient in the emergency room and participate in the patient's evaluation. They'd get a jump on exploring options from home health to next-day follow-up to alternative nursing home coverage (some Medicare Advantage programs might fill the insurance gap). They'd make the necessary arrangements and facilitate communication between the parties involved.

In cases where the patient is admitted, the advocate works with the patient, family and medical team to plan for a safe and effective discharge. Once the patient's back home, the advocate continues to follow up, conducting medication safety evaluations and even accompanying patients to their follow-up appointments.

Some health systems have shied away from transitional care programs because they worry about the financial impact. But the numbers say otherwise. The Palo Alto Medical Foundation estimates that it saved over 25 percent in costs, and it saw a significant reduction in readmissions as well. Studies of the Transitional Care Model show that it saves the health care system an average of almost $5,000 — or 38 percent — per year per patient. (And that figure includes the cost of the advocate.)

It's a powerful concept. After all, if we can deliver high-quality care across the continuum by focusing on patients, integration can wait. Pairing each patient with an advocate involves far less hassle and expense than forging uneasy organizational alliances. Plus the advocate delivers what venue-focused interventions can't: responsive, patient-centered care.

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