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Transitions Between Care Settings

Key Findings

The thrust of ACCC's "Transitions Between Care Settings" project points to the underlying reality that the patient is moving between two important settings of care, i.e., the hospital inpatient setting and the outpatient oncology care setting, that are generally operated by two separate organizations, often without common information systems, and sometimes with only limited shared information. The overarching challenge, then, is to move two distinct organizations to share information and manage the patient during the interim (i.e., the transition), with neither being fully in charge, receiving compensation for the effort, or sharing financial risk.

Another challenge identified in our study is that the patient, once home, is in a new reimbursement environment. Prescriptions and chemotherapy that may have been covered completely in the hospital may not be covered as well at home, which may lead to treatment interruptions or prescriptions going unfilled. Part of the transition task is to help the patient identify the drugs needed (changes may have occurred as a result of the hospitalization) and how these can be paid for, whether by the patient out-of-pocket, through insurance, or by some other means.

Hospitals

• About 85 percent of responding hospitals have a function (or team) assigned to manage the oncology patient transition between care settings. However, only 55 percent of hospitals have a written policy managing the general patient’s transition, and just 3 percent have a policy that relates specifically to the oncology patient’s transition.
• Most hospitals (93 percent) have a usual (or formal) process for contacting the oncologist’s office when a patient is admitted for oncology-related treatments, but far fewer (66 percent)have procedures in place for making the contact when the patient is admitted with cancer as a secondary diagnosis.
• After discharge, hospitals are not very likely to communicate with oncology patients to confirm follow-up appointments have been scheduled or met (only 18 percent do so), or to check in (through a clinician phone call) on how patients are doing more generally (33 percent).
• A low percentage of hospitals have policies in place to monitor the results of a transition. Only 30 percent conduct a follow-up telephone survey and only 17 percent monitor readmissions for transition-related issues.
• Almost 90 percent of responding hospitals have computerized prescription order entry (CPOE) systems, but the operationalization of those systems for the oncology patient transition is far from complete. Respondents indicate that their CPOE systems are likely to offer a reconciled drug listing (60 percent), be accessible by community oncologists (63 percent), have an e-prescription capability (63 percent), and include chemotherapy drugs. However, the home drug inputs to the systems may not be complete. Only 12 percent of hospitals can access a prescription database for home drugs, and only 38 percent follow up with pharmacies when they suspect the list is not complete.
• Most hospitals and oncology practices have fairly effective medication reconciliation procedures in place. The challenge is to take the extra confirmatory step when needed to call the patient's physician or pharmacist to assess which drugs the patient is taking at the time of entry into the hospital or community practice. Almost all hospitals attempt to determine which drugs the patient is taking, but most rely almost entirely on having the patient or family member tell them what the drugs are, their dosages, and prescribed use.
• Most hospitals (80 percent) now have inpatient electronic health record (EHR) systems, and those systems are used extensively to help manage the patient transition function. Among hospitals with EHR systems, 84 percent can be accessed by admitting oncologists from their home or office, but only 35 percent of hospitals with systems report that they can transmit EHR data to independent oncology groups, and only 32 percent automatically forward a discharge summary to independent groups (although 70 percent can fill the discharge summary from the medical record).

Oncology Groups

• Hospital notification of the oncologist when his/her patient is admitted to a hospital by another physician appears to occur "almost always" in less than half of the groups. This notification is a key input to an effective transition process. In addition, about 60 percent of the responding oncology groups take proactive steps to determine whether their patients have been admitted (by checking the electronic health record or the hospital lists).
• About half of the responding oncology groups have designated staff (clinical or administrative) to manage the patient transition after hospital discharge, and most (more than 60 percent) do follow up on or make the post-discharge office appointment. However, few oncology groups have implemented specific policies or checklists to help manage the patient transition.
• Medication reconciliation activities seem to be fairly advanced. Almost 80 percent of the groups engage in medication reconciliation (led by a nurse or pharmacist), and about three in four oncology groups have a CPOE system. About half of the groups can use their CPOE to electronically transmit prescriptions to the pharmacist, but only a small number can use the system to access external prescription databases.
• More than 80 percent of groups indicate that they receive medication lists at discharge from the hospital. The most common way groups access or receive those lists is through the hospital’s electronic health record and by facsimile or email.
• Despite having CPOE systems, most groups performed fewer than half of the 11 medication reconciliation activities identified through the survey questions, suggesting that certain capabilities within CPOE systems are not being used, or do not yet have full linkages to the hospital systems.
• Almost all oncology groups obtain the hospital medical records and discharge summaries, and place that information in the patient’s office chart, but only about one in four groups had a nurse or other clinician review and flag the records for special attention by the oncologist.
• The oncology groups' in-house EHR systems did not appear to have strong capabilities (or operationalized uses) that tied in to the patient transition. Most oncologists who admit to a primary hospital have access to that hospital's inpatient and outpatient EHR (about two-thirds or more have such access).
• Management of the patient transition depends primarily on EHR systems in place at the hospital, and to a much lesser extent depends on complementary EHR systems used by the oncologists and their staffs at the group offices.

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This educational program is made possible through an educational grant from
Eisai Inc.

Health2 Resources provided strategic advisory services and analysis for this project.