Transitions in Care: How Problems Arise & How You Can Prevent Them

An 87 year old client of ours recently moved from a private sector nursing home to one in the public sector. Three weeks she told us that no one had conducted her weekly blood tests yet. These are critical tests for monitoring the effectiveness of a particular medication on this client. If the levels of the medication are found to be too high, the medication will become toxic to her; but if the levels are too low, other medical problems could result. To resolve this issue, we contacted the Director of Care who scheduled a blood test immediately.

The story above is an example of problems in communication which may occur in transitions of care, during which an individual moves from one location, where care or support is being provided, to another. In transitions of care medical records are gathered,collated, sent and received. Faulty communication can occur during any part of that process and can cause illness, hospitalization or in some cases, death.

Care givers should be attentive to the proper transfer of information during them the following eight major types of transitions of care:

1. Home to Hospital
2. Home to Seniors Residence (including independent housing, assisted living, and nursing homes/care facilities)
3. Hospital unit or floor to another unit, floor, or hospital
4. Hospital to home
5. Hospital to Seniors Residence
6. Seniors Residence to Hospital
7. Seniors Residence to home
8. Seniors Residence to Seniors Residence

Problems during transitions of care occur in a few major areas:

1. Medication: Dosages or specific medications may be omitted or incorrect.
2. Tests: The need for blood tests, heart tests, pacemakers, sugar levels, and other regularly scheduled tests may not be communicated.
3. Diagnoses: A diagnosis on the list provided may be omitted or incorrect. This includes relevant past history such as head injuries, diseases, cataracts, surgeries, and others.
4. Equipment: Need for or use of walker, cane or wheelchair, hearing aids, glasses, or other assistive devices may not be communicated.
5. Patient capability and abilities. Cognitive capacity such as memory, insight, decision making ability may be omitted or inaccurate.
6. Supporting information such as family contacts and whether there is a Representation Agreement may be inaccurate.
7. Why do errors occur during transitions of care? As noted above, information may simply not be provided to the “receiver.” Sometimes the information provided isincorrect.Sometimes the information is received correctly, but then transcribed or interpreted incorrectly.Documentation can be lost as it is being transmitted; for example a fax page may not go through.Discharge from hospital entails coordination and communication between a team of professionals which may not go smoothly.

In the case of someone being discharged home, family members or patients may not understand the instructions or how to carry them out. If a patient has some cognitive impairment they may not remember instructions on wound care, medication regimes, follow up or more. Even a Senior who normally is not cognitively impaired may have temporary memory loss due to the effects of anaesthetic, medications, or pain.

It also happens that hospitals or care facilities donot receive correct or complete information from patients/residents or family members at admission. The latter is especially likely to happen when someone goes into hospital in an emergency.

Caregivers need to be aware of the possible glitches during transitions of care, and do everything possible to make sure they do not occur. Here are some tips to help you:

1. Make a list of all medications, dosages, and frequencies and keep them current. Compare it to what is given or being used in hospital or the Seniors Residence. If there is a discrepancy, ask about it.
2. Make a list of all present medical issues and past medical history. Compare it to what the hospital or Residence has.
3. Make a list of all treatments and tests, their frequency, and the last time they were done.
4. When working with a hospital or Seniors residence, make sure they have all current information for contacting family members.
5. Develop a chain of contact for the hospital or residence. Designate one family member the primary contact, and indicate a second or third. Use a programme such The Care Tools to help family members communicate with each other, and let the hospital or Seniors Residence know about the programme you are using.
6. If there is a Representation Agreement and/or Power of Attorney (ideally you have both!), provide copies to the hospital or Residence. Make sure that it is clear who the Representative and Power of Attorney are.
7. Be aware that medications which are provided and paid for in hospital may not be covered after discharge and may incur a considerable expense. This sometimes leads to people stopping the medication without telling anyone. Ask the pharmacy about coverage of medications. It it is not covered ask whether there are generic medications or alternatives which may are. (If there are alternatives, discuss these with the discharging or “receiving” physician.”)
8. Watch for changes in cognition and behaviour after the transition.Sometimes such changes are normal reactions to stress and to be expected, however they could also be the result of a problem occurring during the transition of care. If these arise, consult with a physician or a nurse.

The National Transitions of Care Coalition: Tools and Information for Better Transitions

The National Transitions of Care Coalition (NTOCC) was formed in 2006 bringing together thought leaders, patient advocates, and health care providers from various care settings dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another.

Their website (www.ntocc.org) has information and tools for professionals, patients and family members which can help insure good communication and prevent problems during transitions of care.