This is the current release of the guideline.

Any disease or condition requiring transition of care in the long-term care continuum

Patients undergoing transitions of care in the long-term care continuum

Medline, PubMed, and geriatric-specific journals such as the Journal of the American Medical Directors Association (JAMDA), Annals of Long Term Care, and Journal of the American Geriatrics Society (JAGS) were searched from May 2009 through February 2011. Studies were included if they met the following criteria:

• Studies that are valid, consistent, applicable and clinically relevant
• Studies where the recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence)

Searches were specific to the guideline topic under consideration.

Not stated

Not applicable

Not stated

Original guidelines are developed by interdisciplinary workgroups, using a process that combines evidence and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group works to make a concise, usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field. A bibliography is provided for individuals who desire more detailed information.

Guideline revisions are completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporates information published in peer-reviewed journals after the original guidelines appeared as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

Not applicable

A trial that employed advanced practice nurses to play a central role in coordinating care across sites and healthcare practitioners demonstrated reductions in both hospital readmissions and healthcare costs for elders with congestive heart failure, as well as among seniors considered to be at high risk for hospital readmission. (See Appendix 1 of the original guideline document for a summary of results from three of these trials.)

Financial Issues

A growing body of research suggests that comprehensive transitional care for hospitalized elders can reduce readmissions, improve patient quality of life and satisfaction with care, and reduce per-patient costs by as much as 37% over a 12-month period. Smooth, well-coordinated care transitions can produce cost savings by enabling hospitals to:

• Efficiently move patients to the next level of care, making beds available for new admissions
• Reduce the likelihood that discharged patients will need to be readmitted
• Avoid revenue losses stemming from new Medicare payment policies designed to eliminate payment to hospitals for certain readmissions within 30 days (managed-care and insurance companies will almost certainly implement similar policies in due course)
• Maximize utilization of fixed reimbursement programs

Although evidence-based data linking comprehensive transitional care with improved outcomes and cost savings in the long-term care continuum (LTCC) setting are scant, LTCC facilities may find that well-executed care transitions result in benefits such as:

• Improved customer and family satisfaction
• Attention to patient needs and advance directives
• Repeat customers, as patients, families, and payers recognize the facility's professionalism and compassion
• New business, as satisfied customers tell others
• Reduced liability risks as a result of a decrease in errors during transfers
• Better resource utilization through the implementation of a consistent process to administer patient admissions and transfers (whether planned or emergent)
• Where applicable, improved ability to meet regulatory standards

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

AMDA's guidelines are supported by the following associations/organizations, who are members of its Clinical Practice Guideline Steering Committee. These associations/organizations all have representatives who participate in the external review phase and officially sign off on the guideline before publication: American Association of Homes and Services for the Aging (Now LeadingAge); American College of Health Care Administrators; American Geriatrics Society; American Health Care Association; American Society of Consultant Pharmacists; Gerontological Advanced Practice Nurses Association; Direct Care Alliance; National Association of Directors of Nursing Administration in Long-Term Care; National Association of Health Care Assistants.

Implementation of a Care Transition Program

Note: The care transition process is broken down into a sequence of steps. Certain steps and substeps are particularly relevant in the context of a planned transition, whereas others are most applicable to an unplanned transition (i.e., an urgent or emergent situation). This distinction is indicated in the text as follows: planned transition, unplanned transition, both planned and unplanned transitions.

Step 1: Both Planned and Unplanned Transitions

The patient has a recognized status change.

Management of a care transition generally begins when a patient is identified as having a status change (i.e., deterioration or improvement) that makes it appropriate to evaluate him or her for another setting or level of care.

The best preparation is anticipating that the unexpected will occur and establishing a process for that eventuality. Facilities are advised to follow the process described in the American Medical Directors Association's (AMDA's) clinical practice guideline Acute Change of Condition in the Long-Term Care Setting for recognizing and assessing an unanticipated status change.

Step 2: Both Planned and Unplanned Transitions

Interdisciplinary team members communicate with each other and with the patient/family (unit of care) to determine the most appropriate care transition.

It is important that members of the care team communicate with families about the pros and cons of a proposed transition.

Decisions about transitions should also be guided by the patient's advance directives; if the patient so wishes, no transition may be the best decision.

Table 4 in the original guideline document lists issues that the sending facility should ensure are addressed before a planned patient transfer to another setting or level of care.

Step 3: Planned Transition

The sending facility or care entity communicates with the receiving entity. Patient information received by entity prior to patient arrival.

It is crucial that the information transmitted with the patient include contact information for the sending provider, so that the receiving provider knows whom to contact with questions (including who can be contacted outside of normal office hours, and how). Table 5 in the original guideline document lists the essential patient information elements that should be transmitted from the sending to the receiving entity during any care transition. Table 6 in the original guideline presents a sample universal transfer form developed by AMDA. The recommended elements of a discharge or course-of-treatment summary are listed in the following table.

Step 3A: Unplanned Transition

The patient has an acute change of condition and transfer to an emergency department (ED) is appropriate.

The use of a standard transfer form (see Table 9 and Appendix 10 in the original guideline document) may improve communication between a nursing facility and an ED.

Additionally, caregiving staff may find it helpful to use AMDA's protocols for practitioner communication, both to standardize the patient evaluation that determines the need for an ED transfer and to obtain the data that should be transferred with the patient if a transfer is deemed appropriate. Facilities may also wish to consider placing an identification armband on a patient who is being transferred to the ED.

Appendix 11 in the original guideline document provides a list of quality indicators for transitions between nursing facilities and EDs.

Step 3B: Both Planned and Unplanned Transitions

The patient is being transferred to another care site by emergency medical services.

Facilities should consider developing relationships with emergency medical services (EMS) providers and sharing information about each other's information needs through inservice training sessions. Facility nursing staff should be trained to know when ambulance transportation is appropriate and what patient information to provide to EMS personnel when making a transportation request. EMS personnel should understand the special needs of frail elderly patients who may be cognitively impaired and must be familiar with state-specific regulations concerning the requirement for resuscitation. See the following tables in the original guideline document for additional information:

• Table 10: Patient Information That May Be Requested By an Emergency Medical Service Dispatcher
• Table 11: Summary of CMS Medical Necessity Guidelines for Ambulance Transportation of Medicare Patients
• Table 12: Information Exchange Between EMS Personnel and Sending Facility

Step 3C: Planned Transition

Patient's condition has improved to the extent that transfer to his or her community home is appropriate.

Facility staff must discuss with family caregivers the level of care the patient will require at home and determine whether they are able to provide that level of care. Offer family caregivers training, if necessary, to perform caregiving tasks.

Caregiver assessment is an important tool for understanding family caregivers' needs and capacities and improving quality of care for the patient. Purposes and principles of caregiver assessment are presented in Table 13 of the original guideline document. (See Appendix 12 of the guideline for recommended domains and constructs for caregiver assessment.)

Step 3D: Planned Transition

Patient is approaching the end of life and comfort care only is appropriate.

Any transfer should occur in the context of the patient's expressed wishes. Although every patient's situation is unique, the approach outlined in Table 14 in the original guideline document may provide a guide.

Discussions about withholding aggressive treatment at the end of life may meet with resistance from members of a patient's family. The term "Allow Natural Death" may be more acceptable to families than "Do Not Resuscitate." Please refer to AMDA's information series Palliative Care in the Long-Term Care Setting, which provides extensive resources for decision-making for palliative care.

Step 4: Planned Transition

The patient is physically handed over to the receiving level or setting of care.

The issues to be addressed when a patient is physically handed over to another level or setting of care will depend on the nature of the transition.

The key to a successful transition is communication with the next site of care and transmission of both required information and any additional data considered essential to the provision of quality care.

Step 4A: Planned Transition

Patient is being discharged to his or her community home.

When this transition occurs, the facility must ensure that caregivers have the information and resources they need to successfully assume the patient's care.

Although not every patient will be using home health care services, facilities should anticipate this potential need and make arrangements in advance to avoid a last-minute, often flawed, rush to complete the necessary documentation and obtain the required signatures. The facility should ensure that the patient is connected with his or her primary care providers and that the patient and family understand what the next step in the patient's care is, where it will take place, and the reason(s) it is necessary.

Step 5: Both Planned and Unplanned Transitions

Both sending and receiving entities verify that the patient has been handed over and that essential patient information has been received.

The transition is not complete until both sides have verified that the hand-off has occurred and the providers at the receiving facility have assumed responsibility for the patient's care. The receiving facility must review the information sent with the patient to ensure its clarity and completeness and follow up with the sending facility to obtain any missing information or necessary clarifications.

Table 15 in the original guideline document lists issues that the sending facility should ensure are addressed in the period immediately following a patient's transition to a community home or to another level or site of care.

Step 6: Both Planned and Unplanned Transitions

Sending facility follows up to confirm that the patient has been successfully transitioned to the new level or setting of care.

It is recommended that the sending facility contact the receiving facility within 24 hours after a patient transition has occurred to confirm that the transition has been completed and that providers at the receiving facility have all the information they need to care for the patient appropriately.

A successful transition may be envisioned as a closed loop (see Figure 1 in the original guideline document). To ensure that the loop is closed, the sending and receiving facilities must interact, verify, and clarify that key patient information is both transmitted and acted upon in a timely fashion.

Step 7: Both Planned and Unplanned Transitions

Monitor the facility's performance in managing care transitions.

Review the management of care transitions through the facility's quality improvement process. Table 16 in the original guideline document suggests indicators that a facility may wish to use to measure the success of care transitions. Appendix 14 of the guideline presents selected performance measurement indicators for transitional care from existing tools that facilities may wish to incorporate or modify to meet their needs.

None provided

The type of evidence supporting the recommendations is not specifically stated.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based approaches. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field.

This guideline recommends processes that, if implemented, should help long-term care continuum (LTCC) facilities to appropriately coordinate transitional care for patients entering and leaving their care. Potential benefits associated with the implementation of this guideline include the following:

• Reductions in:
  • Avoidable care transitions (through a patient-centered review of the risks and benefits to the patient from any change in care site)
  • Costs associated with readmissions to higher-acuity levels of care
  • Duplicative use of diagnostic services (e.g., electrocardiograms, laboratory tests)
  • Extended hospital stays for observation
  • Hospital readmissions resulting from avoidable post-discharge complications and adverse events
  • Medication-related adverse events
• Increases in:
  • Patient and family investment in participation in the care process
  • Patient and family satisfaction with care
  • Patient safety
  • Quality of life for patients with complex health care needs
• Improved communication between care providers

Adverse effects associated with the transition process, including:

• Readmissions resulting from avoidable post-discharge complications and adverse events
• Medication-related adverse events
• Patient harm resulting from errors in the transition process

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
   • Identify individual responsible for each step of the CPG.
   • Identify support systems that impact the direct care.
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement.
   • Evaluate the predefined performance measures and obtain and provide feedback.

Importance of Accountability

This practice guideline delineates essential steps and actions required for safe movement across care settings. It does not, however, dictate who should be responsible for performing specific tasks associated with care transitions, as this will vary by care setting. Within each care site, every transition task must be assigned to a designated person, consistently with the organizational structure. It is essential that the specific responsibilities of each person with regard to transitions be identified, along with accountability and clear feedback. Specificity and accountability are essential for good outcomes.

Equally important, individual accountability for specific tasks must be supported by a facility-wide culture that places a high priority on safe transitions and considers them to be everyone's responsibility. For example, the processes recommended in this guideline for ensuring that essential information is transmitted with the patient during care transitions will be effective only if the care providers receiving the patient read them carefully and act on them, including requesting clarification from the sending care providers when information is missing or unclear. Furthermore, the sample forms provided in this guideline will be helpful in conveying information only when processes are in place within the facility to ensure that the forms are used as intended.

When assigning individual responsibilities for care transitions, facility managers should keep in mind that some providers to whom information about a transitioning patient is being conveyed may be more receptive to that information when it is conveyed by a provider of equivalent licensure (e.g., physician to physician, director of nursing to director of nursing). Senior facility staff and consultants should be prepared to participate in communications concerning a transitioning patient when necessary.

Not applicable: The guideline was not adapted from another source.

Organizational and association participants included:

• American Association of Homes and Services for the Aging
• American Association of Retired Persons
• American College of Health Care Administrators
• American Medical Association
• American Geriatrics Society
• American Health Care Association
• American Society of Consultant Pharmacists
• Case Management Society of America
• Gerontological Advanced Practice Nurses Association
• National Association of Directors of Nursing Administration in Long-Term Care
• National Association of Health Care Assistants
• National Transitions of Care Coalition
• Society of Hospital Medicine

sanofi-aventis U.S. LLC was a corporate sponsor of this guideline.

Clinical Practice Guideline Steering Committee

Charles Cefalu, MD, MS, Clinical Practice Committee Chair

James E. Lett, MD, CMD, CPG Chair

Steering Committee Members: Charles Cefalu, MD, MS (Chair); Sherrie Dornberger, RNC, CDONA, FDONA; Sandra Fitzler, RN; Marianna Grachek, MSN, CNHA, CALA; Joseph Gruber, RPh, FASCP, CGP; Susan M. Levy, MD, CMD; Evvie F. Munley; Jonathan Musher, MD, CMD; Barbara Resnick, PhD, CRNP; William Simonson, PharmD, FASCP, CGP

Workgroup Members: James E. Lett, MD, CMD (Chair); Harold Bob, MD, CMD; Gwendolen "Gwen" Buhr, MD, CMD; *Charles A. Cefalu, MD, MS; H. Edward Davidson, PharmD, MPH; Jo Ann Fisher, ARNP; Sandra Goodin-Hicks, RNC, CALN; Marianna Grachek, MSN, CNHA, CALA; Eric Howell, MD; Nancy A. Istenes, DO; Sarah A. Jerro, MA, RN, CDONA/LTC; Cheri Lattimer; Rhonda Richards; Joanne Schwartzberg, MD; Keith Van Meter, MD; Gary Winzelberg, MD, MPH; James "Jim" R. Yates

*Steering Committee Member

Additional Contributors: Cathleen A. Bergeron, RN, CDONA/LTC, MSHA; Alice Bonner, PhD, RN; Eric A. Coleman, MD, MPH; Sandra Fitzler, RN; Murthy Gokula, MD, CMD; Karyn P. Leible, RN, MD, CMD; Richard W. Miles, MD; Joseph G. Ouslander, MD, CMD; Naurshia Pandya, MD, CMD; Thomas Price, MD, CMD; Larry Wellikson, MD, FHM

Technical Writer: Eleanor Mayfield

AMDA Staff: Jacqueline Vance, RN, C. CDONA/LTC, CPG Project Manager, Director of Clinical Affairs

All contributors must submit an Accreditation Council for Continuing Medical Education (ACCME) approved disclosure form prior to being accepted as a volunteer member of the guideline workgroup. This disclosure form is reviewed by the chair of the American Medical Directors Association (AMDA) Clinical Practice Committee. If any conflicts are perceived, that person is not accepted to be part of the workgroup.

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF)  and Flash  and from the American Medical Directors Web site.

Print copies: Available from the American Medical Directors Association, 10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com .

Table 16 of the original guideline document  provides a list of sample performance measurement indicators.

The appendices of the original guideline document  contain a number of checklists and forms useful in the transition of care process.

None available

This NGC summary was completed by ECRI Institute on October 4, 2011. The information was verified by the guideline developer on November 29, 2011.

This NGC summary is based on the original guideline, which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information, contact AMDA at (410) 740-9743.