As a frontline hospital or nursing home professional, you may be feeling increasingly frustrated with the lack of support, community follow-up and caregiver training for your vulnerable patients and residents. Despite your hard work these complicating factors are likely to send your patient or resident back to the hospital. Your administrators may have suggested to you that you focus on reducing readmissions and avoidable hospitalizations, or you may have caught wind of all the efforts underway to improve care transitions. Whatever has brought you here, you certainly have a sense that you need to get started now on ways of caring for your patients and residents differently.
Chances are, you are not in this alone, and others throughout your organization share your concerns—and have ideas for how to improve them. To learn more about what others are doing to fix care transitions and reduce transfer trauma, you might contact your state’s quality improvement organization, which is now charged with coordinating state and local endeavors to improve care transitions. You can find your state’s organization at: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793 You might contact your Area Agency on Aging (for a national list, visit: http://www.n4a.org/about-n4a/?fa=aaa-title-VI) to learn more about its plans to respond to funding opportunities created by the Community-Based Care Transition Program (CCTP), also referred to as Section 3026 funding. If you haven’t already, you might reach out to your colleagues or peers in other local organizations, and find out what they’ve been doing, or what they plan to do.
Once you have a feel for what is going on in your own community, you might join forces with others who are motivated to make improvement happen. You might find that a team already exists, or you might lead the formation of one. You will need someone—usually, several people—who are willing to embody the vision, take some risks, forge coalitions, and anchor the work. You may want to gather data about the experience of people using your community’s health care systems. You may want to gather stories—they are a powerful way to communicate about experiences, to share ideas, and to learn from one another.
More than anything, start the process! Find something that you can do to get things underway. Try your ideas and learn from what works. Encourage others to join you—generate and build on their enthusiasm, and your own. Things may change slowly—but notice that they do.
Refer to the “Get Started” module on improving care transitions, now available online at www.medicaring.org. Based on the experiences of several organizations working to improve care, “Get Started” offers advice, guidance, and examples of how to build and sustain coalitions for this work, and how to measure progress. It is also full of real-life examples from other teams around the country. Build on their ideas and efforts as you develop your own. Be sure to check back often, as we plan to write frequently on issues surrounding care transitions, and on efforts to improve them. Or email us at [email protected]. We look forward to hearing from you.
Keywords: Care transitions, Section 3026, CCTP programs, avoidable hospitalizations, reduced readmissions