Care Transition Rounds – An Important Strategy for Improving Population Health

Compass Editor’s Note: Thanks to Kathy Cvach, manager, Professional Nursing Practice, for assistance in compiling this article with information provided from an educational presentation to the hospitalist staff and nursing leadership by Patty Satjapot, director, Transformation, DaVita Medical Group.

For quality patient care to be successfully and consistently delivered in the inpatient setting, communication of patient data must be easily transmitted from one healthcare provider to another both within and outside the hospital setting. Care Transition Rounds (CTR) create a structured format that helps hold the nurses, hospitalists, rehabilitation therapists, case managers and all other members of the team (for example, physical and/or occupational therapists, social workers, pharmacists, social workers and risk managers) accountable for improving patient-centered care.

“By having everyone participate in a formatted discussion about the patient’s condition, a better picture of the patient, his or her family, and social circumstances emerges,” says Kathy Cvach, director of Professional Nursing Practice for UM Shore Regional Health.

In settings where CTR has been implemented and assesses, the results have been impressive, including:

  • improved team communication
  • improved quality of care
  • better consideration of alternative therapies
  • reduced length of stay and readmissions, and
  • smoother transitions of care

Care Transition Rounds began at UM Shore Medical Center at Easton in April, 2017 and in UM Shore Medical Centers at Chestertown and Dorchester in May, and now take place every weekday in all three hospitals. According to Dennis DeShields, MD, all patients are “rounded” on except for those in intensive care and those who have a private physician or advanced care practitioner attending. Approximately 90-100 patients are rounded on every day at Easton, 20 at Dorchester, and 15 at Chestertown.

The format of UM Shore Regional Health Care Transition Rounds follows the acronym MS-TPN (Medical, Social – Transpire, Plan, Need). Questions addressed under this model are:

M: Medical – Why is the patient here? What is his or her current length of stay? Is the patient a readmission or at high risk for readmission following this hospitalization?

S: Social – Who  will participate  In the patient’s care after discharge? Is there a designated health care decision maker and are there prior end-of-life discussions/documents, if applicable?

T: Transpire – What is likely to occur in the next day/beyond for this patient?

P: Plan – What is the plan to move the patient to the next level of care? Treatments, diet changes, consults?

N: Need – What is needed for the patient to be discharged? What is the anticipated discharge date? What barriers (transportation, financial, etc.) will impact the transition plan?

Providing the right information during CTR comes from asking, “What do we need to know about why the patient is in the hospital to set the stage for the plan for the patient’s care?”  Including staff from the full range of disciplines in CTR also challenges the completeness of that information and holds everyone accountable for the patient’s disposition in a comprehensive but concise format.

As Dr. DeShields explains, “The teams come together to discuss issues in one setting so that everyone is on the same page. Case managers, physicians, nurses, physical therapy, and pharmacy are all at the table so that effective patient outcomes can be achieved and discharge planning can be coordinated, helping to streamline, strengthen and improve the discharge process.”

The Role of Nursing in CTR

The bedside nurse plays an integral role in providing the charge nurse with the information to present that drives and coordinates the CTR among the other care providers. Conversely, the charge nurse has the responsibility to listen for what is needed for the patient and return from CTR with information for the bedside nurse who is the most appropriate individual to assess the patient’s understanding of the plan of care and educational needs for successful discharge.

“Today, discharge planning is more than just transitioning the patient from the hospital to another setting or caregiver,” says Nancy Bedell, regional director, Care Transitions. “The goal of a hospital discharge plan is to ensure that the patient and/or caregivers have the knowledge and tools they need to maintain their health in the community. It’s the first step toward a population health model of care.”