Continuity of care is a fundamental tenet of high quality of care and has been likened to “motherhood and apple pie”1. Unfortunately, patients feel that continuity and care transitions are major problems with their healthcare2. This is not surprising given the increasing use of specialists, such as hospitalists, which results in increased fragmentation of patient care3.Given these trends, investments to improve care transitions are critical to ensuring safe patient care4.
For this reason, the Transitions of Care Consensus Policy Statement produced from a collaboration of six medical societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) is especially timely and welcome5. The formal collaboration of these groups is also impressive and unprecedented. This broad involvement of generalists, hospitalists, geriatricians, and emergency medicine physicians increases the likelihood that these recommendations can impact these stakeholder groups. The policy statement represents an important starting point from which to guide improvement initiatives and policy changes to advance care transitions.
However, in considering how to translate these recommendations into practice, there is more work to do. While the consensus statement appropriately recommends a “patient-centered” approach, it is important to note that the patient perspective is missing from this effort. Likewise, perspectives of other healthcare professionals who play an active role in care transitions, including but not limited to case managers, nurses, pharmacists, nursing home staff, and home health and medical transport professionals, are absent. Interestingly, patient advocates and health care providers from these various care settings, have partnered together to form the National Transitions of Care Coalition (NTOCC), which represents 26 groups, to improve care transitions6. Future engagement of this broader set of stakeholders is a crucial and necessary step to move these recommendations forward. The policy statement outlines high level-principles for care transitions that are generally agreeable to most physicians, but does not delve into the details of how to improve care transitions. While the recommendations call for actions such as physicians communicating effectively and accessing the medical record during a care transition, little guidance is offered on how to achieve these goals. As with all improvement efforts, the difficulty lies in the implementation of these recommendations or simply, “the devil in the details.” At the front lines of patient care, there are numerous practical challenges involved with implementing these recommendations outlined in the consensus statement. There are, however, several additional recommendations outlined below that can help translate this Policy Statement into action for hospitals, office practices, and patients: