The TOCCC first proposed a framework that provides guiding principles for what we would like to measure and eventually report. From those principles are developed a set of preferred practices or standards; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures.
The TOCCC established the following principles:
- Communication: clear and direct communication of treatment plans and follow-up expectations
- Timely feedback and feed forward of information
- Involvement of the patient and family member, unless inappropriate, in all steps
- Respecting the hub of coordination of care
- All patients and their family/caregivers should have and be able to identify who is their medical home or coordinating clinician (i.e., practice or practitioner).
- At every point along the transition the patient and/or their family/caregivers need to know who is responsible for their care at that point and who to contact and how.
- National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions etc, in order to improve patient outcomes and patient safety.
- For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability.
The TOCCC then proposed the following standards:
Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care; e.g., at discharge from the inpatient setting. The timeliness of this communication should be consistent with the patient’s clinical presentation and, in the case of a patient being discharged, the urgency of the follow-up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the MH. Communication and information exchange between the MH and other physicians may be in the form of a call, voicemail, fax or other secure, private, and accessible means including mutual access to an EHR.
The emergency department (ED) represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient depending on whether or not the patient is admitted to the hospital. The outpatient to outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred in to the ED by the medical home or they may self refer. A significant number of patients do not have a physician and self refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist and may or may not require urgent (<24 hours) follow-up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transitions of care coordination.
- Care Plans/Transition Record
The TOCCC proposed a minimal set of data elements that should always be part of the transition record and be part of any initial implementation of this standard. That list includes the following:
- Principle diagnosis and problem list
- Medication list (reconciliation) including over the counter/ herbals, allergies and drug interactions
- Clearly identifies the medical home/transferring coordinating physician/institution and their contact information
- Patient’s cognitive status
- Test results/pending results
The TOCCC recommended the following additional elements that should be included in an “ideal transition record” in addition to the above:
- Emergency plan and contact number and person
- Treatment and diagnostic plan
- Prognosis and goals of care
- Advance directives, power of attorney, consent
- Planned interventions, durable medical equipment, wound care etc
- Assessment of caregiver status
- Patients and/or their family/caregivers must receive, understand and be encouraged to participate in the development of their transition record which should take into consideration the patient’s health literacy, insurance status and be culturally sensitive.
- Communication Infrastructure
All communications between providers and between providers and patients and families/caregivers need to be secure, private, HIPAA compliant, and accessible to patients and those practitioners who care for them.
Communication needs to be two-way with opportunity for clarification, and feedback. Each sending provider needs to provide a contact name and number of an individual who can respond to questions or concerns.
The content of information transferred needs to include a core standardized dataset.
This information needs to be transferred as a “living database” whereby it is created only once and then each subsequent provider then only needs to update, validate, or modify the information.
Patient information should be available to the provider prior to patient arrival
Information transfer needs to adhere to national data standards.
Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.
- Standard Communication Formats
Communities need to develop standard data transfer forms (templates, transmission protocols).
Access to the patient medical history needs to be on a current and ongoing basis with ability to modify information as a patient’s condition changes.
Patients, family and caregivers should have access to their information (“nothing about me without me”).
A section on the transfer record should be devoted to communicating a patients’ preferences, priorities, goals and values (e.g., patient does not want intubation).
- Transition Responsibility
The sending provider/institution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information i.e., transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital-based clinicians will not be required to assume responsibility for the care of these patients once discharged.
Timeliness of feedback and feed forward of information from a sending provider to a receiving provider should be contingent on four factors:
- Transition settings
- Patient circumstances
- Level of acuity
- Clear transition responsibility
This information should be available at the time of the patient encounter.
Medical communities/institutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care
For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence-based, address documented gaps and have demonstrated impact on improving care (comply with performance measure standards) whenever feasible. Results from measurement using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re-evaluated.
All of these standards should be applied with special attention to the varying transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.