Corresponding Author: Mary D. Naylor, PhD, RN, University of Pennsylvania School of Nursing, 418 Curie Blvd, Claire M. Fagin Hall Room 341, Philadelphia, PA 19104-4217, Phone: 215-898-6088, Fax: 215-573-4225, ude.nnepu.gnisrun@rolyan
The publisher's final edited version of this article is available at J Am Geriatr SocSupp AppendixS1: Supplementary Appendix S1. Transitional Care Components and Measures Workgroup Member List
GUID: EF9B0C45-74CB-4240-B692-861B66B7AAD0Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve patients’ health outcomes and reduce preventable hospital readmissions. Yet little is known about the key elements of effective TC and how they relate to patients’ and caregivers’ needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Project ACHIEVE. A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multi-stakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components, then analyzed how well the set aligned with “real-world” patients’ and caregivers’ experiences. Through this process, the workgroup identified eight TC components: Patient Engagement, Caregiver Engagement, Complexity/Medication Management, Patient Education, Caregiver Education, Patient and Caregiver Well-Being, Care Continuity, and Accountability. While the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.
Keywords: engagement, education, continuity, complexity management, accountabilityFor decades, transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve patients’ health outcomes and reduce preventable rehospitalizations and their associated costs. Despite the contributions of many stakeholders, little is known about the key elements of effective TC and how they relate to patients’ and caregivers’ needs and experiences. To address this knowledge gap, in 2015 the Patient-Centered Outcomes Research Institute (PCORI) sponsored Project ACHIEVE (Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence). 1 A primary aim of the study is the identification of transitional care components that yield desired patient and caregiver outcomes. Project ACHIEVE established the Transitional Care Components and Measures Workgroup (TCCMW) to review published research and, guided by a multistakeholder group, identify TC core components. Workgroup findings provided a framework of core components to inform the design of patient, caregiver, and provider surveys; health system and community site visits; and data analyses. Beyond the target populations that are the focus of Project ACHIEVE, the workgroup sought to identify TC components that are essential to ensure positive health outcomes and experiences for the larger population of high-need, high-cost patient adults and their caregivers.
The TCCMW is a multi-stakeholder group that includes transitional care experts, patients and caregivers, and other key players (Supplementary Appendix S1). In its first year, the workgroup’s goals were to 1) identify a set of evidence-based TC components; 2) operationally define each component, with emphasis on perspectives provided by patients and caregivers; 3) describe strategies to accomplish each component, as suggested by published research or recommendations of workgroup members; and 4) suggest metrics to assess each component’s desired processes and outcomes. The workgroup met via teleconferences and webinars multiple times throughout 2015, and received ongoing input from the larger Project ACHIEVE team. This paper describes the workgroup’s findings related to its first two goals---identifying and defining TC core components.
The workgroup determined that a TC core component is “a critical element of traditional medical care, community-based services, and non-traditional services provided by the healthcare team that patients and caregivers should receive to promote positive health outcomes throughout periods of acute illnesses extending from hospital to home.”
After achieving consensus on the definition of a TC component, the TCCMW agreed that categories of problems and concerns experienced by the target patient population and their caregivers throughout transitions from hospital to home would guide the selection of components. Published evidence related to patients’ and caregivers’ issues throughout transitions from hospital to home, including short-stays in skilled nursing facilities (SNFs) or similar settings, guided the identification of relevant strategies and metrics.
As defined in the original Project ACHIEVE proposal 1 , the target patient population for this study is hospitalized Medicare beneficiaries (including fee-for-service and Medicare Advantage members) at high risk for poor post-hospitalization outcomes, including patients with 1) multiple chronic conditions; 2) mental health issues; 3) cognitive impairment; 4) limited English proficiency or low health literacy; 5) lower socioeconomic status; and those who are 6) rural area residents; 7) eligible for Medicaid and Medicare; or 8) disabled and younger than age 65. The Project ACHIEVE study population also includes caregivers of these patients, defined as family members, partners, friends, or neighbors who provide unpaid support. 1
The workgroup used a multi-method approach to accomplish its goals. The TCCMW used categories of common problems and concerns experienced by patients and caregivers during hospital-to-home transitions and a preliminary set of TC components identified in the original Project ACHIEVE proposal 1 as its foundation. Preliminary findings from focus groups and interviews conducted with especially vulnerable older adults and caregivers also informed the workgroup’s efforts. The TCCMW added to available knowledge by identifying newly published evidence. A National Library of Medicine database search found more than 900 abstracts, indexed from January 2013 through July 2015. The following search terms were used: Patient Readmission[MeSH] OR “patient readmission*”[tiab] OR Readmission*[tiab] OR rehospitalisation*[tiab] OR “reducing hospitalization*”[tiab] OR “reducing rehospitalization*”[tiab] OR “re-admission*”[tiab] OR “re-admit*”[tiab] OR Continuity of patient care[MeSH] AND “Care transition*”[tiab] OR “transition* of care”[tiab] OR “transitional care”[tiab] AND Eng[la]. Three Project ACHIEVE members independently reviewed all abstracts, and selected 303 full-text publications for detailed review. Among these, 33 papers offered new evidence regarding problems experienced by patients and caregivers with potential implications for TC components, relevant strategies, and/or measures. Findings from these papers were summarized and then integrated with the body of evidence generated for the original Project ACHIEVE proposal 1 .
Guided by the organizing framework and the updated body of evidence, the workgroup deliberated over a period of months to identify and then operationally define a set of TC components. Throughout this process, members of Project ACHIEVE’s Stakeholder Advisory Group, comprised of patient and caregiver representatives and other key stakeholders, and other members of the larger research team provided feedback and guidance to the workgroup.
After reaching agreement on a set of TC components, the workgroup agreed that an important next step would be to analyze how well the proposed set aligned with “real-world” patient and caregiver experiences. To that end, the TCCMW collected case studies voluntarily shared by patients and caregivers involved with Project ACHIEVE and reviewed published narratives related to TC. One of 12 available cases studies was carefully mapped to the set of TC components to determine if the list was comprehensive and if definitions adequately captured what matters most to patients and caregivers. The case involved a patient with cancer who had a surgical procedure resulting in a colostomy. Neither the patient nor her caregiver was prepared for this outcome. Preparation of the patient to care for her colostomy following hospital discharge did not occur when her caregiver was present. Nor did the patient have any opportunity to demonstrate what she had been taught to confirm comprehension of needed care. The lack of attention to the stress that the colostomy caused both the patient and her caregiver, and the negative impact it had on the patient’s capacity to address her needs following her transition to home, resulted in the addition of “Patient and Caregiver Wellbeing” as a TC core component. Moreover, the limited attention to what this couple needed to know to ensure positive outcomes and the absence of a person designated to address ongoing questions and concerns, led to the identification of “Accountability” as a TC core component. Analysis of this case study also contributed to refined definitions of other TC core components.
Published evidence, reinforced by input from Project ACHIEVE team members, led to identification of the categories of patient and caregiver issues described in Table 1 . The recommended set of TC components relevant to high-risk Medicare beneficiaries transitioning from hospital to home is graphically depicted in Figure 1 . Importantly, although each core component is identified separately, the TCCMW members emphasized that all are related and should be viewed as elements of a holistic care process. The definitions of each component are provided below.