Transitions Between Care Settings

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The Association of Community Cancer Centers (ACCC) is pleased to release its landmark report into the issue of care transition between the hospital cancer program and physician group practices. Within the report, ACCC examines three key areas: 1) the adequacy and completeness of the medical record, 2) the continuity of drug therapy (medication reconciliation), and 3) the communication among providers, such as physicians, nurses, pharmacists, and social workers—both internally (within their own programs) and externally (between the two care settings).

Katherine Herring Capps of Health2 Resources introduced this educational project at ACCC's 2010 Oncology Economics Conference in St. Louis.

Objectives:

To identify the problems that cancer programs and physician practices have when transitioning their patients from one setting to another.
To identify most effective practices in patient transition between the two care settings and how these best practices can be implemented.
To provide tools to measure whether patient care is enhanced by having these best practices.
To raise awareness about potential problems and solutions in cancer patient transition between the hospital and physician practice setting.

Final Report Available: WHY YOU SHOULD READ IT

Learn about the challenges for transitioning cancer patients.
Find most effective practices and innovative solutions that cancer programs and oncology practices like yours have initiated.

Plus, the analysis includes survey results, and a review of care transition literature. Read the complete report (PDF, 2 MB).

Key Findings: In Brief

In this study of how (and how well) the cancer patient’s transition from hospital to outpatient oncology group is managed, ACCC found that some community cancer programs have developed innovative solutions to manage various aspects of the transition process. Nine sites were identified as providing exemplary activities related to transitioning cancer patients between care settings.

Still, there is room for improvement. While some hospitals and oncology groups effectively manage the patient transition, most face considerable challenges in achieving optimal transition activities.

Analysis shows that:

Few hospitals in our study monitor readmissions or follow up with their discharged patients.
Oncology-specific transition policies are largely non-existent (3 percent of surveyed hospitals have one). Transition checklists are rare (15 percent of surveyed hospitals manage the transition with a checklist).
While some organizations had transition programs in place, few of them are using survey and measurement tools to analyze those processes for quality improvement.
Patients often move between two settings of care (i.e., hospital inpatient and outpatient oncology) that are generally operated by two separate organizations, often without common information systems and sometimes with only limited shared information. And multiple problems can occur in the electronic transfer of usable data between the hospital and the oncology group EHR systems, especially for medical groups admitting patients to several hospitals.
Hospitals compete with each other for patients, as do physicians, and sometimes the competition can get in the way of good communication during the patient transition.
The cost of managing the transition is not built into the reimbursement structure.

Generally, there has been substantial progress in recent years in introducing electronic health records (EHR) and computerized physician order entry (CPOE) systems into hospitals and oncology practices. Those systems have greatly improved medication reconciliation and the ability of community oncologists to access appropriate medical records pertaining to their recently hospitalized patients. Nevertheless, despite these improvements, there is room for further improvement in developing specific processes and policies designed to manage the cancer patient’s transition between care settings.

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