Transitions of Care
This is an interesting paper on clinical issues arising at transitions of care, meaning when one physician hands off a patient’s care to another. This can be from a GP to a specialist, or simply as one resident’s shift ends and another takes over. Transitions of care are a notoriously complex, as they involve one physician telling another physician everything they think is relevant, yet there is always information lost for various reasons. Transitions of care have become far more frequent as physician specialization are risen dramatically in recent decades.
Transitions of Care Consensus Policy Statement: “The American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established:
- Accountability;
- Communication;
- Timely interchange of information;
- Involvement of the patient and family member;
- Respect the hub of coordination of care;
- All patients and their family/caregivers should have a medical home or coordinating clinician;
- At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point;
- National standards;
- Standardized metrics related to these standards in order to lead to quality improvement and accountability.
Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.”