The Joint Commission has defined transitions in patient care as "the movement of patients between health care practitioners, settings, and home as their condition and care needs change." A key goal of the Wisconsin Coverdell Stroke Program is to create efficiencies in patient care transition in Wisconsin. To address this priority, the program is partnering with stakeholders to create stroke systems of care guidelines and best practices as illustrated in the graphic below.
The Joint Commission's Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care seeks to provide guidance for improving the effectiveness of patient transition between health care organizations. The document outlines focus areas for improvement of care transitions and identifies the root causes of ineffective transitions of care.
Areas of Focus
The following areas of focus related to improving care transitions have been identified by The Joint Commission, and adopted by the National Centers for Disease Control and Prevention (CDC) and the Wisconsin Coverdell Stroke Program. Researchers and providers agree that improvement and increased understanding in these areas will lead to improved patient outcomes.
- Evaluation of transitions of care measures
- Identification of the root cause of patient 30-day readmissions
- Clinician involvement and shared accountability
- Multidisciplinary communication, collaboration, and coordination
- Comprehensive planning and risk assessment throughout hospitalization
- Standardization of transition plans, procedures, and forms
- Standardization of training and education
- Timely follow-up, support, and coordination after a patient leaves a care setting
Root Causes of Ineffective Care Transitions
In addition to providing the focus areas detailed above, The Joint Commission has identified three primary root causes of ineffective transitions of care. Root causes often differ from one health care organization to another, but those most often described in medical literature and by experts include:
- Communication breakdowns
- Patient education breakdowns
- Accountability breakdowns
More details about these focus areas and root causes can be found in Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care by The Joint Commission.
Coverdell Model Hospital Partnership
The Wisconsin Coverdell Stroke Program offers support for improving overall stroke care across the care continuum. Our Model Hospital partners focus specifically on high risk transitions for patients including, but not limited to, transferring to higher level of care and discharge to home. The keys to any successful patient transition across the care continuum are establishing partnerships, open communication and assessing accountability. Our teams do this by establishing partnerships across care continuum and beyond. These partners work closely with their teams and across hospital systems to improve communication, patient transitions by addressing provider and patient accountability. Our program encourages partners to share quality improvement activities and best practices among the state and nationally.
Model Hospital Partners
- Beloit Health Systems
- University of Wisconsin Hospital & Clinics
- Aurora BayCare Medical Center
In addition to our Model Hospitals, the following WI Coverdell participants have partnered with us on the hospital to home transitions of care initiative:
- Ascension Columbia St. Mary's Hospital Milwaukee
- Ascension Elmbrook Campus
- Ascension St. Joseph Hospital
- Aspirus Wausau Hospital
- Aurora Sinai Medical Center
- Bellin Memorial Hospital
- Froedtert and the Medical College of Wisconsin - Community Memorial Hospital
- Froedtert and the Medical College of Wisconsin - St. Joseph's West Bend Hospital
- Gundersen Moundview Hospital and Clinics
- Milwaukee Fire Department Mobile Integrated Healthcare Team
- ProHealth Oconomowoc Hospital
- ProHealth Waukesha Memorial Hospital
Wisconsin Coverdell Stroke Program Goals
- Link and monitor data across the continuum of stroke care using the Wisconsin Ambulance Run Data System (WARDS) and Get With The Guidelines®.
- Implement quality improvement (QI) to improve efficiencies in transitions of care from emergency medical services (EMS) to the emergency department (ED).
- Improve coordination of post-stroke care, including improvements in patient/caregiver education, coordination with primary care, and coordination with community resources for stroke recovery.
The Wisconsin Coverdell Stroke Program partners with various stakeholders, both at the state and national level, to continue to increase the quality and efficiency of patient stroke care across the care continuum.
- Stroke Follow-Up Call Triage Algorithm P-02361 (PDF)
- Wisconsin Coverdell Stroke Program—EMS
- Wisconsin Coverdell Stroke Program—Hospitals
- CDC Paul Coverdell National Acute Stroke Program
- The Joint Commission Transitions of Care Portal
- Empower People with Knowledge: Community Outreach Stroke Awareness Event Planning Toolkit, P-01861 (PDF)
Nikke Kaemmerer BSN, RN
Stroke Systems of Care Project Specialist, MetaStar, Inc.