Meaningful Use Norm - Transition Planning
What is it?
Preparing for an efficient and effective discharge begins at admission. Some inpatient encounters are short and simple, with patients returning to pre-admission community supports. Others are more complex, with significant changes to patient capacity and needs. These require coordinated multidisciplinary planning to facilitate safe and timely transitions to other facilities or back to the community.
Connect Care provides decision and documentation supports that can help clinicians with transition planning, while improving communication with healthcare providers picking up care after discharge. These tools comprise a "transitions planning package" that helps with:
Admission and Discharge capture of standardized structured data important to planning.
Anticipating and managing an Expected Discharge Date (EDD).
Declaring and sharing discharge readiness determinations from disciplines in the patient's care team.
Focusing attention on key considerations and decisions during multidisciplinary planning (RAPID Rounds) meetings.
Incorporating transition care plan elements into discharge communications with a standardized format and structure.
Calibrating follow-up arrangements to predictors for early re-admission (LACE Index).
Reviewing and updating alternate level of care statuses.
Appropriate and timely use of transition planning tools during inpatient encounters is among the Connect Care Meaningful Use Norms, with compliance feedback provided through Meaningful Use Norms Dashboards.
Why does it matter?
Good transition planning improves patient outcomes, reduces repeat emergency or inpatient encounters and gets the patient to the right place at the right time. A shared Transition Care Plan helps:
Set priorities by clarifying what is needed and when to enable moving to the next care setting.
Optimize use of inpatient resources, including bed management and allocation of allied health services.
Align patient/family and team expectations and preparations.
Thinking about and committing to a (provisional) EDD within inpatient provider teams has been shown to improve discharge planning, reduce lengths of stay, reduce readmission rates, increase patient satisfaction and smooth patient flows.
Shared EDDs help caregivers set priorities by promoting reflection about what is needed, and facilitating coordinated action for smooth transitions.
Agreed EDDs can more confidently be communicated to patients and families, who cite the EDD as their important information need.
Documented EDDs help patient care team members time and sequence activities and deliverables needed for safe discharge (e.g., patient education, medication preparation, home care initiation, etc.).
Documented EDDs trigger facility decisions about triage of rehabilitation, diagnostic imaging and other intervention priorities to facilitate the planned discharge.
Recognizing, and declaring, when patients shift from an "acute" to an "alternate level of care" status helps:
Improve the accuracy of Acute Length of Stay (ALOS) metrics.
Flag patients requiring particular transition services to optimize total lengths of stay.
Highlight taps in patient journeys from one level of care to the best next care setting.
Use of shared transition planning tools ensures that all care team members work from a shared understanding of a patient's needs before admission, factors affecting readiness for discharge and needs anticipated at the expected discharge date when appropriate community supports must be readied.
Ensuring that a patient's level of care status is reviewed and updated facilitates more efficient bed management, as well as allocation of transition facilitation resources within a facility.
Who is responsible?
The admitting hospital service is responsible for entering an initial EDD estimate within 24 hours of admission. The inpatient hospital service is responsible for reviewing, and possibly revising, the EDD every 48 hours during the active inpatient encounter and less frequently for patients with an "Alternate Level of Care" patient status. Prescribers should initiate the EDD, while any hospital service team member can be delegated to review and revise EDDs for active patients.
All disciplines (medicine, nursing, allied health) participating in an inpatient's care team have access to and should maintain discharge readiness determinations for their discipline. Designating team discharge planning reps or scribes can help.
How is it done?
Expected Discharge Date (EDD)
Clinicians may worry about the accuracy of EDD guesstimates, especially early in a hospital stay. Use of Connect Care EDD editing tools allows selection of clinically meaningful intervals using speed buttons, or use of Epic time shortcuts (T+N entered to the EDD date field where N is a number of days): ≤1 day ("T+1"), <3 days ("T+2"), <5 days ("T+4"), <10 days ("T+9"), 10+ days ("T+15")
The "Unknown" button (available in some EDD editing tools) is to be avoided because it nullifies the EDD value, affecting other discharge planning tools. It may be appropriate to "Unknown" for Alternate Level of Care (ALC) patients who are waitlisted for another facility with an, as yet, unknown bed availability date.
Interactive (click-to-edit) EDD displays are available at multiple points in common inpatient workflows, including patient lists, RAPID Rounds tools, admission and discharge navigators, inpatient storyboard and sidebar displays, and standard progress note templates.
Integrated Transition Planning Report
Rapid Rounds patient lists, inpatient chart sidebar displays and interactive documentation blocks expose tools that can facilitate transition planning during inpatient encounters. Users can review and click-to-edit key details about patient supports pre-admission, current needs and barriers to discharge and anticipated community needs. All make use of structured data that all inpatient disciplines have agreed to use, sharing the burden of data entry and maintenance. And the transition care plan details can be pulled into discharge documentation to the extent justified by the complexity of discharge needs.
Integrated Transition Planning Tool (Discharge Readiness "Traffic Lights")
Rapid Rounds patient lists and reports, as well as chart sidebar displays, provide access to interactive discharge readiness "Traffic Lights" that provide at-a-glance overviews of patient readiness from the perspective of health disciplines participating in discharge planning. The visual display supports click-to-edit so that disciplines can quickly revise their readiness determinations. The same display allows users to select standardized intervals for expected discharge date revisions, confirm discharge destinations and align level of care with discharge readiness.
Alternate Level of Care Status
The ALC designation effectively "stops the clock" measuring a patient's actual length of stay (LOS). This ensures that facility LOS measures reflect provision of acute care services and not days awaiting transfer to a more appropriate facility. Rapid Rounds lists and reports include tools for quickly updating the patient status, including prompting of users when a patient's medical issues have been managed and an alternate level of care should be considered.
How is compliance promoted?
Feedback about adherence to EDD meaningful use norms is provided to through a "Connect Care Meaningful Use Norms Feedback" display available in the Hyperspace "Dashboards" activity, available to all inpatient providers. There are separate metrics for setting the EDD and for reviewing the EDD.
EDD Entry
Percentage of patients with an EDD entered by the admitting hospital service within 48 hours of the time of entry of the admission order.
EDD Review
Percentage of discharged patients with an EDD reviewed by the inpatient hospital service within 24, 48, and 72 hours of the time of discharge. Review can occur in either the EDD activity or in the Integrated Transition Planning Tool ("Traffic Lights"). Review is credited if the EDD is changed in either the EDD activity or the Integrated Tool. Review is also credited if the "mark as reviewed" button is selected in either the EDD activity or the Integrated Planning Tool.
Transition Care Plan Use
Percentage of hospital acute care inpatient encounters where the post-discharge needs data element has been interacted with in the Transition Care Planning report.
Discharge Readiness Traffic Light Use
Percentage of hospital acute care inpatient encounters where the Discharge Readiness Traffic Lights have been used at least once.
Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.