Some common risks associated with transitions of care, especially among patients receiving palliative support, include new or worsening symptoms, medication errors, miscommunication, follow-up gaps and patient disorientation. Furthermore, poor transitions can spark hospital readmissions within 30 days, adversely affecting hospital quality ratings and Medicare reimbursement.
A 2023 study by Front Public Health indicated that transitions from hospitals to home settings tend to be particularly complex and tricky. According to the study, approximately 1 in 5 patients experience adverse events during this kind of transition.
“Patients moving from a hospital to a home setting may face challenges in adjusting to self-management or medication regimens,” Transitions Care COO Trish Benson told Palliative Care News in an email. “A lack of coordination between providers, incomplete or outdated patient records, poor communication with the patient and their family, and a failure to address psychosocial or emotional needs” can further complicate care transitions and elicit undesirable outcomes.
Jill Krmpotic, the director of Arizona Supportive Care, a program of not-for-profit Hospice of the Valley, told Palliative Care News that in her experience, medication mishaps appear to be one of the most significant risks associated with transitions of care. Krmpotic said that she and her team often identify unfilled medications on discharge summaries or that patients have misunderstood dosing instructions.
“By our nurses going in each time that they actually do a visit, they’re doing a medication reconciliation to determine that the patients are on the right medications, determine that they understand the side effects of them, when and if to call the doctor if the side effects become too much.” Krmpotic said.
To mitigate some of these risks associated with transitions of care, palliative care providers should focus on the holistic needs of patients and their families and work with both parties to identify goals and potential barriers to health.
“It’s really kind of understanding each patient and what’s going on in their life and how to fit their health into their life,” Krmpotic said. “What is that patient struggling with? And then how do we get them the resources around them to navigate over that barrier?”
In addition to understanding social determinants of health that might influence a patient’s adherence to a follow-up care regimen — such as access to transportation and home-life conditions — Krmpotic said empowering patients with education at multiple points throughout their health journeys is crucial; this allows patients to understand their diseases and disease trajectories better so they have a firmer grasp of “what points there might be when things start changing,” she said.
According to Benson, palliative care providers can also improve transitions by reducing anxiety, bolstering coping mechanisms amongst patients and collaborating with community resources, such as home health services or hospices.
Within the scope of traditional palliative care, a burgeoning field called “transitional” palliative care, which bridges the gap between curative treatments and hospice, has begun taking shape in the healthcare domain.
“While both transitional care and palliative care share the goal of improving patient outcomes, transitional care specifically addresses the challenges of care transitions, while palliative care provides a broader approach to managing a patient’s overall well-being,” Benson told Palliative Care News.
If palliative care refers to more of the long-term management of a severe illness, then transitional palliative care refers to that “really high-risk period after a hospitalization” where a patient is at risk of being readmitted, Krmpotic said. “Those first touches after the hospital are really important.”
As noted by both experts, facilitating smooth care transitions hinges upon effective and regular communication between various parties, including referral partners and other providers.
“Surgeons use scalpels and palliative care providers use their words, and we use our words not only with our patients, but we use our words with our community providers,” Krmpotic stated.
Benson explained that palliative care operators can collaborate with referral partners and other providers by participating in care conferences to align patients’ care plans, coordinating medical treatments and interventions, and sharing resources to support a multidisciplinary approach.
By supporting effective care transitions, providers strengthen patient care, reduce hospital readmissions, improve patient outcomes and better position themselves to attract referral partnerships and negotiations with payers, according to Benson and Krmpotic.
“It’s a win-win for all involved parties,” Benson said.