This article is based on a presentation given at the 2017 IHI/BMJ International Forum on Quality and Safety in Healthcare in London by Dr Paresh Dawda, Dr Andrew Knight and Leanne Wells.  Leanne filmed the introduction and conclusion to the presentation, both viewable on our YouTube channel.

The headline above is from the reputable United States publication Kaiser Health News. It’s the darker side of what most of us would think was a bright event: being let out of hospital.

But when you think more about it, transitions in health care, not surprisingly, can pose challenging times for both patient and health system. The passing from one care setting to another, particularly for patients with complex and chronic care needs, opens the potential for mistakes, oversights and misunderstandings and, far too often, a marked absence of vital information that should flow from hospital to receiving carer.

Transition from one healthcare sector to another presents an increased risk of medication error for instance, according to research cited by the Australian Commission for Safety and Quality in Healthcare. There was a two-fold increase in the relative risk of readmission associated with the omission of medication from a hospital discharge summary. Another study found that one third of patients had a medication error at admission, 85 per cent of which originated in their medication histories.

Medication errors are but one common hazard of care transition. How well prepared are patients, carers and the health system itself to ensure patients receive the thorough care that is possible yet too often absent at times of transition?

It’s a question central to the performance of health services.  The quality of transition care provides a testing measure of our overall health system, where quality of patient-focused care is demonstrated when responsibility passes from one care setting to another.

For Australia, a complicating factor can be the split nature of our health system.  Public hospitals are State government institutions while much community care, particularly that provided by GPs is financed and often regulated by the Commonwealth.

Whatever the explanation, Australia like many other countries, has some way to go to ensure transition care meets the reasonable expectations of consumers for continuing quality of care that is well coordinated and organised around their needs.

Leaving hospital should not mean a plunge into uncertain, incomplete care.  Too often in Australia that is the outcome where often vulnerable patients are discharged without complete medication and other records and a clear care plan, into an unorganised setting in which informed team work by different health professionals is absent.

Like medication misadventure, the downsides of this disruption to care and a failure of our system to coordinate better is profound and comes with many costs.  

Why is this so?  Too often there is a lack of routine and standard practices for care transition including inadequate support in the community by integrated teams of health practitioners well linked in with community services to support what should be expected practice.

Transitional services vary from one State to another and infrastructure to facilitate connected care, shared records and other solutions to smooth transition are insufficient.

But while the settings may change, we know that the patient’s needs will remain.

The one constant is the patient.

What is best for the patient requires a focus on their individual needs: consumer-centred care and good information to patient and carers provided by an integrated team that might include GPs, nurse practitioners, medical specialists and a mix of allied health practitioners such as physiotherapists, psychologists and diabetes educators.

We are about to trial in Australia what should be the next big evolution in primary care, Health Care Homes.

The need for strong integrated care for patients in transition is expanding, like the growth in chronic diseases such as diabetes requiring multi-disciplinary attention, best provided in the community and enabled by medical advances that mean earlier discharge from hospital.

Competent transitional care is also important because of the substantial costs generated by ineffective transitions and adverse events like medication mismanagement, poor handover to GP/community care resulting in avoidable hospital readmission.

Given the patient is the one constant amid varied settings and clinicians, we need to be working with patients and their carers to systematically capture their insights and measure their experiences of care to help guard against ineffective transition and identify where the breakdowns occur.

A key point is that consumers are not homogenous. They have different levels of health literacy, their cases will differ in complexity and they will have different levels of family and social support.  Increasingly we need models of care that are tailored to individuals.

The shift towards patient-centred health care homes and new ways of paying for value rather than volume-driven health care which we hope will flow from the proposed Health Care Home Programme trial provides the kind of ‘step down’ services we need to aid effective transition from hospital to either home or aged care facility.  The key is a transitional care plan that allows for

Information transfer, medicines management planning, care coordination, and access to the right array of ‘step down’ community based services – both medical and non-medical.  

High performing health systems have a strong primary care backbone.

We know in Australia that people find our system hard to navigate and the common experience of care is one of fragmentation and disconnected care.

This is where the Patient Centred Health Care Home, if implemented well, offers the key ingredients such as care coordination and an enhanced level of consumer involvement.

Accountability must be clear about who is responsible for follow-through on transitional care plans.      

We know from experience here and overseas that care systems work best where the emphasis is on clinicians and patient/carers sharing decisions about care and where there is support for patient leaders so they can partner with clinicians and others to create services that optimise patient experience and insight.

Improvements will require health practitioners working in different ways, including specialists working outside of hospital walls.

Electronic health records technology will ease the use of shared records and promote shared decision-making.

And our health services need to take more account of social determinants of health. Concepts such a  social prescribing should be included in the way we implement patient centred health care homes.  Keeping people well and at home is as much a product of access to non-medical services as to medical services.

So the shift to patient centred health care homes is as much about cultural change as it is about a new model of care.  For real success consumers must be the makers and shapers of progressive primary health care transformation in collaboration with clinicians.

To make this work we will need to develop more effective records about patients’ experiences in care transitions requiring organisations and clinicians to verify that they have sent/received/read/acted upon a discharge summary.

There will need to be culture change, system change and different financial incentives to influence behaviour of all involved in transitions of care. 

And there will need to be the right policy enablers that ensures the way we organise healthcare takes a ‘whole of system’ approach. Recent commentary has suggested Primary Care Agreements be put in place between the Commonwealth and the States, supplemented by trilateral, localised  agreements signed by the Commonwealth, the state and the Primary Health Network.  For shared accountability for better transitional care, this seems a step in the right direction particularly if the right targets are put in place.  

Consumers will need to change behaviour, working with clinicians to describe what works and what doesn’t work in transitional care and what combination of people, services and settings need to be in place.

Our health culture is in transition, hopefully to a better place.