ACP Offers Best Practices to Improve Care Transitions Between Settings

Advocate Masthead

New policy paper emphasizes the need for a patient-centered, physician-led care team to improve patient safety and outcomes

May 5, 2023 (ACP) — A new American College of Physicians policy paper provides a roadmap for clinicians and other stakeholders to improve transitions for patients between health care settings. The paper, “Beyond the Discharge: Principles of Effective Care Transitions Between Settings,” makes recommendations for more successful care transitions to improve care team workflow, patient safety and satisfaction, and health care outcomes.

“Moving from one care setting to another is a critical time for patient care,” said Dr. Ryan D. Mire, immediate past president of ACP. “A disjointed health care system, where many patients lack a primary care physician and the electronic record systems of different care settings cannot communicate with each other, present significant challenges to optimal care transitions. The challenges due to the nature of our health care system are often further compounded by systemic socioeconomic injustices that create health and health care disparities for many in our society.”

The policy paper, from the ACP Council of Subspecialty Societies, details best practices for successful care transitions between settings-- such as those from a hospital to a rehabilitation facility or nursing home — and emphasizes the importance of establishing a coordinated, communicative, patient-centered and physician-led care team.

ACP previously addressed best practices for coordination and collaboration between primary care specialists and specialty care teams in its policy papers “Beyond the Referral: Principles of Effective, Ongoing Primary and Specialty Care Collaboration” and “The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices,” according to Sarah Crossan, ACP associate for regulatory affairs.

“Since then, ACP has continued to study and emphasize the importance of effective care transitions,” she said. “Our nation's health care system is increasingly disjointed as the number of people without a primary care physician increases and the utilization of emergency departments and urgent care clinics for basic health care escalates. Facing this reality, we established safe care transitions for patients across all care settings as the priority of this paper.”

In the paper, ACP makes the following recommendations:

  • Health care professionals should engage in conversations with patients and families around factors that influence patient goals during care transitions.
  • Successful care transition interventions (e.g., model, framework or standard) should address social drivers of health, with the goal of decreasing health inequities.
  • The scope of transitional care activities should be expanded to include the total care trajectory during an episode of illness (e.g., the journey the patient experiences from the start of medical care to the end of the episode).
  • Communication among all members of the clinical care team is critical for optimal care transitions. Communication must highlight the most critical information, summarize the most important points and avoid information overload.

“While some of the recommendations may seem intuitive to some ACP members, the best practices outlined in this work highlight aspects of and approaches to patient-centered, whole-person care that require not only our members' consideration and attention, but also [the consideration and attention] of the stakeholders we have highlighted,” Crossan said. “Care coordination and communication are inherently collaborative and require the investment of all stakeholders within the health care system.”

Moving forward, the policy paper urges the Centers for Medicare & Medicaid Services and the National Center for Health Statistics to establish adequate ICD-10-CM nomenclature and payment for social drivers of health codes. “Integrating individual-level social drivers of health into electronic records via ICD-10-CM can assist in risk assessment and predicting health care utilization and health outcomes,” Crossan explained.

Also, she said, the paper highlights how inadequate reimbursement to cover the cost of the total care team and other practice expenses remains a significant barrier to implementation of these recommendations.

Ultimately, Crossan noted, the paper makes the core elements of successful care transitions clear. They involve patients in the discussion, support coordination among multiple care teams across various health care settings and ensure effective communication within care teams.

And, she said, these care transitions must define care team roles clearly, promote availability and clarity of accurate clinical data to patients/caregivers and care teams, empower the patient/caregiver through education on important aspects of their care plan and be able to reliably depend on health information technology system interoperability.

More Information

The policy paper, “Beyond the Discharge: Principles of Effective Care Transitions Between Settings,” is available on the ACP website.

Health Day Logo

Back to the May 5, 2023 issue of ACP Advocate