A Smoother Transition

It’s called the “warm handover”: The handing-off of patients between acute care hospitals and long-term nursing care facilities. Sadly, gaps in the handoff process can lead to negative patient outcomes due to insufficient transmissions of vital data such as patient treatment and medication plans, plus warning signs for long-term caregivers to watch out for.

Addressing these problems is the goal of the National Transitions of Care Coalition (NTOCC). Founded in 2006 by the Case Management Society of America and Sanofi U.S., NTOCC brings together groups and individuals wanting to improve the quality of the “warm handover.” One concrete step they’ve taken is the release of NTOCC’s Transitions of Care (TOC) Evaluation Software.

“The TOC software is based on our research, plus NTOCC’s original transitions-of-care evaluation documents that were introduced in 2009,” explains H. Edward Davidson, PharmD, MPH, a member of the NTOCC task force and one of the software’s developers. “The software is designed to ensure all the necessary data is transmitted between the acute care facility and healthcare providers and caregivers in other care settings, such as nursing homes.”

Available for free at www.ntocc.org/TOCEvaluationSoftware.aspx, NTOCC’s TOC Evaluation Software allows acute-care hospitals and long-term care facilities to assess the quality of their current  transition-of-care procedures. As shown online, the TOC software explains the steps of the evaluation process at the outset. “An evaluation methodology can be used to walk through the key exchanges where we can make an impact on transitions of care,” explains one of the software’s opening pages. “By looking at the framework, we can determine which elements we want to affect and what changes need to take place.”

Compiling the evaluation is done by the user answering a series of yes/no questions, such as “There is documentation that the hospital discharged the resident with the hospital discharge summary” and “There is documentation that the hospital transferred the resident with a medication list.” When the test is assessed for multiple users in the same facilities, percentage scores can be compiled showing the degree of compliance with the NTOCC’s recommended practices. Reports can also be generated to indicate progress over time, after multiple measurements have been recorded.

“There are so many pieces of information that can be transferred between hospitals and long-term care facilities that are of vital importance to reducing negative patient outcomes,” says Davidson, an assistant professor of clinical internal medicine at Eastern Virginia Medical School in Norfolk and partner at Insight Therapeutics, LLC. “They include medication lists, x-rays and CTs, and ‘red flags’ for nursing home caregivers to watch out for. For instance, for patients who are recovering from heart failure, unexpected weight gain and shortness of breath are signals that their condition is worsening and requires attention. Similar data needs exist for patients going home and back under the care of a primary care provider.”

Addressing these and other challenges are the goals of the NTOCC’s TOC software, and medical professionals are stepping up to take advantage of it. “To date, we have up to 400 registered users of our software,” says Davidson. “These are institutions and healthcare professionals who are taking a hard look at their own transitions-of-care procedures, with an eye to making them better and delivering improved patient outcomes.”

It is still early for the NTOCC’s TOC Evaluation Software, so follow-up information as to its impact has yet to be officially compiled. That said, the process of critically examining one’s own TOC procedures is of benefit for any hospital or long-term care facility. The NTOCC’s TOC software makes this possible in a format that is comprehensive, easy to do—and free.

James Careless is a freelance writer with extensive experience covering computer technologies.