The Joint Commission recently released “Hot Topics in Health Care” to encourage greater collaboration among health care providers in order to improve care as patients move from one health care setting to another. The recommendations in the report are based on published research; the insights of health care leaders, discharge nurses, physicians, care coordinators, case managers and social workers that participated in focus groups; and on-site visits to a diverse group of health care organizations.
The paper is the second in a series of reports planned over a three-year period on developments from The Joint Commission enterprise (The Joint Commission, Joint Commission Resources, and Joint Commission Center for Transforming Healthcare) about work underway to address the challenges related to transitions of care. The goal of a transition of care process is to provide the patient a safe, successful transition from one provider to the next, which may also reduce unnecessary readmissions. In response to the knowledge gained about the major facets of care transitions during this initiative, The Joint Commission plans to produce a wide range of materials and products, including potential new standards and an accompanying survey process, to help Joint Commission-accredited organizations provide safe, quality transitions of care for their patients.
The report provides details on common approaches the providers and organizations use in successful transitions of care, common challenges, variables of successful transitions and measuring the effectiveness of transitions. Scientific literature and the knowledge gained through the focus groups and on-site visits to several health care organizations make it clear that organizations in all settings must establish seven foundations to assure safe transitions from one health care setting to another. These foundations include:
• Leadership support
• Multidisciplinary collaboration
• Early identification of patients/clients at risk
• Transitional planning
• Medication management
• Patient and family action/engagement
• Transfer of information

Although the interviews with leaders and staff from focus groups, and the on-site visits at the health care organizations produced general agreement on what comprises a positive transition, they also uncovered many variables on how to make a successful transition from one organization to another. These variables point to the need to have better tools and more in-depth standardized processes. For example, the many tasks involved in a transition – from the exchange of information from one setting to another, to calling the patient after discharge– are done differently from organization to organization, and the person responsible for a successful transition and when their responsibility ends often varies.
“The process of transitioning a patient from one organization to another needs to be better addressed in all health care settings. The current Joint Commission standards and survey process address the discharge from an organization, but they do not adequately address the gap between the sending and receiving care providers,” says Kathy Clark, M.S.N., R.N., associate project director specialist, Division of Healthcare Quality Evaluation, The Joint Commission. “The Joint Commission is taking an in-depth look into how health care organizations can most effectively communicate and collaborate between the time the sender begins to prepare the patient for discharge to when the patient arrives at the receiving care facility. We want to build bridges between our organizations by better aligning their processes.”
To read the new report, “The need for collaboration across entire care continuum,” and the first paper in the series, “The need for a more effective approach to continuing patient care,” visit The Joint Commission’s Transitions of Care Portal.