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How do you measure the quality and outcomes of care transition communication?

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Care transition communication is the exchange of information and coordination of services among health care providers, patients, and caregivers during the transfer of care from one setting to another. Effective care transition communication can improve patient safety, quality of care, and health outcomes, as well as reduce hospital readmissions, costs, and stress. But how do you measure the quality and outcomes of care transition communication? Here are some key aspects to consider.

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Lisa Crawley RN, MN, CPMHN(C)

Nurse Manager at University Health Network and Adjunct Lecturer, Lawrence Bloomberg Faculty of Nursing
Dr.Ajay G.
Shannon Layton, DNP, NEA-BC, CNL, CNE, LICSW-S

Graduate Clinical Faculty UAB School of Nursing

1 Define your goals and indicators

Before you can measure the quality and outcomes of care transition communication, you need to define what you want to achieve and how you will track your progress. For example, you may want to reduce the rate of hospital readmissions, increase patient satisfaction, or improve adherence to care plans. You also need to identify the indicators that will measure your performance, such as the number of follow-up calls, the timeliness of information transfer, or the accuracy of medication reconciliation.

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Shannon Layton, DNP, NEA-BC, CNL, CNE, LICSW-S

Graduate Clinical Faculty UAB School of Nursing
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In order to successfully implement and sustain your plan, you will want to select an outcome, process, and balancing measure. This will ensure that your results are reflective of your efforts and are adding to the overall performance of your institution. If you are unsure how to select these specific indicators, be sure to reach out to experienced quality improvers with data measurement experience. Doing this early in the improvement process will maximize your effectiveness.

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Dr.Ajay G.
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TO check the quality and outcomes of care transition communication one has to track the progress and outcome of care of patients under you and also checklist can be tracked if it is properly maintained or not

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2 Use standardized tools and methods

To ensure the reliability and validity of your measurements, you should use standardized tools and methods that are appropriate for your context and population. For example, you may use surveys, interviews, or focus groups to assess patient and caregiver perspectives, or electronic health records, discharge summaries, or care transition reports to evaluate provider communication. You should also follow the best practices and guidelines for data collection, analysis, and reporting, such as the Care Transitions Measure (CTM) or the INTERACT tools.

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Paul (Pablo) Arias EJD, MIS, BSN, RN, CMAC

Founder and CEO- Case Management, Denial Prevention, Revenue Cycle, Regulatory Compliance, Utilization Review, BPCI, Transitional Care
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When collecting data ensure your methods are solid and do not call a trend without sufficient data points. You need to establish 6 consecutive points or 8 of 9 to show a trend per the guru of data and control charts Shewart. Many times we want data to tell us something prematurely and to celebrate success but to ensure we have a process that is working we need to gather sufficient data to properly analyze prior to that celebration or making further changes. That can be done in a day, a week, or a month depending on the process or data you are trying to analyze or the process you are working on. Kaizen events and mini PDCA cycles can help with that data gathering and process improvement cycle.

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3 Compare and benchmark your results

To understand how well you are doing and where you can improve, you should compare and benchmark your results with other relevant sources. For example, you may compare your results with your own baseline data, with other similar programs or organizations, or with national or regional standards or benchmarks. You should also consider the factors that may influence your results, such as the characteristics of your patients, providers, and care settings, and adjust your comparisons accordingly.

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4 Implement and evaluate improvements

Based on your measurements and comparisons, you should identify the gaps and opportunities for improvement in your care transition communication. You should then implement and evaluate the interventions or strategies that address those gaps and enhance your communication. For example, you may use checklists, protocols, or templates to standardize and streamline your communication processes, or provide training, feedback, or incentives to improve your communication skills and behaviors.

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Dr.Ajay G.
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Care transition communication is like a relay race where one stakeholder passes on the patient information to one another to prevent any loose ends as this can cause an error in patient care which can be detrimental to patients health.So the real success of care transition communication lies in improved patient satisfaction and wonderful treatment outcomes

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5 Involve and engage stakeholders

To ensure the success and sustainability of your care transition communication measurement and improvement efforts, you should involve and engage all the relevant stakeholders, such as patients, caregivers, providers, managers, and policymakers. You should communicate your goals, indicators, results, and improvements clearly and regularly, and solicit their feedback and input. You should also foster a culture of collaboration, learning, and accountability among your stakeholders, and celebrate and share your achievements and challenges.

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Lisa Crawley RN, MN, CPMHN(C)

Nurse Manager at University Health Network and Adjunct Lecturer, Lawrence Bloomberg Faculty of Nursing
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Failing to engage stakeholders and include them from the very beginning will appear as and is tokenism. There is nothing more off-putting to many as feeling like an after thought. Make sure the stakeholders you identify review who has been identified and solicit for any gaps in representation. Ensure that stakeholders are clear on what they are being asked to do. This is more likely to result in better engagement and support of the project. It will also ensure more fruitful outcomes. Share the goals and milestones by reporting back on a regular and agreed upon cadence with all stakeholders.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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How do you measure the quality and outcomes of care transition communication?

1

2

3

4

5

6

1 Define your goals and indicators

2 Use standardized tools and methods

3 Compare and benchmark your results

4 Implement and evaluate improvements

5 Involve and engage stakeholders

6 Here’s what else to consider

Case Management

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How do you measure the quality and outcomes of care transition communication?

1

2

3

4

5

6

1 Define your goals and indicators

2 Use standardized tools and methods

3 Compare and benchmark your results

4 Implement and evaluate improvements

5 Involve and engage stakeholders

6 Here’s what else to consider

Case Management

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