Day of Transition Initiative

Begun in February 2013, the Fund’s Day of Transition Initiative seeks to design and test system changes that improve the day of transition from hospital to home care and develop procedures to close the loop so that all providers, patients, and family caregivers can monitor and report on the safety and effectiveness of the transition. Central to the initiative is the systematic involvement of family caregivers to help diagnose problems, design new procedures and protocols, and monitor and assess their implementation.

The challenges are familiar: hospital discharge often is a “hurry up and wait” experience, one that can be confusing and frustrating. Patients and their family members have a lot of information thrust upon them as they worry about various logistics—transportation home, making the home itself ready, dealing with changes in medications, making a follow-up appointment with the primary care provider. It’s no wonder that they often arrive home stressed and bewildered, and mistakes occur.

Three hospitals were chosen to participate in the initiative—New York Methodist Hospital, Mount Sinai Medical Center, and Metropolitan Hospital—each partnering with a certified home care agency of its choice. The Fund awarded each hospital an initial $50,000 grant to support the effort. Extension grants of $50,000 were awarded in February 2014 to enable continuing participants to build on an excellent start.

In their initial activities, the hospital/home care teams worked to develop strong partnerships, analyzed their current transition processes, and developed a course of action to improve them. Each of the three hospitals has focused on the issues it identified following its initial evaluation:

  • Metropolitan Hospital and its partner, Health & Home Care, have focused on medication education, with heart failure patients as their target population. They have also created a patient and family advisory group.
  • Mount Sinai Medical Center and its partner, the Visiting Nurse Service of New York, have also concentrated on medication education, targeting patients at high risk of readmission. For 30 days after discharge, the two organizations are providing additional services for their home care patients, with home care nurses coordinating with hospital social workers to address each patient’s specific needs.
  • New York Methodist Hospital and its partner, the Visiting Nurse Service of New York (Brooklyn team), found two areas of concern in their initial self-evaluation: medication reconciliation and transportation of the patient to home. The home care partner is now double checking the hospital’s medication reconciliation, and the hospital has streamlined communication and coordination of transportation services.

Lessons learned are routinely shared among all participants.

In its second year, the initiative is focusing on making sustainable the system-level changes that have improved care. Participants are also pursuing further implementation and analysis.

The need for the Day of Transition Initiative was identified as a result of earlier Fund projects, including the Transitions in Care–Quality Improvement Collaborative (2010-12). Two of the Day of Transition Initiative hospital participants—Metropolitam Hospital and New York Methodist Hospital—were also part of the Transitions in Care–Quality Improvement Collaborative.