Hospitalists: Project Aims to Improve Care Transitions for Older Adults


January / February 2008


Project Aims to Improve Care Transitions for Older Adults

Care transitions at the time of hospital discharge have long been a problem in our nation’s healthcare system, especially for older adults. It’s often a stressful and sometimes dangerous process that can impact the health outcomes of the patient.

The problems often begin at admission when patients arrive with incomplete medical histories and uncertain or missing medication lists and continue at discharge when patients often receive less than optimal preparation before leaving the hospital.

Hospital discharge is a critical transition point for all patients, but it especially affects older adults, many of whom have multiple medical problems. Older patients frequently are discharged without a clear understanding of how to care for themselves, take and monitor medications appropriately, or identify new symptoms that require immediate medical attention.

“Once the discharge order for a patient has been given, there is a lot of pressure to make that transition happen quickly. A safe, effective transition out of the hospital requires teamwork and planning that begins on admission, not an hour before the patient leaves the building,” said Tina Budnitz, the Society of Hospital Medicine’s (SHM) senior advisor for quality initiatives.

SHM, the professional organization representing the nation’s 20,000 hospitalists, recently received a $1.4 million grant from the John A. Hartford Foundation to develop after-hospital care coordination tools, curricula, and quality improvement initiatives designed to improve health outcomes for older adults.

“As physicians responsible for the care of hospitalized patients, hospitalists seek to optimize care delivery during the transition from hospital to home and ensure that patients continue on the path to recovery. Only by managing this transition, instead of abandoning involvement, can hospitalists guarantee it will go smoothly,” said Mark Williams, MD, chief of the division of hospital medicine at Northwestern University. “This project uniquely involves multiple experts at the cutting edge of research in this field. The project aims to improve care at both academic and community hospitals using a mentored implementation approach, meaning hospitals and hospitalists who participate will receive ongoing personalized guidance from expert mentors.”

With assistance from an advisory board with partners from some of the most respected and influential healthcare organizations in the country, and a group of expert advisors representing such fields as nursing, pharmacy, case management, and sociology, SHM’s project has gained influence and knowledge from all aspects of the care transition process.

“The timing for the roll out of this project could not be better,” addsÝEric Coleman,Ýdirector of the Care Transitions Program and co-chair of the project’s Advisory Board. “In the past two years there has been a convergence of attention and activityÝamongst many of the nation’s leading quality and safety organizations, many of which are part of our Advisory Board, includingÝThe JointÝCommission, the Institute of Medicine, the Institute for HealthcareÝImprovement,Ýthe National Quality Forum, National Transitions of Care Coalition, and the nation’s Quality Improvement Organizations to name a few.”

Project Creates New Resources
The 3-year project aims to create a transitions toolkit and an array of technical support programs to support its implementation. The toolkit will include a bundle of interventions to optimize the hospital discharge for older adults or, more specifically, improve communication among sending and receiving physicians, better prepare patients for post-discharge medication management and self-care, facilitate follow-up care and transfer patient information, and educate support staff. For each intervention in the bundle, the toolkit will provide supporting evidence for its use, clinical tools, staff training materials, patient education materials, related evaluation strategies, and key messages for gaining local support for the intervention. The toolkit also will provide an instructional manual for quality improvement teams that will help them implement, evaluate, and sustain the interventions.

“SHM realized the need for national standards to enable local hospitals to create and manage a better discharge process. We recognize there is significant work to be done in order to make progress on this issue, but SHM has decided to take a leadership role, with the generous grant from the John A. Hartford Foundation and the help of many prominent healthcare organizations. We are developing tools and materials that will aid hospitals and their staff to make the care transition process a safer one,” said Larry Wellikson, MD, SHM’s CEO.

The project also provides a continuum of technical support options for local quality improvement teams. The online resource room, scheduled to launch in May 2008, will provide self-directed learning options for quality improvement teams. The web-based resource will include the complete discharge planning toolkit, instruction manual, and discussion forums for peer-to-peer and team-to-expert dialogues.

One of the most exciting technical support options is the Transition Planning Mentored Implementation Program (TPMI), a unique opportunity for hospitals to have someone oversee implementation of the transitions bundle. To enroll, hospitals will complete an online application including a needs and resource assessment. Project faculty will be on-hand for day-long training courses and monthly phone calls. The extensive curriculum will provide participants with a step-by-step implementation guide and create a virtual peer community for interaction with other sites. This mentoring approach not only supports adoption of the transition bundle, but builds overall capacity at local institutions to implement and sustain other patient safety initiatives.

Another way hospitals can receive a more hands-on experience is through the On-Site Consultation Program. Interested sites will also be required to complete an online application and needs/resources assessment. Two or three experts will be assigned per site and will meet with teams by phone to understand their needs. The site visit will consist of a team meeting and may also include meetings with hospital management. The on-site expert will then report findings and recommendations within 90 days of the initial visit. SHM will begin enrollment for the TPMI and On-Site Consulting Program in May 2008. Applications will be available on the SHM website.

In addition to the current online resources, SHM will be offering a course specifically for care transitions at Hospital Medicine 2008, SHM’s Annual Meeting. This course, High Impact Quality Improvement: How to Ensure a Successful Project, walks participants through effective implementation of evidence-based, high-reliability interventions. Participants will also learn techniques for designing, implementing, and evaluating quality improvement projects. The objectives of the course are for participants to be able to apply basic quality improvement concepts including setting aims, establishing measures, and selecting changes specific to care transitions and improve the quality of patient care using important clinical processes in the area of managing care transitions. Registration for this course is open and can be accessed by visiting

Currently, resources to implement best practices in discharge planning can be found online at in the Care Transitions in Older Adults Quality Improvement Resource Room. This online resource, which will be updated and improved as a part of the grant, provides literature, a workbook outlining how hospitalists can implement or improve care transitions at their hospital, an “Ask the Expert” forum, where participants can ask questions about care transitions and get quick answers, and more.

The transition out of the hospital can and should be safer for older adults. The toolkit and technical support programs developed by SHM and its partners are a giant step forward to improve patient outcomes and quality of life post-discharge. Ultimately however, success will come from the dedication of local hospital quality improvement teams and the coalition of national leaders redefining quality discharge planning.

Care Transitions in Older Adults Advisory Board

  • American Geriatrics Society
  • American Society of Health-System Pharmacists
  • Case Management Society of America
  • Blue Cross Blue Shield Association
  • Centers for Medicaid and Medicare Services
  • Society of General Internal Medicine
  • Institute for Healthcare Improvement
  • John A. Hartford Foundation
  • Agency for Health Research and Quality
  • National Quality Forum

Heather Abdel-Salam is coordinator of public relations and marketing for the Society of Hospital Medicine in Philadelphia, Pennsylvania. She may be contacted at