Care transitions—when patients are transferred from one care provider or setting to another—are a fragile point on the health care continuum. A group of health care experts, including nurses, are working to improve care transitions and are getting national attention for their efforts.
In February, the Massachusetts Senior Care Foundation received a prestigious award from the American Health Care Association (AHCA) in part because of its Care Transitions Education Project (CTEP), which trains nurses to lead and improve care transitions. CTEP is funded by Partners Investing in Nursing’s Future (PIN), a joint initiative of the Robert Wood Johnson Foundation (RWJF) and the Northwest Health Foundation that supports local foundations to advance nursing in their communities.
“The AHCA leadership specifically cited the Care Transitions Education Project as a key factor in its decision to select us for the award, which was based on state affiliates’ efforts to help their members achieve AHCA quality improvement goals,” said Carolyn Blanks, BA, executive director of the Massachusetts Senior Care Foundation. “The program is innovative but, at the same time, it’s obvious when you think about it. It really is nurses who are front and center in care transitions.”
CTEP got started in 2011 as a way to improve the quality of care during transitions, which are associated with adverse events including medication errors, poor patient outcomes, and preventable readmissions to the hospital. Helping nurses improve care transitions will help boost quality and reduce avoidable hospital readmissions and related financial penalties, according to Laurie Herndon, MSN, GNP, director for clinical quality at the Massachusetts Senior Care Foundation.
The project aligns with the Institute of Medicine’s 2010 report on the future of nursing, which calls for the nursing workforce to be better prepared to lead change and more highly educated to meet changing patient needs, added Kelly Aiken, MS, MEd, director of health care workforce initiatives at the Regional Employment Board of Hampden County in western Massachusetts.
Focus on Nurses
CTEP focuses on nurses because they have access to patients across the continuum of care and because they handle many aspects of care transitions, such as patient education, patient handovers, and care coordination, Herndon said. “Nurses are not only responsible for managing care transitions but for leading ways to improve them,” she added. Herndon, a nurse practitioner herself, did not receive any education on care transitions and realized that both current and future nurses need the knowledge. “That’s how the project was born,” she said.
To get started, Herndon and educators from academia and across the care continuum reviewed scientific literature on care transitions and identified missing educational content on the subject in a “gap analysis.” They then created a curriculum to educate nursing students as well as nurses from acute care, rehabilitation, long-term care, home care and other settings.
The curriculum includes three major components: interactive learning modules, a quality improvement activity, and a “patient tracer” experience in which nurses shadow patients as they transition into different care settings. It will soon be accessible to a broader audience.
CTEP educators conducted a “train-the-trainer” program with nine pilot sites. Those “trainers” then taught almost 350 nurses and nursing students at 32 different pilot organizations in the western part of Massachusetts. Key to pilot implementation was bringing nurses from different settings together to learn from and with each other.
One key aspect of the curriculum focuses on changing attitudes nurses have toward other nurses. “To really improve care transitions, we need to help nurses appreciate the value, skills, and expertise that nurses in other settings bring to the table,” Blanks said. “Unless we change attitudes among nurses in different settings, we can’t achieve the collaboration needed to improve care transitions.”
Initial results show that nurses who completed the training increased their skill and knowledge in leading successful care transitions and developed greater appreciation for the work nurses do across settings. “Nurses understand that they have a broader mission,” Blanks said. “They’re there to help the patient get better and also to make sure the next setting is prepared to receive that patient and help him or her achieve health goals. It’s a more holistic approach to nursing than existed in the past.”
The state’s re-hospitalization rate has dropped from 17 percent in 2009 to 12 percent at the end of 2013, Herndon said. “We’ve seen steady, significant declines since we started this work,” she said, noting that CTEP is one factor among many that may have contributed to the improvement.
Now in its third and final year, project officials are presenting the program to a statewide audience on March 26 to raise awareness and, they hope, to secure funding to continue. “We’re hoping there may be some state-based funding opportunities that would provide support for the phase two testing of the curriculum,” Blanks said.