The work of Telligen’s Brianna Gass, MPH, Quality Improvement Manager, appears in the September issue of The Joint Commission Journal of Quality and Patient Safety. The editorial and published manuscript titled, Optimizing Care Transitions: Adapting Evidence Based Informed Solutions to Local Contexts, studies specific components and contributing factors related to effective interventions for care transitions.

Located in our Denver, CO office, Brianna manages a team of program evaluators that offer services and support related to designing, implementing, monitoring, and evaluating quality management and improvement programs.

The team evaluates national and community-based health care quality improvement efforts, which includes several recipients of the Center for Medicare and Medicaid Innovation (CMMI) Health Care Innovation Awards.

The editorial and publication highlights Brianna’s work as part of Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence), which studies the design and development of best practice recommendations and implementation guidelines for national patient-centered care transition programs. See the abstract below for a high-level overview.

Congratulations, Brianna!

Background: Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models.

Methods: From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations—community hospitals, academic medical centers, integrated health systems, and broader community partnerships.

At each site, direct observation and document review were conducted, as were semi-structured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers.

Results: Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in.

Conclusion: True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization’s formal board agenda, and by incentivizing excellence in providing transitional care services.