Advertisement

Journal of General Internal Medicine

, Volume 24, Issue 8, pp 971–976 | Cite as

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine

  • Vincenza SnowEmail author
  • Dennis Beck
  • Tina Budnitz
  • Doriane C. Miller
  • Jane Potter
  • Robert L. Wears
  • Kevin B. Weiss
  • Mark V. Williams
Health Policy

Abstract

The American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established: 1.) Accountability; 2) Communication; 3.) Timely interchange of information; 4.) Involvement of the patient and family member; 5.) Respect the hub of coordination of care; 6.) All patients and their family/caregivers should have a medical home or coordinating clinician; 7.) At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point; 9.) National standards; and 10.) Standardized metrics related to these standards in order to lead to quality improvement and accountability. Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.

Keywords

Electronic Health Record Medical Home Care Transition Transition Record Academic Emergency Medicine 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Conflict of Interest Statements

Summary:

Conflict of Interest Statement for Faculty, Authors, Members of Planning Committees and Staff

American College of Physicians – Society of Hospital Medicine – Society of General Internal Medicine

The following members of the Steering (or Planning) Committee and Staff of the Transitions of Care Consensus Conference have declared a Conflict of Interest:

Dennis Beck, MD, FACEP (ACEP Representative) President and CEO, Beacon Medical Services has declared conflict of interest of Stocks/Holdings: 100 units of stock options/holdings in Beacon Hill Medical Services

Tina Budnitz, MPH (SHM Staff) Senior Advisor for Quality Initiatives Society of Hospital Medicine has declared conflict of interest of Employment: Staff, Society of Hospital Medicine

Eric S. Holmboe, MD (ABIM Representative) Senior Vice President Quality Research and Academic Affairs American Board of Internal Medicine has declared conflict of interest of Employment: SVP Quality Research and Academic Affairs American Board of Internal Medicine

Vincenza Snow, MD, FACP (ACP Staff) Director, Clinical Programs and Quality of Care American College of Physicians has declared conflict of interest of Research grants: CDC, Atlantic Philanthropies, Novo Nordisk, Bristol Myers Squibb, Boehringer Ingelheim, Pfizer, United Healthcare Foundation, Sanofi Pasteur

Laurence D. Wellikson, MD, FACP (SHM Staff) Chief Executive Officer Society of Hospital Medicine has declared conflict of interest of Employment: CEO, Society of Hospital Medicine

Mark V. Williams, MD, FACP (Co-Chair, SHM Representative) Editor-in-Chief, Journal of Hospital Medicine Past-President, Society of Hospital Medicine has declared conflict of interest of Membership: Society of Hospital Medicine

The following members of the Steering (or Planning) Committee and Staff of the Transitions of Care Consensus Conference have declared No Conflict of Interest:

David Atkins, MD, MPH, (AHRQ Representative)

Associate Director, QUERI, Department of Veteran Affairs, Office of Research and Development, Health Services Research & Development (124)

Doriane C. Miller, MD (Co-Chair, SGIM Representative)

Associate Division Chief, General Internal Medicine, Stroger Hospital of Cook County

Jane Potter, MD (American Geriatric Society Representative)

Professor and Chief of Geriatrics, University of Nebraska Medical Center

Robert L. Wears, MD, FACEP (Society for Academic Emergency Medicine Representative)

Professor, Department of Emergency Medicine, University of Florida

Kevin B. Weiss, MD, MPH, MS, FACP (Chair, ACP Representative)

CEO, American Board of Medical Specialties

Financial Support Statement

The TOCCC was funded under an unrestricted educational grant from Novo Nordisk, as part of the ACP Diabetes Initiative, and from the AHRQ. The funders had no input into the planning, structure, content, participants, or outcomes of the conference.

References

  1. 1.
    Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–7.PubMedGoogle Scholar
  2. 2.
    Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–8.PubMedGoogle Scholar
  3. 3.
    Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005; 165(16):1842–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Tsilimingras D, Bates DW. Addressing post-discharge adverse events: a neglected area. Jt Comm J Qual Patient Saf. 2008;34(2):85–97.PubMedGoogle Scholar
  5. 5.
    Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data From Vital And Health Statistics; No. 386. Hyattsville, MD: National Center for Health Statistics; 2007.Google Scholar
  7. 7.
    Cooper JB. Do short breaks increase or decrease anesthetic risk? J Clin Anesth. 1989;1(3):228–31.PubMedCrossRefGoogle Scholar
  8. 8.
    Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology. 1982;56(6):456–61.PubMedCrossRefGoogle Scholar
  9. 9.
    Wears RL, Perry SJ, Shapiro M, et al. Shift changes among emergency physicians: best of times, worst of times. Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting: p 1420–1423. Denver, CO: Human Factors and Ergonomics Society; 2003.Google Scholar
  10. 10.
    Wears RL, Perry SJ, Eisenberg E, et al. Transitions in care: signovers in the emergency department. Proceedings of the Proceedings of the Human Factors and Ergonomics Society 48th Annual Meeting: p 1625 - 1628. New Orleans, LA: Human Factors and Ergonomics Society; 2004.Google Scholar
  11. 11.
    Behara R, Wears RL, Perry SJ, et al. Conceptual framework for the safety of handovers. In: Henriksen K, ed. Advances in Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality/Department of Defense; 2005: pp 309 - 321.Google Scholar
  12. 12.
    Feldman JA. Medical errors and emergency medicine: will the difficult questions be asked, and answered? (letter). Acad Emerg Med.. 2003; 10(8):910–1.PubMedCrossRefGoogle Scholar
  13. 13.
    Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004; 141(7):533–6.PubMedGoogle Scholar
  14. 14.
    Starfield B, Shi L. The Medical Home, Access to Care, and Insurance: A Review of Evidence. Pediatrics. 2004; 113(5 Supple):1493–8.PubMedGoogle Scholar
  15. 15.
    Redesigning the practice model for general internal medicine. A proposal for coordinated care: a policy monograph of the Society of General Internal Medicine. J Gen Intern Med. 2007;22(3):400–9.Google Scholar
  16. 16.
    The medical home. Pediatrics 2002;110(1 Pt 1):184-6.Google Scholar
  17. 17.
    American College of Physicians. The advanced medical home: a patient-centered, physician-guided model of healthcare. A Policy Monograph. 2006. Available at http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf Accessed March 13, 2009.
  18. 18.
    Coleman EA, Smith JD, Frank JC, et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02.PubMedGoogle Scholar
  19. 19.
    vom Eigen KA, Walker JD, Edgman-Levitan S, et al. Carepartner experiences with hospital care. Med Care. 1999;37(1):33–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for post hospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;433:246–55.PubMedCrossRefGoogle Scholar
  21. 21.
    American Board of Internal Medicine Foundation. Stepping Up to the Plate Alliance. Principles and Standards for Managing Transitions in Care (in press) Available at http://www.abimfoundation.org/publications/pdf_issue_brief/F06-05-2007_6.pdf Accessed March13, 2009.

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Vincenza Snow
    • 1
    Email author
  • Dennis Beck
    • 2
  • Tina Budnitz
    • 3
  • Doriane C. Miller
    • 4
  • Jane Potter
    • 5
  • Robert L. Wears
    • 6
  • Kevin B. Weiss
    • 7
  • Mark V. Williams
    • 8
  1. 1.American College of PhysiciansPhiladelphiaUSA
  2. 2.Beacon Medical ServicesAuroraUSA
  3. 3.Society of Hospital MedicinePhiladelphiaUSA
  4. 4.University of Chicago Medical CenterChicagoUSA
  5. 5.University of NebraskaLincolnUSA
  6. 6.University of FloridaGainesvilleUSA
  7. 7.American Board of Medical SpecialtiesChicagoUSA
  8. 8.Northwestern UniversityChicagoUSA

Personalised recommendations