NU507 Unit 7 care coordination analysis example

Seven Handoffs From the Unit to the Clinic: A Care Coordination Analysis of One Discharge, and Why Changing the Unit's Model Would Not Close the Gap

[Student Name]

Purdue University Global

NU507: Promoting Optimal Models and Systems for Health Care Delivery

Unit 7 Assignment

[Instructor Name]

[Date]

The discharge and its timings are composite and bracketed; the framework and studies cited are published.

The Discharge

Mr. T., 82, is discharged on a Thursday afternoon after four days for a heart failure exacerbation. He has chronic kidney disease and diabetes, takes [12] medications, lives with his wife, who manages his pills, and his primary care clinic is [34] miles away. His diuretic dose was raised, his metformin stopped because of his kidney function, and a daily weight target set. On paper, his discharge is complete: every order is signed and every referral is sent.

The Handoff Map

Each handoff lists who sends, who receives, the medium and the typical time, in brackets.

1. Discharge teaching. Sender: the nurse on duty. Receiver: Mr. T. and, if present, his wife. Medium: conversation and a printed instruction sheet. Time: [30] minutes on the day of discharge.

2. Discharge summary. Sender: the hospitalist. Receiver: the primary care clinic. Medium: electronic record, sent when signed. Time: signed [one to three] days after discharge.

3. Pharmacy fill. Sender: the discharge prescriber. Receiver: the community pharmacy. Medium: electronic prescription. Time: same day.

4. Clinic appointment request. Sender: the unit clerk. Receiver: the clinic scheduler. Medium: electronic referral. Time: appointment given for [10 to 14] days after discharge.

5. Home health referral. Sender: the case manager. Receiver: the home health agency. Medium: electronic referral with orders. Time: first visit within [two to four] days.

6. Caregiver briefing. Sender: the discharging nurse. Receiver: Mr. T.'s wife. Medium: phone call if she was absent at teaching. Time: variable; often not done.

7. First clinic contact. Sender: the clinic. Receiver: Mr. T. Medium: the scheduled visit or a registered nurse care manager call. Time: [10 to 14] days, or earlier if the care manager is alerted.

Where It Fails

Failures fall into two kinds with different remedies: information that degrades as it moves, and accountability that nobody holds. Each is labeled with an activity from the AHRQ Care Coordination Measures Atlas (McDonald et al., 2014).

Information that thins:

1. Handoff 1, teaching. Taught once, on discharge day, sometimes by a nurse new to the patient, with the medication manager absent. Atlas activity: communicate, specifically transfer of information to the patient and family.

2. Handoff 2, the summary. Often not signed or not received before the first clinic contact; discharge summaries frequently fail to reach the first follow-up visit and often omit pending tests and counseling given (Kripalani et al., 2007). Atlas activity: communicate, interpersonal and information transfer between providers.

3. Handoff 6, the caregiver. The person who fills the pill organizer may never hear that metformin was stopped. Atlas activity: support self-management goals.

Accountability that nobody holds:

4. The gap between handoffs 1 and 7. Between the unit's last contact and the clinic's first, no one is responsible for Mr. T. The unit's accountability ends at the door; the clinic does not yet know he was admitted. Atlas activity: establish accountability or negotiate responsibility.

5. Handoff 4, the appointment. Scheduled for [10 to 14] days, well after the first 72 hours in which, on this unit's record review, most readmissions began. No one owns the question of whether that interval is safe. Atlas activity: facilitate transitions.

Better documents would help the first three failures; only a named owner fixes the last two.

The Same Week From the Kitchen Table

Seen from Mr. T.'s home, the seven handoffs look different. On Thursday evening his wife reads the instruction sheet and finds a medication list that does not say, in plain words, which of the pills in the old organizer to throw away. On Friday the pharmacy fills the new diuretic dose, and the old bottle stays in the cabinet. On Saturday he weighs himself, is up two pounds, and does not know whether that matters, because the target on the sheet is in kilograms. On Monday the home health nurse cannot come until Tuesday. The clinic appointment is eleven days away. Nothing in this week is a dramatic failure; each gap is small, and together they are the pattern the unit's readmission review found again and again. By the time anyone from the health system speaks to him again, the risk has already had four days to build.

What Each Unit Model Would Change

Under team nursing, handoff 1 falls to the licensed nurse who happens to have the patient on the last day, handoff 6 depends on whether anyone thinks to call, and failures 4 and 5 are untouched.

Under primary nursing, handoff 1 improves: the primary nurse can teach across the stay, schedule teaching for when the wife visits, and reconcile changes she watched happen. Handoff 6 improves for the same reason. But failures 4 and 5 are unchanged. The primary nurse's accountability, as primary nursing defines it, runs from admission to discharge (Manthey, 2002), so it ends where the most dangerous gap begins.

That finding is the core of this analysis. Changing the unit's model improves teaching consistency but does not by itself bridge the days between leaving the unit and reaching the clinic.

Recommendation

The recommendation assigns the discharge handoff an owner. For patients in the defined population, the nurse who holds the patient at discharge, the primary nurse if the unit adopts primary nursing, calls the clinic's registered nurse care manager before the patient leaves: a warm handoff covering medication changes, the weight target, the caregiver's name and number, and the home health start date. The care manager then calls the patient within [48] hours and moves the first visit forward if needed. This borrows the logic of transitional care models that reduced readmissions by carrying responsibility across discharge, including coaching patients and caregivers to manage the transition (Coleman et al., 2006). It is also a change that works under either unit model, which matters if the unit cannot staff primary nursing.

Whether the handoff works can be measured simply: the share of qualifying discharges with a documented call to the care manager before the patient leaves, the share with a care manager call to the patient within 48 hours, and the share whose first clinic contact happens within seven days. Those three process measures, tracked monthly, would show whether the owner exists in practice before any change in readmissions can be expected.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Manthey, M. (2002). The practice of primary nursing (2nd ed.). Creative Health Care Management.

McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C., Brustrom, J., Malcolm, E., Rohn, L., & Davies, S. (2014). Care coordination measures atlas: Update (AHRQ Publication No. 14-0037-EF). Agency for Healthcare Research and Quality.