AHRQ Views

Blog posts from AHRQ leaders

Jeffrey BradyAs front-line practitioners, nurses are highly attuned to the fact that patients’ needs can be very different depending on their setting of care. This insight gives nurses a unique role in making care transitions safer, a longstanding goal of AHRQ, along with our local and Federal patient safety counterparts, and one where nurses play a pivotal role.

Care transitions occur when a patient is transferred to a different setting or level of care. They can occur when the patient moves to a different unit within the hospital, when a patient moves to a rehabilitation or skilled nursing facility, or when a patient is discharged back home. Among older patients or those with complex conditions, our research shows that care transitions can be associated with adverse events, poorer outcomes, and higher overall costs, if not managed well. They can also lead to an increase in potentially preventable hospital readmissions.

Nurses are typically the first to ask about or notice changes in a patient’s health condition, such as mental status, medication routine, or vital signs, when a patient is transferred to a different hospital unit or care setting. It’s no surprise then that nursing’s largest membership organization, the American Nurses Association (ANA), has identified transitions of care as a key component of its 2016 Culture of Safety campaign. At AHRQ, we support this priority and nurses’ efforts to make transitions safer, both at the local level and through Federal efforts.

One such effort is the Partnership for Patients’ (PfP) Community-based Care Transitions Program that was launched in 2012. The goal was to improve care when Medicare patients move from hospitals to home or to other settings, such as nursing homes. Of the sites that participated in the project, those that successfully lowered hospital readmissions implemented nurses or coaches and offered at least two support services for older patients, according to a 2014 program evaluation report.

Richard RicciardiSome of the hospitals participating in PfP efforts have used AHRQ’s Re-Engineered Discharge Toolkit (RED) to successfully reduce readmissions and improve care transitions. For example, the San Francisco-based Dignity Health system cut its 30-day Medicare readmission rate at its Bakersfield Memorial Hospital by more than half within months by incorporating elements of the toolkit, according to a recent AHRQ case study. Another RED supporter, Euclid Hospital, a Cleveland Clinic facility in Euclid, Ohio, introduced the toolkit to local nursing homes, which saw readmissions for heart failure patients drop from 21 to 5 percent after 6 months.

The RED Toolkit describes a process in which nurses or health coaches lead efforts to oversee the discharge process. Before patients leave the hospital, the nurse makes sure they understand information such as their diagnosis, medications, and how to care for themselves when they get home. Nurses also ensure that patients’ followup appointments are arranged, so posthospital tests or test results don’t fall through the cracks.

Care transitions between units within a facility can also be problematic, especially when teamwork breaks down. AHRQ’s TeamSTEPPS® is a curriculum that promotes a culture of safety by improving communications and teamwork skills among nurses and others on health care teams. Developed originally for use in hospitals, the curriculum has been adapted to apply these safety-enhancing skills to other care settings, such as medical offices and long-term care settings.

Promoting safe and effective care across the many settings where patients receive care is a complex challenge—one that can be addressed only with the input and leadership of nurses. We’re making good progress, especially in the hospital setting, but more work remains. Working together with nurses and other front line clinicians, AHRQ will continue to develop tools and resources to ensure that all patients receive the safest care possible, no matter where it is delivered.

Page last reviewed September 2016
Page originally created September 2016
Internet Citation: Making Care Transitions Safer: The Pivotal Role of Nurses. Content last reviewed September 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/blog/ahrqviews/pivotal-role-nurses.html