Case Management

Effectively transitioning requires asking the right questions

Case Management Insider, February 10, 2015

In December 2014, the Commission for Case Manager Certification and its CMLearning Network® explored the best and most effective ways to improve transitions for patients.

Mary D. Naylor, PhD, FAAN, RN, Marian S. Ware professor in gerontology and director, New Courtland Center for Transitions & Health University of Pennsylvania School of Nursing outlined some research-proven strategies in the webinar Care Transitions: Evidence-Based Practices for Case Mangers. (Check out the full story on her presentation in the March issue of Case Management Monthly.)

Following the presentation, Naylor touched on some important points in a question and answer that discussed how to identify patients at risk for transition failures and what red flags to look for to prevent a problem.
Below is a summary of her comments.
Q: Do you have a specific screening tool that you recommend or is that going to vary by patient?
A: The University of Pennsylvania developed a standardized risk assessment tool to screen high risk patients. The tool is designed to identify priority needs for patients at risk of poor outcomes and also goes on to identify the two or three main problems that may lead to poor outcomes for that patient.
In addition, a team at UPenn has also developed other tools to help spot potential problem areas that could lead to transition failures. For example, the team developed a tool to measure patient satisfaction, which does far more than just ask patients if they were happy with their experience at the facility, said Naylor. The tool delves deeper touching on three areas of the patient’s experience that may predict whether they will transition successfully.
The first question the team asks patients is if their symptoms are under control. This is done because symptom management is a critical part of a successful transition, she said. The goal is to find out if symptoms exist and how bothersome they are to the patient so that they can be better managed in some cases. In addition the team also asks patients how they rate their overall quality of life. Research has found that people who perceive their quality of life as poor or fair are much more likely to have poor outcomes than people who rate it as excellent or good. In addition the team also looks at the functional status of the patient to determine how well they are getting by in their new setting. All of these are important outcomes. We have learned over time that for the people we serve, functional status is very important, as is symptom status and quality of life.
The goal of the assessment is to understand not only the patient’s experience with care, but also the challenges they face. “We used to measure satisfaction but we found this was a poor indicator,” said Naylor.
If your organization is merely asking patients about their satisfaction levels, you might want to consider revising your approach to look at these other quality indicators, which may be better predictors of a successful transition.

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