Development of a template in the primary care electronic health record to standardize care of patients transitioning from hospital to home

Background: Many patients experience a gap in care during the transition from hospital to home, placing them at high risk for re-admission within 30 days of discharge.  Such readmissions are considered preventable events by Medicare, resulting in financial penalties and poor quality scores. Most work on transition care has focused on hospitals’ role in supporting patients in transition. Primary care has a critical role to play as well.  

Objective: To standardize primary care-based care coordination for patients in transition, a template was embedded in the electronic health record as part of the rollout of nurse-driven care coordination at Community Health Center, Inc. (CHCI), a large multi-site Federally Qualified Health Center and Patient Centered Medical Home.

Methods: The transition care template was built as a collaboration between CHCI Business Intelligence, quality improvement department, and the nurses who use it daily. The content of the template is based on Coleman’s work for hospitals on transition care. It addresses medications, whether new prescriptions have been filled, follow up appointments, review of symptoms that indicate worsening of a patient’s condition, and the discharge plan, e.g., support at home, supplies and involvement of local agencies.

Results: The tool standardizes documentation and quantifies clinical processes in the coordination of care for patients in transition. It is a source of data regarding the needs of CHCI populations in transition, and can identify missed opportunities for providing transition care.  Aggregate data captured from the templates can enable CHCI to be more pro-active regarding patient needs.  For example, in the first three months of template use, 2% of patients report they cannot afford to fill new prescriptions.

Conclusions:  A standardized care transitions template for primary care nursing may help close the care gap between hospital and home and  prevent re-admission to the hospital for high risk patients.