Strategies for Improving Transitions of Care for Patients With Diabetes: An Interview With Jennifer N. Clements, PharmD

The American Journal of Managed Care^® (AJMC^®): What constitutes a transition of care? What factors are associated with worse outcomes during these transitions?

Jennifer N. Clements, PharmD: Generally, a transition of care is defined as a patient transitioning from one care setting to another. For example, a patient can move from one unit to another within the hospital (eg, critical care to non—critical care unit once status stabilizes). Another example of a transition of care is the movement from an inpatient to an outpatient setting, particularly at the time of discharge from the hospital. Transition of care can also be the movement of a patient from one provider to another, such as when a primary care provider consults a specialist to manage a patient’s disease state or multiple conditions. Overall, it is important to have continuity of care and a collaborative approach among health care professionals and the patient during any transition of care.

Published literature regarding transitions of care can help health systems identify barriers as well as develop successful strategies for overcoming barriers. Several factors may be associated with worse outcomes. One such factor is medication errors, which can occur at the time of admission if discrepancies are not addressed after a medication reconciliation has been completed by a health care professional. Another factor that may lead to worse outcomes is lack of communication among health care professionals. When there is a lack of accountability, communication can fall through the cracks and the patient is (or remains) uninformed regarding their medical care. The lack of standardized policies and procedures can also be a factor for worse outcomes during transitions of care.

AJMC^®: In your experience, what barriers do patients face during transitions of care? For example, do they face issues related to access to care, communication, insurance, and/or social determinants?

Clements: Based on experience, one of the biggest barriers for patients during transitions of care is instructions on home medication regimens at the time of discharge. Discharge planning should begin at the time of admission, and the patient should be updated frequently regarding the potential plan of action for discharge. This strategy could help providers relay important information and allow patients to have questions answered in a timely manner, rather than saving this information for the end of the stay and rushing through discharge counseling.

Other barriers related to transitions of care include access to care and insurance coverage. I am extensively involved with the management of persons with diabetes in the hospital, and I often make evidence-based recommendations for discharge, depending on current medical history. However, I am often unable to make a specific or evidence-based recommendation because the patient does not have a primary care provider and would need follow-up or clinical monitoring. In addition, the recommendation may require a prior authorization due to insurance requirements.

Access to certain resources can be helpful to the treatment team. For example, I try to keep the case managers up-to-date on changes, particularly regarding the cost of diabetes medications. Over the past couple of months, there have been several changes with the cost of certain insulin products. I try to maintain an updated handout with a list of financial resources to help patients obtain access to medications prior to discharge.

AJMC^®: How do you foster effective communication both among clinicians and between clinicians and patients/caregivers throughout the hospital stay and during the transition to outpatient care?

Clements: Overall, accountability is key to fostering effective communication. Every health care professional has a role in the patient’s care. We are all here to help the patient and each other, rather than take “full control” of the patient.

Effective communication is essential during all transitions of care. For example, when there is change in treatment team, written documentation should be complete so that anyone can understand the previous medical plan for a patient. Complete documentation can be an example of a written handoff. Other type of strategies could include allowing adequate time for verbal handoffs from one provider to another or one treatment team to another. Effective handoffs allow for accountability to be carried from one group or service to another, without the “ball being dropped” in the patient’s care.

In my previous experience in the outpatient setting, it has always been effective to communicate with a patient’s primary care provider after discharge, via either a telephone call or a standardized letter. These can provide an overview of the patient’s hospitalization, medical care received, and discharge instructions, to facilitate continuity in the outpatient setting. This is also an opportunity to mention that the patient may be a candidate for a medication that was not initiated during the hospitalization or discharge; therefore, it could be a consideration for the primary care provider who would be seeing the patient more frequently for follow-up visits.

AJMC^®: What strategies do you use when educating patients on their disease state and medications? In particular, how do you promote medication adherence?

Clements: It is important for patients to understand and take ownership in their health and disease state management. When educating patients on their disease state and medications, it is important to empower them in any way possible. I generally try to determine the patient’s motivation and desire to change, because then I can adapt my educational sessions based on their own personal goals. I also like to allow the patient to tell me what they think their goals should be, rather than me telling them what their goals are and how they should accomplish the goals. I assist patients in modifying their goals and suggest that they start with small goals on their way to reaching their ultimate long-term goals.

As a pharmacist, I want to dig deeper in terms of patient concerns regarding a particular medication or why a specific medication was not effective in a previous trial. For example, if the patient is not willing to inject any medication, then I need to focus on oral medications. I also tend to focus on what their insurance is, because a medication can only be effective if the patient is able to afford and take the medication. Therefore, I will take the extra steps to review the patient’s insurance formulary or contact their insurance company about preferred options. Various strategies can be implemented to lower the cost of medications, such as using co-pay cards or other coupons.

AJMC^®: What initiatives has your health system introduced to help improve care transitions?

Clements: Within our health care system, we have adopted several strategies to help improve transitions of care. One specific initiative is the Meds-to-Beds program. Patient eligibility for this program is reviewed at the time of admission; eligible patients can receive their medication and an individualized counseling session prior to discharge. However, there are patients who do not qualify for this program and we are thinking about other initiatives to provide discharge counseling to these patients.

There are many other established programs related to transitions in care in which multidisciplinary groups of health care professionals will enroll and provide follow-up care at a patient’s home. These patients may be enrolled in Medicare coverage or may be a member in a high-risk group (eg, patients with diabetes, heart failure, and/or chronic obstructive pulmonary disease). In addition, we are looking at other ways to implement evidence-based practices at discharge. As an example, SGLT-2 [sodium-glucose cotransporter 2] inhibitors are highly recommended for patients with diabetes and heart failure with reduced ejection fraction. It would be ideal to start these medications at discharge. A clinical service focused on postdischarge patient monitoring could be beneficial, because blood pressure, weight, and renal function would all need to be reevaluated after hospitalization.

Also, we have elevated the role of several associates within each institution. We started identifying diabetes unit champions—nurses, case managers, and dietitians—to help them stay up-to-date regarding the changes within our institution and related to diabetes in general. This type of program will help with “paying it forward” to other associates, as all associates cannot be educated at the same time.

We have a lot of other ideas on paper on how to further improve transitions of care within our institution. We want to focus on 1 or 2 projects, do them well, and demonstrate continuous quality improvement, rather than start too many initiatives and not see any results. Some of these proposed transitional programs involve ways that we can continue to provide comprehensive assessment of the patient in a proactive manner in terms of monitoring, care coordination, coaching, and patient support. We should all be advocates for patients regarding these types of transitional services, because we know that they really can improve quality of care.

AJMC^®: How have the coronavirus disease 2019 (COVID-19) pandemic and the shift toward providing care via telehealth impacted transitions of care?

Clements: The COVID-19 pandemic has definitely had an impact on transitions of care, specifically on direct patient care in the ambulatory care setting. During this pandemic, health care professionals have adapted to provide continuity of care by focusing on how to access patients during this difficult time. Telehealth or telemedicine services vary depending on the institution as well as on the health care professional who is providing the service or conducting the encounter. In addition, the patient population can vary among institutions and regions, and some patients may have more access to telehealth or telemedicine services compared with others (eg, those in rural areas). By accessing the internet and conducting virtual appointments, health care professionals have been able to continue having face-to-face interactions with patients. However, there can be barriers or drawbacks to virtual face-to-face encounters—for example, a physical patient assessment cannot be completed.

Some health care professionals have been able to continue direct patient care only through follow-up telephone calls. In this case, potential barriers include that the patient’s nonverbal behaviors cannot be evaluated as well as that a physical assessment of the patient cannot be completed. Other institutions with clinics have been creative. Rather than discontinue services, they have been able to maintain face-to-face patient encounters with specific instructions on the practice of social distancing and other precautions due to the pandemic. During this time, health care has shown its ability to adapt to any change that may occur on a global level. It will be interesting to see how telehealth and telemedicine practices change in the upcoming years.