Most care transitions between healthcare settings, including hospital to long-term care, are effective. But fragmentation of care delivery, communication issues and worker shortages are the top barriers to success, say the authors of a new insights report from the NEJM Catalyst — Innovations in Care Delivery.
The report is based on data from a January 2023 survey of NEJM Catalyst Insights Council members. Respondents included clinicians, clinical leaders and executives of care delivery organizations from around the world.
Fully 70% of respondents in the United States (and 62% globally) reported high-quality transitions between hospitals to long-term care facilities in the United States. There were similar opinions globally by those rating transitions from acute inpatient to post-acute care (76%) and acute inpatient to outpatient care (70%).
Where transitions break down
But the responses also showed that these handoffs break down when organizations are outside of each other’s control and visibility, said Kenneth Lam, MD, of the Geriatrics Division at the University of California San Francisco School of Medicine and an expert on transitions into long-term care.
In fact, 56% of respondents rated fragmentation as the top barrier to effective transitions. This was followed by poor communication between providers (41%) and problems related to social determinants of health (40%).
In the United States, hospital-based respondents may think they are doing well with transitions, “but this could reflect how easy it feels to discharge patients and not whether the patient was adequately cared for throughout their journey,” Lam wrote in the report. With few people working in both settings, “who has a vantage point to even know what a smooth transition looks like?” he said.
Data and payers
In addition, hospitals and long-term care facilities rarely share data in order to make improvements, Lam added. And their major payers, Medicare and Medicaid, are not set up to facilitate cooperation.
Lam’s co-author Cheri Blauwet, MD, of Harvard Medical School said that these transition problems are just a small part of the broader issue of care fragmentation.
Although 63% of U.S. respondents reported that their organization has dedicated resources for managing transitions, “for hospital to post-acute and long-term care transitions, the destination is almost always an organization that’s outside of the healthcare system,” Blauwet said.
Workforce shortages
Workforce shortages are also placing quality care transitions to long-term care under unprecedented pressure, the report’s authors found. “While nursing shortages are bad in acute care hospitals and trauma centers, they are much worse in post-acute care and long-term care,” Blauwet said. Clinicians, particularly nurses, are overwhelmed by an increasing amount of work, she reported.
The result of widespread understaffing is transition backlogs in the acute care setting, the authors noted. Fully 79% of survey respondents agreed that one solution to these backups is home-based care. But questions remain about how gains from inpatient post-acute rehabilitation stack up against the results of home-based rehabilitation, and how to manage patients who aren’t ready to return home, the authors noted.
The report, containing additional insights, detailed survey data and survey respondents’ comments was published in NEJM Catalyst.
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