Name that
Core ToC
Core ToC
Example: A patient is being sent home from the hospital.
What is Discharge?
Taking five or more medications regularly is referred to by this term.
What is polypharmacy?
The transfer of patient information between providers or healthcare teams
What is handoff?
What does ToC stand for?
What is Transitions of Care?
This kind of failure includes transitions during shift changes and EMR discrepancies
What are system/process failures?
Example: A patient is transferred from the ED to the ICU at Brooklyn-methodist NYP.
What is Intra-hospital?
This age group is at highest risk during hospital transitions due to comorbidities and functional limitations.
Who are older adults (≥65 years)?
Care that involves receiving treatment and going home the same day
What is outpatient care?
This is a common solution to reduce medication errors after discharge, often involving a pharmacist
What is medication review?
This principle of care transitioning emphasizes that both referring and receiving providers share responsibility for safe interpersonal transitions.
What is shared accountability?
Example: During a nurse shift change, the outgoing nurse gives a bedside report to the incoming nurse.
What is Shift-to-Shift or Provider Handoff?
This type of medication mistake occurs when a patient is accidentally prescribed the same drug twice during a transition of care.
What is medication duplication?
Communicating with patients to ensure they have appropriate support once they leave the hospital, as well as an understanding of post-discharge care instructions.
What is discharge planning?
Under the Hospital Readmissions Reduction Program, hospitals with excess 30-day readmissions for certain conditions have their Medicare payments reduced at this percentage.
What is 3 percent?
This component of the care transition can be improved by providers using plain language, teach-back methods, and visuals, as well as having patients ask questions
What is health literacy?
Example: A patient changes insurance and can no longer get coverage at hospital A. She now gets care at hospital B.
What is Transitions Between Care Systems?
Losing important information about pending labs or code status during a handoff is an example of this kind of error.
What is an incomplete or poor handoff?
This encompasses acts of providing medical and social services to patients after hospitalization
What is post-acute care?
How much does poorly coordinated care transitions cost hospitals annually?
What is $12 billion to $44 billion per year?
Aligning treatment goals between these two types of providers helps ensure effective continuity of care.
Who are primary care providers and specialists?
Example: A patient hospitalized for advanced COPD has frequent exacerbations and is discharged not just to home, but enrolled in a home-based palliative care program
What is Post-Acute Care Transitions?
This type of patient engagement helps prevent errors and adverse events, but can be reduced in patients with cognitive or functional impairments.
What is patient self-advocacy?
When healthcare providers work together and communicate with each other using a patient-centered approach
What is care coordination?
On What Day and year did the CMS (Centers for Medicare & Medicaid Services) launch the Hospital Readmissions Reduction Program (HRRP)?
What is October 1, 2012?
This is when the specialist informs the primary care provider that they have seen the patient, and shares test results.
What is closing the referral loop?