Key strategies for improving transitions of care collaboration: lessons from the ECHO-care transitions program

ABSTRACT

Transitioning the care of a patient from a hospital to a skilled nursing facility (SNF) is critical and often risky. Poor care transitions can result in delays, medication mistakes, incomplete follow-up care, and adverse health outcomes. Ensuring a smooth and effective care transition is the goal for providers at both the hospital and SNF. At its foundation, successful care transitions rely on teamwork, relationship building, and communication among diverse groups of providers. Beth Israel Deaconess Medical Center (BIDMC) developed the ECHO-CT (Extension for Community Healthcare Outcomes-Care Transitions) program to improve transitions of care through structured, bi-directional communication between hospital-based and SNF-based providers. This paper describes key strategies for success in this model including: facilitating teamwork, eliminating hierarchy, and encouraging a bi-directional learning environment. We propose these as strategies that could be implemented in other organizations seeking to improve value during transitions of care.

KEYWORDS:

• Communication
• transitions of care
• teamwork
• interprofessional collaboration
• quality improvement
• interprofessional

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website.

Additional information

Funding

This work was supported by the Agency for Healthcare Research and Quality [5R01HS025702-02].

Notes on contributors

Lauren Junge-Maughan

Lauren Junge-Maughan serves as the Program Manager for the ECHO-Care Transitions program. In this role, she oversees the weekly program activities, expansion to a community hospital, and looks for ways to add value, tools, and services to the project. Lauren has a strong background in healthcare quality improvement and management having served in similar roles at Harvard Medical School and the University of Michigan Health System. She holds a bachelor’s degree in Health Science from Michigan State University.

Amber Moore

Dr. Amber Moore has been involved with the ECHO CT program since 2015. As a hospitalist, she has led the weekly clinic sessions and developed and implemented the transitions curriculum for the hospital medicine team. Currently, she leads the day-to-day operations for the program. In addition to her leadership of the program and commitment to improving transitions of care, Dr. Moore is passionate about medical education. She works as a hospitalist at MGH where she continues to teach residents and medical students and holds a leadership role on the department of medicine’s operations team.

Lewis Lipsitz

Lewis A. Lipsitz, M.D., is chief of the Division of Gerontology at Beth Israel Deaconess Medical Center (BIDMC) and a Professor of Medicine at Harvard Medical School. He is also director of the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife (HSL), where he holds the Irving and Edyth S. Usen Chair in Geriatric Medicine. Dr. Lipsitz serves as principal investigator of the ECHO-Care Transitions program funded by AHRQ. His research focuses on the mechanisms and management of falls, the relationships between cognition and mobility, and interventions to improve the quality of life and care of older adults.