A key component of improving care transitions is the timely transfer of relevant clinical information between care settings. In IHI’s initial work to improve communications after a patient is discharged from the hospital, we set out to learn about baton handoffs from the US Olympic Relay Teams. In a relay race, the speed and skill in the baton exchanges is every bit as important as the sprinters’ times. Get the exchanges done poorly in a relay race, and you can forget about gold, silver, or bronze. The same principle applies when patients are discharged from the hospital — lack of timely and relevant clinical information in the hands of clinicians in community settings can lead to poor outcomes for patients and, in some cases, readmission to the hospital.

Good handoffs require skill, collaboration, and careful coordination. In the STAAR Initiative and the IHI’s Reducing Readmissions seminars, the IHI faculty members are coaching cross-continuum teams (CCTs) to “co-design processes for handover communications.” That sounds like a no-brainer — but in health care, in-depth conversations between hospital teams and clinicians and staff in community settings rarely occur. Clinicians in hospitals and post-acute care providers don’t routinely discuss what information is most relevant for follow-up care, or even in what form it could best be transmitted. Engaging in this critical dialogue to redesign the seamless transfer of clinical information is one of the primary aims of the cross-continuum teams in STAAR.

Building on lessons learned from baton exchanges in relay races, here are a few strategies that CCTs have found to be useful:

·         Co-design reliable processes for baton exchanges. What are the needs of the first runner, second runner, etc.? When a busy doctor or nurse in primary care or a specialty clinic gets a call from a patient two days after discharge, access to the patient’s electronic medical record is often difficult to navigate. Ideally, the format for handover communication when a patient is being discharged from the hospital should be designed with the needs of the “receiver” in mind.

·         Ensure baton exchanges are made within the takeover zones. In relay races, the pass is completed when the baton is in the hand of the receiving runner — but this exchange must occur with the boundaries of the takeover zone. What is the “takeover zone” after a patient is discharged from the hospital? Forty-eight hours? Seven days? Two weeks? We encourage hospital teams in STAAR to complete real-time handover communications at the time of discharge in a simple one- or two-page summary of critical information.

·         Runners employ verbal cues when they foresee challenges. If the runners predict that there will be challenges in completing the baton exchange, they alert the next runner to either slow down or speed up in order to effectively make the exchange. In STAAR, hospital teams are enacting “warm handovers” where phone calls are made to primary care providers, specialists, and staff in skilled nursing facilities to discuss concerns about patients who have complex needs and are at high risk for readmission. This bidirectional communication allows for dialogue about the patient‘s clinical status as well as opportunities for inquiry and clarification about the plan of care — facilitating better coordination of care for high risk patients. Just imagine the imperceptible handshake at the moment when the baton is transferred between two clinicians, and the “sender” asks, “Do you have it?” and the “receiver” replies, “Yes, I have it.”

·         Understand mutual interdependencies. If one runner falters or one of the baton exchanges goes poorly, the relay team will likely place poorly in the standings. The co-design of effective handover communications can be complicated, but as CCTs work together to understand each others’ needs and interdependencies, creative solutions for seamless communications among care settings are emerging. Two particularly effective tools for information exchange were developed for the INTERACT Quality Improvement Program — the Nursing Home to Hospital Transfer Form and the Hospital to Post-Acute Care Transfer Form: http://interact2.net/tools_v3.aspx

Health care providers have been treating patient care like a solo sprint event for far too long. As more clinicians across the continuum of care co-design and provide timely information exchanges about the care of patients at the time of transfer, we will be able to go the distance to  provide higher quality, longitudinal care for patients.

I’ll detail more practical strategies for improving care transitions and reducing avoidable readmissions in future posts. In the meantime, I hope you’ll share your own ideas and suggestions in the comments.