Communication at Transitions: One Audacious Bite at a Time

To be audacious and take significant steps toward achieving the Quadruple Aim (improving the patient experience of care; improving the health of populations; reducing the per capita cost of health care; and improving the work life of clinicians and staff), we patients and caregivers need to better understand key features of our health journeys. When on that health journey, we are patients interacting with a series of care teams: our home team (social network), our community agency teams, our emergency care team, our hospital teams, and on and on. These care teams include ourselves, our caregivers, clinicians, other professionals, and direct care and support staff—people at the center of care. The actions taken by people at the center of care to improve, maintain, or adapt to our health or illness represents our health care. Actions can be diagnostic, taking medications, undergoing procedures, learning, living life and getting help living life. So, our health journey is teams of people at the center of care taking such actions to provide healthcare and service to us. During this journey, we transition from one setting to another, from one team to another, repeatedly. Communication knits this maze of actions, interactions, and transitions together. At its core communication is two or more people or parties sharing some information via some channel (voice, paper, digital, dramatic), one time or several times in a particular setting, hoping to accomplish something that moves us along in our health journey. One of the most persistent and ubiquitous frustrations in health care is that of poor communication. Poor communication at transitions is at the root of much overuse, underuse, and misuse of health resources, and results in the inability of patients to complete recommended treatment. For the patient and their family this means unnecessary delays in returning to health or worse. For those professionals on the care team the incidents of harm, burnout, stress, and frustration cause financial, emotional and career-ending consequences. Poor communication at transitions impacts each of the Quadruple Aims. The potential return for the investment in communication may cross over one or more organizational boundaries. Organization Boards and the C-Suite customarily focus on activities within their institutions, not between. The daunting nature of the challenge, caused by the shear volume and variety of transition nodes, can paralyze those in decision making roles, leading to smaller, more manageable local solutions. I support building a more holistic solution that includes the necessary governance, infrastructure, habits, and relationships. This leads to systematically applied common standards for local, node-specific solutions. Development should include all persons at the center of care in governance, design, operations and learning for systemic and local solutions. Refined clinical work flow should be constructed to respect patient and care partner life flow. Solutions should use interoperable technology to aid, not replace, communication. Transition information and processes should be transparent to patients and their care partners.


The Big Picture
The Quadruple Aim [1], a unifying goal for the health care industry, is being widely adopted across the full continuum of care. The Quadruple Aim includes: • Improving the patient experience of care; Some say that striving towards a goal that can never be totally reached is folly. I believe that working towards the Quadruple Facing such a large challenge, some are tempted to ignore the opportunity completely, some continue to do that which they already do well, and others nibble at the problem. This essay is for the people who believe in the inadequacy of these responses.
Anecdotes abound indicating that our current health care system has far to go before approaching success in achieving the Quadruple Aim. Statistics are readily available-but we won't focus on them here; you may find or recall your own favorites! But here are two worth repeating: • Approximately 30% to 50% of US adults are not adherent to long-term medications, leading to an estimated $100 billion in preventable costs annually [2].
• In 2011, there were approximately 3.3 million adult hospital readmissions in the United States associated with about $41.3 billion in hospital costs [3].
Where else inside of a modern organization can one witness such a wide range of people-from highly trained and specialized professionals to technical staff to housekeeping staff? Where else can you find such a high volume of patient (individual) interactions whose results can be life-or-death critical and may be time restricted to as little as 8 minutes? What industry is so complex that everyone finds part of it a complete mystery? What industry is projected to be the single largest segment of the US economy by 2024? Health care.

Health as a Journey
To be audacious and take significant steps toward achieving the Quadruple Aim, we patients and caregivers need to better understand key features of our health journeys. When on that health journey, we are patients interacting with a series of care teams: our home team (social network), our primary care team, our specialist team(s), our community agency teams, our emergency care team, our hospital teams, and on and on. These care teams include ourselves, our caregivers, clinicians, other professionals, and direct care and support staff-people at the center of care. The actions taken by people at the center of care to improve, maintain, or adapt to our health or illness represents our health care. Actions can be diagnostic, taking medications, undergoing procedures, learning, living life, and getting help living life. So, our health journey is teams of people at the center of care taking such actions to provide health care and service to us. During this journey, we transition from one setting to another, from one team to another, repeatedly. The adult child of an elderly woman describes their journey:

Communication at Transitions
Communication knits this maze of actions, interactions, and transitions together. At its core, communication is two or more people or parties sharing some information via some channel (voice, paper, digital, dramatic), one time or several times in a particular setting, hoping to accomplish something that moves us along in our health journey. One of the most persistent and ubiquitous frustrations in health care is that of poor communication.
These are some common complaints about communication, as expressed by real patients: In general, a tension exists between the wealth of transition information needing to be communicated and the time needed to create, share, absorb, and understand that information. Acute care and clinic settings have the most time constraints. Chronic care and non-acute settings have more time, hence more opportunity for relationship building and person-centered information. Unfortunately, it seems that many organizations and teams only allocate adequate resources for improving transition communication after pain points have been reached or are threatened (harm, lawsuits, financial loss, public attention, and complaints) rather than proactively and systematically. Financial pressure to keep labor expense per patient as low as possible impacts effective communication.

Current Efforts
Many tools and mnemonics exist to aid in the consistency of transition communication. Mnemonics, a memory device used to standardize and train many people during frequent encounters, are each designed for a specific setting/node of communication. A limited number have evidence as to their effectiveness [4]. Most contain identifying information, summary and current state, immediate plan, current or anticipated risk, and opportunity for learning (questions and synthesis).
Current published transition communication tools are predominantly acute care and medicine-centric [5]. Yet, transitions occur across the health continuum and with all members of the health team (licensed and non-licensed, professional and non-professional). Membership of a person's health team can include the patient, their family and care partners, pharmacists, integrated health practitioners (chiropractors, massage therapists, nutritionists, etc), and community health agencies. Transitions increasingly occur outside of the hospital and traditional medical clinics, in settings such as mobile health, community and home, and retail walk-in and urgent care centers. In fact, such transitions increasingly include social services such as criminal justice, employment, housing, education, and child services. This is the extended continuum of care.
Organizations cited as exemplary in transition communication excel in one or maybe two nodes of transition. Technology could help, yet existing electronic health records are seldom interoperable or easily accessible at time of transition by all stakeholders. Hence, much communication still occurs on paper, via fax, by voice, or telephone. Too often the patient provides substantially all the communication and coordination.

Solutions
Meeting the audacious goal of achieving the Quadruple Aim through collaborative, smooth, sustainable, and effective communication at all transition nodes in the health journey requires an infrastructure for implementing sustainable change to achieve success. This transition of care communication infrastructure includes patient and caregiver engagement, policies and standards, workforce management, technology, work flow and life flow, governance, and learning (see Textbox 1).
Sustainable implementation of transition communication can be tool agnostic. Building the infrastructure is an iterative, growing, learning endeavor with common system and leadership requirements. Designing the work flows and tools for specific transition nodes has unique local, operational components depending on the participants, the setting, and the culture.
Communication usually occurs in dyads-a dynamic of two individuals or two teams (nurse-nurse, patient-doctor, hospital-nursing home, etc). Each individual or team in the dyad can have widely varied comfort and skill in that communication. That variation occurs for clinicians, support staff, patients, families, and site of care. Individuals and teams need to take their dyad partner where they are and persistently increase comfort and skill. This means first, understand the stages of skill and comfort (engagement, activation, background, experience), next quickly assess your dyad partner's stage, and then fine-tune the communication to that assessment. All this requires learning and continuous improvement: orientation, training, continuing education, coaching, process and outcome measurement, and work flow refinement.

Final Thoughts
The Quadruple Aim can be significantly accelerated by effective communication at transitions. Why don't health care organizations invest more in comprehensive, sustainable solutions? I believe the potential return for the investment in communication may cross over one or more organizational boundaries. Organization boards and the C-suite customarily focus on activities within their institutions, not between. The daunting nature of the challenge, caused by the shear volume and variety of transition nodes, can paralyze those in decision making roles, leading to smaller, more manageable local solutions.
I support building a more holistic solution that includes the necessary governance, infrastructure, habits, and relationships. This leads to systematically applied common standards for local, node-specific solutions. Development should include all persons at the center of care in governance, design, operations and learning for systemic and local solutions. Refined clinical work flow should be constructed to respect patient and care partner life flow. Solutions should use interoperable technology to aid, not replace, communication. Transition information and processes should be transparent to patients and their care partners.
Critical to success: 1. Board and C-suite prioritize 2. All levels of management accountable