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March/April 2011 Issue

Monitoring Care Transitions
By Carol Levine, MA, and Jennifer Rutberg, MSW
Social Work Today
Vol. 11 No. 2 P. 6

Sixty-eight-year-old Sally Smith (a pseudonym) became disoriented and fell at home. While the emergency department staff was able to get her dangerously elevated blood pressure under control, she was still somewhat confused, so she was admitted for further cardiac tests.

Two days later, with a newly diagnosed cardiac problem, a fistful of new prescriptions, and a recommendation that she lose some weight, Mrs. Smith was ready to be discharged. The nurse responsible for Mrs. Smith’s discharge instructed her to follow up with her primary care doctor and asked whether she understood the medication list. A social worker asked whether she had told her husband what time to pick her up and suggested that she check around her home for area rugs and other items that may pose a risk of falls. Everyone wished her well.

Three days later, Mrs. Smith was back in the emergency department after another, more serious fall. She was taking her new medication along with a similar one that she had been taking prior to the hospitalization, and the double dose spelled trouble. The second hospital stay was longer than the first, and Mrs. Smith’s recovery was slow and difficult.

Why did this happen? Isn’t medication reconciliation standard practice in hospitals? Actually, everyone in this scenario did what was required. Yet when Mrs. Smith left the hospital, she had barely absorbed any of the information she’d received. While her husband felt guilty that he had not taken better care of her at home, he knew even less about what she needed and what to watch out for. Even though he visited his wife every day during her first hospitalization, he had never spoken directly to the physicians or nurses.

This type of scenario occurs regularly. The result is not only a bad outcome for the patient but also increased healthcare costs from easily avoidable rehospitalizations. The Centers for Medicare & Medicaid Services (CMS) states that almost 18% of Medicare patients are readmitted to the hospital within 30 days of discharge. A 2009 New England Journal of Medicine study of Medicare beneficiaries who had been discharged from a hospital found that nearly 20% were readmitted within 30 days and one-third within 90 days. The cost of unplanned rehospitalization was $17.4 billion, highlighting the importance of improving transitions. Many such efforts are under way. Nearly all focus on provider-to-provider interactions, which is certainly crucial. And nearly all focus on the ideal of an independent older adult’s ability to self-manage. But patients like Mrs. Smith are unable to manage on their own or at least not initially.

Caregivers as Glue
If Mr. Smith had been included in the discharge planning, he would have been better prepared to help manage his wife’s medications and recognize the first signs of an adverse impact. In reality, family caregivers, for all their frailties and faults, are the glue that holds our healthcare system together. Integrating family caregivers into healthcare providers’ daily work with patients is good not only for the patient but also for the provider.

Family caregivers can help ensure medical advice is followed, medications are taken properly, appointments are kept, and tests and therapies arranged. They can reach out for guidance when situations do not go as planned and report on elders’ functioning at home. They can coach, guide, and support elders through their care. They often know the patient’s medical history better than the patient, and they can report to the provider on treatment efficacy, treatment plan adherence, and unaddressed issues. But they cannot do this alone.

Next Step in Care
Family caregivers need training and support as well as structure to help frame what they need to know and when they need to know it. An important resource for healthcare providers and family caregivers is the Next Step in Care website (www.nextstepincare.org), which offers free downloadable guides and checklists in English, Spanish, and Chinese. Developed over three years by the United Hospital Fund, a nonprofit health services research and philanthropic organization in New York City, the Next Step in Care campaign was designed to foster change in the healthcare system by focusing on the contributions and needs of family caregivers, particularly around transitions in care settings such as a move from hospital to home or rehabilitation unit or the opening and closing of a home care case.

Medication management—the problem that brought Mrs. Smith back to the hospital—is one of the most common yet troublesome challenges for family caregivers. The Next Step in Care website provides three useful tools: a guide for healthcare providers to help prepare family caregivers to manage medications, a corresponding guide for family caregivers, and an easy-to-use medication management form. The form was designed to be started in the office or healthcare facility, modified by the caregiver at home, and given back to the provider for review at the next appointment. Field testing of the form showed that it was a significant time-saver for providers as well as a convenient way to assess caregiver understanding of and patient adherence to the medication regimen.

Another pair of guides assists in assessing caregivers’ needs. All too often, the caregiver cannot carry out the plan of care—sometimes due to lack of education and training and other times due to an inability to perform specific functions. The caregiver self-assessment form, which can be completed in a few minutes—often during a waiting room stay—can reveal limitations and obstacles before they turn into barriers to discharge or major problems at home. In addition to the family caregiver self-assessment form, the Next Step in Care website offers a corresponding guide to assist healthcare providers in assessing family caregivers’ needs. If Mr. Smith’s needs had been addressed, the hospital staff would have been alerted to his lack of knowledge regarding his wife’s care.

While working with family caregivers isn’t always easy, healthcare providers clearly need to work in partnership with them to ensure the best outcomes for their patients. And when working with family caregivers, it’s the conversation that counts, without which there can be no negotiation and no coming together for the same goal. While the Next Step in Care materials cannot replace such conversations, they can certainly facilitate and supplement them. And they can ensure that patients like Mrs. Smith remain healthier, happier, and safer during transitions.

— Carol Levine, MA, is director and Jennifer Rutberg, MSW, is senior project manager of the Families and Health Care Project, United Hospital Fund in New York City.


There are 20 Next Step in Care guides available at www.nextstepincare.org. The following are some important ones:

• “HIPAA: Questions and Answers for Family Caregivers” — A clear explanation of how the federal privacy law pertains to family caregivers and why it is often misused.

• “What Do I Need as a Family Caregiver?” — A questionnaire the family caregiver can fill out alone or with a staff member to help make a realistic plan for discharge.

• “Going Home: What You Need to Know” — A discharge checklist that covers supplies, equipment, and follow-up information often required after a hospitalization.

• “Planning for Inpatient Rehabilitation Services” — When the discharge plan includes transfer to a rehabilitation unit, family caregivers need basic information about what to expect.

• “A Brief Guide to Home Care” — Introduces services, people, and limits of home care.