Bridging the gap: An integrated approach to transitions in care.

Abstract

327 Background: Acute leukemia necessitates specialized care across multiple settings. Poorly executed transitions pose risks to quality and safety. Through the implementation of Lean Six Sigma methodology, we introduced an experienced APP (Advanced Practice Provider) known as the ‘Transitions Coordinator’ to collaborate with primary team, educate patients about disease/treatment plans, facilitate advanced care planning, and ensure smooth transition to post-acute outpatient care. Methods: The Transitions APP applies clinical guideline expertise to assess data, facilitate care coordination, and provide recommendations to the primary team. Other crucial aspects of the intervention encompass structured counseling sessions with patients to enhance health literacy, evaluation of patient values through advanced care planning, and a post-discharge phone call to verify understanding of instructions. The intervention concludes with a formal handoff process accompanied by thorough documentation. Results: Results show significant improvements post-intervention. The 30-day unplanned readmission rate decreased from 24.6% to 19.1%, surpassing the goal of 20%. The Serious Illness Conversation (SIC) rate increased from 11% to 92%, exceeding the 80% target. Staff perceptions of patient care improved, with increased confidence in follow-up care (2.7% to 29.2%) and patient support (12% to 41.5%). Patient experience ratings also indicated enhanced communication with doctors. Conclusions: Our intervention successfully addressed the challenges in acute leukemia care transitions. The integration of an APP Transitions Coordinator led to better communication, reduced readmission rates, and improved advanced care planning. This model can be applied to various patient populations with serious diagnoses requiring complex care. Lessons learned include the need for a customized approach and key elements such as education, advance care planning, discharge phone calls, and formal handoff processes. By bridging the gap between inpatient and post-acute care, we achieved better overall patient outcomes. This approach has the potential to benefit patients with other serious conditions like heart failure or chronic lung disease. Our experience highlights the importance of adapting the role to individual patient needs and ensuring timely delivery of necessary content.