IMPROVING THE PROCESS OF CARE SETTING TRANSITIONS FOR
ADULT PALLIATIVE PATIENTS:
RECOMMENDATIONS FOR NURSE PRACTITIONER PRACTICE

by
F. Julia Kajan
BSN, University of Northern British Columbia, 2007

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING:
FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
November, 2014
©F. Julia Kajan, 2014
UNIVERSITY ot NORTHERN
BRITISH COLUMBIA
LIBRARY

Prince George, B.C.

ii

ABSTRACT
The number of transitions between care settings for palliative patients increase as they
approach death. In Canada, 40% of palliative patients experienced one care setting transition
prior to death, 6.3% experienced five or more transitions, and 47% made at least one care
setting transition in the last four weeks of life. Often, palliative patients are transferred
between care settings in order to receive the care necessary to improve their quality of life.
Many times these transfers lead to patient and caregiver anxiety and dissatisfaction,
medication errors, and ultimately a decrease in the quality of care. The aim of this project is
to answer the following question: "How can nurse practitioners improve care setting
transition processes for adult palliative patients in the context of primary care in British
Columbia?" An integrated review was undertaken and an extensive literature search was
conducted by way of electronic databases, journals, reference lists, and guidelines. Results
are grouped into three categories or levels: system, clinician, and patient. Within these
categories, the key fmdings in this review include improving communication, continuity of
care, and multidisciplinary communication, effective medication reconciliation, adequate
health information technology, and improving patient and caregiver education and
empowerment. Recommendations for nurse practitioners as primary care practitioner are
presented in the areas of practice, education, and future research considerations.
Keywords : care setting transitions, transitional care, palliative care,
collaboration, communication, education, empowerment, nurse practitioners, primary
care providers, medication reconciliation, health information technology

iii

TABLE OF CONTENTS
Abstract

11

List of Tables

v

Acknowledgements

VI

Chapter 1

Introduction
Project Aim

1

Chapter 2

Background
Transitional Care
Palliative Care
Population
Barriers to Effective Care Setting Transitions Processes
The system level
The clinician level
The patient level
Manifestations of Poor Care Setting Transitions
Nurse Practitioners as Primary Health Providers

5

Methods
Stage One: Searching Electronic Databases
Inclusion and Exclusion Criteria
Stage Two: Screening Abstracts and Hand Searching
Stage Three: Extensive Review for Importance and
Relevance
Literature Reviewed
Analysis Technique

20
20
21
21

Chapter 3

Chapter 4

Findings
The System Level
Connecting care settings through communication
Patient care plans and discharge or transitional
summaries
Effective medication reconciliation
Adequate health information technology
The Clinician Level
Care provider or care team continuity
Clinician and patient communication
Clinician training in care setting transitions and
cross-site collaboration
The Patient Level
Improving patient and caregiver education
Patient and caregiver empowerment

2

5
8
9
10
11
14
15

17
18

23
23
25
27

27
28

30

33
35
37
37
40

42
43
43
45

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Limitations

Chapter 5

References

Discussion
How NPs can Facilitate Communication at Each Level
How NPs can Improve Collaboration
How NPs can Improve Health Information Technology
How NPs can Facilitate Adequate Medication
Reconciliation
How NPs can Further Patient Education and
Empowerment
Recommendations
Recommendations for Education
Recommendations for Future Research
Recommendations for Practice
Conclusion

48
51
51
56
59
60
63
66
67
67
68
71
74

Appendices
81
Appendix A: Palliative Performance Scale
Appendix B: Overall Search Strategy
82
Appendix C: Search Terms and Number of Results
83
Appendix D: Table of Evidence
84
Appendix E: Elements of an Ideal Transition Record
90
Appendix F: Hospital Discharge Information that Skilled Nursing Facility
91
Nurses Need to Develop and Implement a Safe Plan of Care
Appendix G: SBAR: Tool for Effective Communication Between Health
Care Professionals
92
Appendix H: Suggested/Common Essential Data Elements for
93
Medication Reconciliation
Appendix I: Personal Medication List
96
Appendix J: Subsequent Patient Interactions Checklist
98
99
Appendix K: Care Planning Checklist for Care Setting Transitions

v

LIST OF TABLES
Table 1 Search results obtained from hand searching journals

22

Table 2 Patient transfer checklist

46

Table 3 Recommendations for practice: Ways for nurse practitioners as primary
care providers to improve the care setting transition processes for adult
palliative patients

69

vi
Acknowledgements
First and foremost I would like to thank
my husband, parents, and many other close family and friends
who contributed to my completion of this project and degree,
for their unlimited support and encouragement during this process.
Thank you to my sons, Orin and Elias, for reminding me daily, the importance of
perseverance, strength, patience, and love.
Thank you to my professors for sharing their knowledge,
my clinical preceptors for their wisdom and guidance,
and my committee, Linda Van Pelt and Helen Bourque,
for their contributions to this project.
And finally, thank you to my fellow students, especially Jamie Tourond, who endured this
experience with me, because they too have a passion for
nursing, education, and medicine.
Alone, I could not have succeeded.

1

CHAPTER!
Introduction

Everything dies. That is the law of life-the bitter unchangeable law
-David Clement-Davies, Fell, 2007
Death is one of the only sure things in life and, for most Canadians, dying is a process
rather than a sudden event. It has been estimated that only 10% of deaths are sudden, with
the remainder of people dying more slowly from terminal illness, organ failure, or frailty
(Carstairs, 2010). Therefore, 90% of the people who die in Canada could potentially benefit
from specific care at the end of their life-palliative care or hospice/end-of-life care. Medical
professionals who provide palliative care are able to assist patients to experience
improvement in their quality of life until their death. Since almost all palliative patients
transition between care settings during their palliative and end-of-life days, health care
providers are increasingly seeking to understand why these transitions occur, and what steps
can be taken to improve the transition process (Burge, Lawson, Critchley, & Maxwell, 2005).
The quality of the transitions likely to occur between care settings prior to death can
have a strong impact on the process of dying and the perception of death, for both patients
and their families . Nurse practitioners (NPs), as primary care providers (PCPs), are in a
position to contribute to effective care setting transitions for their patients. While this paper
will focus on how to improve the process of transitions between care settings, as opposed to
improving the quality of the palliative process, it should follow that the quality of the
palliative care received will improve as a positive consequence of improving the transition
process. At the same time, it is important to recognize that an improvement in the transition
between care settings is only a small component amongst a multitude of considerations NPs
must take into account when caring for palliative patients. It is equally important to

2

acknowledge and improve upon the physical, mental, and spiritual aspects of palliative care,
but these considerations are outside the scope of this paper. Additionally, this paper will not
examine other important issues such as practitioner scope of practice, specific functions of
team members, narcotic prescriptions, palliative care forms, and activities outside of scope of
any team member. Ultimately, identifying and understanding the factors that facilitate
effective care setting transition processes will help to inform the role of the NP working in
the context of primary health care in British Columbia (BC).

Project Aim
In my lived clinical experience as a registered nurse, I am familiar with a broad
array of palliative care processes, having worked on an acute care ward in a tertiary
hospital, as well as in a community care setting as a home care nurse. As my knowledge
of palliative care grows, I am increasingly aware of the discontinuity between care settings
with respect to palliative care. Much of my time spent caring for palliative patients in the
community was used to contact PCPs for necessary orders, track down missing information
from hospital discharge summaries, reconcile medication lists, and speak with patients and
families about their palliative care needs and wishes.
Specifically, I can readily recall my feelings of panic and my sense of inadequacy
when a palliative patient close to death was about to be transferred home from an acute care
setting. This inevitably seemed to happen on the weekend, where the patient would be
transferred without new medication orders, without an updated care plan or a discharge
summary, in uncontrolled pain, to be received by an uninformed family or an informal
caregiver. This scenario is often exacerbated with difficulties in contacting the patient's PCP,
and not being able to communicate with a health care provider from the discharging care

3
setting due to any number of reasons. These feelings of unease around not having the
necessary tools or information to effectively transition palliative patients back home continue
to resonate with me.
Over time, I also became aware that the consequences of these discontinuities and
disconnects as they were experienced by palliative patients, caregivers, and health care
providers would be compounded over time. For example, in my experience, difficulty
contacting a patient's PCP for new orders, or for clarification of existing orders would lead to
inadequate pain control and uncertainty around current care needs. Untimely delivery of
discharge summaries from hospitals would create confusion about the treatment that had
been given and the subsequent plan for care. Additionally, health information technology had
yet to be implemented in these care settings-which further compounded the ineffective care
setting transitions of palliative patients. Put together, all the ineffective elements that
contribute to poor care setting transition processes effectively decreased the quality of patient
care, and increased my workload as a practitioner.
This project will identify the key factors that improve care setting transition processes
for palliative patients using the methodology of an integrated review. A diverse set of
sources have been taken into account-including qualitative and quantitative studies,
opinions of expert authorities in the health care field, and reports from expert committeeswith the purpose of identifying the interventions necessary for NPs to effectively improve the
processes of care setting transitions. Following the analysis and synthesis of the findings,
recommendations for NPs in the areas of practice, education, and research are presented. The
aim of this project is to answer the following question: "How can NPs improve care setting
transition processes for adult palliative patients in the context of primary care in British

4Columbia?" To preface this question, a number of key terms and central concepts will be
identified in order to establish a clear context for identifying relevant improvements in the
care setting transition process for the palliative population.

5
CHAPTER2
Background

Transitions between care settings for palliative patients can have a negative impact on
patient quality of life if these transitions are not carried out effectively. This chapter will set
out the key terms and concepts associated with the transition process, and thereby provide
the necessary background to the examination of the ways in which NPs can best improve the
process of transitions between care settings for palliative patients. The following section will
describe the various areas of transitional and palliative care. It will identify the barriers to
effective care setting transition processes, and the way in which poor care setting transitions
manifest. It will also look at the role ofNPs as primary care providers in BC.

Transitional Care
Transitions between care settings can be complex, confusing, and burdensome for
patients, families, and health care providers (Cawthon et al. , 2012; Rooney & Arbaje, 2013;
Vander Block, Bilsen, Van Casteren, & Deliens, 2007). Chalmers and Coleman (2006)
explain that transitional times lead to increased patient vulnerability, and can therefore hinder
the patient's recovery or decrease their quality of life prior to death. "Transitional care" has
been specifically identified within the complexity of care setting transitions. Coleman and
Boult (2003) define transitional care as "a set of actions designed to ensure the coordination
and continuity of health care as patients transfer between different locations or different
levels of care within the same location" (p. 556). This paper will focus on such transitions as
they occur between care settings. These transitions may include, but are not limited to,
hospitals, sub-acute and post-acute nursing facilities, patients' homes, hospice, primary and
specialty care offices, and long-term care facilities (Coleman, 2003).

6

A number of sources agree that transitional care includes both the sending and
receiving aspects of the transfer, coordination between all the health care providers involved,
logistics of all arrangements, and preparation of both the patient and the family for self-care
(Burge et al., 2005; Chalmers & Coleman, 2006; Coleman & Boult, 2003). It is well known
that, over the course of care setting relocations, patients will come into contact with many
different health care providers. These providers may include registered nurses, occupational
and physiotherapists, nurse practitioners, primary care physicians, medical specialists, and
home support workers (Parry, Coleman, Smith, Frank, & Kramer, 2003). Depending on the
care setting, the health care providers involved may be connected within care teams, by way
of collaborative groups, or they may practice independently.
Transfers between care settings can occur for a multitude of care-based reasons.
Generally, the first reason for these transfers is that the complex care needs of adults with a
palliative diagnosis frequently require care available in a multiplicity of different settings and
locations (Schoenborn, Arbaje, Eubank, Maynor, & Carrese, 2013). Also, although most
palliative patients have chronic comorbid conditions, acute events can precipitate a need for
immediate transfer (Chalmers & Coleman, 2006; Chhabra et al., 2012). For example,
Lawson, Burge, Critchely, and Mcintyre (2006) found that, during the last month of life, pain
and symptom control became a significant factor, which was likely to result in a greater
number of care setting transfers. Patients may also be transferred in order to reduce the stress
and workload experienced by their informal caregivers, or because the patient lacks an
adequate network of familial supports necessary to their level of care (Chhabra et al., 2012;
Lawson et al., 2006). Finally, palliative patients may require transfer due to their decreased
cognition or their increased frailty (Chhabra et al., 2012; LaMantia, Scheunemann, Viera,

7
Busby-Whitehead, & Hanson, 2010). Regardless of the reasons for these transfers, it is
important to understand the impact that care setting transitions have on all parties involved.
As noted above, the number of transfers between care settings often increases as
patients near death, and it is therefore critical to develop a heightened awareness of the ways
in which practitioners can provide effective care setting transitions for palliative patients.
Often, for palliative patients, a transfer to an acute care setting tends to happen just prior to
death (Canadian Institute of Health Information, 2007). A Canadian study found that 40% of
palliative patients experienced one care setting transition prior to death, 6.3% experienced
five or more transitions, and 47% made at least one care setting transition in their last four
weeks of life (Lawson et al., 2006). This reported increase in the number oftransitions
between care settings as the palliative status progresses is consistent with my experience as a
registered nurse working in home and community care.
Burge et al. (2005) emphasize that "the ultimate goal of understanding these
transition issues better is to reduce unnecessary changes, help to predict care needs, enhance
transitions that improve patient and caregiver quality of life, guide communication links
within the health care system and maximize cost-effective utilization of different care
settings and providers" (p. 2). While research that focuses on the issues that arise for
palliative patients in the home, hospital, or community setting, is equally important, focusing
on the process of patient transitions between these settings, identifying the barriers to
effective transition processes, and taking a strength-based approach to improve overall care
is paramount in order to generate an effective model for palliative care.

8
Palliative Care
The most widely used definition of palliative care is that proposed by the World
Health Organization (WHO), which defines palliative care as "an approach that improves the
quality of life of patients and their families facing the problems associated with lifethreatening illness, through the preventions and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual" (WHO, 2014, para. 1). The WHO reminds us that palliative care
should strive to inform patients that dying is a normal process; it emphasis that palliative care
requires a holistic approach, supports patients and families, enhances the quality of life by
way of appropriate interventions, and employs a team-based approach to better deliver care
(WHO, 2014). Most often, the process of palliative care completes with the end-of-life stage
of care, i.e., the medical care provided during the last days or weeks of life (Plonk & Arnold,
2005).
In Canada, the type and quality of palliative care depends to some extent on
geographic location and the allocation of resources. Currently, as few as 16%-30% of people
dying in Canada have access to palliative or end-of-life care services (Canadian Hospice
Palliative Care Association, 20 14; Carstairs, 201 0). Carstairs (20 10) notes that this apparent
shortage in the delivery of palliative and end-of-life services is largely due to the disparity in
health care resources between Canadian communities. She also points out that the limitations
on the delivery of health services due to demographic and geographic variables are
compounded by the ever-growing gap in human resources allocated to health care. It is not
the purpose of this project to underscore the need for increased access to palliative care

9

services in BC, it is nonetheless important to note the wide gap between those who need
palliative care and those who actually receive it.
The term palliative care, in the context of this project, refers to care that begins from
the initial designation of palliative status, continues right through the end-of-life care,
terminating only when death occurs. In BC, a patient can be registered with the "BC
Palliative Care Benefits Program" on the basis of the following criteria: if the patient is
living with a life-limiting or progressive illness, if curative treatment is not the primary focus
of care, if the patient or their representative has agreed to accept palliative care services, and
if the patient has a life expectancy of less than 6 months (British Columbia Ministry of
Health, 2013). Additionally, the patient's score on the Palliative Performance Scale must fall
at 50% or below to qualify for benefits. An example of the Palliative Performance Scale can
be found in Appendix A. The palliative care benefits program covers the cost of eligible
drugs, medical supplies, and equipment needed for the care of palliative patients.

Population
In order to understand the ways in which NPs will have an impact on improving the
care setting transition processes, the relevant population that will benefit from these
improvements is identified in the following way. In BC, the term "adult" refers to any person
19 years of age or older (Family Law in British Columbia, 2014). Correspondingly, the term
"adult palliative patient" refers to any patient 19 years of age or over who has been
designated as having palliative status as outlined in the BC Palliative Care Benefits Program.
Canada's population is also ethnically and geographically complex, encompassing a
wide diversity in language and cultural practices, in both urban and rural settings. The
median age in Canada is 40.6, with 16.7% aged 0-14, 68.5% aged 15-64, and 14.8% aged 65

10
and older (Statistics Canada, 2011 ). Furthermore, as with many developed countries,
Canada's population is aging. Seniors aged 65 and older now comprise the fastest growing
segment of the population, and this trend is expected to continue for the next several decades
(Employment and Social Development of Canada, 2014).
Despite the vast amount of habitable land in BC, as much as 86% of the population is
concentrated in urban centers according to a 2011 census, with the majority residing in the
vicinity of Vancouver (Statistics Canada, 2011). The remaining 14% ofBC residents live
near rural centers, many having a population of less than 1,000 people with less than 400
people per square kilometer. As it is otherwise beyond the scope of this paper to take into
account the cultural and demographic diversity among transitioning palliative patients, the
following findings are proposed to represent adult palliative patients in general in BC.

Barriers to Effective Care Setting Transition Processes
Hanratty et al. (2012) note that end-of-life care "is a time when health and well-being
may be at their lowest, and outcomes are sensitive to how well the components of the system
work together" (p. 80). The current literature on care setting transitions outlines a number of
areas of concern, grouping them in three distinct categories or levels: the system, the
clinician, and the patient. For the purpose of this project, the system level refers to the level
of health care delivered by the provincial government (which includes various health
authorities across the province ofBC); the clinician level refers to all health care providers
involved at the various stages of palliative care; and, the patient level includes both the
patient and their informal caregivers. Following is a discussion of the main barriers to
effective care setting transition processes at each level.

11
The system level. The way in which the current health care delivery system is
organized creates a number of barriers to effective delivery of care across various settings.
These barriers essentially stem from the fact that practice settings tend to operate much as
silos do, as independent care settings having little to do with the processes that occur within
the other settings (Coleman, 2003; Coleman & Berenson, 2004; Parry et al. , 2003). The
barriers often emerge as a consequence of the insular and specialized nature of the practice
settings themselves. This results in fragmentation in the continuum of care in several
discernible areas, and is particularly evident in the disconnection between care facilities or
primary care homes (Coleman 2003 ; Parry et al. , 2003 ; Rooney & Arbaje, 2012), and in poor
patient care plans and discharge or transitional summaries (Council et al. , 2012; King et al. ,
2013; Parry, Kramer, & Coleman, 2006; Parry et al. , 2003). Such barriers are also
exacerbated by improper medication reconciliation (Kripalani, Jackson, Schnipper, &
Coleman, 2007; Meier & Beresford, 2008) and inadequate health information technology
(National Transitions of Care Coalition, 2010b).
First, Coleman (2003) points out that one of the major barriers to effective care
setting transitions comes about because of the absence of a formal relationship between
different care settings-resulting in an ineffective relationship which leads to inadequate
communication and insufficient collaboration (Coleman 2003 ; Meier & Beresford, 2008;
Parry, et al., 2003). It should be noted that patient care plans and discharge or transitional
summaries represent the primary means to communicating up-to-date patient information
between care settings. Patient care plans are documents that include important patient
information on current therapies, health changes, medical history, information about other
health care providers involved, and other relevant information that may affect the patient's

12
health or treatment options (Government of Alberta, 2009). Discharge or transitional
summaries are summaries of the patient's stay in a given care setting and should include
patient details, PCP details, admission and discharge information, clinical information,
medication information, follow-up and future management, and the details of the person
completing the discharge summary (Health Information and Quality Authority, 2013).
Despite the importance of these documents, findings indicate that little time is given
to developing patient care plans, either prior to admission or after discharge (Council et al.,
2012). Moreover, a number of findings also indicate that both patient care plans and
discharge summaries are missing vital information, thereby leading to delays in patient care
(Council et al., 2012; King et al. , 2013; Parry et al. , 2006; Parry et al. , 2003). Additionally,
practitioners report that discrepancies are routinely found between the oral report given by
transferring care settings, and the written report received at the other end (King et al., 2013).
To further complicate these transitions, findings indicate that there is often a time delay
between the arrival of the patient in the new care setting and the actual receipt of the
discharge summary or updated patient care plan (Kripalani et al., 2007).
Adding to the inadequate communication at strategic points in the process, there is
also a pattern of improper or absent medication reconciliation, which will contribute to
adverse outcomes for palliative patients being transferred across care settings. Medication
reconciliation is "a formal process in which health care providers work together with
patients, families and care providers to ensure accurate and comprehensive medication
information is communicated consistently across transitions of care" (Institute of Safe
Medication Practices Canada, 2014). Discrepancies between the prescribed medication
regimen and the preadmission regimen occur for a number of reasons. For example, an

13
accurate, comprehensive medication history may not have been obtained on first admission;
the medication regimen may well have been necessarily altered during the stay; and,
medications may not have been systematically reconciled at the time of transfer to the next
care setting (Kripalani et al. , 2007; Meier & Beresford, 2008).
Finally, the lack of widespread health information technology (HIT) creates a
significant gap in the sharing of patient information between care settings. Health
information technology is defined as "the application of information technology products,
services and solutions to the health care field with the objective of lowering costs, improving
efficiency and reducing errors, while delivering better health outcomes to patients" (British
Columbia Institute of Technology, n.d. , p. 2). This discontinuity hampers communication
and compromises the possibility for coordinated care (National Transitions of Care Coalition,
2010b).
The health care system has yet to implement comprehensive, interconnected
technology, and instead uses electronic charting systems that are not capable of sharing
information (Coleman & Berenson, 2004; National Transitions of Care Coalition, 2010b).
North American medical information systems currently do not support an overarching
system that will facilitate the timely transfer of essential patient information across the
various settings a palliative care patient is likely to encounter (Kaye, Kokia, Shalev, Idar, &
Chinitz, 201 0). In Canada, only 34% of physicians use any form of electronic medical
records (EMRs) as of2010 (Biro, Barber, & Kotecha, 2012).
Due to the diverse needs of palliative patients, care is most often multidisciplinary by
nature, where communication and coordinated care become even more essential. A
multidisciplinary team approach "utilizes the skills and experience of individuals from

14
different disciplines, with each discipline approaching the patient from their own
perspective" (Jessup, 2007, p.330). As the deficiencies at the level of the system intersect in
the areas described above, they interact to create a cumulative impact across the continuum
of care for palliative patients.

The clinician level. At the clinician level, barriers to effective care setting transition
processes occur for multiple reasons, among which the following stand out: the lack of
communication and continuity of care between care providers, poor clinician-to-patient
communication, and inadequate clinician training. Continuity of care has been defined
simply as "the continuous relationship between a provider and a patient, as well as the
coordination and sharing of information between providers" (Gill, Mainous, & Nsereko,
2000). Over time, the health care system has evolved to include more and more specialty
practitioners. While in the past it was common for one practitioner to follow a patient across
a number of care settings, this is becoming increasingly less common (Coleman & Fox,
2004; Delva, Kerr, & Schultz, 2011; Kripalani et al., 2007). In this increasingly used model
of specialized health care, continuity of care is difficult to preserve, thus contributing to
ineffective palliative care setting transitions.
Ineffective clinician-to-patient communication will intensify unsatisfactory care
setting transitions for palliative patients. Slort et al. (20 11 ), in their study of perceived
barriers between patients and their general practitioners, found that patients actually
perceived practitioner communication as both dishonest and inappropriately short.
Insufficient practitioner knowledge in palliative care and care setting transitions will also
contribute to poor patient communication (Aslakson et al., 2012). Similarly, an absence of
empathetic communication will reinforce the barrier to effective communication where

15
practitioners avoid any reference to the emotional and social impact of problems arising from
the patient's situation (Ha, Anat, & Longnecker, 2010). On the other hand, positive clinicianto-patient communication is found to result in strong interpersonal relationships, facilitate the
exchange of information, and give the patients a sense of inclusion in the decision-making
process (Ha et al., 2010).
Finally, a lack of clinician training in cross-site collaboration and care setting
transitions along with insufficient clinician knowledge of other care sites, all contribute
significantly to ineffective care setting transitions. Few clinicians have any formal training in
cross-site collaboration, a situation that contributes directly to under-informed care setting
transitions (Coleman, 2003). All these potential shortcomings will contribute to transfers that
are likely not to be beneficial for the patient (Coleman & Berenson, 2004).

The patient level. Current research identifies patient education and empowerment as
two areas in need of additional development in order to improve the care setting transition
processes for palliative patients. A major insufficiency in patient education is inappropriate
communication between the patient and the practitioner (Kripalani et al., 2007). For example,
in a recent study, palliative patients were dissatisfied with communication styles of
practitioners that they felt were controlling, or where the practitioner appeared to have little
knowledge about end-of-life care, or appeared to be uncomfortable discussing certain aspects
of palliative care (Stephen, Skirton, Woodward, Prigmore, & Endacott, 2013). For some
patients, the sense that they are not being heard, or the sense that the practitioner does not
have time to talk to them, creates a barrier to their understanding of their diagnosis, their
prognosis, and the underlying rationale to their therapy (Hanratty et al., 2012).
Furthermore, patients are often transferred between care settings without having been

16
prepared in advance to optimize the health care available from the accepting care setting
(Coleman, 2003). A primary reason for this is that care setting transitions may be acute and
not anticipated, and precipitated by a sudden change in patient status. In addition, these
changes often occur after hours when PCPs are not aware that a transition has taken place
(Coleman & Fox, 2004). Additionally, once discharged from a care setting, patients may well
not be provided with sufficient information about how to access, or make best use of,
available community services (Hanratty et al., 2012). Following a discharge, patients may
also experience delays in reconnecting with their primary care or other health care provider
(Coleman & Berenson, 2004; Meier & Beresford, 2008; Parry et al., 2006).
Additionally, inadequate patient empowerment by health care providers will further
hinder effective care setting transitions. The National Transitions of Care Coalition (20 1Ob)
found that patients are generally not active participants in their medical care-largely due to
poor encouragement from within the health care system. It appears that patients often
misunderstand or underestimate their role in their own care, making them poor advocates
for their own care (Coleman & Berenson, 2004). Often, in situations where palliative
patients attempt to take an active role in their own care, their knowledge or their requests
may not be taken seriously (Hanratty et al., 2012). This lack in patient education, and the
accompanying perception of disempowerment contributes to patient dissatisfaction, and
compromises their safety during care setting transitions. All of these insufficiencies at the
level of the patient contribute to significant barriers that hinder the process of effective care
setting transitions for palliative patients.

17
Manifestations of Poor Care Setting Transitions
Ultimately, palliative care is provided for the benefit of the patient, and ineffective
care transitions will lead to any number of adverse patient events. For palliative patients, the
consequences of poor transitions manifest in various ways, all with the potential to contribute
to ineffective care setting transitions. Abarshi et al. (20 10) emphasize the "potential
relationship between end of life transitions and patient safety, comfort, quality of life and
general well being" (p. 166). Coleman (2003) points out that poor preparation of patients
prior to transfer to another care setting leads to increased anxiety and dissatisfaction, which
effectively places a greater burden on that patient, as well as the care providers. Additionally,
King et al. (2013) remind us that untimely transfer of patient care plans and discharge
summaries results in care delays leading to unsafe patient care, along with patient and
caregiver dissatisfaction.
To this, there is the not-uncommon situation of inadequate medication reconciliation,
which has potentially deadly consequences for patients. At the very least, inadequate
medication lists or orders for medication stand in the way of proper pain management and
symptom control for palliative patients (Meier & Beresford, 2008). Chhabra et al. (2012)
note that 46%-54% of all preventable adverse drug reactions occur at transition points of
care. Above all, poorly executed transitions can lead to re-hospitalization or permanent
institutionalization, which, in the context of palliative care, often precipitates a death in a
hospital (King et al. , 2013 ; Meier & Beresford, 2008). For each decision to transfer, the
potential benefit must be weighed against the potential harm. Although no transition comes
without risks, increasing the efficiency and efficacy within this area will improve the entire
continuum of palliative care.

18

Nurse Practitioners as Primary Care Providers
Nurse practitioners in BC are health care providers with a graduate level of education
and an advanced scope of practice. In BC, NPs have the ability to complete advanced
medical histories and physical assessments autonomously; diagnose and manage common
diseases, disorders, and conditions; order, conduct, and interpret diagnostic tests; prescribe
pharmacologic, non-pharmacologic, and complementary therapies; perform advanced
interventions for patients across the lifespan; and refer patients to appropriate specialists
(Canadian Nurses Association [CNA], 2010; College of Registered Nurses of British
Columbia [CRNBC], 2013a). Nurse practitioners work independently, yet collaboratively
with other health cares providers including physicians through a process of consultation and
referral (CRNBC, 2014b). Ideally, NPs use a holistic approach to patient-centered care,
promote health, prevent disease, and work collaboratively within a multidisciplinary health
care system-all with the intent to ensure the best physical, emotional, and spiritual
outcomes for their patients (CNA, 2010; CRNBC, 2014b). Nurse practitioners, as PCPs in
BC, have the skills to lead collaborative health care teams, and therefore may well find
themselves at the center of a network of care providers coordinating overall care for
palliative patients.
Although the NP role in North America has been in existence since 1895 (American
Association ofNurse Practitioners, 2014), NPs are a relatively new addition to the BC health
care system. In 2005, the BC government implemented legislation, under the Health

Professions Act, to allow NPs to practice within the province (CRNBC, 2014b). Within BC
there are three separate types ofNPs-family, adult, and pediatric-with the majority being
family NPs (Roots, 2011). The largest employers ofNPs are the provincial health authorities,

19
accounting for 75% ofthe NP jobs (Roots, 2011). The other 25% ofNPs are employed
privately, by the federal government, by universities, or are currently not employed (Roots,
2011). Geographically, 61% ofBC NPs work in the Greater Vancouver and Abbottsford
region, with the remainder divided between Greater Victoria (7%), regional centers (10%),
and rural and remote communities (22%) (Roots, 2011). Each year, the number oflicensed
NPs grows and, as of September 2014, there were 319 registered NPs in BC (CRNBC,
2014d).
For the purpose of this project, the focus will be on NPs as PCPs practicing in
community primary care settings. Many NPs provide primary care for palliative patients, and
in their roles, have the skills and knowledge to improve care setting transition processes for
these patients.

20

CHAPTER3
Methods
In order to best answer the question of how can nurse practitioners improve care
setting transition processes for adult palliative patients, an integrated review was
undertaken. An integrated review combines both theoretical and empirical sources in an
attempt to produce the most comprehensive review possible (Whittemore & Knafl, 2005). An
extensive search of this nature will incorporate electronic databases, journal hand-searches,
web searches, reference lists, and guidelines (Whittemore & Knafl, 2005). A well-defined
search strategy is an integral component of a credible integrated review. Following is an
outline of the search undertaken for this project. A flow chart of the overall search strategy
can be found in Appendix B.
Stage One: Searching Electronic Databases
Stage one of the literature search was completed by way of the following electronic
databases: CINAHL, MEDLINE Ovid, PsychiNFO, Social Work Abstracts, and Cochrane
Reviews. Initially, no search limiters were set in order to avoid excluding any relevant
literature. The search terms chosen were obtained by way of key terms that came up in the
course of reading relevant articles, and with the help of the Northern Health Sciences
Librarian at the University of Northern British Columbia. The medical subject heading
(MeSH) terms used were: palliative care, terminal care, hospice care, transfer, discharge,
transitional programs, and patient transfer. The keywords used were: end-of-life care, care
transition*, patient transfer*, care setting transition*, and transitions between care settings.
The asterisks indicate that all possible endings of the term would be included. Appendix C
shows the search results in terms of the number of results obtained for each search.

21
Pertinent terms were combined with Boolean operators (e.g. , and, or, not) to arrive at
sets of results, which were combined, and then duplicates were removed. Since limiters were
not set at the outset, the sources initially gathered included a wide variety of ages, disease
processes, types of transitions, locations of study, methodology, and dates published. The
titles of all272 potentially relevant articles were assessed and retained if the following
inclusion or exclusion criteria were met.

Inclusion and Exclusion Criteria
The inclusion and exclusion criteria were applied at all stages of the search. Articles
were included if they met the following criteria: written in English, focusing on adults, and
addressing transitions between any care setting, transitional care, patient transfers, and
palliative patients. Following this, articles were retained if they were published between 2000
and 2014. The reason that limiters were placed on the dates of publication was to ensure
improvements in care setting transition processes that have already been rectified to date
were not included. Articles that discussed other types of transitions, such as transitioning
from pediatric care to adult care, or transitioning from medical to palliative care, were
excluded, along with those concerned with the pediatric population. A total of 100
potentially relevant articles were retained on the basis of the content of the titles.

Stage Two: Screening Abstracts and Hand Searching
Stage two of the search filtered the articles retained to this point on the basis of
scanning the abstracts according to the inclusion criteria. Google Scholar was used to
produce some results, and relevant journals, identified in the course of the various electronic
searches, were then searched by hand. Lists of references from relevant articles were also
searched for relevant material. Hand-searching ensured that salient articles on the topic of

22
palliative care and transitional care were not missed during the electronic database search.
The publications with pertinent abstracts were retained on the basis of the inclusion criteria.

In total, 44 potentially relevant articles were retained from the electronic database search
results.
The six journals that were hand-searched included the Journal of Palliative Care,

Journal of Palliative Medicine, Palliative Medicine, Generations: Journal ofAmerican
Society on Aging, BMC Palliative Care, and Journal ofAmerican Geriatrics Society (see
Table 1). Since these journals pertained exclusively to palliative or adult care, the only key
term used as a further search criterion was transition*. This broad term could be used
because the number of articles found within each publication was not overwhelming. Only
articles that met the inclusion and exclusion criteria were kept. This step added 18 articles to
the 44 articles identified in the electronic search, resulting in a total of 62 articles for review.
Table 1 Search results obtained from hand searchingjournals

TERM SEARCHED
Transition*
Number taken after reading
titles and abstracts: (no
duplicates)

16
0

60
3

134
4

65
4

43

2

105
5

Following this, Google Scholar was searched using the terms palliative, terminal,
hospice, or end-of-life care, combined with transitions, care transitions, and patient transfer.
No new relevant articles were found. The reference lists of the articles pertaining specifically
to care transitions during palliative care revealed five more potentially relevant publications,

23
bringing the total to 67 articles for review-the final number of potential articles after which
it can be said a saturation point was reached. Full-text articles were then printed, and
potential publications that were not available through the University of Northern British
Columbia were obtained by way of interlibrary loans.
Stage Three: Extensive Review for Importance and Relevance

The 67 potentially relevant articles that were retained after this lengthy search process
were closely read to determine their relevance, and a final number of pertinent articles were
chosen-again, based on the inclusion and exclusion criteria. Additional exclusion criteria
were applied at this stage. Articles that discussed the care setting transitions of patients with
dementia, critical care patients, or care transitions within nursing homes were excluded. Also
excluded were articles that discussed the physical transfer of patients between care settings
rather than the transition of patients between care settings-given that the focus of this paper
is on the care setting transition process and not on process of physically transferring the
patient.
A final number of 16 articles was retained on the basis of a focus on care setting
transition processes for palliative patients and patients with complex care needs, patientcentered transitions, and care transitions of older adults. Two guidelines from the National
Transitions of Care Collation website were also examined and incorporated into the

literature analysis. The final group of articles was then analyzed for common themes that
focused specifically on improving care setting transition processes for adult palliative
patients.
Literature Reviewed

The 16 publications that were retained for this review addressed different aspects of

24

the ways in which the care setting transition processes might be improved. The articles
reviewed were primarily American publications, with the exception of an English source.
There were very few articles that focused specifically on care setting transitions for palliative
patients and, after careful consideration, only one article was included. While there were a
number of studies that looked at transitions between care settings for palliative patients, they
did not focus on the question of improving these transitions. In actuality, only one study
looked directly at improving care setting transitions in the palliative population, it became
clear that the research looking at improving care setting transitions for the elderly and
chronically ill would yield findings that could be applied to palliative care transitions.
The majority of the articles chosen for review directly addressed the issue of improving the
transition processes in the care settings of older adults with a chronic illness, and more
broadly, outlined ways for clinicians to improve on care setting transition processes in
general. Four publications specifically focused on medication reconciliation; one looked at
end-of-life care setting transitions, four examined patient perspectives on the ways in which
care setting transitions could be improved, and the remainder examined general ways to
improve care setting transitions .
Five of the studies reviewed were qualitative in nature, two provided systematic
literature reviews, and one presented the results of a randomized controlled trial.
Additionally, two reports written by expert committees under the auspices of the National
Transitions in Care Coalition were included, and the remaining five presented the opinions of
expert authorities on the topic of improving care setting transition processes.
The sample sizes of the qualitative studies ranged from 27 to 125 participants; the
randomized controlled trial included 750 participants; and, the qualitative reviews included

25
five to seven studies. Each publication included in this review was analyzed on the basis of
study type, population, purpose, and strengths and limitations. Further discussion of study
characteristics is addressed in the Findings section, below.

Analysis Technique
Research in the area of care setting transitions emphasizes the importance of a
systematic and thorough analysis of the selected literature as a way of ensuring the credibility
of a high quality integrated review. This analysis of the qualitative data began with just such
a reliable and thorough search strategy (documented above) . Following a careful selection of
relevant articles, based on specific inclusion and exclusion criteria, the resulting body of
literature was closely examined to ensure that all aspects of its content was well understood.
In the process each publication was analyzed in detail with attention to the level of evidence,
the characteristics of the population studied, the sample size, the focus of the study, and the
strengths and limitations of the study (and/or content). This process ensured both the
credibility and validity of the selected material, and also determined whether the source
ultimately added data to answer the question posed for the review. A detailed table of
evidence outlining the elements analyzed was compiled and can be found in Appendix D.
Fallowing this process, each publication was critiqued on the basis of its own merits
in order to identify patterns, themes, and relationships (Torraco, 2005 ; Whittenrnore & Knalf,
2005). Three broad categories emerged as overarching themes according to which the
content could be categorized-the system level, the clinician level, and the patient level.
Once all material was thoroughly analyzed, connections between the sources were identified
in order to demonstrate the way in which one concept might influence another. By
synthesizing the combined content in this way, it became possible to identify specific nodes

26

in the care setting transition process most in need of improvement. Finally, thematic content
analysis was undertaken in order to identify key care setting transition process
improvements. The findings that resulted from this multiple-stage process are presented
below.

27
CHAPTER4
Findings
Following a comprehensive search for pertinent literature on the topic of improving
the transition process between care settings for palliative patients, 16 publications were
chosen for this review. Results of the literature analysis were grouped according to three
levels or categories: system, clinician, and patient. Within these categories, a number of
different themes emerged to provide a structure by which to discuss the data in a systematic
way. The themes identified at the system level were as follows: connecting care settings,
improving patient information flow , effectively reconciling medication, and providing
adequate health information technology. At the clinician level the themes included care
provider continuity, clinician-to-patient communication, and the furthering of clinician
education; and, at the patient level, the themes were primarily related to improving the
education of the patient and facilitating their empowerment. It is important to note that most
themes may have some overlapping characteristics, given that the literature chosen for
review addressed interrelated elements of care setting transitions. The following section will
outline the themes noted in the material analyzed, and will focus on bringing about a better
understanding of where exactly improvements can be made to the process of care setting
transitions for adult palliative patients.

The System Level
At the level of the health care delivery system, four themes emerged with respect to
the improvement of care setting transition processes. As discussed earlier, the most common
barriers to effective transitions at this level are the disconnect between care settings,
inadequate patient care plans (including inadequate discharge or transition summaries), poor

28

medication reconciliation, and inadequate health information technology (HIT). The analysis
of the literature revealed a number of distinct areas where improvement is both feasible and
necessary.
Connecting care settings through communication. The necessity for a better
connection between health care settings emerged as a common theme in many of the articles
reviewed. Generally speaking, the proposition is that connectivity can be improved through
effective and standardized communication-in tandem with a multidisciplinary approach.
Overall, effective communication between transitioning care settings is seen as essential to
achieving positive patient outcomes (Chhabra et al., 2012; Coleman, 2003; Coleman & Fox,
2006; King et al., 2013; Kripalani et al., 2007; Rooney & Arbaje, 2013 ; Schoenborn, et al.,
2013).
First, Kripalani et al. (2007) propose that communication between settings should be
viewed as a two-way dialogue rather than the more typical one-way transfer of information
from the discharging care setting to the accepting care setting. One of the ways proposed for
increasing open dialogue between care settings is to have the discharging setting provide the
patient, the caregivers, and the primary care provider (PCP) with the contact information for
the discharging physician (Coleman, 2003 ; King et al., 2013; Kripalani et al. , 2007). These
sources argue that having a direct line to the discharging physician will expedite the process
of acquiring any missing patient information, and will allow a timely clarification of any
questions remaining (Coleman, 2003; King et al. , 2013). Two-way communication will also
allow providers to formulate a cohesive follow-up plan specific to the tasks to be performed
in the course of the initial visit with the patient's PCP (Kripalani et al., 2007).
Schoenborn et al. (2013) emphasize that the patient's PCP should connect with the

29

discharging care setting by way of a telephone interchange that addresses the patient's course
of time in hospital. Furthermore, they note that that, ideally, cross-site communication should
be initiated by notifying the PCP soon after the patient has been admitted. In this way, by
notifying the palliative patient's PCP with respect to all admissions at the time they occur,
more time would be available for coordinating appropriate care prior to discharge. It is worth
noting that Schoenborn et al. found that clinicians acknowledged that they were more likely
to communicate directly with a patient's PCP if the clinician had a prior relationship with
that PCP. Their findings emphasize the need for increased connectivity between care
settings.
Furthermore, a number of the articles also emphasize the need for a greater
standardization of the communication process between care settings as a way to improve care
setting transitions for patients. The National Transitions of Care Coalition (20 1Ob) states that,
"the safety and effectiveness of care transitions requires some degree of standardization
among providers to ensure the completion of critical activities common to all transitions of
care" (p. 16). The literature indicates that care providers need to relay patient care
information accurately between care settings-the main effective tactic for bridging the
communication gap between care settings (Coleman, 2003 ; Flora, Parsons, & S1attum, 2012).
An example of an ideal, standardized transition record is presented in Appendix E.
The final theme at the level of the health care system-with respect to resolving the
disconnect between care settings by way of effective communication between care settingsis the advocacy for a multidisciplinary approach, one that includes collaboration based on
common goals and mutually agreed upon patient expectations (Flora et al., 2012; Kripalani et
al., 2007; Rooney & Arbaje, 2013). According to some findings, clinicians themselves

30
perceive communication across a diverse range of staff as an important part of their role,
thereby reinforcing the importance of a team-based approach throughout the care setting
transitions (Schoenborn et al., 2013).
A multidisciplinary approach is also likely to improve patient safety and the quality
of care at time of discharge. An exemplary discharge planning team could include a nurse
case manager, a social worker, and a number of other care specialists, such as a PCP, an
occupational therapist, a pharmacist, and a physiotherapist, all of whom can work in
conjunction with each other to facilitate a proper assessment of the full spectrum of needs of
both the patient and the caregivers (Kripalani et al., 2007). In summary, interconnecting care
settings for palliative patients by establishing a two-way dialogue, standardizing
communication processes, and employing a multidisciplinary approach have all been
identified as important contributors to the improvement of care setting transitions.
Patient care plans and discharge or transition summaries. A good part of the
research reviewed examined ways to improve care setting transitions by way of identifying
flaws that could be readily fixed in the way patient care plans are put forward and discharge
or transition strategies are summarized. Various sources advocate for a clarification of the
elements to be included in these documents, and call for better and more timely access to the
information contained therein (Coleman & Fox, 2004; Flora et al., 2012; King et al., 2013;
Kripalani et al. , 2007; National Transitions of Care Coalition, 2010a).
The research indicates that, in order for patient care plans and discharge or transition
summaries to be effective, the accepting institution must receive accurate documents in a
timely manner. However, ideas as to what constitutes "timely" for the receipt of critical
patient information varied. Kripalani et al. (2007) recommend that PCPs should be provided

31
with some information about the patient's hospital stay on the day of discharge, with a
detailed discharge summary following within the week. King et al. (2013) disagree with the
proposal for same-day discharge summaries, proposing instead that essential patient
information should be transferred, correctly and completely, at least 24 hours prior to patient
discharge. They argue that to relay pertinent information well before discharge will allow the
necessary time to ensure that appropriate medications and supplies are available on arrival.
King et al. (2013) also found that, even when discharge summaries were received at a
skilled nursing facility in a timely manner, the amount of material nursing staff still had to
sift through in order to find the necessary information, had an impact on the care setting
transition of the patient. As a result, King et al. developed a list of essential discharge
information required from the discharging hospital in order to allow the skilled nursing
facility staff at the other end an effective means by which to develop and implement a safe
plan of care for patients following their discharge (Appendix F). While the extent and
content of this list may not be applicable to a primary care setting, many elements were
nonetheless deemed essential for improving the care of transitioning palliative patients by
their PCP.
Coleman and Fox (2004) emphasize that-while standardizing the content of the
information in patient care plans and discharge/transition summaries has been proven useful
for improving care transitions according to a number of sources (King et al., 2013; Kripalani
et al., 2007; National Transitions of Care Coalition 2010a)-in order for clinicians to fully
understand the type of information needed in these documents, staff from the discharging or
transferring care setting should first visit the accepting care setting. These writers indicate
that patient information can vary between care settings, and that the best way to identify

32
various needs is for clinicians to take a proactive approach to gathering this information.
Parry et al. (2006) undertook a study to explore ways in which patient-centered
coaching interventions could improve the care setting transitions of chronically ill older
adults . One intervention used a dynamic patient health record as a self-management tool.
This personal tool provided a means for patients to accurately keep track of health
information, and relay this information to their various care settings. The patients who used
this tool reported feeling "more prepared to function as active participants in health care
interactions because they had a resource they could reference" (p . 48). Using this
intervention strategy allowed Parry et al. to remove an important barrier to the provision of
accurate and timely discharge summaries and patient care plans by having the patients
themselves provide practitioners with the pertinent health information. A limiting feature of
this strategy, in the context of the palliative population, would be the progressive decline in
the functionality of the patient, leaving the patient faced once more with a barrier to timely,
up-to-date information transfer. Alternatively, many palliative patients have informal
caregivers who could assist patients with the updating of their personal health records.
It is worth remembering that palliative patients and their caregivers are often the only

constant in the transitioning process between care settings. The National Transitions of Care
Coalition (20 1Ob) advocates that patients and their caregivers actively participate in the
development of patient care plans. Similarly, Coleman and Fox (2004) recommend that care
plans incorporate patient goals and preferences for both the short and long term. Palliative
patients and their PCP, or other members of their health care team, can work together to
formulate these goals and make sure that these patient-centered plans are maintained.
In summary, accurate and up-to-date care plans that benefit from patient and

33
caregiver input, timely delivery of discharge or transition summaries, and a dynamic patient
health record self-management tool are identified in the research reviewed as effective means
whereby the transition of patients between settings of care can be facilitated.
Effective medication reconciliation . Improper or absent medication reconciliation is
identified in the literature as a major contributing factor to adverse patient events during
times of transition. The primary goal of medication reconciliation is to eliminate adverse
outcomes for patients transitioning between care settings. Proposals to ensure that medication
reconciliation occurs emphasize the necessity for obtaining an accurate medication history,
comparing preadmission medication regimens with discharge orders, and involving a
pharmacist in the process of medication reconciliation.
Proper medication reconciliation must begin by establishing a thorough history of
medication use. Kripalani et al. (2007) acknowledge that the process of obtaining an accurate
medication history is dependent on gathering information from a number of different
sources-which include the patient and their caregivers, a list of medications provided by the
patient, an inventory of prescription bottles, outpatient medication records, and prescription
refill information acquired from community pharmacies. In a follow-up to the Pharmacist
Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study conducted in
2010, Cawthon et al. (2012) reiterate the importance of compiling a detailed medication
history from multiple sources; in this way, discrepancies in the medication regimen are more
likely to show up. Kripalani et al. (2007) note that the most effective mitigator of
discrepancies is the involvement of both the patient and caregiver, along with to the PCP and
pharmacist. Since practitioner time is often an issue when resolving medication
discrepancies, the combined scrutiny of the PCP, pharmacist, registered nurse, or other care

34
team members could well contribute to a resolution of potential discrepancies.
The National Transitions of Care Coalition (2010a) has developed a standard set of
essential data elements that should be incorporated into all medication reconciliation forms
or patient charts. The key elements are "demographics; medications (active and chronically);
other medications (over the counter, herbal remedies, dietary supplements); medical history;
primary physician; and validation" ("Medication Reconciliation Through Electronic", para.
4). Having a standardized checklist of key elements will help clinicians compare preadmission medication lists with discharge lists (Kripalani et al., 2007; LaMantia et al., 2010).
Research indicates that clinicians do recognize that best practices should include an
examination of the actual medication bottles and an overall simplification of medication
regimens (Schoenborn et al, 2013). If a thorough medication history was taken during the
admission process, creating a coherent list of discharging medications should be less
complicated than current practices allow.
A number of studies identify pharmacists as key contributors to effective medication
reconciliation (Cawthon et al., 2012; Chhabra et al., 2012; Flora et al., 2012; LaMantia et al.,
2010; National Transitions of Care Coalition, 2010a). For example, 72.8% of patients who
participated in a phone survey following the PILL-CVD study rated speaking to a pharmacist
at the time of hospital discharge as the most helpful intervention (Cawthon et al., 2012).
These patients found that an explanation given by the pharmacist on how to take their
medications, and how to prevent or manage side effects, as the most pertinent information
they were able to obtain at the time of their discharge. Patients also reported feeling more
comfortable about discussing the medication with their health care providers once they had
met with the pharmacist (Cawthon et al., 2012).

35
By contrast, a systematic review conducted by LaMantia et al. (20 10) found no
intervention prior to discharge that clearly improved the transmission of accurate medication
lists between hospitals and nursing homes. At the same time, initial evidence from the same
study suggests that a review of patient medication lists by a pharmacist after their transfer,
together with a detailed transfer medication list, will improve accurate and appropriate
medication use. Although ongoing medication reconciliation is necessary to ensure safe
patient care, it is also important to remember that redundancy in the workload would be
mitigated by multidisciplinary communication (Kripalani et al., 2007).
The National Transitions of Care Coalition (2010b) emphasize the importance of HIT
in increasing the efficacy of medication reconciliation. Improving medication
reconciliation-specifically, by taking medication histories and reconciling preadmission and
discharge medication regimens (with pharmacist involvement whenever possible), as well as
integrating HIT into the process-is found to be among the most important ways to improve
patient transitions.
Although the goals of care often differ in the palliative context, the importance of
medication reconciliation also applies to care setting transitions for palliative patients. In
these situations, many regular medications are discontinued following a palliative diagnosis;
these are often replaced by medications for symptom management, either in the process of
admission to a care facility or in the process of organizing care at home. Proper medication
reconciliation for palliative patients has the same implications for safety as it does for
transitioning elderly or chronically ill patients.

Adequate health information technology. Implementing standardized HIT at the
system level would remove many barriers that currently exist when it comes to ready access

36
to patient information, thereby improving care setting transition processes in significant ways
for palliative patients. A recent study by King et al. (2013) identified that much work still
needs to be accomplished at the national level in order to allow health systems to share
information across care settings. Although improvements to HIT are ongoing, electronic
communication can only be effective if all of the sites in a patient's continuum of care have
access to both sending and receiving information (National Transitions of Care Coalition,
201 Ob). Patients and their caregivers are at the centre of a health care constellation, which
only works well when the full complement of practitioners and settings-the PCPs, hospitals,
nursing homes, home health care organizations, rehabilitation centers, hospice, and other
services - are well integrated (National Transitions of Care Coalition, 2010b). Given the
complexity of this care constellation, the necessity for a phased-in, universal electronic
health record system seems self-evident.
Although a number of sources reviewed refer to the need to improve HIT as part of
developing better care setting transitions, only the National Transitions of Care Coalition
(20 1Ob) put forward recommendations for actual implementation. They specify that, in order
for HIT to be effective, all electronic health records must incorporate specific elementssuch as patient preferences and advanced directives, sharable and interactive plans, referral
tracking, preferred provider, compliance tracking, and consultants' recommendations/care
plans. Unfortunately, none of the sources provide a clear outline of steps to be taken at the
system level that would allow implementation to move forward and connect health care
settings through HIT. Despite the numerous challenges to developing more effective care
setting transitions at the system level, there is solid evidence to indicate that implementing
HIT would certainly reduce the complexity of these transitions.

37

The Clinician Level
According to the sources reviewed, the barriers to effective care setting transition
processes at the clinician level reside in the lack of care provider continuity, poor clinicianto-patient communication, and inadequate practitioner training in cross-site collaboration and
care setting transitions. The following interventions for improvement at the level of the
clinician emerged from the sources reviewed.

Care provider or care team continuity. A significant theme in the findings is that
improvement in care setting transitions are likely to come about when there is continuity in
communication between the various care providers. A number of sources indicate that
continuity between specific practitioners leaves patients transitioning between settings with a
sense of safety and being well cared for (Coleman, Parry, Chalmers, & Min, 2006; Flora et
al., 2012; King et al. , 2013; Parry et al. , 2006; Schoenborn et al., 2013). Since a patient's
PCP is unlikely to remain as the main care provider at each care setting, effective
communication between sending and receiving providers is essential (Coleman & Fox, 2004;
LaMantia, et al., 2010; National Transitions of Care Coalition, 2010a; Schoenborn et al.,
2013). While most sources appear to focus on practitioner continuity, Coleman and Fox
(2004) indicate that other professionals, such as case managers, are also often unaware when
their patients are transitioned between care settings; they emphasize that continuity must
occur between all health care providers right across the care continuum and that this
continuity must be in place whether the care teams are formally connected or not.
Schoenborn et al. (2013) found that, when interviewed, clinicians were well aware of
the benefits of clinician communication to patient care. In this study, PCPs indicated that
they coached patients on how to effectively advocate for clinician-to-clinician

38
communication, advising them to make sure that the next provider in the process contact the
patient's PCP or care team. In particular, they instructed patients to give the next provider the
PCP or care team's contact information, and to insist that this provider contact the patient's
PCP or care team to advice them of the patient's admission.
The above study also points out that, unfortunately, even though clinicians are aware
of the importance of clinician-to-clinician communication, improvements at this level still
need to be formalized. The barriers identified in this area include issues relating to time
shortage, high staff turnover, fragmented care, lack of standardized communication systems,
and difficulty accessing other clinicians (Schoenborn et al., 2013). Clinicians in this study
also identified barriers to the flow of knowledge due to inadequate feedback, and inadequate
education related to care setting transitions-both factors that contributed to poor clinicianto-clinician communication.
Additionally, improving provider accountability during patient transfer is seen as a
way to enhance continuity in care setting transitions . The providing practitioner at the
originating site needs to maintain responsibility for patient care until the receiving provider
can assume care (Flora et al., 2012). While agreeing in principle, Schoenborn et al. (2013)
argue that sustaining organizational accountability of care providers during transitions will
continue to be difficult as long as individual provider roles remain ambiguous. Some time
ago, Coleman (2003) also pointed out the ambiguities in the role of care providers in the
post-discharge period, but actual recommendations with respect to the ways that clinicians
can become more accountable have not been explored until now. In short, Schoenborn et al.
(2013) recommend two ways to reduce ambiguity-that providers share patient

39

responsibility, and that they engage in dynamic feedback. Further research in this area is
called for.
Finally, patients who participated in the "Care Transitions Intervention" consistently
cited the importance of the continuity provided at each point of transition (Coleman et al. ,
2006; Parry et al. , 2006). This intervention used advanced practice nurses as transition
coaches, whose main function was to facilitate patient and caregiver roles, rather than behave
in the traditional manner associated with a PCP. The transition coach initially met with
patients in the hospital prior to their discharge, then completed a home visit 48-72 hours
after their discharge, followed by three telephone calls over the next 28 days. Not only was
there a significant improvement in patient and caregiver satisfaction during the transition
period, but also findings showed a decrease in patient re-hospitalization at 90 and 180 days.
Coleman et al. (2006) emphasize that, "the findings suggest that the continuity of the
coaching relationship fostered a sense of caring, safety, and predictability about the
transition" (p. 1826).
In the context of health care in BC, using advanced practice nurses such as NPs as
transition coaches for palliative patients may not be the best use of health care resources.
This relates to issues of sustainability and cost benefit in these models of care. Although the
composition of the health care system and the specific roles of practitioners in BC may not
lend themselves to the implementation of a transitions coach model, the idea that continuity
of patient care is important during care setting transitions, is nonetheless a valid finding.
Maintaining continuity of care, either through one provider across the sites of care, or
through effective clinician-to-clinician communication, can greatly improve care setting
transition processes for palliative patients.

40
Clinician and patient communication. The literature reviewed discusses the

importance of continuous practitioner and patient communication throughout the transition
process. Often patients, especially those who are chronically ill or palliative, are transferred
between care settings with little notice. Coleman and Fox (2004) recommend that all PCPs
engage their chronically ill patients in a dynamic care setting transition planning discussion.
Since many palliative patients have multiple comorbid conditions, it follows that palliative
patients would also benefit from care setting transition planning. Even though Coleman and
Fox did not specifically site evidence that care setting transition planning improves patient
perspectives of care transitions, results from a following study confirm that the positive
effects of the transition coach initiating conversation with the patient prior to discharge
improved patient satisfaction and thereby contributed to effective transitions (Coleman et al. ,
2006).
The research indicates that there is a significant advantage to having ongoing
communication between provider and patient by way of follow-up visits and telephone calls.
There is also consensus between a number of sources, agreeing that all patients discharged
from a care setting should have a timely follow-up appointment with their PCP (Kripalani et
al., 2007; LaMantia et al., 2010; Perry, Kramer, & Coleman, 2006). Two sources recommend
that a follow-up visit be scheduled within two weeks of discharge (Kripalani et al., 2007;
Rooney & Arbaje, 2013).
Considering that palliative patients can experience a number of adverse events in the
post-discharge period (including death), a belated follow-up with a PCP weeks after
discharge is often inappropriate. One way to impart clinician and patient communication
prior to a formal clinic visit is with a follow-up telephone call (Kripalani et al., 2007; Parry et

41
al., 2006; Rooney & Arbaje, 2013). Kripalani et al. (2007) recommend that a telephone call a
few days after discharge can help bridge the gap between inpatient and outpatient. Rooney
and Arbaje (2013) prefer that a telephone call be made within 48 hours of discharge in order
to optimize patient safety. They also found that a Master's-level of education for social
workers forms an ideal fit when it comes to making these post discharge telephone calls.
Kripalani et al. (2007) note that a physician, an advanced practice nurse, a registered nurse, a
pharmacist, or a care manager can equally and effectively carry out a telephone follow-up. In
any event, the professional making the call must be familiar with the patient's recent course
of events and medical history.
Aside from the timing of communication, practitioners must know how to
communicate information effectively to patients and caregivers. Kripalani et al. (2007) set
out a number of proposals on how best to relay information to patients. First, written material
should be provided for all important instructions, since patients are unlikely to fully
remember verbal directions. Next, and perhaps most important, practitioners must confirm
that patients are comprehending the instructions by asking the patient to show their
understanding by repeating the discussion. Additionally, practitioners should ask open-ended
questions and allow patients and caregivers ample time to discuss concerns or ask questions.
Finally, patients should also be asked to demonstrate any new self-management skills
required for their care.
While these communication interventions may be applicable to palliative patients
soon after diagnosis, it is also understood that, as palliative status progresses, effective
clinician-to-patient communication often becomes a mute point. However, in this event,
clinician communication can change focus and involve informal caregivers where present.

42

Clinician training in care setting transitions and cross-site collaboration. Even
though many clinicians complete a number of years of formal education prior to becoming
independent practitioners, the current curricula generally does not provide education with
respect to care setting transitions or cross-site collaboration (Coleman & Fox, 2004; King et
al., 2013; National Transitions of Care Coalition, 2010a). Coleman and Fox (2004) note that,
"practitioners generally lack training on how to execute effective transfers and often do not
recognize their role in transition planning" (p. 34). Similarly, King et al. (2013) point out that
accreditation guidelines for both physicians and nurses are quite vague when it comes to the
type or extent of care setting transitions training required. Given the inadequacies in
practitioner training when it comes to care setting transitions, more formal and detailed
accreditation guidelines need to be implemented to ensure a minimum standard of
practitioner knowledge and training with respect to care setting transitions (Coleman & Fox,
2004; King et al. , 2013).
Correspondingly, the National Transitions of Care Coalition (2010a) has developed
education strategies for improving the understanding of health care providers with respect to
the impact that poor transitions have on patients, and has set out guidelines designed to
ensure that transitions between care settings are more effective. These education tools can be
found on the National Transitions of Care Coalition website. While practitioners often
encounter time restraints when it comes to their ongoing education, the tools available on the
National Transitions of Care Coalition website are readily obtainable and can be used to
achieve continuing competencies for maintaining licensure. Acquiring this knowledge will
undoubtedly facilitate a better match between patient needs and care setting services. In
summary, it is possible to achieve greater success in the management of care setting

43
transitions for palliative patients by way of inter-practitioner communication and
collaboration, clinician-to-patient communication, and further clinician education.

The Patient Level
Barriers to effective care settings transition processes at the patient level include
insufficiencies in the patients' knowledge and inadequacies in patient empowerment.
Although many of the proposals for improving care setting transitions at the patient level
ultimately depend on clinician and system components, this review of the research revealed
several scenarios where patients have the potential to contribute to optimal care setting
transitions. Since most palliative patients eventually are unable to be solely responsible for
their own care, the interventions at the patient level would also apply to informal caregivers.
As patients progress towards death, the subject for, or recipient of, education and
empowerment becomes the family or the caregiver. The ultimate goal-to have patients and
caregivers take a more active role in the delivery of their health care--can only be achieved
by improving patient knowledge and ways in which patients gain empowerment (Coleman et
al., 2006).

Improving patient and caregiver education. Research shows that the areas where
patient and caregiver education is inadequate concerns the management of medication,
condition management and, again, in the area of managing care transitions-specifically,
knowing what is required of patients during these transitions (Coleman et al., 2006). Sources
emphasize that clinicians should provide patients with a complete written list of medications
to be taken, complete with indications and instructions for administration (Kripalani et al. ,
2007; Parry et al. , 2006). As well, clinicians should ensure that patients and caregivers know

44
and can recognize the warning signs of a worsening condition that could necessitate the need
for further medical evaluation (LaMantia et al. , 201 0; Parry et al. , 2006).
The National Transitions of Care Coalition (20 1Ob) advises that the active
engagement of both patients and their caregivers in the patients' health care is essential and
should occur during every health care encounter. This ongoing engagement has the potential
to lead to a significant improvement in their knowledge and their understanding of current
medications. Sources emphasize that patients should always maintain a detailed medication
list in order to minimize errors (Flora et al. , 2012). Cawthon et al. (2012) found that patients
feel more comfortable about discussing their medications with PCPs after they have spoken
with their pharmacist and have some knowledge of their medications. Again, patient
preparation prior to a transfer is an essential component of effective care setting transitions .
Since the majority of transitions between care settings are acute and unplanned, preparation
for transition is best done prior to any patient transition, as part of overall palliative care
planning (Coleman & Fox, 2004). Primary care practitioners are essential to this education
and planning process, especially since the practitioner often has a consistent and ongoing
relationship with the patient.
It is perhaps no surprise that Cawthon et al. (20 12) found that patients with

inadequate or marginal medical knowledge were significantly more likely to report the
benefits of further education than those patients with adequate medical knowledge. This
finding reinforces the necessity to improve patient knowledge given that patients with
minimal medical knowledge are more likely to have difficulty navigating the health care
system. All the sources consulted agree that clinicians play a pivotal role in the development
of patient education. However, apart from highlighting the importance of clinician

45
involvement, the sources lacked suggestions as to other ways in which patients could be
given the means to improve their medical knowledge.
Improving patient education in the palliative population may well contribute to
improving the process of care setting transitions early on following their diagnosis, but as the
palliative status progresses and patients become less able to participate in their care, patient
education becomes less useful. Nonetheless, it is important to keep in mind that findings
indicate that reasonably well-educated patients and/or caregivers naturally improve care
setting transitions, and this would also apply to the palliative population. Further exploration
of the education tools and concepts that PCPs use to improve patient education-such as
communication and appropriate knowledge exchange-will be outlined in the discussion.
Patient and caregiver empowerment. While increasing patient knowledge is a critical
component of patient empowerment, studies have found that encouraging active patient
participation is the primary means by which patients become empowered. A number of
sources stress the importance of encouraging patients and caregivers to take a more active
role during their care setting transitions (Cawthon et al., 2012; Coleman & Fox, 2004;
Coleman et al., 2006; Flora et al., 2012; Kripalani et al., 2007; National Transitions of Care
Coalition, 2010a; Parry et al., 2006). Again, it is important to remember that, as palliative
status progresses, patients are often unable to participate in their own care, which presents a
potential limitation to the relevance of this finding in the context of palliative care. Patient
empowerment soon after diagnosis is critical to bettering patient care and care setting
transitions, while caregiver empowerment is beneficial as palliative patients progress towards
death.

46
Next, patients should be encouraged to participate in the formulation of their care
plans and their transition plans. In order for this to work, clinicians must provide patients
with the resources and tools to enable patients to understand the aspects of care that should
be included in these plans (Coleman & Fox, 2004). Accordingly, Coleman and Fox (2004)
developed a patient transfer checklist for patients or caregivers to complete prior to leaving a
care facility (see Table 2).
Table 2 Patient transfer checklist
• I have been involved in decisions about what will take place after I leave the facility
• I understand where I am going after I leave this facility and what will happen to me
once I arrive
• I have the name and phone number of a person I should contact if a problem arises
during my transfer
• I understand what my medications are, how to obtain them, and how to take them
• I understand the potential side effects of my medications and whom I should call if I
experience any of them
• I understand what symptoms I need to watch out for and whom I should call if I
experience any of them
• I understand how to keep my health problems from becoming worse
• My doctor or nurse has answered my most important questions prior to my leaving
the facility
• My family or someone close to me knows that I am coming home and what I will
need once I leave the facility
• Ifl am going directly home, I have scheduled a follow-up appointment with my
doctor, and I have transportation to this appointment (Coleman & Fox, 2004, p. 39)
Note: Adapted from "One Patient, Many Places: Managing Health Care Transitions, Part II:
Practitioner Skills and Patient and Caregiver Preparation," by E.A. Coleman and P.D. Fox,
2004, Annals ofLong-Term Care, 12(10), 39.
Coleman et al. (2006) also found that encouraging patients and caregivers to take a more
active role in their care transition ultimately reduced hospital admission rates. Although their
study did not consider palliative patients, the prediction that patient and caregiver
empowerment would lead to fewer care setting transitions for palliative patients is plausible.
If palliative patients and caregivers are given the necessary education and skills to manage
appropriate care, the number of patient transfers could potentially decrease.

47

As noted above, Coleman et al. (2006) implemented the use of a personal health
record as one of the interventions during the "Care Transitions Intervention". This record
was developed as a tool to empower patients to take an active role in their transitions by way
of increasing their knowledge while also serving as a reminder of questions to be asked at the
next appointment. It turned out that only half of the participants regularly used the personal
health record, but those who did reported that they felt prepared to participate more actively
in their health care interactions (Parry et al., 2006). The reasons given for the lack of
participation included a preference for an existing system, ambivalence about managing
one's health, a general sense of disempowerment, and a lack of support or validation from
health care providers.
Furthermore, the National Transitions of Care Coalition (2010a) emphasizes that
improved transitional communication can indeed be achieved through patient and caregiver
empowerment, and encourages practitioners to provide patients with the necessary tools and
resources . At the same time, it should be noted that patients and caregivers need time to
process information, weigh options, ask questions, and express concerns (Coleman & Fox,
2004). In any event, findings indicate that supportive practitioner attitudes will reinforce
patient and caregiver self-management (Parry et al. , 2006). Likewise, Cawthon et al. (2012)
note that, "by educating patients on self-care and empowering them to have a more
informative discourse with their providers, it may be possible to improve patient selfmanagement after hospital discharge" (p. 322).
While common themes noted within the literature were used to systematically discuss
the ways in which to improve care setting transitions for palliative patients, it is important to
note that real change can only occur with improvements to all interconnected areas as a

48

whole. LaMantia et al. (2010) summarize it this way: "Effective transitional care can be
understood as a summation of several key steps: communication between sending and
receiving clinicians, preparation of the caregiver and patient for the transition, reconciliation
of the patients' pre- and post hospitalization medication lists, arrangement of a plan for
follow-up of outstanding tests and for an appointment with the receiving physician, and
discussion of warning signs that might necessitate further more-emergent medical
evaluation" (p. 781 ).
Limitations
There are a number of limitations to this review. An obvious limitation is the
potential for publication bias: only articles published in English were used for this review,
and only sources published after the year 2000 were included. The majority of the articles
were published in the United States and describe health care from an American standpoint.
Only one report from England, and no pertinent Canadian studies surfaced in the searches or
bibliographies. Even though studies pertaining to care setting transitions of palliative patients
in Belgium, Italy, and the Netherlands were identified, these studies did not specifically
address ways to improve the care setting transition processes. Given the American
standpoint, one can ask whether these findings can be generalized to the PCPs functioning
within the health care setting in BC. For example, daily PCP practice as it occurs in BC may
not be conducive to the implementation of some of interventions described in the literature
reviewed.
It is also possible that key material pertaining to care setting transitions of palliative

patients were inadvertently omitted, despite a thorough and methodical search. As well, it is
possible that material was unintentionally excluded where studies did not refer to

49
improvements for care setting transitions in their title or abstract. The fact that some of the
data discussed here did not arise out of qualitative or quantitative studies might be seen as a
potential limitation, but this can be offset by the credibility and authority of the sourceswhich include some of the most influential authorities with respect to modem research in
care setting transitions in the United States. Their extensive experience, insights, and
observations in the field of care setting transitions added greatly to the findings of this
project.
Additionally, the palliative patient population presents certain limitations on the
possibility of conducting studies, not to mention the obvious ethical barriers to the usual
methodology used in double-blind clinical trials or randomized controlled trials. This limits
certain kinds of evidence available for consideration and puts a greater burden on qualitative
research that involves patient and/or caregiver surveys and interviews. As well, some studies
used a limited number of participants, which may be seen to compromise the external
validity of the findings .
Only one study reviewed here pertained definitively to care setting transitions for
palliative patients, while the remaining material focused on care setting transitions of
chronically ill older adults, or care setting transitions in general. This literature indicated
potential limitations to implementing the proposed interventions in the palliative population,
but nonetheless revealed possibilities where PCPs could improve care setting transition
processes for palliative patients. Additionally, although the literature recognized that
inadequate practitioner time creates barriers to effective care setting transitions, the sources
did not otherwise address ways to rectify or alleviate this shortcoming in current care
practices. Since there is often an increase in the number of care setting transfers experienced

50
by palliative patients as their illness progresses, the ultimate outcome of a care setting
transition, namely death, is much different than the outcome of a care setting transition in a
resolvable acute episode.

51
CHAPTERS
Discussion
The primary objective of this project was to examine the ways in which nurse
practitioners (NPs), as community based primary care providers in BC, can better facilitate
more effective care setting transition processes for adult palliative patients. The findings
from this project make a strong case for improvements to better facilitate effective care
setting transition processes. Improvements need to be made at three levels: the system, the
clinician, and the patient. Communication, collaboration, health information technology,
medication reconciliation, education, and empowerment surfaced as common themes across
all three levels. These themes have been set out below to provide a framework for the
discussion of the literature. The following section will synthesize the evidence as it relates to
NP practice, and will conclude by identifying a number of key recommendations for the
ways in which NPs can improve the care setting transition processes for adult palliative
patients.

How NPs can Facilitate Effective Communication at Each Level
Times of transition between care settings for palliative patients are often emotional,
confusing, and difficult for patients and caregivers. Effective communication has a direct
impact on patients ' quality of care, safety, and overall satisfaction with the care they are
receiving (Australian Government, 2014). Facilitating effective communication as a means
by which care setting transitions can be improved is a common theme that arises in all three
levels-system, clinician, and patient. This commonality indicates that improving
communication at all levels is fundamental to the well-being of transitioning patients.
Although the ways in which communication can be improved differ for each of the three

52
levels, there appears to be a universal conviction that effective communication contributes to
improved patient outcomes. The literature on the whole recognizes the positive effect of
effective communication at every level during palliative care. For example, the Canadian
Hospice Palliative Care Association (2013) stated that effective communication is
"fundamental to both the process of providing care, the team-based approach to person and
family-centered care and the efficient function of a hospice palliative care organization (p.
9).
At the system level, the findings indicate that one of the barriers to effective care
setting transitions is the disconnect between care settings. Research findings propose that
improving connectivity between care settings by way of effective communication embedded
in a standardized and multidisciplinary approach is likely to improve care setting transitions
(Chhabra et al., 2012; Coleman, 2003; Coleman & Fox, 2006; King et al., 2013; Kripalani et
al. , 2007; Rooney & Arbaje, 2013; Schoenborn et al., 2013). Nurse practitioners can improve
the connection between care settings for palliative patients with a number of interventions
that have been found effective.
At the outset, the palliative patient's NP or care team must be notified soon after the
patient is admitted or transferred (Schoenborn et al., 2013), allowing ample time for patient
care planning. Nurse practitioners can facilitate this process by providing direct contact
information (usually a telephone number) to all palliative patients, and by strongly
encouraging each patient to have the care setting contact his or her health care provider.
Since no one provider will be available at all times across the board, facilitating effective
communication between the accepting care setting and the patient' s care team will increase
the quality of the overall communication process required to improve care setting transitions.

53
Next, and perhaps the most important proposal at this level is the call for clinicians to
view communication between care settings as a two-way dialogue rather than the more
traditional one-way transfer of information (Kripalani et al., 2007). A two-way dialogue
between care settings opens the lines for further communication and connectivity. Open
dialogue can be achieved when NPs and other health care providers take the initiative to
build relationships with supporting health care providers through multidisciplinary
collaboration, either by way of telephone or in-person exchanges.
There is also a call for the standardization of information about patients that is being
communicated between care settings. The National Transitions of Care Coalition (2010b)
clearly sets out the minimum criteria that would be included in an effective transition record.
See Table 2. Variation across the province, in terms of care setting processes, and care
population characteristics, means that information pertaining to admission and discharge may
also vary. For this reason, all health care providers working with palliative patients should
have input into the patient information necessary to ensure patient safety and enable
practitioners to do their jobs correctly.
Finally, the findings emphasize that all practitioners must remember the value of
accurately and comprehensively relaying patient information to and from palliative care
settings. The most effective and timely way to relay information such as care plans, transition
records, and discharge summaries is through EMRs (National Transitions of Care Coalition,
2010b). Further discussion on the role NPs can play in facilitating more comprehensive
health information technology (HIT) will be addressed later in this discussion.
At the clinician level, the literature reviewed indicates that effective communication
amongst health care providers is crucial for ensuring that patients receive safe, high-quality

54
care. However, within most health care settings, effective communication is hampered by a
number of barriers. Discussions regarding patients are often conducted within a busy work
environment where providers are dealing with many patients and numerous tasks .
Instructions are sometimes communicated over the phone rather than in person, and often
this information has to be presented quickly. Many health care settings deal with this by way
of a using a common tool while communicating by phone-"Situation, Background,
Assessment and Recommendation" or SBAR (Canadian Foundation for Healthcare
Improvements, 2014). SBAR is a technique that allows providers to quickly and effectively
share pertinent patient information in a concise and structured format (Appendix G). SBAR
was originally used in health care for nurse to physician communication, but has more
recently been found to be beneficial for communication between all health care providers
(Canadian Foundation for Healthcare Improvements, 2014; Lenert, Sakaguchi, & Weir,
2014; Vardaman et al., 2012).
Another tool which clinicians can utilize to improve communication specific to
palliative patients is the Palliative Performance Scale (Appendix A). This scale is an 11-point
scale designed to measure patients' performance status in 10% decrements from 100%
(healthy) to 0% (death) based on five observable parameters: ambulation, ability to do
activities, self-care, food/fluid intake, and consciousness level (Victoria Hospice Society,
2006). The Palliative Performance Scale serves as a way for clinicians and multidisciplinary
health care teams to communicate with each other, as this scale can be used as a guide to
help in initiating and facilitating conversations about a palliative care or end-of-life care
transition.

55
The material reviewed also stresses that clinicians must remain accountable to the
palliative patient--even after transfer to a receiving care setting has occurred-until the next
provider has been made aware of the patient' s needs, and full care for the patient has been
assumed (Flora et al., 2012; Schoenborn et al. , 2013). Schoenborn et al. (2013) point out that
accountability can be achieved through shared patient care and improved clinician-toclinician communication. For this reason alone, it is important that clinicians shift their focus
from patient discharge to patient transfer. Improving HIT and using standardized patient
records at the system level will also improve communication at the clinician level.
In summary, NPs can implement the interventions necessary to improving
communication at the clinician level by using communication assistance tools such as SBAR
and the Palliative Performance Scale, by remaining accountable to patients during transfer,
by being attentive to standardizing patient information, and by making use of available HIT.
At the patient level, the fmdings indicate that effective NP-to-patient communication
is required for the provision of reasonable care setting transitions for palliative patients.
There are many steps NPs can take to improve communication with palliative patients. Slort
et al. (20 11 ), in their examination of palliative patient perspectives, outlined a number of
areas that patients identified as facilitators of primary care practitioners (PCP) and patient
communication in general. Their findings indicate that patients want the PCPs to be
accountable to the patient. Patient perception of PCP accountability was influenced by
factors such as home visits, being able to access the PCP by way of the telephone,
experiencing continuity in care, and feeling that the PCP had allotted adequate time. Slort et
al. also note that PCPs should practice active listening. This means encouraging patients to
express their emotions, allowing for silence during conversations, helping patients articulate

56
their concerns, and being sensitive to patient signals. Patients also identified honesty as
fundamental to effective communication with their PCPs: they indicated that PCPs need to
be open, honest, prepared to share, straightforward, friendly, respectful, empathetic, and to
able to treat each palliative patient like a person. Although many NPs already communicate
with these attributes, in an increasingly busy health care setting it remains important to be
mindful in the course of patient interactions.
The literature specific to care setting transitions identified the importance of
providing timely follow-up care. Rooney and Arbaje (2013) found that improved outcomes
were realized when patients discharged from a care setting were contacted by telephone
within 48 hours, during which a clinic visit would be arranged to take place, ideally within
two weeks from the date of discharge. In order to accomplish this kind of prompt connection,
NPs can ask office staff, for example medical office assistants, to contact discharged
palliative patients in order to schedule both the follow-up telephone calls and the clinic
appointments. In summary, effective communication at the system, clinician, and patient
levels leads to better care delivery decisions, a more effective plan for patient care, greater
patient and caregiver satisfaction, and less stress for everyone involved.
How NPs can Improve Collaboration
Multidisciplinary collaboration is more important than ever before given the diversity
of skilled medical practitioners and the increasingly specialized compartments within the
health care system. It became evident in the course of this review that collaboration at the
system, clinician, and patient levels is among the requirements necessary to improve care
setting transition processes for palliative patients. Although most NPs understand that
collaboration is invaluable in order to provide effective care setting transitions for palliative

57

patients, the ways in which collaboration can be facilitated might not be immediately
evident. Through formal education preparation and clinical practice as collaborators and
team members, NPs are both able to collaborate with other team members as well as take on
a leadership role within their clinical practice (Burgess & Purkins, 2010; CRNBC 2013a).
The following discussion will provide insight as to how NPs can improve collaboration at
each level.
The literature reviewed indicates that, at the system level, it is beneficial to organize
both a multidisciplinary discharge planning team as well as a palliative care team. This
would help ensure and improve patient safety and quality of care during care setting
transitions (DeMiglio & Williams, 2012). Many communities in BC have both discharge
planning teams and palliative care teams. Often these teams are composed of health care
providers specially trained in palliative care. Minimally, these would include nurse
practitioners, physicians, registered nurses, and social workers. To further improve care
setting transitions, PCPs can enter into a collaborative partnership with a palliative care team
(DeMiglio & Williams, 2012). For rural or remote BC communities that do not have a
sufficient complement of health care providers needed to form a palliative care team, Doctors
ofBC supports a provincial palliative care telephone line (BC Medical Journal, 2010). This
line, which NPs can access, is staffed by hospice palliative care physicians, and offers health
care providers advice about symptom management, psychological issues, or difficult end-oflife decision-making.
At the clinician level, care setting transitions could further benefit from collaboration
between NPs and clinicians at the accepting or discharging care settings. Nurse practitioner
visits to care settings, such as hospice, long-term care homes, and hospitals, will foster a

58
better understanding of the care and services these settings offer, as well as help the NPs to
understand the scope of other health care providers (Coleman & Fox, 2004). In order to be
effective, collaboration between health care providers must be knowledgeable and grounded
in a relationship of trust. Nurse practitioners can secure these relationships by being prepared
to learn more about their team members. When practitioners work to understand the specific
role they are better able to appreciate the specialized knowledge particular to each team
member, In this way a team achieves a level of confidence in one another's skills and
abilities, and trusting relationships are formed (Zillich, McDonough, Carter, & Doucette,
2004).

The patient level. Research indicates that there is also a need, at the patient level, for
PCPs and palliative patients and their caregivers to collaborate more effectively in order to
improve their care setting transitions. Much of the needed collaboration can be achieved by
way of shared decision-making. Slort et al. (20 11) identified a number of interventions that
would provide PCPs and patients with the opportunity to work collaboratively. These include
discussions concerning the meaning of the medical condition, how to choose an appropriate
method of care, negotiating palliative care options, deciding on treatment options together,
and the necessity of being proactive in general. Patient input into completing their
medication histories and assisting with medication reconciliation will promote an
improvement in care setting transitions (Kripalani et al. , 2007). Patient input has been shown
to be effective when discrepancies arise in a patient's medication regimen particularly when
their input is combined with outside resources such as pharmacists, PCPs, and other health
care providers (Kripalani et al. , 2007).

59
Collaboration between NPs and palliative patients has been shown to improve the
process of transition between care settings when collaboration includes patient-centered
advance care planning along with care setting transition planning. According to Council et al.
(2012) patient-centered care plans provide a tool to create "negotiated goals that incorporate
the values of the patient and the health care team into a mutually agreed upon explicit action
plan" (p. 191 ). A patient-centered care plan must ideally be goal-based, identify patient
strengths, and be continuously managed. Council et al. identified three integral components
to patient-centered care plans: medical summaries, patient snap shots, and goal directed
action plans developed by both the patient and the NP. Although there are challenges when it
comes to formulating and making use of patient-centered care plans-at both the clinician
and patient levels-there is strong evidence to support the proposition that there are
significant benefits to integrating care plans into care setting transitions (King et al., 2013 ;
Kripalani et al. , 2007). In summary, through collaboration at the system, clinician, and
patient levels, NPs can further remove barriers and facilitate effective care setting transitions
care for palliative patients.

How NPs can Improve Health Information Technology
Many of the improvements proposed for care setting transitions can be facilitated by
standardized HIT. For example, communication between care settings and health care
providers would be enhanced, continuity of care would be better maintained, timely access to
vital patient information such as care plans, discharge, and transitional summaries would be
significantly increased, and medication lists would be kept up to date more efficiently
(National Transitions of Care Coalition, 201 Ob). HIT improvements must take place at both
the system and clinician levels.

60
A consideration of solutions to government-related issues around HIT
implementation are beyond the scope of this project, it is nonetheless useful to summarize
the barriers to HIT implementation at the system level in order to highlight the larger issues
at play. At the system level, significant barriers to widespread HIT use are in place due to
both economic and structural factors. The economic requirements for implementing
widespread interconnected HIT are significant to say the least. Under the current information
sharing structure, HIT systems are characteristically fragmented, attempting with little
success to combine a multiplicity of EMR programs from multiple different providers (Kaye
et al. , 2010). Within BC, there are a number of different EMR vendors supplying systems
across and within health authorities. This proliferation of multiple vendors has created a
significant barrier to the potential for connectivity across EMR systems. In summary,
although HIT in Canada is far from adequate, Canada Health Infoway (2012) continues to
push for improvements in this area under the umbrella of federal funding.

How NPs Can Facilitate Adequate Medication Reconciliation
Inadequate medication reconciliation is known to create any number of adverse
patient outcomes. The literature review reveals a resounding collective call for adequate
medication reconciliation; improving on this is particularly important in care setting
transitions. Barriers that stand in the way of better NP implementation of medication
reconciliation include inadequate HIT at the system level, incomplete medication histories
and poor discharge reconciliation with preadmission medications at the clinician level, and
minimal patient or caregiver involvement at the patient level. The following discussion will
outline ways for NPs to improve medication reconciliation for transitional palliative patients
at each of the three levels.

61
First, at the system level, it is evident from the literature that, when improvements are
made in certain aspects ofHIT, the process of medication reconciliation is enhanced. Present
HIT allows providers to input information about current and discontinued medications, but
does not allow providers to compare medications or rectify discrepancies (Bassi, Lau, &
Bardal, 2010). Next, HIT should include interoperable EMRs that are accessible to clinicians
across all palliative care settings (Bayoumi, Howard, Holbrook, & Schabort, 2009). Finally,
effective HIT would require that prescribers be provided with secure access to patients' drug
plan profiles (Bayoumi et al. , 2009). As HIT expands, medication reconciliation will
continue to improve, and each of these interventions will contribute to better outcomes for
palliative patients during transitions.
At the clinician level, obtaining a complete and accurate medication history on each
palliative patient creates a foundation on which to build further medication reconciliation
(Kripalani et al., 2007). This is best accomplished using a multidisciplinary approach that
includes patients, caregivers, pharmacists, and other involved health care practitioners. This
approach will not only ensure that an accurate history is obtained, but will also help to
eliminate redundant work. Additionally, PCPs should perform a detailed in-home medication
review involving actual medication bottles, blister packs, vitamins, and other supplements
(Bayoumi et al. , 2009). While practitioner time constraints create a barrier to this
comprehensive approach, research shows that the education and skills possessed by
pharmacists make them ideal providers of accurate medication histories (Brown, Maack, &
Mehling, 2013). Accordingly, through PCP and pharmacist collaboration, accurate and
complete medication histories for palliative patients can be obtained (Kelly et al., 2013).
Ultimately, if the patient's NP or a pharmacist is not available, registered nurses or other care

62

team members knowledgeable about medications could compile an accurate medication
history.
In order to reconcile medications intended for administration between palliative
admissions and discharges, health care providers must ensure accurate and timely
communication of patient medications. This begins with proper documentation, which is
ideally accomplished through the use of standardized medication reconciliation forms, which
can be accessed through the National Transitions of Care Coalition and the American
Pharmacists Association. An example of a standardized medication reconciliation form can
be found in Appendix H. These forms must be updated with each mediation change and
provided to the patient, as well as to current and future health care providers, and to the
patient's PCP (American Pharmacists Association, 2012).
Finally at the patient level, it is important that NPs involve palliative patients (and
their caregivers) in their own medication management. Patients should also be encouraged to
use personal medication lists as well as contribute to an accurate medication history
(Bayoumi et al., 2009). Personal medication lists, in cases where patients or their caregivers
are able to manage them, provide an up-to-date record that patients can carry with them,
allowing them to share this important information with all health care providers in the course
of each care setting transition. Although some patients may be reluctant to make use of this
personal tool (or unable, in cases where illness has advanced), NPs nonetheless need to
convey to the patients and their caregivers the value of carrying an accurate medication list
through the continuum of care (American Pharmacists Association, 2012). An example of a
personal medication list can be found in Appendix I. In summary, the extent to which NP
practice is able to incorporate these strategies and interventions into their practice will

63
determine the degree of improvement in the reconciliation of medication. With
improvements in this area, some of the barriers currently standing in the way of effective
care setting transitions will be removed.

How NPs can Further Patient Education and Empowerment
As knowledgeable members of the health care community, and advocates for
improved patient outcomes, NPs, along with other health care providers, have the teaching
skills necessary to educate palliative patients and their caregivers. The findings underscore
the importance, at the patient level, of improving patient knowledge through specific
education initiatives, particularly in the areas of care setting transitions, medication
administration, and warning signs of worsening condition (Coleman et al., 2006). In order to
improve care setting transition processes, NPs are advised to encourage newly diagnosed
palliative patients to schedule a clinic appointment specifically to address care planning. This
kind of planning (which includes care setting transition planning) should take place prior to
any transition or admission, and is important for preparing palliative patients, their
caregivers, and their care team for these likely events. Care setting transition planning,
whether carried out by the NP, PCP, or another qualified health care provider familiar with
the patient, should be shared with the care team when completed.
While ongoing patient education is necessary, it is also important to remember that all
patient and caregiver education must be provided at a level and in a manner that maximizes
the patient understanding of the content, and is also appropriate to their needs, to the stage of
their palliative journey, and to their capacity to take it in (CRNBC, 2013a). These findings
indicate that it is important for NPs to recognize and take advantage of all opportunities to
tailor and improve the means by which they communicate appropriate and helpful health

64

information in order to improve care setting transitions for palliative patients. Having the
right knowledge allows patients and their caregivers to make informed decisions, it allows
them to understand the need for the care setting transfer, and understand the process by
which it occurs. This transfer of knowledge through education will work to maximize
effective care setting transitions.
Similarly, patient empowerment is closely connected to improved patient education.
Through education comes empowerment, and with empowerment comes self-care (Williams
& Sidandi, 2001). The literature as a whole recognizes that patients benefit by receiving

ongoing education from their health care providers. For example, Stajduhar et al. (2011)
found that empowered palliative patients and their caregivers experienced increased comfort,
felt more positive about their care experience, were less reliant on health care services, and
had the potential to remain at home longer. The goal of patient empowerment is to promote
independence, improve well-being, and increase patient satisfaction (Funk, Stajduhar, Purkis,
201 0). Since informal caregivers often assume responsibility for the care of a patient as
palliative status progresses, NPs need to empower both the palliative patients and their
caregivers. This review of research findings indicates that, when patients feel empowered in
the process of care setting transfers, their transitions felt less burdensome
In general, palliative patients and their caregivers identified education, preparation,
and reassurance as vital components of their sense of empowerment (Stajduhar et al., 2011 ).
The literature also identifies the empowering effects of education when PCPs share their
knowledge with a patient with respect to their disease, the expected progression of their
illness, ways to problem solve, important health care resources, and ways to navigate the
health care system. Studies also stress that PCPs should encourage patients to actively

65
participate in the formulation of care plans. Preparing patients and their caregivers by
engaging them in planning and decision-making is also seen as an important contributor to
patient empowerment. The implication is that providers must encourage patient and caregiver
participation at every step along the way. This can be accomplished by allowing time for
patients and caregivers to ask questions, weigh options, and express concerns. Funk et al.
(20 10) found that patients were reassured when PCPs advocate for the wishes of the patient,
ease their fears , provide guidance with respect to handling crises, and show respect for, and
acceptance of, patient and caregiver decisions.
When it comes to the care setting transitions for palliative patients, NPs need to go
beyond the general considerations that have been identified above as productive for
facilitating the empowerment of patient and caregivers. All palliative patients should be
encouraged to formulate a dynamic self-management personal health record in collaboration
with their PCPs because this record can also serve as a tool to promote independence and
ease the transition process (Coleman et al. , 2006). While a self-managed personal health
record may be too burdensome for some palliative patients to sustain, the task can be
extended to involve caregivers. Additionally, PCPs should provide palliative patients with
Transfer Checklists during their care setting transition planning session (Table 2). This
checklist will help patients or caregivers feel more prepared for the care setting transition.
Furthermore, patients also report that they feel a greater sense of empowerment when
they perceive a supportive attitude on the part of the NP. It has been shown that, when
patients and their family care givers have a sense of empowerment, there is an increase in
their self-care, which in turn has been shown to improve patient safety and satisfaction in the
process of care setting transitions . This highlights the need for NPs to continually promote

66
palliative patient empowerment. Nurse practitioners can further promote a sense of
empowerment by encouraging patients to ask questions, a process which has been shown to
improve medication accordance and accuracy, making action plans, and gathering patient
feedback (Lambert & Keogh, 2014).
It became evident in the course of this review that a multifaceted approach is required

in order to improve care setting transition processes for adult palliative patients.
Improvements need to be made at the system, clinician, and patient levels in order to better
enable NPs to provide effective care setting transitions. It is important to note that many of
the improvements must be made at the system level. It is also important to note that NPs
have the skills and education required to facilitate many of these improvements.
Recommendations
The overall purpose of this project was to identify recommendations with respect to
improving care setting transition processes for adult palliative patients that could be applied
to the practice ofNPs in BC. Although this review only uncovered one useful study-that
looked specifically at improving care setting transitions for palliative patients- by
integrating the findings of the literature that looked at the needs of palliative patients with the
literature that looked at improvements of care setting transitions this review has been able to
provide a solid link between care setting transitions and the palliative population. While
some of the findings do not specifically apply to the palliative population, there is enough
overall evidence to allow the formation of solid recommendations at the education, research,
and practice levels. Correspondingly, integrating the following recommendations for NPs has
the potential to remove barriers that stand in the way of care setting transition processes and
thereby improve the transitional experience for palliative patients.

67
Recommendations for Education

Nurse practitioners, along with all other PCPs, are expected to maintain clinical and
educational competencies. As part of the yearly renewal process for NPs through the
CRNBC, all NPs must complete a minimum of three personal development activities. These
activities can include attending educational forums or taking an academic credit course
(CRNBC, 2014c). The findings reviewed here recommend furthering education in the areas
of care setting transitions and cross-care setting collaboration. While it is often difficult for
practitioners to fmd time for further education, the National Transitions of Care Coalition
(2014) website provides quick reference tools to assist with care setting transitions.
Specifically, NPs should have the necessary training to be able to recognize the need
for care setting transition education in the palliative population. Primary care practitioners
must to be alert to the changing needs of their patients, aware of the appropriate times to
discuss death and dying; they must also be able to facilitate conversations about patient and
caregiver goals, values, and wishes. Much of this knowledge is acquired through clinical
experience. With proper training, education, and clinical experience, PCPs in general and
NPs in particular are more likely to have a positive impact on the care setting transition
processes for palliative patients.
Recommendations for Future Research

A greater understanding of the care setting transition processes as it applies to the
palliative patients is necessary in order to gain insight into the specific nature of palliative
care setting transitions. Research is needed to identify the specific patient information
necessary for palliative care plans and transitional summaries, as well as information that
would contribute to the development of standardized palliative transitional plans.

68

Performance indicators for effective palliative care transitions need to be developed and
implemented in order to evaluate which aspects of care contribute to furthering effective care
setting transitions. Additionally, a consideration of the cultural aspects involved in palliative
and end-of-life care is important; therefore, both international literature and further research
in North America would be useful to further recommendations with respect to Canada's
culturally diverse population. Further, care settings transitions can be improved with further
research into health information technologies that facilitate inter-institutional and interpractitioner communication and collaboration.
Studies on how best to encourage patients and caregivers to serve as integral
components in their multidisciplinary palliative care team are needed to help clinicians
empower patients and caregivers to take an active approach in their health care. As well,
research on how to best foster collaboration between clinicians, health care settings, and
patients or caregivers is needed to improve care setting transition processes at all levels.
Further, more research into the utilization of transitional care coaches could benefit palliative
patients and if this model is effective, sustainable, and cost effective.

Recommendations for Practice
As advances in health care are made, and patient needs become more complex, time
in the NP's workday becomes more limited. While there are numerous interventions that NPs
could implement into their practice in order to improve care setting transition processes for
adult palliative patients, the time required to do so may not fit with the realities of clinical
practice. The following recommendations (Table 3) identifies key ways in which NPs can
improve care setting transition processes for palliative patients that can be integrated into the
usual workflow of daily practice.

69

1.

2.
3.

4.

5.

Table 3 Recommendation for practice: Ways for nurse practitioners, as primary care
providers to improve the care setting transition processes for adult palliative patients
COMMUNICATION

Prepare patients to advocate for communication between accepting facility and care team
• Provide patients with contact information and processes to reach members of their care team
• Educate patient and caregivers on the importance of advocating for the accepting care facility to
inform their NP and care team of their care setting transfer
Use care plans and discharge or transfer summaries to share timely information between providers.

Ensure patients receive a telephone call within 48 hours of transition back to the community setting,
with an in-person appointment with the NP or appropriate team member within 1 week.
• Ensure that the NP/Team Medical Office Assistant schedules both the telephone and in-person
appointment, prior to or just after transition
Obtain a written and/or verbal patient discharge or transfer summary
• Request discharge information prior to patient discharge or transfer
• Locate discharge summary if is not received
Initiate and maintain two-way dialogue between NP/care team and current patient care setting

6.
7.

Utilize SBAR as needed for telephone interactions with care setting providers.
Utilize the Palliative Performance Scale as a way to help in initiating and facilitating conversations
about a palliative care or end-of-life care transition

1.

Use a multidisciplinary team-based approach
• Share and apply NP knowledge and skills related to collaboration and multidisciplinary care
• Learn the role of each team member, and those of providers caring for patient in other settings
• Ensure processes are in place to clarify provider accountability during care setting transitions
• Utilize team based approach to share care and workload related to patient care setting transitions
• Use two-way dialogue, when collaborating with other care providers

1.

Ensure all pertinent patient information is kept up-to-date in the EMRs, when available, and or written
records and within personal patient tools
• Documentation in the EMR to be completed by all team members after each patient interaction
• Utilize Subsequent Patient Interactions Checklist (Appendix J)

2.

Advocate for EMR use and HIT improvements in one's own .iurisdiction

1.

Obtain and maintain an accurate and comprehensive medication history
• Collaborate with a pharmacists when required
• Utilize Subsequent Patient Interactions Checklist (Appendix J)
• All care team members and caregivers to update medication list during each visit.
Assist patient/caregiver to utilize personal medication list

2.
1.

2.

COLLABORATION

HEALTH INFORMATION TECHNOLOGY

MEDICATION RECONCILIATION

PATIENT AND CAREGIVER EDUCATION AND EMPOWERMENT

Include care planning, including care setting transition planning as part of the education and care for
each newly diagnosed palliative patient
• Schedule a care planning appointment for all newly diagnosed palliative patients
• Utilize Care Planning Checklist for Care SettingTransitions (Appendix K)
Provide education at a level and in a manner that maximizes understanding of the content provided,
and is appropriate to their needs, stage of their palliative journey, and capacity

70

The above table summarizes the areas of improvement needed with respect to
communication, collaboration, health information technology, medication reconciliation, and
patient/caregiver education and empowerment. A Care Planning Checklist for Care Setting
Transitions (Appendix K) and a Subsequent Patient Interaction Checklist (Appendix J) were
developed as tools to be utilized by care teams in an attempt to save practitioner time and
ensure all important elements of the care setting transition process are addressed.
Additionally, an example of a standardized medication reconciliation form is included in
Appendix H and an example of a personal medication record is included in Appendix I.
In the beginning of this paper I recalled personal feelings associated with my
experiences as a registered nurse with respect to ineffective care setting transitions for
palliative patients. Through the implementation of these recommendations for practice, it is
my hope that all health care providers, and specifically NPs, can effectively address issues
related to transition processes when transitioning palliative patients between care settings.
Specifically, difficulty tracking down missing information from hospital discharge
summaries, or the untimely transfer of this information, can be improved through utilizing a
multidisciplinary team based approach to collaboration, ensuring written or verbal patient
discharge or transfer summaries are obtained, maintaining a two-way dialogue between
practitioners, and ensuring all pertinent patient information is kept up-to-date in the EMRs or
written records .
Next, health care providers can have improved communication with the patient' s NP
or care team if patients are better prepared to advocate for this communication between the
accepting facility and the care team, and if a two-way dialogue between the NP or care team
and the current patient care setting is initiated early after transfer and maintained throughout

71
the patient's stay. Medication reconciliation can be improved through health care providers
obtaining and maintaining a comprehensive and accurate medication history, assisting
patients to utilized personal medication lists, and ensuring patients receive a follow-up
telephone call within 48 hours of transition back to the community setting.
Finally, speaking with patients and caregivers about their needs and wishes is seen as
a way to improve patient education and empowerment. Patients need to be involved with
their palliative care planning, care setting transition planning, and personal care plan
formulation. The education provided must be at the level and in a manner that maximizes the
patient's understanding. As well, patients and their caregivers will feel empowered through
the utilization of their personal medication record and personal health record. Adopting the
process changes recommended will improve the quality of palliative care setting transitions
and provide NPs as PCP the efficiencies to better provide care to this patient population.
Conclusion

Transitions between care settings for palliative patients are often burdensome and
troubling for both patients and caregivers. As palliative illness progresses, the number of
transfers between care settings often increases. This integrated literature review has
examined how NPs can facilitate effective care setting transitions for adult palliative patients.
A comprehensive literature search was conducted using electronic databases, pertinent
journals, references lists, and guidelines. As a result, 16 publications were selected for
revtew.
The publications were critically analyzed for their strengths, limitations, relevance,
and potential contributions to improving care setting transition processes in the context of
palliative care. The key findings were grouped under the system, clinician, and patient levels.

72
Specifically, improvements needed within the health care delivery system have been
identified, including connecting care settings by way of improved communication strategies,
improved and timely delivery of care plans and discharge or transition summaries, effective
medication reconciliation, and adequate health information technology. At the clinician level,
improvements are needed in terms of caregiver continuity, clinician and patient
communication, and clinician training in care setting transitions and cross-site collaboration.
Finally, improvements at the patient level aimed at improving the process of transitions
between care settings involved contributions from clinicians, and included improving patient
and caregiver education and encouraging patient empowerment.
The most pertinent recommendations for NP practice have been made in the areas of
communication, collaboration, medication reconciliation, health information technology, and
patient and caregiver education and empowerment. It is the hope of the writer that, with
implementation of the practice recommendations, NPs will be better able to utilize their time
effectively in the preparation for, and management of care setting transitions of palliative
patients.
This review also identified important gaps in the literature with respect to effective
care setting transitions specific to palliative patients. For this reason, recommendations for
future research include improving care setting transitions specifically for palliative patients,
creating performance indicators to identify effective transitions, and further incorporating
patients and caregivers into the transitional process. As well, recommendations for education
are based on the identified barrier of insufficient clinician knowledge about care setting
transitions and collaborative practice.

73
In conclusion, this integrative review identifies current barriers and proposes

facilitators of effective care setting transition processes for palliative patients. This project
adds to the current literature on improving care setting transitions by focusing on the role of
NPs as PCPs. Most important, this project identifies specific practice strategies that can be
implemented by NPs and other PCPs in order to further facilitate effective care setting
transition processes for adult palliative patients.

74

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Health Information and Quality Authority. (2013). National standard for patient discharge
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Jessup, R. L. (2007). Interdisciplinary versus multidisciplinary care teams: Do we understand
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Kaye, R., Kokia, E., Shaler, V., Idar, D., Chinitz, D. (2010). Barriers and success factors in
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78

Kelly, D. V., Bishop, L., Young, S., Hawboldt, J., Philips, L., Keough, T. M. (2013).
Pharmacist and physician views on collaborative practice: Findings from the
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Pharmacotherapy, 38, 764-770.

81
Appendix A
Palliative Performance Scale (PPSv2) Version 2
(Victoria Hosp ice Society, 2006)

Palliative Performance Scale (PPSv2) version 2

Instru ctions for Use of PPS (eee a lao defi nition of terms)
1.

PPS scclf8s are de! ermined by raadmg horizootally at each level to find a 'best fit' for the patient which Is then IS!l19J1ed as !he PPS"-'o $COI'8.

2.

Begin at the lefl column and reacl downwards unlil the appropriate ambulation level is reached , the n read acros s to the next column and downwards again until the activityfevidcnce of disease is located. These
steps ate repeated until ill lin columns are cov"'"ed before assigning the actual PPS for that patient. In this WI'J, 'leftward' columns (columns to the left of any spedtic oolumn) are ·stronger' determinants and
generally take preoedcnce over others.
Example 1: A patient who spends the majority ol the day sitling or lying down due to la1igue from advanced disease and requires oonsidefable assis1ance to walk even for shari dis1af'I001; bu1 who is
othef'wise fully conscious level with good intake would be scored at PPS 50%.
Example 2: A patient who tlas become paralyzed and quadriplegic requ iring kllal care would be PPS 30%. AllttOYgh this patierd may be plaoed irl a wheelchair (and perhaps seem initially kl be alSO%),
the score ls 30% because he or she would be otherwise lotally bed bound due to the disease or complication lf it were nollor caregivers providing lotal care Including JiMransfer. The patient may have
normal in1ake and NJI conscious level.
Eltample 3: However, iflhe patient in eumple 2 was parapleg ic and bed bound bts1 still able to do some sell·care such as ~ themselves , then the PPS would be higher at 40 o

15 not ·totaJ e~~ e.

~ since he or she

3.

PPS se::orM are ln tO% iocrements ooty. Sometimes. there llfe several columns eaSily placed at one level but one or two ......,.wen seem bettat at a higher or lower level. One !hen neetk to make a ·bMtlil'
deci5ion. Choosing a 'haM-lit' value of PPS 45•.t.. lor example. is nol oorrect. The eombinatton of dinical
d m ~land 'leltwllfd precedence ' is used 10 det&rmlf1e whether 4()-.4 or 50-.4 is the more accurate score

4.

PPS may be used for several purposes. First. it i5 an e)(oellent oommunication tool lor quickly describing a patient's current function•l level. Second, it may have value in criteria lor wcxkload assessment or

lor !hat patient.

oiher meawrements and comparisons . Finally, it apPears to have prognostic value .

82

Appendix B
Overall Search Strategy

ELECTRONIC DATABASES SEARCHED:
• CINAHL
• MEDLINE Ovid
• PsyciNFO
Cochrane Reviews
• Social Work Abstracts

.
..•
.

JOURNALS SEARCHED
Palliative Medicine
Journal of Palliative Medicine
Journal of Palliative Care
Generations: Journal of
American Society on Aging
BCM Palliative Care
• Journal of American Geriatrics
Society
N=18

.

STAGE 1
NUMBER
EXCLUDED~

N=172

'-

All results from electronic databases
screened by title, and potentially relevant
articles were identified based on inclusion
and exclusion criteria.
N=IOO

/"

NUMBER
EXCLUDED

"-

N=56

STAGE 2

-

..4

'--

..1

~

The abstracts of the remaining database
articles were screened

.,_,

/

N=67

GOOGLESCHOLAR
N=O

f

'

...

REFERENCE LISTS

.,,.

~

..1

'

N=S

,,
STAGE 3
NUMBER
EXCLUDED
N=53
\...

,.>
./

All potential articles in step 2 re-read in
detail for appropriateness.

\ ..

GUIDELINES
The National Transitions of
Care Coalition
N=2

~

~

N=l6
_.J

\..

_.J

83

Appendix C
Results Obtained From the Databases Searched
"<:t

........
0

N
(")

o-2
l ~

z ..
-~
C.lf-;

.... <t:

SEARCH TERMS

[Hospice Care OR
Palliative care OR
Terminal Care OR Endof-life care]
AND
[Care transition* OR
Patient transfer* OR
Transfer, discharge OR
Care setting transition]
Transitional programs
AND Care transition*
Transitions between care
settings
Care transition*
TOTALS
TOTAL: After duplicates
removed
DATA BASES TOTAL:

~

85

114

6

46

0

0

12

17
Used above

0
33

6
Used above

0

131

39

25

8

80

31

15

7

Used
above
143
139
346

After DUPLICATES
272
removed
Kept after reading
100
TITLE:
Kept from ABSTRACTS : 45

18

6

0

2

-

-----

Author, Date,
&
Country
Cawthon et al.
(2012)
USA
Male and
female, mostly
Caucasian,
median age of
63 who were
within 30 days
of previously
participating in
the PILL-CVD
study

VI
Qualitative
Telephone
surveys

-- - · -

Population

Level of
Evidence
The participants'
assessment of
different
components of the
previously done
RTC to reduce
medication error
with care setting
transitions

Focus of Study

- - -

----

125 Survey
participants

Sample

.

Findings of feeling
comfortable with
discussing medication
with out patient providers
was increased across
patients with both low
and high health literacy

Strengths

.
.
.

•

dis

lla

~

Relatively small sample
SIZe
Excluded all patients who
did not manage own
medications
Limited health literacy of
sample was already lower
than national average
Study did not adjust for
which pharmacist provided
the intervention, how long
the counseling sessions
were, or is the pharmacist
contacted patient after

Limitations

The level of evidence indicates the study design used by the investigators to assess the effectiveness of an intervention, and
reflects the degree to which bias has been eliminated by the study design (National Health and Medical Research Council , 2000). The
following table of evidence was used with the different levels outlined below (LoBiondo-Wood, Haber, Cameron, & Singh, 2013).
Level I: Systematic review or meta-analysis of randomized controlled trials (RCTs), evidence informed clinical practice
guidelines based on systematic reviews
Level II: A well-designed RCT
Level III: A controlled trial without randomization (quasi-experimental study)
Level IV: Single non-experimental studies, case-control, correlational, cohort studies
Level V: Systematic reviews of descriptive and qualitative studies
Level VI: Single descriptive or qualitative studies
Level VII: Opinion of expert authorities or reports of expert committees

Table of Evidence

AppendixD

84

VII
Opinion of
expert
authorities

VII
Opinion of
expert
authorities

II
RCT

Coleman &
Fox (2004)
USA

Coleman,
Parry,
Chalmers, &
Min (2006)
USA

review of
qualitative
studies

Level of
Evidence

Coleman
(2003)
USA

Country

&

Author, Date,

Hospitalized
patients 65
years or older,
with l of ll
selected chronic
diseases, and
originally from
a community
dwelling

Practitioners
caring for
patients during
care transitions

databases
between 19502010, reference
lists, and an
Agency for
Healthcare
Research
website
Persons with
continual
complex care
needs being
transitioned
between care
settings

Population

Randomized to
either usual care or
to receive care
transition
interventions

Recommendations
for practitioners on
how to improve
care transitions for
patients

Identify the
problems with
transitions,
manifestations of
poor transitions,
barriers to effective
transitions, and
elements for
effective transitions

reconciliation
interventions in
patients transferred
to and from longterm care settings

Focus of Study

750 subjects

Not defined

Not defined

Sample

.
.

•

.

•

.

•

.
.
.
.

.

•

Interventions and
methods are clearly stated
Study was conducted in a
clinical setting
Inclusion and exclusion
criteria relevant and
clearly stated
Research assistants were
blinded

Peer reviewed journal
article
Author is an expert in the
field of transitional care
Provides solid, referenced
barriers and solutions to
transitional care
Discusses possible needs
for future research
Included over l 00
academic recourses
Authors are experts in the
field of improving
transitional care
Recommendations are
consistent with those
found in other literature

Systematic and thorough
literature search
performed in duplicate by
multiple authors
Review compared
publications both in and
out of the USA

Strengths

..•

.
.

•

•

-

Potential citation bias
Potential interpretation bias
Very few references cited
as this is more of an
opinion piece
Many recommendations set
forth with little outside
referencing
Study participants were not
blinded
Difficult to know if the
interventions were applied
equally to all participants
Unsure if the results could
be sustained over time

This is not a study
Subject to citation bias
Subject to opinion bias

.

..
.

Results could not be pooled
across studies because of
the differences of outcomes
considered in each
Possible studies were
missed during inclusion and
exclusion phase

.

Limitations

85

Level of
Evidence

VII
Opinion of
expert
authorities

VI
Qualitative
In-depth
interviews
and
thematic
analysis

VI
Qualitative
usmg
grounded
dimension
al analysis,
focus
groups,
and indepth
interviews

Flora, Parsons,
& Slattum
(2011)
USA

Hanratty et al.
(2012) England

King et al.
(2013)
USA

Country

&

Author, Date,

Older adults
begin
transferred
between care
settings
Patients
between 69 to
93 years old,
who moved
between at least
two care
settings in the
last three
months, and
who were
thought to be in
their last year of
life
Registered
nurses
representing
five skilled
nursing
facilities,
recruited
through staff
meetings, onsite flyers , and
e-mail

Population

Examine how
skilled nursing
facility nurses
transition the care
of individuals
admitted from
hospitals, the
barriers they
experience, and the
outcomes
associated with
variation in the
quality of
transitions

How to better
manage
medications to
improve care
transitions
To explore older
adults' experiences
as they move
between places of
care at the end of
life, diagnosed with
either lung cancer,
heart failure, or
stroke

Focus of Study

27 registered
nurses

30 patients

Not defined

Sample

•

.
.
.

•

•

•

•

Appropriate method was
used for the type of data
collected
Analysis to collected data
progressed through all
three stages
Analysis also occurred
during the interviews to
facilitate ongoing
constant comparative
analysis
Strategies used to
maintain rigor and ensure
accuracy included the use
of multidisciplinary

The finding of reduction
in hospital rates is
comparable to results
found in previous studies
References cited include
pertinent studies and
influential articles from
expert authors in
transitional care
Despite the use of patients
with different disease
trajectories, the themes
that emerged were still
common to all conditions
included
Results showed little or
no variation with
socioeconomic status,
thus data is relevant
beyond the older adults
interviewed

Strengths

.

•

•

•

•

•

.

..

The hospitals used may no
be representative of all
hospitals nationwide
Did not include for-profit
nursing homes since
negative outcomes
described by nurses in these
homes may be exaggerated
since they have lower
staffing ratios
No demographic
information was collected
on participating nurses
Examined only transitions
to skilled nursing facilities

Participants were identified
from a range of health
professionals leading to
variation on the application
of criteria
Disproportionate number of
interviewees were from
disadvantaged areas
Patients with lung cancer
had fewer inpatient
episodes

Potential citation bias
Potential interpretation bias

Limitations

86

Literature
search of 3
academic
databases up to
June 2008 ,
reference lists,
and suggestions
by experts in
geriatrics

v

Systematic
literature
review of
qualitative
studies

VII
Report
from
expert
committee

LaMantia,
Scheune-mann,
Viera, BusbyWhitehead, &
Hanson (2010)
USA

National
Transitions of
Care Coalition
(2010a)
USA
Recommendatio
ns aimed at
health care
providers and
established for
improved

Adult patients
following
discharge from
hospital

VII
Opinion of
expert
authorities

Kripalani,
Jackson,
Schnipper, &
Coleman
(2007)
USA

Population

Level of
Evidence

Author, Date,
&
Country

Identify and
evaluate
interventions to
improve
communication of
accurate and
appropriate
medication lists and
advanced directives
for transitions
between nursing
homes and hospitals
Improving care
transitions through
communication,
medication
reconciliation, care
coordination, and

Reviews challenges
to providing highquality care as
patients leave the
hospital

Focus of Study

Not defined

5 articles

Not defined

Sample

.

•

.
.

•

•

•

.

Collaboratively compiled
with the input of health
care professionals,
academics, organizations,
councils, and research

Peer reviewed journal
article
Authors are experts in the
field of transitional care
Provides solid, referenced
barriers and solutions to
transitional care
Analyzes the included
literature well
Included over I 00
academic references
Search strategy was
developed in assistance
with the assistance of a
research librarian
Did not include pertinent
journals in their search
strategy

research team, member
checking, and
maintenance of memos

Strengths

.

•
•

•

.
.

•

..

.

This is not a study
Subject to citation bias
Subject to opinion bias

English only literature was
used
The interventions in the
included studies were
performed in varying health
care settings and with
limited sample sizes
The sustainability of the
results and effectiveness of
the interventions found in
the studies is unclear

so findings cannot be
generalized to other settings
No direct participant
observation took place, so
there is no certainty about
how often nurses encounter
deficiency in quality
information transferred
This is not a study
Subject to citation bias
Subject to opinion bias

Limitations

87

VII
Report
from
expert
committee

VI
Qualitative
descriptive
design:
openended,
semistructured
telephone
interview
format
VII
Opinion of
expert
authorities

VI
Qualitative
: semistructured
interviews

National
Transitions of
Care Coalition
(2010b)
USA

Parry, Kramer,
& Coleman
(2006)
USA

Schoenborn,
Arbaje,
Eubank,
Maynor, &
Carrese (2013)
USA

Rooney &
Arbaje (2013)
USA

Level of
Evidence

Author, Date,
&
Country

Physicians,
home health
care
administrative
and field staff,
social workers,
nurse
practitioners,
physician
assistances, and

Recommendatio
ns aimed at
health care
providers and
established for
improved
patient care
Aged 60 or
older with one
or more chronic
diseases, who
were
hospitalized,
and who
participated in
The Care
Transition
Intervention
Older adults
transitioning
between care
settings

patient care

Population

A need to look
beyond the medical
model of care to
changing the
culture of practice
to support care
transitions
To identify the
perceived roles and
responsibilities of
clinicians during
care transitions of
older adults

Explored patients '
experiences with
coaching
intervention that
provided patients
with support tools
to enhance selfmanagement during
care transitions

performance
measures
Using health
information
technology to
improve transitions
of care

Focus of Study

40 health
care
professionals

Not defined

32
participants

Not defined

Sample

.
.

•

•

•

.

•

Equal interview length
was used for each
participant
Saturation was reached
for the findings presented

Peer reviewed journal
article
Provides solid, referenced
barriers and solutions to
transitional care

Purposeful sampling to
contain equal proportions
of gender and eligible
diagnoses
All interviews were equal
length and audio recorded

Collaboratively compiled
with the input of health
care professionals,
academics, organizations,
councils, and research

Strengths

.

.

..
.

•

•

•

..

Study was conducted in one
metropolitan area and
might not represent
transition experiences
elsewhere
The interviews were done
in 2005/2006 and might not
reflect potential changes
since

This is not a study
Subject to citation bias
Subject to opinion bias

Limits in validity and
generalizability include
small sample size, social
desirability effects, and the
relatively high education
level of the population
perhaps further enhancing
the self-management aspect

This is not a study
Subject to citation bias
Subject to opinion bias

Limitations

88

Author, Date,
&
Country

Level of
Evidence
hospital case
manager
different
community and
hospital based
fac ilities

Population

Focus of Study

Sample

Strengths

Limitations

89

•
•
•
•
•

•

•
•
•
•
•

Principal diagnosis and problem list
Medication list, including over the counter/herbal, allergies, and drug interactions
Clear identification of medical home/coordinating physician and contact information
Patient's cognitive status
Test results/pending results and normal value ranges and explanation for patients
Emergency plan and contact number and person
Treatment and diagnostic plan
Prognosis and goals of care
Advanced directives, power of attorney, consent
Planned interventions, durable medical equipment, wound care, etc .
Assessment of family caregiver status

Elements of an Ideal Transition Record
(National Transitions of Care Coalition, 201 Ob)

Appendix E

90

Contact Information
• Discharging unit and telephone numbers
• Attending doctor and telephone number
• Other providers who will manage specific conditions
• Registered nurse who cared for individual and telephone
number
• Spouse or partner and telephone number
• Family member(s) involved in care and telephone number
• Power of attorney, if activated, and telephone number
Past Medical History and Hospital Stay
• Remarkable medical history
• Remarkable events during hospital stay
• Comorbidities
• Code status
Medications
• Discharge medication list
o Drug names
o Dose
o Diagnosis and rationale for every medication
o Start and stop dates and last dose administered
• Opioid prescriptions
• Significant medication changes
o Change in psychiatric medications during stay
o Change in opioid medications at discharge
o Withdrawal of medications because of side effects

Allergies and Intolerances
• Medications
• Food
• Latex
Functional Status
• Ability to perform and assistance required activities of
daily living
• Sensory aids
• Mobility status
o Level of assistance needed
o Equipment requirements
o Fall risk
Psychosocial and Behavioral Concerns
• Personal interests/communication preferences
• Cognitive status
• Behavioral symptoms related to dementia
Treatments
• Wound care
• Peripherally inserted central catheter line care
Elimination status
• Bowel or bladder incontinence
• Use of indwelling catheter and if and when it was
discontinued
Nutritional status
• Swallowing of feeding concerns
• Appetite

Hospital Discharge Information that Skilled Nursing Facility Nurses Need
to Develop and Implement a Safe Plan of Care
(King eta!., 2013)

Appendix F

91

A: Assessment
R: Recommendation

S: Situation
B: Background

Briefly state the situation in 5-l 0 seconds
Identify the factors leading up to the current situation (pertinent history
and objective data)
State what you think the problem is (include severity)
State what you think needs to be done for the patient (include timeframel

SBAR: Tool for Effective Communication Between Health Care Professionals
(Canadian Foundation for Healthcare Improvement, 2014)

Appendix G

92

~

.~.m

flt .

f. f . .n

Patient/caregiver

Interviewer

Patient/caregiver

Other elements for consideration
Primary Ian !Uage
Demob'Taphic
Patient/caregiver
Religious, cultural factors
Medications
Prescriber
Compliance level
Medical history
Known medical
condit ions
Primary health care provider
NPI#
--- -------

medications

Other
medications/OTC/herbal
remedies/nutritional
supplements/time-limited

Medications (active, taken
chron ically)

Allergies/intolerances
Date of assessment
Name - generic/trade
Dose
Form
Frequency
Reason for use
Name - generic/trade
Dose
Form
Frequency

contact information

status

Patient/caregiver

----

knowledge of complete
medication list, cognitive

medication list, cognitive
status

Patient/caregiver
knowledge of complete

patient

--

----- - - - -

To be able to identify conditions that may not be
treated

Variety of methods to provide info on compliance

Stop dates for short term medications

-- -

May also include time of transport of info
NDC will be used in automated systems - name + dose

ASSESSMENT ON ACCESS TO CARE SETTING (E.G HOSPITAL ADMISSION NURSING HOME ADMISSION)
Category
Source(s)
Barrier(s)
Element
Comments
Demographic
Name
Patient/caregiver
Cognitive status
Universally available unique identifier information
Date of birth
ID Number
Gender
Contact information
Caregiver name and
Caregiver
Caregiver knowledge of

Suggested Common/Essential Data Elements for Medication Reconciliation

t

®

A-pp-eumx""n
Suggested/Common Essential Data Elements for Medication Reconciliation
(National Transitions of Care Coalition, 2008)

93

physicians orders,
universal order
sheet

Patient/caregiver

Name - generic/trade
Dose
Form
Frequency
Reason for use
Expected duration of use
(chronic, time limited)

Abi lity to self medicate

Medications (to be continued
at home, in long term care
facility, etc.)

Validation
Name/date/signature

A llergics/intolerances
Health care
provider, other

Poor coordination of
transfer, provider/other not
avai lable to validate

communication among care
providers

Incomplete documents,
missing information, poor

MAR, health care

Barrier(s)
Patient/caregiver lack of
knowledge regarding, or
difficulty navigating,
benefit plans or programs,
lack of patient/caregiver
financial resources, gaps
in pub Iic and
manufacturers
pharmaceutical assistance

setting personnel ,

ASSESSMENT/RECONCILIATION ON TRANSFER OF CARE

Source(s)
Patient/caregiver,
health care setting
personnel

Element
Prescription benefits,
out-of-pocket costs,
public and manufacturers'
pharmaceutical assistance
programs,
patient/caregiver access
to pharmacy (e.g., in rural
areas or in neighborhoods
where pharmacies won ' t
carry certain drugs, such
as pain medications)

Category
Patient access to medications

information on subsequent access to care. For home

Person taking responsibility for accuracy of list on
transfer and conm10nication with patient and caregivers

Assign specified duration of use as appropriate for
selected medication (e.g., end date, number of days).
Examples include high risk medications such as
anticoagulants following surgery, antibiotics, and
steroids
Patient/caregiver should be able to reconcile new
medication list with previous list ifselfmedicating at
home

enhance adherence.

care or other self care setting, should include a plan to

Transfer information can serve as admission

Comments
To ensure patients will be able to obtain prescribed
medications.

94

Person/department

Patient/caregiver or
health care
personnel
Health care
provider, other

Source(s)
Health care
provider

Barrier(s)
Time to provide
information, gather
documents
Patient/caregiver/health care
setting personnel lack of
knowledge
Poor coordination of transfer
Who to contact in the previous health care setting
regarding medication issues

To ensure patient will be able to obtain medications
prescribed on transfer

Comments
Could be provided in portable document tile, printed
documents
I

I

Note. From "Improving Transitions of Care: The Vision of the National Transitions of Care Coalition," by National
Transitions of Care Coalition, 2008, Appendix A. Copyright 2008, by NTOCC. Reprinted with permission from the
National Transitions of Care Coalition, 750 First St, NE Suite 700, Washington DC 20002, www.ntocc.org

Rev. 4/ 17/08

Some important questions to consider with implementation of a medication reconciliation program are:
I . How is the information transferred or "harmonized" within the permanent medication record?
2. Who is responsible for signing off on the reconciliation tool?
3. Who is responsible to close the list and pass this document on to the next provider?
4. How is a provider reimbursed for completing this medication reconciliation form?
5. How is the information from the medication reconciliation tool at the provider's level to be transferred to the patient' s personal medication list?

NTOCC reali zes that health care systems vary in their method of data collection, access, and communication . This list of essential data elements is an attempt to
provide a list of variables one should commonly and routinely consider when an individual is entering and leaving a different system or level of health care. Other
elements are also offered for completeness when the resources and technology are available to complete the medication record.

Point of contact

Other elements for consideration
Category
Element
Medications
Reason for use
Monitoring parameters,
frequency
Patient access to medications
Payer or other source

95

Li!;r" Ci"111 help you and yo ur farnily kl'CP f~ll..

or ('Vt.•ryd tittA

Next, think abmu what you t.akt' in t ~ nomin~. afH:rnoon, around
dintwr tim.: , ;:UlJ bdon· you go to ~lt. d .

m~ Sllfl' lO

Wh t'fH'Vet

pd~te '' My Med icine U.st"' .

Y<'ll stop mking something or start tak ing som!!llting new,

t ~

,•• :;;;!.'"".,.;:;...."".::!. ~nofi

~~

t<;

and thr> ASHr Jk<.r.ueh and F.d11(11tion Foundatmn thmug.h il spunsor.-.hlp Irom
t nll i LIS. LI.L 10/1007

.?:j \1r \ltt>dknw l.1<;t "m"' dt. ~ pecl by th.: ·"-m<'Jicm Sock1y of llelll ~ i it m Ph:mn:u.:i ...

8. If you havr any questions ahout your nwdi dnes. t:onUl<'l your doctor
ur rharm ..,cisl.

7 . When you: go Sl'l' tht• doctor, your p ~ macist . a
~ te~n. or havt• to
go Lo t lw lw.:;pital <Yr ('mt•rgt-n<'Y room., t.ake this form with y<nl.

6.

5. Alway!>. keep t i~ c..ud with you. Fold it n11d keep it in your wallet or
purse. so you '\viii have ir iu ca. i~o of an emergency.

Zoti)r, Sirw..u_.;1ulin, 40 mg

Drug nllnu:
:bra'!d >l:tmr. xn1ntc 11amt'. ,/Mt;)

Hrn 'o; an t:xUnl('lc:

4 . for every mt~didm (including om~s yon ~ l without :.:1 p ~~~c ipt.ion .
vitamin or hnh you ta ~ you rwt·d to write down th e ...::t· things:
• 1\w narrw of what. yo u t.akt:" ( like Ty le nol, 1\<..::t:LarninPphen 500 rnA)
• How much y~ t.'lke of thi'> ( I pilL 3 drops, 2 purL!")
• Wh:.H it look'> likt· (round, whitt: ~nd reel , clt·ar liquid)
• How you take it (hy mouth. with food, with a needlt')
• You sta rted ta in~ this on: (Sep t. 15 , 2007)
• You will stop taking th is on: (Se.pt. 30. 2007)
• Why you take it (fo r 111}' arthri tis., for my heart. to lown cholestero l)
• Who told mt to uo;c il (my intnn ist. my rheurnatolop,ist.)

~

Lhis phone nttmht> r:

Birth date:

- - - - - - - - - E-mai l: - -- - - - - - - -

U pda ted on:

U.<e l.hc guide on rh c back l.o fill our
My Metliciue .list

'\:

Upda1<'d by:

. m~~.li. t~.t i

Questions for my doctor or pharmacist:

Reviewed by: I Reviewed on :

with your d<>cwr. pharmacist. nurse. or othe.r health care professionaL

lwlow 10 rrvi cw and updat r y<1ur " l\.1y Medici ne List '". You ra n do Lhis

1t is very important to krrp this infonTtation current . Use the c han

Keeping My Medicine List up-to-date:

l also have some other problems with medicines:

lam allergic to:

on~

~ besl way to get i.n rouclr with m~~ emergency co11tact i:>:

Fmerg('nry co nt act ~ ..

this e-mail:

If you ne ~ i to get in wuch with mt~. tLo;c;

Name:

1. W ith hdp from yonr hrahhL'art· pn)fr!':;,,c;i..)nal. fill out the form .

io l~ tcxh"'y!

This medicine list is for:

2¥ In urdn to fill out the fur111. you nntl a li:-tt of all ol your mctlicim·-, or
t t ytllin~ you t~ e in ln>lll uf you. Bt: ~ c y(lu iru.:lude m<:"clicinl' you
t~ c !rom aH pharmacks that you ll~ a"' w(.·ll a5 any ov(.·r-the-c0ullttr
med icine-s , itmnin~. hnb-5 or mine-rals you may t~ t ..

t~l l using "My ~. dtc. im

<.lr ot!lt.'r hc.ahh c.:nrc wvrk..-rs t.akt> IK::tt«.>r car..: of you .

you take to kt•ep }'(lU lu·althy-your pi11!'>. \'itamins. and h erbs. 1-hwing ~~
of )'OUr n . d i ci n~.o in Ollt plac.t al-.o lwlp~ your do cLor, phannadsL. hospital.

"My t~di ill

How to use My Medicine List:

AlJpeuu..:x-r

Personal Medication Record
(National Transitions ofCare Coalition, 2008)
96

Before ! go to bed, I take:

the evening, I take:

I

How
numyl

I

How !wh it

I

I

I

I s to p
I stt~ned
t11ki ng this on: taking this o n:

W hy lt" kc n

I

\\'ho told me
IO take it

Note. From "Improving Transitions of Care: The Vision of the National Transitions of Care Coalition," by National
Transitions of Care Coalition, 2008, Appendix B. Copyright 2008, by NTOCC. Reprinted with permission from the
National Transitions of Care Coalition, 750 First St, NE Suite 700, Washington DC 20002, www.ntocc.org

I

Other medicines that I do not U$e every dav:
----

I

Thh looks l i ~

In the afternoon I take:

~~ n
......

· ·4 9'

7"-

e,)

~ thlm l"
a~td name. generic nalllt', dt>S<)

97

Medications
o Medications reconciled and updated
inEMR.
o Patient reminded to update Personal
Medication Record.
o Pharmacist consulted (as needed)
Patient-Centered Care Plan
o Care-Plan reviewed, updated in
EMR.
o Patient reminded to or assisted to
update Personal Health Record.
Education (Teach back method)
o Time allotted for patient questions.
o Patient concerns addressed.
Follow up next visit:

SUBSEQUENT PATIENT INTERACTIONS CHECKLIST
Date
Date
Date
Date

Subsequent Patient Interactions Checklist

Appendix J

Date

98

- - - - ··-

- -

-------

-·- - - - -

CARE PLANNING CHECKLIST FOR CARE SETTING TRANSITIONS
(To be completed during overall care planning)
Appointment scheduled o Date and time:
Patient Tools and
o Discussion on care setting transitions.
Education:
o Printed contact information and processes.
(updated at each
o Transfer Checklist.
subsequent contact as
o Copy of care plan including health record and medication list that
needed)
can be updated by the patient or caregiver.
o Pertinent easy-to-read educational materials.
Provider Completed:
o Medication History.
(updated with each
o Home visit completed (as needed, but appropriate
subsequent contact as
provider).
needed)
o Pharmacist consulted (as needed).
o Patient-Centered Collaborative Care Plan.
Patient/Caregiver
o Time allocated for patient questions.
Questions:
o Concerns addressed.
Items to be addressed at
subsequent visits:

Care Planning Checklist for Care Setting Transitions

Appendix K

99