Evaluating Transitions of Care of Hospitalized Medical Patients to Long-Term Care Facilities

Abstract

Venous thromboembolism (VTE) is a significant but preventable cause of hospital-related morbidity and mortality. Prevention of in-hospital VTE, thus, has become a major quality improvement initiative within hospitals. However, addressing VTE prophylaxis rates and appropriateness on transition to other facilities has not been fully characterized to date. The authors of this study retrospectively evaluated VTE prophylaxis on transfer from medical inpatient settings to long-term care facilities. Analysis indicated that on transfer to other facilities, VTE prophylaxis recommendations were not routinely documented. Interfacility communication is crucial to ensure that appropriate prophylaxis recommendations are addressed during transitions of care. New processes evaluating VTE prophylaxis recommendations at the time of care transfer warrant further study.

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative

“…Communication about discharge prophylaxis should routinely occur among the primary care provider, hospital provider, and patient to establish care coordination and continuity of care. 70,71 Studies indicate that primary care providers "very much prefer" to communicate with hospitalists by telephone during admission and discharge. 72,73 This means that primary care providers may need to create an office strategy in which hospitalists can reach them with minimal delay.…”