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Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine

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Abstract

The American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) developed consensus standards to address the quality gaps in the transitions between inpatient and outpatient settings. The following summarized principles were established: 1.) Accountability; 2) Communication; 3.) Timely interchange of information; 4.) Involvement of the patient and family member; 5.) Respect the hub of coordination of care; 6.) All patients and their family/caregivers should have a medical home or coordinating clinician; 7.) At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point; 9.) National standards; and 10.) Standardized metrics related to these standards in order to lead to quality improvement and accountability. Based on these principles, standards describing necessary components for implementation were developed: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.

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Conflict of Interest Statements

Summary:

Conflict of Interest Statement for Faculty, Authors, Members of Planning Committees and Staff

American College of Physicians – Society of Hospital Medicine – Society of General Internal Medicine

The following members of the Steering (or Planning) Committee and Staff of the Transitions of Care Consensus Conference have declared a Conflict of Interest:

Dennis Beck, MD, FACEP (ACEP Representative) President and CEO, Beacon Medical Services has declared conflict of interest of Stocks/Holdings: 100 units of stock options/holdings in Beacon Hill Medical Services

Tina Budnitz, MPH (SHM Staff) Senior Advisor for Quality Initiatives Society of Hospital Medicine has declared conflict of interest of Employment: Staff, Society of Hospital Medicine

Eric S. Holmboe, MD (ABIM Representative) Senior Vice President Quality Research and Academic Affairs American Board of Internal Medicine has declared conflict of interest of Employment: SVP Quality Research and Academic Affairs American Board of Internal Medicine

Vincenza Snow, MD, FACP (ACP Staff) Director, Clinical Programs and Quality of Care American College of Physicians has declared conflict of interest of Research grants: CDC, Atlantic Philanthropies, Novo Nordisk, Bristol Myers Squibb, Boehringer Ingelheim, Pfizer, United Healthcare Foundation, Sanofi Pasteur

Laurence D. Wellikson, MD, FACP (SHM Staff) Chief Executive Officer Society of Hospital Medicine has declared conflict of interest of Employment: CEO, Society of Hospital Medicine

Mark V. Williams, MD, FACP (Co-Chair, SHM Representative) Editor-in-Chief, Journal of Hospital Medicine Past-President, Society of Hospital Medicine has declared conflict of interest of Membership: Society of Hospital Medicine

The following members of the Steering (or Planning) Committee and Staff of the Transitions of Care Consensus Conference have declared No Conflict of Interest:

David Atkins, MD, MPH, (AHRQ Representative)

Associate Director, QUERI, Department of Veteran Affairs, Office of Research and Development, Health Services Research & Development (124)

Doriane C. Miller, MD (Co-Chair, SGIM Representative)

Associate Division Chief, General Internal Medicine, Stroger Hospital of Cook County

Jane Potter, MD (American Geriatric Society Representative)

Professor and Chief of Geriatrics, University of Nebraska Medical Center

Robert L. Wears, MD, FACEP (Society for Academic Emergency Medicine Representative)

Professor, Department of Emergency Medicine, University of Florida

Kevin B. Weiss, MD, MPH, MS, FACP (Chair, ACP Representative)

CEO, American Board of Medical Specialties

Financial Support Statement

The TOCCC was funded under an unrestricted educational grant from Novo Nordisk, as part of the ACP Diabetes Initiative, and from the AHRQ. The funders had no input into the planning, structure, content, participants, or outcomes of the conference.

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Correspondence to Vincenza Snow MD.

Appendix

Appendix

APPENDIX: CONFERENCE DESCRIPTION

In the Fall-Winter of 2006 the Executive Committees of the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the Society of Hospital Medicine (SHM) agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings was selected as an ideal topic for collaboration for the three societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the three organizations decided to convene a consensus conference to develop consensus guidelines and standards around transitions between inpatient and outpatient settings through a multi-stakeholder process. A steering committee was convened, chaired by Kevin B. Weiss, MD, MPH, FACP of the ACP and co-chaired by Doriane Miller, MD, representing the SGIM; and Mark Williams, MD, FACP representing the SHM. The steering committee also had representatives from the AHRQ, ABIM and AGS. The steering committee developed the agenda and invitee list for the Consensus Conference. After the conference was held the steering committee was expanded to include representation from the emergency medicine community. The American College of Emergency Physicians was represented by Dr. Dennis Beck and the Society of Academic Emergency Medicine was represented by Dr. Robert Wears.

During the planning stages of the Transitions of Care Consensus Conference (TOCCC), the steering committee became aware of the Stepping Up to the Plate (SUTTP) Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The Alliance formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP developed a set of principles and standards for care transitions and agreed to provide their draft document to the TOCCC for review, input, and further development and refinement.

The TOCCC was held over two days on July 11-12, 2007 at ACP Headquarters in Philadelphia, PA. There were 51 participants representing over thirty organizations. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies, such as the AHRQ and CMS, performance measure developers, such as the NCQA and AMA PCPI, nurses associations, such as the VNAA and Home Care and Hospice, pharmacists groups, and patient groups such as the Institute for Family-Centered Care. The morning of the first day was dedicated to presentations covering the AHRQ Stanford Evidence-based Practice Center (EPC) Evidence Report on Care Coordination, the literature around transitions of care, the continuum of measurement from principles to standards to measures, and the SUTTP principles document. The attendees then split into breakout groups that discussed the principles and standards developed by the SUTTP and refined and/or revised them. All discussion were summarized and agreed on by consensus and presented by the breakout groups to the full conference attendees. The second day was dedicated to reviewing the work of the breakout groups and further refinement of the principles and standards through a group consensus process. Once this was completed, the attendees then prioritized the standards using a group consensus voting process. Each attendee was given one vote and each attendee attached a rating of 1 for highest priority and 3 for lowest priority to the standards. The summary scores were then calculated and the standards were then ranked from those summary scores.

The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented in a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are:

  1. 1.

    All transitions must include a transition record

  2. 2.

    Transition Responsibility

  3. 3.

    Coordinating Clinicians

  4. 4.

    Patient and Family involvement and ownership of the transition record

  5. 5.

    Communication Infrastructure

  6. 6.

    Timeliness

  7. 7.

    Community Standards

The final activity of the conference was to discuss some of the overarching themes and environmental factors that could influence the acceptance, endorsement, and implementation of the standards developed. The TOCCC adjourned with the tasks of forwarding its conclusions to the SUTTP Alliance and to develop a policy document to be reviewed by other stakeholders not well represented at the conference. Two such pivotal organizations were the American College of Emergency Physicians and the Society of Academic Emergency Medicine that were added to the Steering Committee after the conference. Subsequently the ACP, SGIM, SHM, AGS, ACEP, and SAEM approved the summary document and forwarded it to the other participating organizations for possible endorsement and to national measures and standards developers for use in performance measurement development.

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Snow, V., Beck, D., Budnitz, T. et al. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J GEN INTERN MED 24, 971–976 (2009). https://doi.org/10.1007/s11606-009-0969-x

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