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Q&As improving care transitions webinar
Published By Beth Lueders on December 20, 2019

“The most effective way to prevent readmissions is to have successful care transitions,” said Katherine E. Watts, LMSW, ACM-SW, during the Right at Home-sponsored webinar, “Improving Care Transitions: Data and Strategies to Achieve Success.” Watts and Kelly A. Tappenden, Ph.D., RD, covered the latest data and costs associated with transitions of care and health outcomes during the November 21, 2019, webinar. The presentation also discussed common characteristics of a successful transitional care program and the importance of interfacing with a multidisciplinary care team.


care transitions role of interdisciplinary team

Watts and Tappenden answered questions from participants at the end of the webinar. Their answers are summarized below.

Hospital-to-Home Transitional Care Improves Patient Outcomes

Q1: What can we (healthcare professionals) do if a patient has no help at home?

A1: During the admission process, healthcare professionals can clarify with patients if they have a caregiver at home. The caregiver may be a family member, neighbor, or even a co-worker. Knowing upfront if a patient has support from a caregiver will help healthcare professionals plan the discharge follow-up a lot better. If the patient does not have a caregiver, enlisting help from home care agencies and incorporating the in-home caregiver into the post-discharge care plan will allow healthcare professionals to improve health outcomes.

Q2: How do you address the issue of caregiver competence? How do you make sure the person living with the patient can offer the required care?

A2: Patient education — making sure patients understand their medications and empowering patients with the knowledge to achieve their healthcare goals and manage their diseases — should be provided to not only the patients, but also their caregivers. Arrange a meeting with both patients and their caregivers to review the medications and/or discharge plan — use the meeting as a teaching moment. Find out what the patient knows. Ask questions such as, “Can you tell me what I said to you in your terms?” Then do the same with the caregivers because it is important for them to understand the discharge plan and follow through. At discharge, provide patients and their caregivers with resources, and give them a number to call for any questions they may have.

Q3: How many hours of post-discharge care would a patient need for the care to be effective?

A3: The care plan for each patient needs to be specific to that particular patient. Some patients excel with as little as four hours of care, while other patients may need more than the 20 hours, for example, that the RightTransitions® in-home care partnership between Lexington Medical Center and Right at Home provides. The most important thing to remember is there is no standard amount of care that makes care transitions successful. Healthcare professionals need to communicate with patients to determine their goals of care before developing the plan of care.

Q4: Where does advance care planning fit into transitional care planning?

A4: Advance care planning is an essential element of transitional care. Again, healthcare professionals have to meet the patients where they are at, and discuss their health goals and preferences of care. In their advance care planning, patients should:

  • Name the person who will be making care decisions on their behalf when they are no longer able to do so.
  • Indicate what life-saving measures they want their providers to utilize or not utilize.
  • Specify their end-of-life goals, if needed.

The Role of Nutrition Post-Hospital Discharge

Q5: What is the best way to diagnose malnutrition?

A5: Measuring the levels of albumin, a type of protein produced by the liver, used to be the way to diagnose malnutrition. But we now know that albumin levels correlate with inflammation and are not a good indicator of malnutrition.

Today, clinicians evaluate an individual’s dietary history and look at six characteristics to ascertain malnutrition: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation (edema), and decreased functional status. The presence of two or more of these characteristics will put an individual into a category of malnutrition.

The Malnutrition Screening Tool (MST) published by the American Society for Parenteral and Enteral Nutrition provides data reference for clinicians. But more importantly, the MST indicates what every member of the care team can do to address malnutrition based on their role and expertise.


care transitions additional cost considerations

The MST is simple — it consists of only two questions: (1) “Have you lost weight recently without trying?” and (2) “Have you been eating poorly because of a decreased appetite?” These questions are validated with a score to see whether an individual is at risk for malnutrition and should have an evaluation done by a dietician.

Q6: What is the best way to get a client, who has refused to eat for days, to eat?

A6: A number of factors can discourage patients to eat or can decrease their appetite — fatigue, taste alternations or ill-fitting teeth are a few. While it is difficult when patients refuse to eat or are not eating adequately, understanding their food preferences would help improve their nutrition. What do they want to eat? Do they have their dentures? Are they able to chew? When a patient does not have an appetite or is tired, offer small meals and snacks rather than one large meal. Instead of asking a patient to consume oral nutritional supplements out of a can, offer the supplements in a glass on ice. There are also recipes on nutritious puddings and soup on the internet. Ultimately, if it is appropriate and indicated, you may use tube feeding. The bottom line is to make sure patients understand the importance of nutrition and why they should try their best to prevent the loss of lean tissue.

Resources on Improving Care Transitions, Avoiding Hospital Readmissions and Detecting Undernutrition

Right at Home spoke with Katherine Watts, LMSW, ACM-SW, Director of Medical Social Services at Lexington Medical Center, and Lorraine Grote Johnson, RN, BSN, Director of Care Quality at Right at Home, to gather information for the “10 Common Causes for Hospital Readmissions” and “10 Questions to Ask Before Your Hospital Discharge” blogs.

For more information regarding senior nutrition, please refer to our blogs, “10 Frequently Asked Questions for Registered Dietitians” and “How to Detect Undernutrition in Seniors.”



Author Beth Lueders

About the Author

An award-winning journalist who has documented stories in nearly 20 countries, Beth Lueders is an author, writer and speaker who frequently reports on diverse topics, including aging and health issues for both U.S. and international corporations.

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