Key strategies for improving transitions of care collaboration: lessons from the ECHO-care transitions program

Authors

Lauren Junge-Maughan, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
Amber Moore, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
Lewis Lipsitz, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Bostton, MA, USA; Hebrew Senior Life Institute for Aging Research, Boston, MA, USA

Document Type

Article

Publication Date

7-16-2020

Abstract

Transitioning the care of a patient from a hospital to a skilled nursing facility (SNF) is critical and often risky. Poor care transitions can result in delays, medication mistakes, incomplete follow-up care, and adverse health outcomes. Ensuring a smooth and effective care transition is the goal for providers at both the hospital and SNF. At its foundation, successful care transitions rely on teamwork, relationship building, and communication among diverse groups of providers. Beth Israel Deaconess Medical Center (BIDMC) developed the ECHO-CT (Extension for Community Healthcare Outcomes-Care Transitions) program to improve transitions of care through structured, bi-directional communication between hospital-based and SNF-based providers. This paper describes key strategies for success in this model including: facilitating teamwork, eliminating hierarchy, and encouraging a bi-directional learning environment. We propose these as strategies that could be implemented in other organizations seeking to improve value during transitions of care.

Recommended Citation

Lauren Junge-Maughan, Amber Moore & Lewis Lipsitz (2021) Key strategies for improving transitions of care collaboration: lessons from the ECHO-care transitions program, Journal of Interprofessional Care, 35:4, 633-636, DOI: 10.1080/13561820.2020.1798900