There & Home Again: AMA’s 5 Patient Safety Guidelines

The American Medical Association (AMA) has outlined five key responsibilities physicians should adopt when providing care for patients recently discharged from the hospital. The recommendations listed in the report were developed to improve safety and reduce hospital readmissions for patients returning home, according to the AMA Center for Patient Safety. With the new guidelines, The Center for Patient Care study says it hopes to break a historic trend that left the responsibility for transition plans almost solely in the hands of the inpatient clinical teams. Inpatient teams face important limitations in ensuring safe transitions to ambulatory settings, according to the report. Given the great variability of inpatient and ambulatory care team resources and capabilities, there can be no 'one-size fits all' model for safe care transitions; but certain tasks during care transitions are probably best carried out by members of the ambulatory rather than the inpatient care team, since the ambulatory practice will be responsible for providing ongoing care to the patient in the ambulatory setting. The five responsibilities outlined in the report include: 1. Assessment of the patient’s health; 2. Goal-setting to determine desired outcomes; 3. Supporting self-management to ensure access to resources the patient may need; 4. Medication management to oversee needed prescriptions; 5. Care coordination to bring together all members of the health care team. The report was issued in February 2013 - shortly after Medicare announced that it will accept the newly created Current Procedural Terminology codes for care coordination to pay physicians for the management of patients who have recently been discharged from a hospital or skilled nursing facility, the AMA said. The AMA’s CPT Editorial Panel built the codes to catalog care management services, including time spent talking about a care plan, connecting patients to community services, transitioning them from inpatient settings and preventing read missions. Improving care coordination and transitions is expected to become more important in the coming years, the report says, as new models of care delivery, improved methods of communication, and changes in payment systems will each propel an emphasis on understanding optimal roles for ambulatory practices in supporting safe care transitions for patients entering and leaving hospitals and other inpatient facilities.
http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf