Delivery of Optimized Inpatient Anticoagulation Therapy

Consensus Statement From the Anticoagulation Forum

Edith A Nutescu PharmD FCCP; Ann K Wittkowsky PharmD CACP FASHP FCCP; Allison Burnett PharmD PhC; Geno J Merli MD FACP; Jack E Ansell; David A Garcia MD


The Annals of Pharmacotherapy. 2013;47(5):714-724. 

In This Article

7. Care Transitions

The anticoagulation management system should be designed to ensure appropriate care transitions for patients receiving anticoagulant therapy.

The health care system in the US has a fragmented structure, and care transitions from one health care setting to another have been shown to be prone to error. Thirty-day hospital readmission rates among Medicare beneficiaries, a commonly used indicator of appropriateness of care transitions, are nearly 20% and associated annual costs exceed $26 billion.[40] Patients with complex or chronic medical conditions, including those on high-risk anticoagulation therapy, are particularly prone to adverse outcomes from inadequate care transitions. Therefore, an inpatient anticoagulation management system should be designed to ensure appropriate care transitions from inpatient to outpatient or other settings for patients receiving anticoagulation therapies, thus avoiding unnecessary readmissions.

There are 3 fundamental elements of effective care transitions: education, follow-up care, and communication (Figure 2). Education on anticoagulant agents through written, oral, and electronic media should be provided to the patient and family as well as staff involved in the patient's care. The empowerment of patients and their families through heightened awareness of medical conditions and appropriate use of medications is strongly recommended, as they are the most constant element in the care transition process. In addition to education on anticoagulant therapies, it is recommended that health care professionals undergo transition-specific competency training, as most do not receive this during medical education.

Figure 2.

Basics of care transition programs. Care Transition Metrics = readmission, recurrent thromboembolic events, bleeding, follow-up visits, primary care provider (PCP) or specialist contacted, discharge summary of hospitalization in 24 hours; staff (nursing, pharmacy, physicians), residents, and medical students trained and involved in care transition processes; Disease Management = management of diseases requiring anticoagulation; Discharge Summary = dictated within 24 hours of discharge; Patient and Family = education program for patient and family; Follow up Appointments and Calls = Follow-up appointments with primary care physician, specialists, anticoagulation program; Contact PCP or Specialist = phone call placed at time of discharge to PCP and specialists.

The second critical element of care transitions is follow-up care. A follow-up appointment with the patient's primary care physician or subspecialist should be scheduled within a prespecified period of time after discharge to ensure patient safety. This time frame should be delineated in hospital policy. A follow-up patient phone call within 48–72 hours after discharge is beneficial to identify issues that may occur in the immediate postdischarge period. Similarly, the patient and/or family should be provided with a "safety net" telephone number prior to discharge should they need to call for assistance with barriers to care in the postdischarge period. The final step in effective care transition is communication with the receiving health care provider through verbal and written communication. For anticoagulant therapy, this includes inpatient dosing history, patient discharge instructions, and a discharge summary. The inpatient anticoagulation management system should use a care transition checklist to ensure all essential elements have been addressed prior to discharge (Table 8). It is also essential to address care transitions when patients receiving anticoagulant therapy are admitted to the hospital.