What Causes Care Coordination Problems? A Case for Microanalysis.

To explore experiences of healthcare providers, stroke survivors and caregivers on stroke transitional care delivery at a tertiary hospital in Tanzania. A qualitative descriptive design with a phenomenological approach was used. Colaizzi's thematic analysis was conducted using Dedoose software to identify significant information that describes the transitional care experiences of the study participants. This study was conducted in the internal medicine and outpatient departments of a tertiary hospital in Tanzania. 15 triads of healthcare providers, stroke survivors and caregivers were purposively recruited to participate in semi-structured in-depth interviews between June and September 2024. The analysis identified four themes: communication and exchange of information, involvement of patients and caregivers in transitional care, coordination of transitional care and experiences with changing care setting. Effective communication and information exchange among healthcare providers, survivors and caregivers ensured that survivors and their caregivers were well informed about the care process, clinical condition, prognosis and transitional care needs. A collaborative care approach enabled survivors and caregivers to actively participate in care, decision-making and discharge planning during hospital-to-home transition. Coordination of care was equally important during hospital-to-home transition as it provided survivors with home-care instructions and opportunities for follow-up care. However, miscommunication among the healthcare team, insufficient information exchange, inadequate discharge planning, poor social support and lack of care coordination prevented smooth hospital-to-home transition leading to a crisis at home. The experiences of healthcare providers, patients and caregivers during stroke transitional care in Tanzania highlight achievements and key areas for improvement. Hospital-to-home transition is often characterised by uncertainty and emotional strain, emphasising the need for effective communication, involving patients and caregivers in care, as well as coordinating transitional care to address medical and psychosocial needs of survivors and their caregivers during and after discharge.

BackgroundAmong hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement.MethodsIn this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services.ResultsStaff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions.ConclusionsOrganizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.

CMMI Demonstration to Reduce NH Hospitalizations Moves to Phase 2

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers. This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered. Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses. Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

BackgroundFor patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients’ needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients’ full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs.MethodsIn a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey.DiscussionTaken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

In North Carolina, ∼5% or 57 000 children enrolled in Medicaid have complex medical conditions and account for >50% of the Medicaid dollars spent each year on the medical care of children. In 2012, Community Care of North Carolina (CCNC) received a Center for Medicare and Medicaid Innovations grant to establish the North Carolina Child Health Accountable Care Collaborative (CHACC) to address the health care needs of these children. Care coordination is an integral part of health reform activities, including many Medicare programs. CHACC appears to use a unique approach of targeting higher-cost pediatric Medicaid patients and placing specialty care managers in tertiary children's services.1,2 CCNC serves North Carolina Medicaid beneficiaries through a statewide, community-based public–private partnership, providing care through medical homes using population management approaches to improve care and contain costs.3 CHACC encourages medical and other health professionals to improve quality and cost-effectiveness of care for children on Medicaid with complex medical conditions. A primary goal of CHACC is to ensure that every child with a complex illness has a medical home in the community where he or she lives and receives coordinated primary and subspecialty care to reduce care fragmentation and cost. One target is reduction of unnecessary emergency department visits and hospitalizations. Although hospital revenues will be affected, hospitals will be better positioned to compete in the value-based care environment.4 CHACC patients are all North Carolina Medicaid beneficiaries enrolled in CCNC for care, allowing seamless identification and clinical information exchange by CHACC staff who are CCNC employees.Historically, CCNC has focused on primary care; however, CHACC bridges subspecialty and hospital-based care at 13 North Carolina hospitals with tertiary children's services with embedded care coordinators. The care coordinators are nurses or social workers with pediatric clinical experience. Their activities include completion of a comprehensive assessment of patient and family needs, care plan development, referrals to community services, patient and caretaker education, and collaboration with providers and caregivers to facilitate transitions in care. They provide a "warm handoff" to the community-based CCNC care coordinators in primary care practices and serve as dedicated links between the subspecialist team and primary care professionals. Care plans for these children are posted on a secure CCNC web-based provider portal, giving primary care professionals a centralized site to review and download care plans and to communicate with the community-based and tertiary care coordinators and subspecialists. The care plans have been well received by the community-based physicians caring for these children, reducing the communication burden of caretakers as intermediaries. A family satisfaction survey is being used to gain insight into caretaker perspectives. As one of the participating pediatric surgeons said, "This [CHACC program] is what I have been waiting for. With the care plan, I had everything I needed to care for the child in front of me. It is better than our brand new EHR!"Identifying the target population for CHACC enrollment is a continuing challenge. Nationally accepted tools for predictive models to identify children with complex medical conditions whose care may be "impactable" (quality improvement and cost reduction) have not been developed. To address this gap, North Carolina Medicaid claim data were used to help identify patient populations who may benefit from the program. In parallel, claim data for CHACC-enrolled children are being collected to determine impact on Medicaid costs, initially comparing CHACC patients with historical groups of similar patients. Advanced analytics are being developed to create predictive models to identify "impactable" patients early in their course, providing the opportunity for care managers to improve quality of care, comanagement, and cost reduction. To date, >1500 patients have been enrolled in CHACC in the first 6 months of the program. Collaborative learning is a key part of CHACC. At the 5 academic centers, work is under way to develop approaches for transitioning care to medical homes in the community using comanagement partnerships with subspecialists. For example, in a 29-county area of eastern North Carolina, the Department of Pediatrics at East Carolina University established the Center for Children with Complex and Chronic Conditions (C5) in 2008. From 2008 to 2010, C5 enrolled 234 children with complex conditions (eg, tracheostomies, gastrostomy tubes, ventilators, feeding pumps, cerebral palsy, intellectual disabilities, complex genetic syndromes) and began coordinating inpatient and outpatient care of these children. CHACC is aiding C5 with additional care managers and new communication links with primary care physicians. So far, C5 staff have documented a 20% reduction in average inpatient length of stay for ventilator-dependent patients, a 36% reduction in readmissions during the first month after discharge, a 26% reduction in readmissions during the first year after initial discharge, a 55% reduction in overall rehospitalizations, and an 11% reduction in emergency department visits. The calculated savings total for 2008 to 2010 is >$6 million.5 To continue this program, care coordination is necessary to support these children in the community. Also, residents, primary care physicians, and parents need more education about the patient's care.To address issues of access to subspecialists across North Carolina, CHACC is developing concise guidelines to aid primary care providers in the care of children with common pediatric conditions often referred prematurely or unnecessarily to pediatric subspecialists. CHACC guidelines are developed in joint day-long work groups of pediatric subspecialists from North Carolina academic medical centers and community primary care physicians. The work group reviews evidence-based data, published guidelines, and, where conclusive data are not available, consensus of subspecialists and primary care physicians on guideline content. A subgroup writes a draft guideline, sharing it for review with subspecialists and generalists across the state. The final guideline is published on the CCNC Web site (https://www.communitycarenc.org/emerging-initiatives/child-health-accountable-care-collaborative/chacc-gi/). Guidelines include consensus recommendations for appropriate primary care clinical evaluation, including laboratory, imaging, management guidance, "red flag" guidelines for immediate referral, and patient and family educational material. Final guidelines include endorsement from the subspecialty groups at all 5 North Carolina academic medical centers. The CHACC steering committee works with the North Carolina chapter of the American Academy of Pediatrics and the CCNC networks across the state to educate primary care health professionals about the guidelines and to encourage their use. Guidelines for constipation, gastroesophageal reflux, and chronic abdominal pain are available, and a guideline for headaches is in draft review.Informal feedback from primary care providers describes the guidelines as easy to download in a busy primary care practice and useful for patient care and family education. It is expected that this tool will aid in convincing families and patients to continue care in the primary care setting unless patients manifest "red flag" symptoms or meet referral guidelines. More formal evaluation of the impact of these guidelines on subspecialty access is under way.CHACC appears to create a unique, care management–based, statewide engagement of pediatric subspecialists and general pediatricians and primary care providers for developing comanagement protocols for children with complex conditions and promoting coordinated, efficient, high-quality, and cost-effective care. As medical providers in North Carolina engage in payment reform transition, including risk-based contracting, CHACC provides a platform to evaluate high-cost medical care for children. We anticipate that the cost savings from CHACC will be useful in justifying continuation of the program after completion of the grant-funded work and will be a stepping stone to value-based care for children in North Carolina Medicaid and adults with high-cost chronic illness moving between levels of care.Our work leads us to call for more development of tools for predictive analysis and risk adjustment for medically complex children, and we are pleased to see others working in this area.6 More work is needed in subspecialty referral management using tools such as the CHACC guidelines. We believe the medically complex child and the structure of the health care delivery system for these children reinforces the old saying, "Children are not just little adults."7Elizabeth Cuervo Tilson, MD, carried out the initial review of the manuscript and provided revisions to the original document.

148 Background: Care coordination (CC) has been identified by the IOM as critically important for the delivery of quality medical care. Coordination of care is especially important in oncology due to multiple encounters, many physicians, significant toxicities and several care transition points. Standard patient satisfaction surveys do not accurately measure CC and there are few instruments to measure a patient’s perspective of CC directly. In this project, multiple PDSA cycles were utilized with oncology patients to develop a Care Coordination Instrument (CCI) that was then used to compare the level of CC in two distinct practices. Methods: Survey questions were initially prepared by the research team after review of existing literature, submitted to oncology RNs, NPs and MDs and then modified based on their feedback. A new survey was then administered to 30 patients. This was again modified to eliminate or improve questions that were confusing to patients. A third survey instrument was developed and administered to an additional 30 patients. Statistical analysis identified that several questions were too structured leading to many “not applicable” responses. These were changed to a more conceptual framework. The survey was then administered to 30 patients in the myeloma practice and 30 in the GI oncology practice. Results: The CCI included questions from 4 areas of coordination (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care) and 3 domains (Communication, Operational, Navigation). The GI oncology practice scored significantly better than the myeloma practice on the communication and navigation domains (p < 0.01). There was no significant difference in the operational domain. Conclusions: Testing to date suggests that the CCI is a useful instrument in measuring an oncology patient’s perception of CC. For two distinct practices, significant differences in the delivery of CC were identified. Further refinement is necessary to modify or eliminate questions with high levels of missing data due to non-responsiveness. Separate sub-scores across domains help identify specific targets for quality improvement interventions.

Care coordination is a core attribute of Primary Health Care (PHC), yet its conceptual, methodological, and contextual approaches remain insufficiently mapped. This study aimed to synthesise international evidence on care coordination in PHC, emphasising main approaches and barriers. A scoping review was conducted following PRISMA-ScR guidelines. Searches were performed in July 2024 across PubMed/Medline, LILACS/BVS, Scopus, and Web of Science, including studies published between 2014 and 2024. Eligible publications addressed care coordination in PHC in different contexts worldwide. Exclusion criteria were studies restricted to specific diseases, previous reviews, unavailable full text, older than 10 years, or not centred on coordination. Screening was performed in Rayyan, yielding 26 included studies. Five thematic categories emerged: (1) management of the patient care journey within the health system; (2) coordination across hospital–primary–secondary care transitions; (3) interprofessional and intersectoral collaboration; (4) information integration and interoperability; and (5) case-management approaches for specific populations. Barriers included organisational and resource constraints, service fragmentation, technological limitations, gaps in care transitions, and challenges of professional and sociocultural engagement. Advancing institutional capacity, technological infrastructure, and the active engagement of professionals and users is essential to strengthen care coordination in PHC across different settings.

Transitions in care are key junctions during which care coordination, communication, and individualized support are required to ensure optimal health outcomes for patients. This is particularly true for patients who face social disparities, such as poverty, limited health literacy, or belonging to a racial or ethnic minority, who are particularly at risk for experiencing poor care transitions. Interdisciplinary primary care-led transition clinics are an intervention that have shown promise in improving care transitions for diverse patient populations, including those that face social disparities, but their role in improving transitions in cancer care remains largely untapped. In this commentary we highlight why the time-limited support of an interdisciplinary primary care-led transition clinic that targets socially vulnerable cancer patients holds the promise of achieving more equitable healthcare access, healthcare quality, and ultimately more equitable health outcomes for cancer patients.

Transitions of care are pivotal, vulnerable times as patients are discharged from the hospital. Telephonic care coordination is standard care, but labor intensive. We implemented a patient postdischarge digital engagement (PDDE) program to scale coordination. We hypothesized that PDDE could reduce readmissions for low-risk patients and supplement care coordination for medium- and high-risk patients. Pragmatic, stepped-wedge cluster randomization trial with 5 implementation waves based upon primary care clinic region. All inpatient hospital discharges between March 2020 and November 2020 were stratified by readmission risk. Low-risk patients were offered access to PDDE, and moderate-risk and high-risk patients were offered access to PDDE and care coordination. Readmission was defined as an unplanned inpatient admission within 30 days from discharge. An intention-to-treat primary analysis was conducted using mixed-effects logistic regression clustering for wave; a treatment-on-the-treated analysis was also conducted to assess the impact among program users. A total of 5490 patient discharges were examined (2735 control; 2755 intervention); 1949 patients were high risk, 2032 were medium risk, and 1509 were low risk. PDDE intervention did not significantly affect readmission among low-risk (95% CI, -0.23 to 0.90; P = .23), medium-risk (95%CI, -0.14 to 0.60; P = .21), and high-risk (95% CI, -0.32 to 0.64; P = .48) groups after adjustment for time and patient factors. In a treatment-on-the-treated analysis, among patients who activated the PDDE program, readmission was also similar among the low-, medium-, and high-risk cohorts. Our study expanded resource-limited care coordination by offering low-risk patients a service they were unable to receive previously while having no impact on readmission. PDDE efficiently provided additional touch points between patients and providers.

SummaryBased on a small number of predominantly low-to-moderate quality studies with moderate-to-high risk of bias, the FLS-to-primary care transition is portrayed as a challenging time for patients, GPs, and FLS clinicians, who experience numerous barriers to care continuation and coordination at this care juncture.PurposeContinuity and coordination of care between fracture liaison services (FLS) and primary care is required for optimal long-term osteoporosis care. This study aims to explore (1) how patients and healthcare providers (HCPs) experience the FLS to primary care transition, (2) the barriers and facilitators to primary care follow-up after FLS, and (3) interventions that enhance integration of FLS with primary care.MethodsAn integrative review was performed and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) Statement 2020. Online bibliographic databases were searched using the terms “osteoporosis”, “primary care”, and “fracture liaison services” and related terms for original English-language studies conducted between January 1, 2003 and December 29, 2023. Manuscripts were assessed for relevance using pre-defined criteria, and for quality and bias using validated instruments. Thematic analysis was used to extract key themes relevant to each research question.ResultsOverall, 14 relevant manuscripts were identified. Among the four studies that addressed patient and HCP experience of the FLS-to-primary care transition, five key themes emerged: (1) time and workload pressures, (2) limited confidence in primary care follow-up, (3) GP knowledge gaps, (4) siloed or disconnected care, and (5) communication issues. Twelve studies addressed barriers and facilitators to primary care follow-up after FLS, which fell into five themes: (1) patient knowledge and understanding (2) miscommunication and misinformation, (3) understanding roles and responsibilities, (4) GP engagement, and (5) GP-patient relationship. Additionally, single studies suggested healthcare policies and funding, accessing primary care from residential facilities, and GP gender influenced primary care follow-up. Five studies detailed interventions to enhance FLS-to-primary care integration. GP education and patient reminders, delivered as part of a multifaceted intervention, appeared to improve integration of acute and primary post-fracture care; however, the contribution of these individual interventions to outcomes remains unclear. While telephone coaching and bone marker monitoring were identified as potential interventions, there was insufficient evidence to conclude they are effective.ConclusionAvailable evidence was generally low-to-moderate quality with moderate-to-high risk of bias. Integration of the available evidence portrays the FLS-to-primary care transition as a challenging time for patients, GPs, and FLS clinicians, who experience a multitude of barriers to care continuation and coordination. There is insufficient data to support any single intervention as effective for enhancing care coordination beyond those considered standard components of FLS models. Knowledge gaps exist regarding the patient experience of the FLS-to-primary care transition, facilitators to primary care follow-up, interventions to support FLS integration with primary care, and how such information may be integrated to optimise care for patients with osteoporosis.

IntroductionAs health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare. ObjectivesTherefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations. Design and methodsThis study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses. ResultsEmployee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = −0.55, p < .001).Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings. DiscussionWhile results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

A projected rise in patients with complex health needs and a rapidly ageing population will place an increased burden on the healthcare system. Care coordination can bridge potential gaps during care transitions and across the care continuum to facilitate care integration and the delivery of personalised care. Despite having a national strategic vision of improving care integration across different levels of care and community partners, there is no consolidation of evidence specifically on the salient dimensions of care coordination in the Singapore healthcare context. Hence, this scoping review aims to uncover the key themes that facilitate care coordination for patients with chronic conditions in Singapore to be managed in the community while illuminating under-researched areas in care coordination requiring further exploration. The databases searched were PubMed, CINAHL, Scopus, Embase, and Cochrane Library. Results from Google Scholar were also included. Two independent reviewers screened articles in a two-stage screening process based on the Cochrane scoping review guidelines. Recommendation for inclusion was indicated on a three-point scale and rating conflicts were resolved through discussion. Of the 5792 articles identified, 28 were included in the final review. Key cross-cutting themes such as having standards and guidelines for care programmes, forging stronger partnerships across providers, an interoperable information system across care interfaces, strong programme leadership, financial and technical resource availabilities and patient and provider-specific factors emerged. This review also recommends leveraging these themes to align with Singapore's national healthcare vision to contain rising healthcare costs.

Transition from pediatric to adult-oriented care is often characterized by a lack of coordination and discontinuity in care resulting in poor health outcomes as well as diminished psychosocial well-being and impaired quality of life. Most young adults seen in endocrine consultation have chronic, often rare diseases that require coordinated transitional care (TC). While endocrine TC is widely acknowledged as important, relatively few models have been formally evaluated. This review provides an overview of the relevance of TC in endocrinology, summarizes the needs of young adults and families for TC, and highlights the multidimensional considerations for TC. Particular attention is given to the role of nursing in endocrine TC. We report findings of a structured literature review identifying the current state of disease-specific TC in endocrinology for growth hormone deficiency, congenital hypothyroidism, congenital hypogonadotropic hypogonadism, Klinefelter syndrome, Turner syndrome, congenital adrenal hyperplasia, disorders/differences of sex development, and late effects. We show the results of a structured endocrine TC program with a dedicated transition nurse implemented at the University Hospital of Lausanne (Switzerland). Implications for practice, teaching, and research are discussed, and key advice and resources are highlighted.

The author is the Community Services Coordinator at FMQAI: The Florida ESRD Network. She is also a member of D&T’s Editorial Advisory Board. G uest Edtorial The number of patients involun­ tarily discharged from facilities is a concern throughout the coun­ try. Many of these individuals become displaced, with no facility willing to accept them. These patients are forced to go to hospital emergency rooms for treatment, thus contributing to an already over-burdened system, and receive little or no continuity or coordination of care. Any end-stage renal disease (ESRD) patient without access to regular chronic dialysis and the necessary support services is at increased risk for morbidity and mortality. The new ESRD Conditions for Coverage mandate that facilities inform patients of their right to file a grievance without reprisal or denial of services. Further, patients must be informed of the facility’s policies for transfer, routine or involuntary discharge, and discontinua­ tion of services. Patients must receive a 30-day written notice of an involuntary dis­ charge, and the facility must follow specifi c involuntary discharge procedures. A patient being involuntarily discharged must have an order for discharge signed by the facility’s medical director and the patient’s attend­ ing physician. An abbreviated discharge procedure is allowed only in the case of immediate severe threats to the health and safety of others. The medical director has specific responsibilities and accountability to the governing body for patient care and outcomes and is responsible for ensuring that the interdisciplinary team adheres to discharge and transfer policies. With these new regulations in place, the challenge for providers is to fi nd creative solutions to work more effectively with diffi cult and special needs patients.