Transition of Care for Patients with Venous Thromboembolism at ATHN Affiliated Sites

This quality improvement project is designed to standardize and optimize the transition of care (TOC) for patients with venous thromboembolism (VTE) from the inpatient to the outpatient setting. It targets neonates, pediatric, adolescent and adult patients receiving care through 14 of the 135 federally-funded hemostasis and thrombosis treatment centers across the United States that are affiliated with the American Thrombosis and Hemostasis Network (ATHN).  Five hundred sixty patients who are discharged on anticoagulant medications will be included.  TOC  quality improvement interventions include a standard transition protocol, written discharge instructions, medication reconciliation and a post discharge follow-up phone call to  reinforce instructions. As a result of the TOC interventions, it is expected that patient knowledge of selfmanagement will increase, hospital readmissions will decrease, and patient and health care provider satisfaction will improve. This project will be the first large scale multi-institutional study of its kind to simultaneously implement a uniform standard TOC model at pediatric and adult centers across the United States.