Optimizing transitions of care to reduce rehospitalizations
ABSTRACTTransitions of care—when patients move from one health care facility to another or back home—that are poorly executed result in adverse effects for patients. Fortunately, programs can be implemented that enhance collaboration across care settings and improve outcomes including reducing hospital readmission rates.
KEY POINTS
- Traditional health care delivery models typically do not have mechanisms in place for coordinating care across settings, such as when a patient goes from the hospital to a skilled nursing facility or to home.
- Transitions can fail, leading to hospital readmission, because of ineffective patient and caregiver education, discharge summaries that are incomplete or not communicated to the patient and the next care setting, lack of follow-up with primary care providers, and poor patient social support.
- A number of programs are trying to improve transitions of care, with some showing reductions in hospital readmission rates and emergency department visits.
- Successful programs use multiple interventions simultaneously, including improved communication among health care providers, better patient and caregiver education, and coordination of social and health care services.
You have spent several days checking on a patient hospitalized for an acute exacerbation of heart failure. You have straightened out her medications and diet and discussed a plan for follow-up with the patient and a family member, and now she is being wheeled out the door. What happens to her next?
Too often, not your desired plan. If she is going home, maybe she understands what she needs to do, maybe not. Maybe she will get your prescriptions filled and take the medications as directed, maybe not. If she is going to a nursing home, maybe the physician covering the nursing home will get your plan, maybe not. There is a good chance she will be back in the emergency room soon, all because of a poor transition of care.
Transitions of care are changes in the level, location, or providers of care as patients move within the health care system. These can be critical junctures in patients’ lives, and if poorly executed can result in many adverse effects—including rehospitalization.1
Although high rehospitalization rates gained national attention in 2009 after a analysis of Medicare data,2 health care providers have known about the lack of coordinated care transitions for more than 50 years.3 Despite some progress, improving care transitions remains a national challenge. As the health system evolves from a fee-for-service financial model to payment-for-value,4 it is especially important that health care providers improve care for patients by optimizing care transitions.
In this article, we summarize the factors contributing to poor care transitions, highlight programs that improve them, and discuss strategies for successful transitions.
TRANSITION PROBLEMS ARE COMMON
Transitions of care occur when patients move to short-term and long-term acute care hospitals, skilled nursing facilities, primary and specialty care offices, community health centers, rehabilitation facilities, home health agencies, hospice, and their own homes.5 Problems can arise at any of these transitions, but the risk is especially high when patients leave the hospital to receive care in another setting or at home.
In the past decade, one in five Medicare patients was rehospitalized within 30 days of discharge from the hospital,2 and up to 25% were rehospitalized after being discharged to a skilled nursing facility.6 Some diagnoses (eg, sickle cell anemia, gangrene) and procedures (eg, kidney transplantation, ileostomy) are associated with readmission rates of nearly one in three.7,8
The desire of policymakers to “bend the cost curve” of health care has led to efforts to enhance care coordination by improving transitions between care venues. Through the Patient Protection and Affordable Care Act, a number of federal initiatives are promoting strategies to improve care transitions and prevent readmissions after hospital discharge.
The Hospital Readmission Reduction Program9 drives much of this effort. In fiscal year 2013 (beginning October 1, 2012), more than 2,000 hospitals incurred financial penalties of up to 1% of total Medicare diagnosis-related group payments (about $280 million the first year) for excess readmissions.10 The penalty’s maximum rose to 2% in fiscal year 2014 and could increase to 3% in 2015. The total penalty for 2014 is projected to be $227 million, with 2,225 hospitals affected.11
The Centers for Medicare and Medicaid Innovation has committed hundreds of millions of dollars to Community-based Care Transitions Programs12 and more than $200 million to Hospital Engagement Networks13 to carry out the goals of the Partnership for Patients,14 aiming to reduce rehospitalizations and other adverse events.
At first, despite these efforts, readmission rates did not appear to change substantially.15 However, the Centers for Medicare and Medicaid Services reported that hospital readmission rates for Medicare fee-for-service beneficiaries declined in 2012 to 18.4%,16 although some believe that the reduction is related to an increase in the number of patients admitted for observation in recent years.17
TRANSITIONS ARE OFTEN POORLY COORDINATED
Although some readmissions are unavoidable—resulting from the inevitable progression of disease or worsening of chronic conditions18—they may also result from a fumbled transition between care settings. Our current system of care transition has serious deficiencies that endanger patients. Areas that need improvement include communication between providers, patient education about medications and treatments, monitoring of medication adherence and complications, follow-up of pending tests and procedures after discharge, and outpatient follow-up soon after discharge.19–21
Traditional health care does not have dependable mechanisms for coordinating care across settings; we are all ensconced in “silos” that generally keep the focus within individual venues.22 Lack of coordination blurs the lines of responsibility for patients in the period between discharge from one location and admission to another, leaving them confused about whom to contact for care, especially if symptoms worsen.23,24
Gaps in coordination are not surprising, given the complexity of the US health care system and the often remarkable number of physicians caring for an individual patient.5 Medicare beneficiaries see an average of two primary care physicians and five specialists during a 2-year period; patients with chronic conditions may see up to 16 physicians in 1 year.25 Coordinating care between so many providers in different settings, combined with possible patient factors such as disadvantaged socioeconomic status, lack of caregiver support, and inadequate health literacy, provides many opportunities for failures.
Research has identified several root causes behind most failed care transitions:
Poor provider communication
Multiple studies associate adverse events after discharge with a lack of timely communication between hospital and outpatient providers.26 One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.27 Discharge summaries often lack important information such as test results, hospital course, discharge medications, patient counseling, and follow-up plans. Most adverse drug events after hospital discharge result directly from breakdown in communication between hospital staff and patients or primary care physicians.28 Approximately 40% of patients have test results pending at the time of discharge and 10% of these require some action; yet outpatient physicians and patients are often unaware of them.21
