A transition of care (ToC) involves moving a patient from one care site to another. These “moments of truth” are critical to ensuring continuity of care that is safe, efficient, and supports a successful healthcare journey.
Care transitions can include movement between hospitals, skilled nursing facilities, and homes or between an ICU to a cardiac rehabilitation center. Other specific instances of transition are applicable, as well.
Poor transitional care management, however, can lead to significant patient safety issues and cost burdens. With more than3.8 million hospital readmissions annually in the US and an average readmission cost of $15,200, care transitions are now a key focus for quality performance measurements and improvement.
Transitions of care are ubiquitous (and costly)
Transitions of care entail extensive discharge planning. This involves informing and equipping the patient and their family to manage self-care. For care management providers, transition support may include:
Scheduling follow-up appointments
Arranging new treatments or equipment
Medication management and reconciliation
Self-management education and care plan adherence
Community or social services
Figure 1 visualizes theeight types of transitions of care among various care settings. These ToCs can happen within one care setting, between or across locations, or among providers.
One or more of these transitions can occur within a single medical episode.
"The big risk for errors is from acute care to where the patient goes next – rehab, home or nursing home. Discharge plans are so complex now, but if they aren't followed closely, the patient will get readmitted, and now there are penalties. If you don't get the transition right and the readmission could have been avoided, it will cost the system more money." - Tom Sullivan, MD, chief strategic officer for Rockville, Maryland-based DrFirst
Readmissions from post-acute care providers to acute care environments are of specific concern to healthcare organizations, particularly because they can come with apenalty from Medicare. According to theCenters for Medicare & Medicaid Services (CMS), they amount to more than $26 billion annually and affect almost 20% of beneficiaries.
Each component plays a critical role in planning, communication, coordination, and team-based care across sites. They work in tandem, providing data insights, risk stratification, and timely activity in a systematic fashion.
Data interoperability is probably the most critical aspect of modern ToCs. Having accurate, accessible, and timely information and documentation is the heart of effective transitions. Interoperability ensures that the right people can exchange information seamlessly.
A2022 survey revealed that 99% of hospitals and physicians are more likely to refer patients to post-acute providers that offer interoperability. That same study found that 72% would be willing to switch vendors who offered a system that met their most essential interoperability requirements.
Additionally, health information exchanges (HIEs) have beenshown to improve care by providing health information at critical times of need.
Robust data analytics can help stratify high-risk patients and provide guidance on how to manage their transitions of care. Claims-based machine learning models are often used to generate accurate predictions for transition planning.
Real-time decision support analytics, for instance, can recommend the next best site of care for a patient. In fact, discharge destination has been shown to be a significant indicator of readmission.
Real-time decision support could provide visibility into network and claims data to show the best subsequent care destinations.
Care coordination platforms play a crucial role in communication across care teams. They can support continuity of care at a critical time when patients must adjust to new medications and self-care activities.
From the time when a patient is admitted, their subsequent discharge and transition depend on workflow orchestration.
Care managers work with case managers at hospitals or skilled nursing facilities to lay the groundwork for a successful discharge. This can include:
Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)
Explicitly defining and equipping specific care transition roles and responsibilities is foundational.
Tech-enabled integrated teams are at the crux of ToC activities. For example, Kaiser Permanente’s Northwest US branch reduced its all-causereadmission rate by nearly one-third by introducing a post-discharge team-based strategy.
A New York–based health planreduced readmissions by 21% for its dual-eligible Medicare and Medicaid members. It did so through provider coordination, patient communication, at-home visits, family engagement, and patient education.
According toMcKinsey, “tech-enabled data sharing, readmission analytics, workflow modules, and health services partnerships provide the basis for high-ROI ToC program design.”
Health plans and provider organizations are working together to prioritize the deployment of high-touch, actively-managed care transitions.
Keeping patients at the center of transitions of care
Even with the best data-sharing technologies, a stellar care team, and a well-oiled workflow, it’s pivotal that the entire care team understands the challenges patients face.
When patients are discharged from one care setting to another, they can be overwhelmed with change. New or adjusted medications, new self-care activities, and changes to health routines take time and support to be successful.
It’s critical that everyone involved provides timely, consistent, and compassionate follow-up, education, and support. This not only supports patient safety through transition, but addresses care beyond discharge that avoids costly readmissions.
How ThoroughCare can help
ThoroughCare’s intuitive software platform can help healthcare payors and providers use digital care coordination to support patient transitions. Our solution can help:
Streamline discharge planning with guided checklists to close gaps
Create and share discharge reports to inform stakeholders at every step
Develop patient care plans and motivate behavior with SMART Goals
Analyze patient risk factors and generate clinical recommendations
Track and log services for an audit-proof record of care