Transitional Care and Readmission Rates

You’ve probably heard the term, transitional care before but many lack the understanding of what it is. This article seeks to answer the question What is Transitional Care?

Transitional care can be defined is the coordination and continuity of healthcare is a patient moves from one healthcare facility to another or moves home after receiving treatment. The transition could also mean a patient moving between healthcare providers or within departments within the hospital. Transition can be volatile and ironically it is patients with a chronic or acute illness who need to go through transition between healthcare practitioners and between departments in the facility.

Reducing Readmission Rates

One major consequence of a lack of proper transitional care is readmission. Patient readmission is a big issue in the healthcare industry. The weeks following after a patient is just discharged are critical and can be challenging. Research has shown that approximately 1 in 5 patients experience adverse events such as adverse drug events (ADEs) and hospital-related complications during this period.1-3 Unfortunately, readmission to the hospital after discharge is common nearly 20% of hospitalized older Medicare patients will be readmitted within 30 days.

Benchmarking to Reduce Readmission

There are many industries that the healthcare industry can learn from when it comes to refining their readmission process. For example, the hospitality industry, hotel, spas, etc can all be benchmarked against by healthcare organization to learn their best practices. Care must be taken when benchmarking not get carried away.

While investing in such material assets like in the hospitality industry is easily done and provides immediate gratification, findings from our research using six years of data from nearly 3,000 acute-care hospitals suggest that it is the communication between caregivers and patients that have the largest impact on reducing readmissions. In fact, the results indicate that a hospital would, on average, reduce its readmission rate by 5% if it were to prioritize communication with the patients in addition to complying with evidence-based standards of care.

The Centers for Medicare and Medicaid (CMS) and the U.S. Agency for Healthcare Research and Quality (AHRQ) rolled out the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey in 2006 to measure standards of hospital care from the patient standpoint. Just two years ago, CMS began to use these survey scores, along with process-of-care measures, to adjust reimbursement rates. The penalty for falling short isn’t insignificant. Hospitals risk losing 1.5% of their Medicare reimbursements in Fiscal Year 2015 if they don’t show simultaneous improvements in both process of care measures and patient experience. By 2017, that looming cut will grow to 2%, which equates to millions of dollars for an average hospital.

The result of these studies should not come is a surprise. The importance of improving their process-of-care measures is nothing new for hospitals. Having the right patient care and patient relationship is important in a healthcare organization. Having a good doctor-patient relationship and a good atmosphere in the healthcare organization improves the morale and psyche of a patient.

In 2013, about 96% of eligible heart attack Medicare patients received this basic medication, which means 5,761 patients admitted for heart attack did not. Although it can be expensive to improve the process-of-care measures by standardizing processes, caregivers widely recognize the value given the scientific evidence behind these measures.

Steps to a Good Transitional Care

A healthcare organization can take the following steps to help better their transitional care:

Start Discharge at the Time of Admission

From the minute the patient walks in and is admitted, a hospital should already put things in place that will make their discharge easy and effortless. When a care manager learns that a patient is readmitted, they contact the case manager at the hospital or skilled nursing facility. This initial contact lays the groundwork for a successful discharge that lowers the risk of readmission. Taking note of the following information and putting it in their file for when they need to be discharged is key.

  • What’s the care plan?
  • What’s the expected length of hospitalization?
  • What kind of care will the patient need when they go home?
  • Does the patient need to be discharged to a facility other than homes, such as a skilled nursing facility or a rehabilitation facility?

Proper Communication to Reduce Readmission

Getting the right communication flow started is crucial. Taking care of things like How will the case manager communicate the discharge plan to the patient, family, or caregiver? Timely communication is essential to preventing a readmission.

Communication about discharge between the transitional care manager and hospital or facility case manager is particularly critical. As hospital stays become shorter in duration, care is best coordinated when the community or transitional care manager collaborates on discharge plans with the facility care manager immediately upon admission. The care manager, as part of discharge planning, will communicate with the facility care manager to coordinate visiting nurses, or other community agencies, for immediate home health assistance.

For example, if a patient is discharged on a Friday, the visiting nurse agency may not get to the home for an assessment until the following Monday or Tuesday. This is an avoidable gap in care that would leave the patient without care for up to four days, increasing the risk for readmission. The case manager must ensure agencies are aware of the discharge and schedule timely visits prior to discharge.