Care Transitions: An Easy Area to Improve Outcomes at a Low Cost

Care transitions can be a pinch point in our healthcare system, contributing to high rates of health service use, increased spending, and growing rates of avoidable hospitalizations. Transitions can also expose patients with chronic illness to lapses in quality and safety.

With a few changes, we can avoid these excess costs and missteps in healthcare. Since the implementation of the Affordable Care Act, its become increasingly essential for organizations to improve integration and continuity of care across settings and episodes.³

With the ACA in place, healthcare providers must become more familiar with the financial side of their practice as well. Administrators and practitioners alike now need to understand healthcare decisions in terms of ROI: better outcomes at lower costs. For example, Avalere Health with the help of the SCAN Foundation calculated ROI in five transition models that care for high-risk Medicare beneficiaries and found savings that ranged from 32% to over 600%.³

ROI should be calculated on the organizational level to evaluate effectiveness and efficiency on a macro level, as well as at the individual (clinician) level to ensure higher value per patient. As the industry moves from a volume-based reimbursement model to a value-based system centered on outcomes, practicing clinicians must incorporate the value (ROI) of providing care. In fact, the Centers for Medicare and Medicaid Services (CMS) aims to connect 50% of its fee for services payments to quality by 2018.⁴

Common Components of Transitional Care³

Integrating care transitions with long-term care management reduces costs. If providers focus on continuous patient education through assessment, monitoring, and counseling, they can substantially reduce emergency department visits and hospitalizations.³ Care transitions are easily improved when providers pay attention to the following:

• Standardized discharge protocols
• Discharge planning and implementation
• Regular follow-up by transition counselors

Clinicians need to follow up through each of these transition points. The progress a patient makes in therapy is not valuable if it’s not sustained. The goal for a transition to the home is to optimize the quality of life and functional ability with sustainability.

Clinician Action Items³

To demonstrate their value to both patients and CMS, providers can immediately implement these best practices to reduce costs and improve outcomes:

• Patient Education – Provide on a continuous basis
• Follow-up Communication – By phone, email, app or patient engagement service
  • Assess changes/risk factors to avoid emergency department visits and hospitalizations
  • Encourage and monitor adherence to exercise programs and safety recommendation

These changes reduce emergency department visits and hospitalizations. With current policy wrapped in the triple aim of the Institute for Healthcare Improvement, prevention of re-hospitalization, and improving quality of life and health are key values of our current health care system.

Clinician actions are one facet of effective care transitions. However, clinicians are limited in effectiveness and productivity when the information needed for clinical decision-making is either inaccurate or missing altogether. Mnemonics can help to standardize and improve the accuracy of written handoffs and communication. For example, one mnemonic called I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) developed as part of TeamSTEPPS reduced medical errors and potentially avoidable events by 23% and 30% respectively.⁶

Organization Action Items^2,7

Organizational changes affect patients, clinicians, and the healthcare landscape. Here are several that can make an immediate impact:

• Adopt Effective Transitional Interventions
  • Comprehensive discharge planning with home follow-up
  • Post-discharge communication (phone, email, or app-based services are available)
  • Telehealth support for post-discharge monitoring
  • Full assessments and plan of care
  • Scheduled interactions with post-acute providers
  • Coordination and referral to community resources/supports
  • Thorough medication review and plan of management
• Transparency and Accountability
  • Use standard, specific measures that address patients’ and caregivers’ experiences with transitional care.
• Workforce Development
  • Provide training to healthcare professionals on effective transitional care.
  • Support patient self-management
  • Use patient-centered coaching interventions
  • Maintain consistency of care through a learning management system

Clinicians and healthcare organizations must use evidence-based tools to move towards value-based clinical decisions. In our changing healthcare landscape, we must work towards improving healthcare delivery and the patient experience at a lower per capita cost.