Transitional programs work

by Stefani Daniels, Managing Partner
Published on Aug 25, 2018

A couple of years ago, there were two studies published in the Archives of Internal Medicine that demonstrated the value of formal transitional care programs.  Researchers used readmission metrics as the value component.  One of the studies, involving Rhode Island hospitals, resulted in lower readmission rates for patients who were offered and accepted post-op follow-up. The other study at Baylor, was also successful in reducing readmission rates. 

Transitional care programs typically focus on the post-hospital continuum while transitions-of-care generally focus on the movement of the patient from one area of the hospital to another and then discharged.  Transitional care is the formal continuum of care that selected patients receive after they leave the hospital. A combination of electronic/phone contact, home-visiting programs and transitional clinic visits have all been proven effective to reduce all-cause readmissions, preventable ED visits, and mortality. These interventions should receive the greatest consideration by systems that are in the process of transforming their hospital case management programs to meet the demands of the new marketplace. 

While readmission rates may have been the initial impetus for transitional care, the fact is that as long as Medicare is still paying the DRG for the hospital stay, albeit with a 3% payment reduction, there is little incentive in the C-suite to heavily invest in these programs.  But that may be changing.

Patients can now view readmission rates on the CMS' Hospital Compare web site.  As patients become more aware of their risk of readmission, they may start putting more pressure on their physician and the hospital to help them better manage their condition after discharge. Then there are bundled payment models that continue to be introduced, which links payment for various services that patients receive across an entire care episode. Some iterations of that payment method make effective transitional care a must. And finally, with more payers creating or participating in ACO programs, third party payers may want to offer transitional care programs to their members - and reimburse the hospital for its costs. If the insurer doesn't have to pay for another admission, they'll be happy and if hospitals can avoid readmissions and fill an open bed with a surgery patient that generates revenue, then the hospital is happy too.  Its a win-win for everyone.