Transitional Care

Many hospitals and health systems are challenged to stay in touch with their high-risk discharged populations, manage their recovery, motivate and support behavior change and avoid preventable readmissions. In today's healthcare environment, where resources are already stretched thin, new payment models are challenging execs to do just that.

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. One of the studies involving Rhode Island hospitals had lower readmission rates for patients who were offered and accepted post-op follow-up. The other study at Baylor, was also successful in reducing re-hospitalizations.

While readmission rates may have been the initial impetus for transitional care, the fact is that as long as Medicare is still paying for the hospital readmission, albeit with a 3% payment reduction, there is little incentive in the C-suite to invest in these programs. But that seems to 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 hospital leaders to help them better manage their condition after discharge. Then there is episode based payment models that continue to expand, and which links payment for various services that patients receive across an entire 90-day care episode. Some iterations of that payment method - now being adopted by commercial payers - 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 makes it more money, then the hospital execs are happy too. Its a win-win for everyone.

Transitional Care (TC) is a time-limited service designed to ensure continuity after discharge and prevent poor outcomes among at risk populations.  While no single best practice has been identified, key features of successful programs include patient education, face to face patient encounters within 48 hours of discharge, medication management and timely follow-up with outpatient providers.  Among the lessons learned by mature programs is the importance of a formal introduction to the TC coordinator before the patient leaves the hospital.

There are a range of models from telephonic and smart phone "Facetime" follow-up, messages from care team members, to brick & mortar TC clinics or 'Clinic-on-Wheels' dedicated to high risk patients who are closely monitored.  Other innovative models target 'high utilizers' (think of the Camden Coalition),  ACO members or specific populations identified through the hospital's community assessment report who are at risk for acute care. Personnel vary as well from nurses, therapists, and social workers to lay coaches, 'church ladies,' and the much touted innovation at HonorHealth in Arizona of using veteran corpsmen and medics as transition specialists.  Another innovation spotlights a rural hospital exec who entered into a partnership agreement with the local retail pharmacy to fund a shared practitioner at their 7-day walk-in "minute clinic.'  Transitional Care is becoming a necessary strategy under new payment models.  Is your care management program ready to cross the continuum of care?