While there’s no single magic bullet to improve care transitions, healthcare providers and health plans have succeeded in addressing some primary causes of avoidable complications and readmissions to help patients move safely to the next care setting.
The URAC Industry Insight Report, “Transitions of Care: Proven Strategies to Close Care Gaps,” explores the primary causes and uncovers strategies employed by innovative healthcare organizations to prevent errors and complications, and reduce readmissions.
Transitions of care occur when patients move from one care setting to another, such as from hospital to home, hospital to skilled nursing facility or rehabilitation facility to home. Many errors that harm patients and lead to costly and unnecessary readmissions occur during care transitions, particularly errors involving medication and lapses in care. It’s estimated that 75 percent of hospital readmissions are avoidable and result in approximately $44 billion in annual wasteful healthcare spending.
“Planning for the care transition has to be meticulous and address all of the patient’s needs,” says Deborah Smith, product development principal at URAC.
Communication gaps are perhaps the most consistent risk that impact care transitions, since they lead to a myriad of problems for patients—from delayed care and missed treatments to medication errors and hospital readmission.
The report shows how Danville, Pa.-based Geisinger Health Plan (GHP) is working to prevent transition-of-care communication gaps—between providers and between providers and patients—by embedding GHP clinicians into nursing homes to focus on discharge planning, care coordination and patient education. Known as ProvenHealth Navigator, the program has reduced the average 30-day readmission rate among patients discharged after a short nursing home stay to just 15 percent—well below the national average of 25 percent.
“It’s been a big win for us, and for patients, more importantly,” says Janet Tomcavage, chief population health officer of GHP and Geisinger Health.
The report also details how the Tallahassee (Fla.) Memorial Transition Center has reduced unnecessary emergency room visits and hospital readmissions by 68 percent, saving hospitals up to $1 million annually, by improving the transitional care delivered to low-income patients with complex medical needs.
Whenever possible, a physician from the transition center rounds with the inpatient medical team to help prepare patients for hospital discharge. Immediately following discharge, the transition center’s multidisciplinary team works with social service agencies and other organizations to connect patients with primary care, as well as everything from financial assistance and medical equipment to low-cost medications and transportation.
“We are a stepping stone to help these patients connect with primary care,” says Dean Watson, MD, vice president and chief medical officer at Tallahassee Memorial HealthCare. “These are patients who would otherwise go to the emergency department because they don’t have a doctor and, in many cases, don’t even have insurance.”
The report reveals that the healthcare providers and organizations with the safest, most effective transitions of care processes have several key factors in common:
- They identify and target patients with the highest risk for readmissions, such as patients with complex medical and social needs and those lacking the financial resources necessary for accessing post-discharge care.
- They leverage technology and data to improve quality and integrate care across settings.
- They plan early for patient handoffs and coordinate with providers in the next care setting.
- They partner with social service agencies to address patients’ unmet social needs.
- They educate patients and caregivers about the patient’s condition, care plan and medications.
“At the end of the day, providing truly safe, patient-centered care means personalizing not just the care, but the transfer of care to the patient’s specific needs,” says URAC’s Smith, noting that URAC has created a Transitions of Care (TOC) Designation that is built around many of the best practices identified in the Industry Insight Report. The Designation is available for organizations that achieve URAC’s Case Management Accreditation.
The white paper, “Transitions of Care: Proven Strategies to Close Care Gaps,” can be downloaded for free at http://info.urac.org/transitionsofcare.