Transitional care encompasses a broad range of services and environments designed to promote the safe and timely movement of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex care needs. Any gaps in care that exist for patients and their caregivers during critical transitions can lead to adverse events, unmet needs, low satisfaction with care, and high hospital readmission rates. Improving the quality of care for chronically ill older adults during critical transitions is important for lowered healthcare costs and improved health outcomes.
Nearly 13 percent of Medicare beneficiaries discharged from hospitals experience three or more provider transfers during a thirty-day period. Approximately 20 percent of Medicare beneficiaries discharged from hospitals were readmitted to a hospital within thirty days and more than 30 percent are readmitted within ninety days. It is during these transitions that mistakes commonly occur giving rise to adverse clinical events. For example, a patient transitioning from a hospital to a nursing home or other facility may not have their medication and treatment plan communicated clearly. There may be discrepancies in the prescriptions, medical supplies or care instructions for home health as another example.
Earlier this year the Centers for Medicare and Medicaid Services (CMS) unveiled Comprehensive Primary Care Plus (CPC+) in an effort to strengthen primary care services through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ is a new advanced primary care model. Set to begin in January 2017, CPC+ will reward quality and value through modified payment structure supporting primary care.
The program will offer two primary care practice tracks consisting of incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices. The two tracks will focus on:
- Comprehensiveness and Coordination
- Planned Care and Population Health
- Care Management
- Patient and Caregiver Engagement
- Access and Continuity
Caring for a loved one with chronic conditions or disability is rewarding – but it can also be challenging. In most cases a caregiver is the lifeline between the provider and the patient. As a caregiver for a family member or others with complex health concerns, it’s easy to become overwhelmed by a host of responsibilities. Some tasks may come easy or feel familiar, while others may be daunting and very intimidating. Over a period of time, caregivers can begin to feel frustration or fatigue and run the risk of burnout.
Caregivers who find the right support flourish in their role. Having a dedicated care coordination team behind you can help alleviate anxiety, stress, anger, grief or guilt associated with managing a multitude of care related issues. Care Coordination provides caregivers with the know-how to ensure that patients or family members with complex conditions or disabilities can realize and preserve physical, mental, or cognitive functioning.
Social conditions and chronic disease are related. Overcoming social factors can be a challenge for the two-thirds of Medicare beneficiaries with two or more chronic conditions. Many of these patients struggle with housing concerns, lack of access to transportation, inadequate nutrition, and job loss. Some are isolated from family and face fragmented care.
Unfortunately, healthcare providers have traditionally had little success in addressing the social, environmental and cultural factors that affect health. Patients can feel ashamed and not share information during a typical doctor's visit or even while in the hospital. Most healthcare providers are ill-prepared to assist patients with difficult issues such as food access, substandard housing, family conflicts, social isolation, or in some cases childcare or adult caregiving issues. Having a plan of action to address these factors can prevent disability and illness.