Health systems are challenged with reevaluating transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients. Care transitions entail moving patients between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness. The settings involved in care transitions include hospitals, nursing facilities, the patient’s home, rehabilitation facilities, home health agencies, primary and specialty care offices, community health centers, community-based settings, hospice, long-term care facilities, and others. Better care transitions have the potential to reduce readmissions—the “back and forth” movement of a patient between these settings and the instability, anxiety, and risks to health this may cause.
Articles in Category: Readmissions
Frail and chronically ill older adults often experience many hospitalizations. The costs to patients, family, and caregivers for these hospitalizations can add up quickly. Hospitalization itself and complications that develop during hospital stays can cause additional morbidity, loss of functional abilities, and death for older adults. Many hospitals and health systems face stiff penalties and increased liabilities from frequent hospitalizations.
Rates of potentially preventable hospitalizations are higher for vulnerable populations with limited access to care. One out five older adults are readmitted to the hospital within 30-days of discharge. Many of these readmissions are avoidable and often point to poor discharge planning, system failure regarding patient stability or lack of ongoing communication between healthcare providers and the patient. Reducing potentially preventable hospitalizations is important for increasing the quality of care and reducing overall medical costs. Medical conditions such as asthma, urinary tract infections, and complications of diabetes are considered ambulatory care sensitive conditions, meaning that when those conditions are present, primary or preventive health care can reduce the need for emergency department (ED) visits and inpatient hospitalization. Inpatient stays might be avoided with the delivery of high-quality outpatient treatment and disease management, complimented by care coordination that addresses unmet community health needs.