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04.21.16

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Articles in Category: Transitional Care Management

How Transitional Care Reduces Readmissions

How Transitional Care Reduces Readmissions

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.

Ensuring Quality in Transitional Care

Ensuring Quality in Transitional Care

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.

Transitional Care: A Team Approach for Better Care

Transitional Care: A Team Approach for Better Care

Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.

One in five Medicare enrollees is readmitted to the hospital, ED or urgent care within 30 days of discharge, and nearly three-quarters of these readmissions are preventable. Miscommunication, lack of provider accountability, and inadequately prepared or shared care plan leads to ineffective care transition. Consequently, the patient is vulnerable to adverse events. Under the Patient Protection and Affordable Care Act, along with shifts to value-based care and shared risk models, providers and healthcare systems now face financial penalties due to unnecessary readmissions.

Catching Your Breath Through Transitional Care

Catching Your Breath Through Transitional Care

When someone can’t breathe nothing else matters. Enjoying the simplest pleasures of daily life become a struggle. Patients with complex health conditions and seniors with serious breathing problems take in less oxygen and therefore have less energy for daily tasks. This can dramatically reduce one's quality of life. As a result, patients can often feel anxious, fatigued, and depressed. The help of caregivers becomes increasingly important as breathing difficulties persist.

Chronic obstructive pulmonary disease (COPD) (i.e. emphysema or chronic bronchitis), and asthma are two chronic breathing conditions that burden seniors and patients with complex conditions the most. Damaged air sacks (alveoli), obstructed airways, or chronically inflamed lungs can block breathing and increase risks for developing infections. These patients are highly sensitive to irritants and require more assistance in reducing and preventing exposure to triggers that exacerbate symptoms.

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