Poorly managed care transitions from hospitals to other healthcare settings result in substantial financial burdens, estimated between $12 billion and $44 billion annually. These ineffective transitions also frequently lead to negative patient health outcomes. Common adverse effects include medication errors, post-procedure complications, infections, and falls.
Healthcare providers are increasingly prioritizing improvements in care transitions, partly driven by reimbursement reforms introduced under the Affordable Care Act. Since October 2012, the Centers for Medicare and Medicaid Services (CMS) has implemented penalties for facilities demonstrating high readmission rates within 30 days for conditions such as myocardial infarction (heart attack), heart failure, and pneumonia. Hospitals may face reductions of up to one percent in their annual Medicare payments. Furthermore, novel payment models, including bundled payments and shared savings programs for Accountable Care Organizations, are incentivizing coordinated transitions and care delivery in less acute settings. CMS is also promoting safer transitions in outpatient settings through new reimbursement codes established in 2013, allowing providers to bill for care transition services when seeing patients within 14 days post-discharge from hospitals, skilled nursing facilities (SNFs), or rehabilitation facilities. Enhancing care transitions, particularly for complex patients moving between hospitals, SNFs, homes, or other settings, can yield significant cost savings while simultaneously improving patient safety.
Doctor reviewing care transition best practices in notebook.
Many healthcare providers are actively working to improve these transitions, spurred by the reimbursement changes linked to the Affordable Care Act. Key best practices in care transitions include:
- Comprehensive discharge planning to prepare patients for their next care setting.
- Timely and effective communication through sending discharge summaries to outpatient providers to ensure continuity of care.
- Proactive assessment of potential financial barriers patients might face in accessing and filling necessary prescriptions.
- Utilizing the “teach-back” method to confirm and enhance patient understanding of their discharge instructions and medication regimens.
- Diligent follow-up with outpatient providers to monitor patient progress and address any emerging issues post-discharge.
