The Importance Of Transitional Care In Achieving Health Reform

Abstract

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines

“…Fragmentation of care underlies many of the problems in the US healthcare system, contributing to unnecessarily high rates of health services use and spending, and exposing patients to lapses in quality and safety. 11 Indeed, failure in care coordination is the root cause of many preventable patient harms, estimated to represent between $25 billion and $45 billion in annual spending. 12 The accountable care organization (ACO) model is an attempt to address this problem through the alignment of accountability for providers across the continuum of care.…”

Transitions at the end of life for older adults – patient, carer and professional perspectives: a mixed-methods study

“…A recent review identified nine interventions that had a positive effect on measures related to hospital readmissions. 100 Having a nurse as a leader or clinical manager was a common feature of these nine successful interventions. Encouraging patients and families to play a more active part in their care, guidance from a 'transition coach' and interventions to improve communication across settings have been shown to reduce the rate of readmission to hospital for adults over 65 years in the USA.…”

The Effectiveness of a Care Transitions and Rapid Response Nurse Intervention at Reducing Readmissions and Emergency Department Use for High Risk Patients

“…Many transitional interventions have longer periods of follow-up and have demonstrated longer-term success in changing health status and health utilization behaviours of the population they serve [44,45]. Naylor et al [46] suggests that although transition interventions are successful in improving the patient's self-management capacity, there is a need for on-going follow-up in the post-discharge period given the on-going progressive nature of the chronic conditions of patients and in the case of this particular study, increasing levels of frailty.…”

“…The assertion is that what gets measured drives leadership and organizational behaviour. Naylor et al [46] argues for the expansion of publicly reported measures for both transitional care processes and outcomes as a way to generate real system change with measures which address patient and care-giver experience, with potentially avoidable readmissions and financial benefit identified as priority areas of measurement [46,48]. A more formally structured accountability relationship at the organizational (macro) level to better link the outcomes of the teams at the micro level to organizational outcomes and accountabilities may have been of benefit in the case of this intervention.…”