Care transitions: Best practices and evidence-based programs
Poorly coordinated care transitions from the hospital to other care settings cost an estimated $12 billion to $44 billion per year. Poor transitions also often result in poor health outcomes. The most common adverse effects associated with poor transitions are injuries due to medication errors, complications from procedures, infections, and falls.
Providers are focused on improving transitions, due in part to reimbursement changes under the Affordable Care Act. In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted penalties for facilities with high readmission rates within 30 days of discharge for three conditions: myocardial infarction (heart attack), heart failure, and pneumonia. Hospitals face reimbursement reductions of up to one percent of annual Medicare payments. New payment models, including bundled payments and shared savings programs for Accountable Care Organizations , also create incentives to coordinate transitions and provide care in less intensive settings. CMS is also encouraging outpatient providers to focus on safe transitions through new reimbursement codes issued in 2013. Providers may bill for care transitions services if they see patients within 14 days of discharge from a hospital, skilled nursing facilities (SNF), or rehabilitation facility. Improving care transitions for complex patients moving from hospitals to SNFs, to their own home, or to another setting can result in significant savings while improving patient safety.
Many providers are focused on improving transitions, due in part to reimbursement changes under the Affordable Care Act. This paper summarizes best practices in care transitions, including:
- comprehensive discharge planning,
- sending discharge summaries to outpatient providers,
- assessing financial barriers to filling prescriptions,
- using a “teach back” method to ensure patient understanding,
- following up with outpatient providers, and more.