Successful care transitions hinge on communication


A recently released health policy brief examining the efforts in the U.S. healthcare system to improve care transitions concludes that simple solutions would go a long way toward improving patient care and saving costs.

The brief, created by Health Affairs and the Robert Wood Johnson Foundation, makes note of the causes of poor care transitions and ways to improve those transitions. Among the causes and cures: communication.

[See also: Robert Wood Johnson report calls for healthcare payment reform]

Lack of communication between a hospital and the patient’s regular outpatient provider is a major factor causing poor care transitions, notes the policy brief, and that can lead to costs.

Poorly managed care transitions cost the U.S. healthcare system a great deal, noted Rachel Burton, the brief’s author, who is a research associate at the Urban Institute, since, ultimately, they can lead to hospital readmissions.

“MedPAC estimates that the Medicare program spends $12 billion a year on potentially preventable hospital readmissions. Among Medicare beneficiaries who are readmitted to the hospital within 30 days of a discharge, half will not have had any contact with a physician between their first hospitalization and their readmission – suggesting a lack of care transition management,” said Burton.

[See also: Readmission costs even higher than suspected]

“We actually know what activities providers can do to improve care transitions, reduce readmissions and save money – evidence from randomized controlled trials shows that specific care transitions interventions can cut hospital readmissions by a third,” said Burton. “And it’s pretty low-tech stuff – like calling patients to make sure they understand their discharge instructions, and reconciling the drugs patients got in the hospital with the ones they were already taking to make sure medications are not contra-indicated.”

The only thing that isn’t known, she said, is the best way to pay providers to incentivize them to engage in these activities.



For example, hospitals do not always forward a patient’s records back to a primary care physician; therefore, doctors are not always aware that a patient may need follow-up care. Patients also do not always understand discharge plans and medication instructions they are given at the hospital.

The Affordable Care Act, Burton said, may offer some direction. It has created several new programs and pilots to test different payment approaches to incent better care coordination and smoother care transitions.

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