Care Transitions and the Continuum of Care

Ensuring proper hand-offs and care transitions depends on maintaining effective communication between all members of the transition team, from the primary care doctors to the specialty care consultants, says Dr. Stuart Levine, MD, MHA, corporate medical director for Healthcare Partners Medical Group of California.

We think about care transitions any time there is a handoff in healthcare between any types of delivery systems. This is a way to start to look at these handoffs. The patient who starts out well, then develops obesity, then develops hypertension (HTN) and then gets diagnosed with diabetes and then they have their first heart attack, that heart attack leads to CHF, CHF leads to renal failure, renal failure leads to overall unraveling of that patient over a 40- or 50-year period.

The handoff on that patient is not going to be taken care of by one part of the health system over those long number of years. Most of those patients stay in our delivery system during that entire time.

We have coordination calls between all of the high-risk people on a daily basis. In between the hospitals and the other high-risk practitioners, as well as good communication with the primary doctors. Our specialists are capitated and act as true consultants, oftentimes going on-site to the clinics to practice the specialty care, not in silos, to make sure that the handoffs even between primary care and specialty care are better.

Source: Guide to Reducing Medicare Admissions, Volume II, June 2011

The Guide to Reducing Medicare Readmissions, Vol. II examines innovative interventions to reduce preventable admissions, rehospitalizations and ER visits by high-utilizing Medicare beneficiaries.

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