Whether patients go directly home after a hospitalization or ER visit or spend time at a nursing home or long-term care facility, the hospital discharge can be the tipping point to both improve care transitions and reduce avoidable readmissions, particularly among Medicare beneficiaries. Following are opinions expressed by several thought leaders during a recent forum presented by the Robert Wood Johnson Foundation.
“The hospital discharge is either a moment where we can deliver great care, or we could fail,” stated Nancy Snyderman, MD, NBC chief medical editor, who led the forum on reducing readmissions along with Robert Wood Johnson Foundation President and CEO Risa Lavizzo-Mourey, MD, MBA.
“All patients need to have seamless journeys back to their communities after a hospitalization,” said Dr. Lavizzo-Mourey in her opening remarks.
What succeeds with patients during care transitions is largely dependent upon the population. No cookie cutter care transition model fits all, and many organizations are tailoring and/or self-developing a transitions management program to suit the population. Interdisciplinary care teams that include a transition navigator are one key to reducing hospital readmissions and improving transitional care, although case managers and providers are assuming greater responsibility in this area. Of all the innovations in transitional care management presented during the 90-minute forum, a novel idea emerged: ask the patient what they need.
“We need to better engage patients and family members,” suggested Eric Coleman, MD, who developed the popular Care Transitions Intervention™ a template for transitional care. Doing so can uncover specific issues that contribute to readmissions, such as lack of transportation or a burned-out caregiver.
Dr. Coleman also implored hospitals to recognize that causes of readmissions are very broad and often outside the scope of what hospitals can accomplish. “A hospital might not be able to address a patient’s transportation issue, but an Office on Aging can.”
Thirdly, communication and the exchange of health information need to improve, he said.
Guide to Care Transition Management examines data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown and award-winning initiatives supporting patients’ seamless transitions back into their communities. In all, hundreds of data points are provided and 20 critical FAQs answered.