Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.
To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.
Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.
Following are eight more care transition management metrics derived from the survey:
- The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
- Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
- A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
- Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
- Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
- Discharge summary templates are used by 45 percent of respondents.
- Home visits for recently discharged patients are offered by 49 percent of respondents.
- Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.
2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.