The Importance Of Transitional Care In Achieving Health Reform

Article (PDF Available)inHealth Affairs 30(4):746-54 · April 2011with1,133 Reads
DOI: 10.1377/hlthaff.2011.0041 · Source: PubMed
Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

Full-text (PDF)

Available from: Karen Hirschman, Jul 28, 2014
    • "This allowed for the PSH team (Fig. 1) to play a role as the liaison that manages care transitions between the community and hospital period, aspiring to achieve a seamless " handshake " between the two (Fig. 2 ). Transitions or " handoffs " are particularly vulnerable exchange points that expose patients to lapses in quality and safety (Naylor et al. 2011; Auerbach et al. 2016). Lastly, the CPC clinic provided educational classes that both managed patient expectations and elucidated important safety initiatives. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Efforts to mitigate costs while improving surgical care quality have received much scrutiny. This includes the challenging issue of readmission subsequent to hospital discharge. Initiatives attempting to preclude readmission after surgery require planned and unified efforts extending throughout the perioperative continuum. Patient optimization prior to discharge, enhanced disease monitoring, and seamless coordination of care between hospitals and community providers is integral to this process. The perioperative surgical home (PSH) has been proposed as a model to improve the delivery of perioperative healthcare via patient-centered risk stratification strategies that emphasize value and evidence-based processes. ResultsThis case report seeks to specifically describe implementation of readmission reduction strategies via a PSH paradigm during total joint arthroplasty (TJA) procedures at the University of California Irvine (UCI) Health. An orthopedic surgeon open to collaborate within a PSH paradigm for TJA procedures was recruited to UCI Health in October of 2012. Institution specific data was then prospectively collected for 2 years post implementation of the novel program. A total of 328 unilateral, elective primary TJA (120 hip, 208 knee) procedures were collectively performed. Demographic analysis reveals the following: mean age of 64 ± 12; BMI of 28.5 ± 6.2; ASA Score distribution of 0.3 % class 1, 23 % class 2, 72 % class 3, and 4.3 % class 4; and 62.5 % female patients. In all, a 30-day unplanned readmission rate of 2.1 % (95 % CI 0.4–3.8) was observed during the study period. As a limitation of this case report, this reported rate does not reflect readmissions that may have occurred at facilities outside UCI Health. Conclusions As healthcare evolves to emphasize value over volume, it is integral to invest efforts in longitudinal patient outcomes including patient disposition subsequent to hospital discharge. As outlined by this case management report, the PSH provides an institution-led means to implement a series of care initiatives that optimize the important metric of readmission following TJA, potentially adding further value to patients, surgical colleagues, and health systems.
    Article · Dec 2016
    • "This study took reference of the transitional care model structure built by Naylor [45] and Coleman [46] , which includes interfacing the predischarge phase with the post-discharge phase, continued with planned, proactive, and sustained follow-up for the post-discharged patients [42] . The design of the transitional care model in this study shares the essence of transitional care proposed by Naylor and Coleman to ensure post-discharge healthcare continuity and to avoid preventable readmissions [39,[45][46][47] but differs in the content by introducing the principles of HF palliative care as mentioned above. The key features in the transitional model of care to be used in this study are known as the four Cs, and were proposed by Wong et al. [42, 43,[48][49][50]. "
    [Show abstract] [Hide abstract] ABSTRACT: Heart failure (HF) is characterized by high rates of readmission after hospitalization, and readmission is a major contributor to healthcare costs. The transitional care model has proven efficacy in reducing the readmission rate and economic outcomes, and increasing satisfaction with care. However, the effectiveness of the transitional care model has not been evaluated in patients with end-stage HF. This study was designed to compare the customary hospital-based care and a comprehensive transitional care model, namely the Home-based Palliative HF Program (HPHP), in terms of readmission rate, quality of life, and satisfaction with care among end-stage HF patients under palliative care. This is a randomized controlled trial taking place in hospitals in Hong Kong. We have been recruiting patients with end-stage HF who are identified as appropriate for palliative care during hospitalization, on referral by their physicians. A set of questionnaires is collected from each participant upon discharge. Participants are randomized to receive usual care (customary hospital-based care) or the intervention (HPHP). The HPHP will be implemented for up to 12 months. Outcome measures will be performed at 1, 3, 6, and 12 months post-discharge. The primary outcome of this study is quality of life measured by the Chronic Heart Failure Questionnaire - Chinese version; secondary outcomes include readmission rate, symptom intensity, functional status, and satisfaction with care. This study is original and will provide important information for service development in the area of palliative care. The introduction of palliative care to end-stage organ failure patients is new and has received increasing attention worldwide in the last decade. This study adopts the randomized controlled trial, a vigorous research design, to establish scientific evidence in exploring the best model for end-stage HF patients receiving palliative care. Trial registration This trial was registered as NCT02086305 on 7 March 2014 in the United States Clinical Trials Registration, and in the Clinical Trials Registry, Hong Kong University with the trial number UW12202.
    Full-text · Article · Dec 2016
    • "It also suggests that SNF patients would benefit from transitional care services, designed to " promote coordination and continuity of care " as they transition between settings and providers of care [8, 9]. Randomized trials of formal transitional care interventions in hospitals and in one SNF have demonstrated reductions in the rate of hospital readmissions after older adults transfer to home [10][11][12][13] . These effective interventions used specialized transitional care staff to provide services before discharge (e.g., medication reconciliation and disease self-management education ), services that bridged hospital and communitybased care (e.g., patient-centered discharge records) and services after discharge services at home (e.g., follow-up calls or home visits) [11]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Among hospitalized older adults who transfer to skilled nursing facilities (SNF) for short stays and subsequently transfer to home, twenty two percent require additional emergency department or hospital care within 30 days. Transitional care services, that provide continuity and coordination of care as older adults transition between settings of care, decrease complications during transitions in care, however, they have not been examined in SNFs. Thus, this study described how existing staff in SNFs delivered transitional care to identify opportunities for improvement. Methods In this prospective, multiple case study, a case was defined as an individual SNF. Using a sampling plan to assure maximum variation among SNFs, three SNFs were purposefully selected and 54 staff, patients and family caregivers participated in data collection activities, which included observations of care (N = 235), interviews (N = 66) and review of documents (N = 35). Thematic analysis was used to describe similarities and differences in transitional care provided in the SNFs as well as organizational structures and the quality of care-team interactions that supported staff who delivered transitional care services. Results Staff in Case 1 completed most key transitional care services. Staff in Cases 2 and 3, however, had incomplete and/or absent services. Staff in Case 1, but not in Cases 2 and 3, reported a clear understanding of the need for transitional care, used formal transitional care team meetings and tracking tools to plan care, and engaged in robust team interactions. Conclusions Organizational structures in SNFs that support staff and interactions among patients, families and staff appeared to promote the ability of staff in SNFs to deliver evidence-based transitional care services. Findings suggest practical approaches to develop new care routines, tools, and staff training materials to enhance the ability of existing SNF staff to effectively deliver transitional care.
    Full-text · Article · Dec 2016
Show more