Addressing the Need for Transitional Care
The most vulnerable population in the United States is the elderly, and the highest-risk phase of care for these patients is at discharge.
However, in most cases, hospitals provide no coordination in transitional care for elderly patients. Information doesn’t transfer from one point to the next in the delivery of care, leaving elderly patients discharged from hospitals with unresolved issues and with care needs too complex for themselves and their caregivers to handle.
For example, in the course of an acute exacerbation of an illness, a patient might receive care from a primary care physician or specialist in an outpatient setting, then move to a hospital physician and nursing team during an inpatient admission before moving on to another care team at a skilled nursing facility. Finally, the patient might return home, where he/she would receive care from a visiting nurse. Each of these shifts is defined as a transition.
Part of the problem is the “silo” effect of healthcare. A hospital physician is focused on the acute event that brings the patient into the hospital, while the next physician is focused on rehabilitation or other post-hospital care. Patients may receive fantastic care at a hospital and at a nursing home But if the hospital and nursing home aren’t in sync, then the patient is not well-served.
Perhaps the most serious issue in the lack of transitional care has to do with prescription medications. In one clinical study by the University of Pennsylvania, 70% of patients experienced some form of medication reconciliation error during care transition. As health care professionals, we see the need coming “head-on” and realize it is important for elderly patients and their caregivers to become more active participants in their transitional care. A lack of transitional care directly leads to a high readmission rate within 30 days of discharge, which leads to higher healthcare costs. Many of these readmissions could be prevented by improved transitional care. One of the most common reasons for the hospitalization of elderly patients is heart failure, and patients with heart failure typically have multiple chronic conditions.
In 2005, studies have shown , there were 600,000 indexed hospitalizations for elderly patients being admitted to hospitals for heart failure. The readmission rate within 30 days was 27% and by 90 days, the rate was nearly 40%.
CMS is taking a hard look at the issue. It has begun a three-year pilot project that will examine readmission rates of elderly patients to hospitals, especially within 30 days, from the same diagnosis. The agency will seriously consider not paying hospitals that readmit patients for the same diagnosis within 30 days or substantially reduce payments.
