Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Transition Care Support

Transition care support is one of five key areas known to reduce avoidable readmissions. Care transition occurs when patients move between different care settings. Studies have shown that interventions that include close coordination of care in the post-acute period along with early post-discharge follow-up care have lowered readmission rates.

Hospitals working on this topic will focus on ensuring that transition plans are in place and followed so that the patient's care is coordinated between one caregiver and another. Interventions may include the role of care coach, transition coordinator and post-transition follow-up care.

Because care transitions require coordination across settings, hospitals, post-acute facilities, home care agencies, clinicians, and community-based organizations, will all be interested in the interventions, tools and resources below that seek to improve the effectiveness of care transitions.

Transition Care Support - Tools and Resources >

Typical Transition Failures

  • No follow-up appointment scheduled, or follow-up appointment needed with additional provider expertise
  • Follow-up with provider too long after hospitalization
  • Follow-up is seen as solely the responsibility of the patient
  • Patient inability to keep follow-up appointments because of illness or transportation issues
  • Lack of an emergency plan, including telephone number the patient should call first
  • Multiple care providers and patient believes someone is in charge of care

Best Practices/Strategies for Improvement

  • Assess the patient's understanding of the discharge plan by asking them to explain in their own words the details of the plan
  • Assign accountability for patient issues between hospitalization and next provider visit and inform the patient of who is in charge of their care and how to contact them
  • Give the patient his/her patient health record that includes patient diagnosis, test results, prescribed medications, follow-up appointments, who to call with issues and what issues to look for
  • Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge
  • Provide a coach for a pre-discharge hospital visit, a home visit and follow-up telephone calls
  • Make post hospitalization follow-up home visit and/or phone call
  • Prior to the patient leaving the hospital, make follow-up visit plans with the patient for 5-7 days post hospitalization
  • Establish community networks for meeting patient needs
  • Use telehealth in patient care to monitor patient progress
  • Closely coordinate care in the post acute period using a multidisciplinary team approach
  • Enhance patient education and self-management training
  • Organize post discharge outpatient services and medical equipment and inform patient and family of the providers and services they should expect and when

Proposed Process or Outcome Measures

  • Next clinic appointment is made and documented
  • Discharge instructions include warning signs and symptoms
  • Discharge instructions include who to call if experiencing warning signs and symptoms
  • Teach back for patient education is documented
  • Primary clinician and primary clinician's clinic is documented
  • Problem list is up-to-date with current and active diagnoses
  • Medication list is up-to-date, active
  • Electronic copy of health information is provided to patients; discharge summary and procedures for hospitals
  • Post discharge follow-up call is made within 24 hours of discharge
  • Percent reached by follow-up phone call within 24 hours of discharge
  • Follow-up appointment occurs within a specified number of days of discharge
  • Medication reconciliation occurs within a specified number of days of discharge

National Quality Forum - Specifications for the Three-Item Care Transition Measure. Provides the detailed specifications for the proposed measure of patients' perspectives on coordination of hospital discharge care, the three-Item Care Transition Measure (CTM-3). This measures is under consideration for endorsement by the National Quality Forum as a voluntary consensus standard. (7-page PDF)

Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.