Evidence Supports Transitional Care Programs Essay

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

In 2013 an average of one out of eight Medicare patients are readmitted within a 30-day period which lead to the estimated costs of around $18 billion a year for Medicare patients alone. Hospitals will either be penalized or receive bonuses for their performance with readmissions. This program will encourage hospitals to concentrate on ways to improve coordinating transitions of care while improving the safety and quality of care provided. In order to

The aim of the Affordable Care Act (ACA) is to reduce hospital readmission and to increase implementation of transitional care coordination for low health care cost. One benefit of establishing this

This memorandum describes Central Health’s Readmission Reduction Program set to commence in May 2017. The Centers for Medicare and Medicaid Services (CMS) has raised concern over the increasing readmission rate and poor quality of care. To address this issue, Congress has created Hospital Readmission Reduction Program (HRRP) statute under the Affordable Care Act, 2010, which was recently updated under 21st Century Cures Act of 2016. Under the constant pressure of a penalty, Central Health has considered to establish its own Hospital Readmission Reduction Program to address specific imperatives, such as care-coordination, treatment adherence program, and streamlined patient discharge process.

There is a problem of avoidable hospital readmission rates for the Medicare and Medicaid populations that lead to adverse consequences not only for the patient, but also the payer and hospital. In order to decrease these avoidable readmission rates it is important to identify processes that can be implemented at the health plan level such as pre-discharge hospital visits by health plan staff, and post-discharge care coordination.

Policy makers created the Medicare Hospital Readmissions Reduction Program (HRRP) in an attempt to improve quality of patient care and lower costs (James, 2013). In order to avoid these penalties, healthcare leaders must recognize that CMS has identified a correlation between readmissions and a lack of quality care. Therefore, the aim is not to focus solely on hospital readmissions, but to seek clinical excellence by investing in quality improvement (Silow-Carrol, Edwards & Lashbrook, 2011). However, reducing readmissions is a complex undertaking, because not all readmissions can or should be prevented. Indeed, some readmissions are planned as part of sound clinical care. Furthermore, while hospitals work to reduce readmissions caused

The health care organizations have big opportunity to improve their quality of healthcare service as well as improve life quality of customers through reducing an avoidable readmission. The readmission is defined by Centers for Medicare and Medicaid Service (CMS) “Admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital” Hoffman, J.H. (2012). Readmissions can be classified four different categories, including (1) Planned readmission which the reason of the readmission is related to the initial admission. For example, reconstructive surgery with subsequent steps or it could be series of treatment such as cancer chemotherapy. (2) Planned but the reason is not related to the initial readmission.

With a variety of trends that account for the increasing cases of the elderly population at risk for hospital readmission, the authors discuss an in depth evaluation on why this occurs. Hospital readmission, a growing health concern, tallied in a whopping $17 B in Medicare cost for unplanned hospitalizations. Readmission, refers to a return to the hospital after discharge from a recent stay where rates are reported mostly at 30, 60, and 90-day intervals after discharge. Even though the elderly, aged 60 years or older, unfailingly represent the highest rate of hospital readmissions compared to other age groups, according to the authors, readmission rates have been associated with patient demographics, chronic conditions and utilization factors. Additionally, although the aforementioned factors contribute to readmission, adverse events such as injuries that result from hospitalization or at home like medication errors. According to (Robinson, Howie-Esquivel, & Vlahov)

In December 2015, The Joint Commission launched a campaign seeking to reduce readmissions by providing resources for both health care providers and patients to engage patients in the discharge planning process.1,2 According to voluntarily reported data collected by The Joint Commission between January 2014 and October 2015, the major contributors to 197 sentinel events were failures in patient communication, patient education, and patient rights.2 A review of communication during the hospital discharge process found that discharge summaries often lacked information on counseling, treatments, discharge medications, test results, and follow-up plans.3

This brief describes in short, the Medicare Hospital Readmissions Reduction Program established in the Affordable Care Act (ACT, 2012), that provides a financial incentive to hospitals to lower readmission rates. Hospitals fear unintended consequences for safety-net hospitals that may threaten care for vulnerable populations. Patient’s who refuse to change life style and comply to

A hospital readmission is defined as one that occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this time period is defined as 30 days. Some of the quality care issues arise within the hospital among staff and also at home after patient discharge. Some of the highest rates of readmission within the 30 days are related to some of the following factors: complications from treatments during a hospital stay, inadequate treatment/inadequate care, coordination and follow up care at home and unexpected worsening of the disease after discharge from the hospital. Patients often face challenges with medication compliance and administration, not understanding the nature of their disease, and also where to get their questions answered once at home. The health care system has come to the conclusion that most of these issues is the leading factor in patient readmission. The most cost efficient solution to the problem of avoidable readmissions is patient education and after discharge follow up. Providing discharge instruction pamphlets to patients is not adequate enough information to yield results. Often times it is left with the patient’s belongings in a bag and never read. This gap in quality care is costing hospitals

Decreasing the rate of hospital readmissions has been targeted as a high priority for United States healthcare reform. Proper discharge planning that utilizes an interprofessional team, while determining appropriate patients that will benefit from such models will go a long way in reducing readmissions, meeting the patients at the level of their needs, meeting a performance measure that has been saddled with discouragement by the staff, and finally opening up access to care of patients otherwise that will have ben occupied with those that did not need or could not use it.

Kaiser Family Foundation defines readmissions as an event where a patient is admitted to a hospital within specified time period after being discharged from an initial hospitalization, for example, in case of Medicare, this time period is set at 30 days (Boccuti & Casillas. 2015). High hospital readmission rates have been a problem for many years in US healthcare system, however in recent years intense measures and practices to reduce avoidable re-hospitalization coupled with awareness of the issue has become a high priority for all healthcare providers. According to a study conducted by Jencks, Williams & Coleman, after analyzing the Medicare claims data from 2003 - 2004, almost 20% of the patients were re-hospitalized within

The following databases were reviewed for this systemic review: CINAHL Plus, MEDLINE, ERIC and Cochrance. The following journals were reviewed and information obtained for this systemic review: Nursing Times, Journal of Gerontological Nursing and The American Journal of Nursing. The following expert organizations were reviewed: World Health Organization (WHO) and Centers for Medicare and Medicaid Services (CMS). This systematic review was conducted by searching for “Effective discharge planning; does it decrease hospital readmission rates?”. The search was further limited by information that was published within the last five years and in the United States.

This project was an observational program evaluation. The purpose of this project was to evaluate 30-day readmission, medication compliance and outcomes of patient who received traditional care (services provided prior to October 1, 2015) to that of patient who received care from Post Myocardial Infarction Transitional Care Program and Advanced Practice Provider Transitional Care Clinic (which started October 1, 2015). This project focused on evaluation of the following questions: