Transitional Care Literature Review

Patients recently discharged from acute care back to the community are at an increased risk for hospital re-admission (3). Efficient collaboration between interdisciplinary health professionals and nurse liaison can improve discharge planning processes.

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 searching information regarding the rehospitalization rates and the drop of Medicare reimbursements for those stays, I was surprised to have found there was so much information regarding this and the tools that are out there also to use. My direct supervisor, Amy Suydam RN CPS, was also helpful in bringing up some things not thought of that would assist in the success of our organization in achieving our goal of decreasing rehospitalizations by 10% within the next 6 months. Amy Suydam RN CPS did not feel this was an unreasonable timeframe and decline to be looking towards. This is something we have discussed many times as our organization is non-for profit and this is very important that we follow through with our teachings and get all the information put out there that we can regarding these changes.

Readmission to a hospital creates strain and added expense for the patient and hospital; in 2011, hospital costs due to readmission were almost $41.3 billion (Hines, Barrett, Jiang, & Steiner, 2014; Rau, 2014). There are many aspects of healthcare associated with readmission, such as lack of discharge planning and education, which need to be addressed i to decrease the amount of preventable re-hospitalizations.

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

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

Transition of care appeals to me the most in my practice as a case manager. When a patient gets admitted, the interdisciplinary team starts working on the discharge planning. I always wonder how can the team know for sure, that the patient is ready to be transitioned and how can we know for sure that the transition of care is safe and it would not be overlook?

The majority of the meting was focused on the care transitions program presentation and discussion. The presenters lay out was familiar as it was a community nursing care plan that included identifying, assessing, diagnosing, implementing, and evaluating the project she presented. The other members had a lot of questions about the process and a lot of time was spent on the social determinants of health. The presentation relied heavily on the in home part of the process and a nurse present on the board or for the presentation would have helped to connect the story for these patients in both settings. It was discussed that the elderly are a particularly vulnerable population during times of transition and that this program might help to bridge the vulnerabilities.

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.

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

Interventions to Reduce Acute Care Transfers is a quality improvement program that has been used throughout health care settings worldwide. Its main goals are to decrease hospitalizations and readmissions, with an overall aim of improving quality of care (Ouslander et al., 2014). Interact’s website provides health care facilities with affordable and easy to use “tool kits” that are based on five fundamental strategies including; principles of quality improvement, early identification and evaluation of changes in condition, management of common changes in condition, improved advance care planning, and improved communication and documentation (Ouslander et al., 2014). By using the tools health care providers can help prevent unnecessary hospitalizations and related complications, at the same time receive financial

Bates, O’Connor, Dunn, and Hasenau (2014) seek to understand the STAAR interventions relating to improving post-CABG surgical patient care. The article is a quantitative comparative study with exceptionally qualified authors. The level of evidence for the article is at the studies level. The background of the study introduces the Institute for Healthcare Improvement (IHI), which created a Triple Aim initiative. Triple Aim is able to target specific populations, focusing on three goals: (1) improved individual health outcomes, (2) improved experience of care, and (3) lower overall per capita cost (Bates et al., 2014). Because of high 30-day readmission rates in the post-CABG population, IHI added to the Triple Aim framework by also creating the STate Action on Avoidable Rehospitalizations (STAAR) initiative. STAAR incorporated two nursing interventions for the CABG patients: (1) a teach-back method to facilitate patient education, and (2) scheduling of post-discharge appointments prior to hospital discharge. The overall purpose of the study was to implement STAAR interventions to decrease post-CABG 30-day readmission rate (Bates et al., 2014). The quantitative comparative study was executed from 2011-2012 at a tertiary care facility located in the Midwest United States. Two groups were studied, a pre-intervention group containing 97 patients and a post-intervention group containing 92 patients. Total sample of post-CABG patients was

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.

In future models of care we need to direct more attention to the transitional times that occur in patient care. Naylor, Aiken, Kurtzman, Olds and Hirschman define these transitional times as “vulnerable exchange points that contribute to unnecessarily high rates of health services use and healthcare spending and they expose chronically ill people to lapses in quality and safety” (2011, p. 746). Examples of these transitional times are hospital discharges, receiving