Safely Handling the Transition from Hospital to Home

We’ve said it before, and we’ll say it again — being released is only the halfway point of a successful hospital experience. The shift from in- to out-patient status is known as “care transition,” and it must be managed carefully to ensure the patient recovers fully.

Two new studies in the Archives of Internal Medicine reinforce the notion that one’s chances of being readmitted to the hospital are significantly improved when health-care providers and patients follow a program of care transition.

That term, according to the the Care Transitions Program at the University of Colorado’s School of Medicine, “refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”

Although the new studies were small — it proved difficult to recruit sufficient numbers of people — real-world applications of what were previously controlled trials showed reduced rates of admission when the hospital discharge process included complete communication.

One program to reinforce post-discharge self-care instructions and the need for a follow-up physician visit reduced 30-day readmissions by 39% among participating Medicare patients in Rhode Island. Another program with different interventions but the same goal for heart failure patients in Dallas showed a 48% reduction in 30-day readmission rates.

A lower incidence of hospital readmission is important not only as a measure of improved care, but reduced cost. Sort of — reduced for whom? Certainly the patient, but not necessarily the hospital.

In one of the studies, as described in MedPage Today, the advanced practice nurse-led program cost $1,1110 per patient but reduced in-hospital health-care costs by $524 from admission to 30 days afterward. And the hospital lost an average $751 in revenue by preventing readmissions.

No one is suggesting that being in the hospital longer than you need is a good idea, but the numbers do suggest a need for change in how hospitals are reimbursed for care administered but not for preventing adverse outcomes, according to Mitchell H. Katz, M.D., of the Los Angeles County Department of Health Services. He wrote an editorial about the studies.

Another fly in the reduced readmission ointment is patients themselves, who must be willing to participate in a prescribed transition program. That’s proving elusive perhaps because people just want to be left alone to recuperate after their hospital experience, and the program can seem intrusive, with home visits and/or phone calls for the purposes of patient and family education and to monitor the patient’s condition.

In a nutshell, care transition is about communication. It’s an organized way, as CU’s Care Transition Program says, to make the “handover from hospital to home go smoothly and to help you stay out of the hospital.” Visit its transitions skills page for information about:

  • The Personal Health Record;
  • The Discharge Preparation Checklist;
  • Medications;
  • Follow-up Visit with your Primary Care Doctor or Specialist;
  • Understanding your Health Conditions;
  • Reaching Your Health Goals.
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