The CMS has defined transition of care as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.⁷ Patients with complex care needs, such as those with chronic conditions, often require care from various providers in multiple settings.

The patient and caregiver may be the only common thread between the different healthcare settings. Each care transition opens an opportunity for a breakdown in communication, resulting in a negative outcome for the patient and the risk of readmission to the hospital. Experts have demonstrated that by focusing attention and resources on transitions of care, readmissions can be sharply reduced.

Transitional care, as defined by a position statement from the American Geriatrics Society, is “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.”⁸ Early researchers in transitional care have included the various environments and providers in their comprehensive plans for this level of care.^9,10

Many factors can contribute to poor transitions of care; however, the medical literature describes several common themes. Ineffective communication and care coordination: Patients with complex care needs are at especially high risk during discharge from the hospital, and established processes do not always ensure adequate communication and coordination from one setting and provider to the next.

The growth of the hospitalist model of care contributes to the problem, as fewer primary care physicians are participating in the acute management of their patients. Under this model, a patient’s primary care physician turns over inpatient care to hospitalists, who are physicians specially trained for acute management; the primary care physician resumes responsibility following the patient’s discharge.

This process intensifies the need for effective communication and information transfer at the time of transition. Although effective care plans may have been developed, institutions may fail to relay essential elements of the patient’s plan of care. Ineffective communication results in providers practicing in “silos,” without adequate knowledge to treat the patient, while timely information exchange is necessary for success.¹¹ Key information about diagnosis, diagnostics, treatment, medication changes, pending tests, and follow-up care need to be relayed to the next primary care provider accurately and promptly.

One researcher found that several of these important elements were lacking. For example, diagnostic test results were missing 38% of the time, and 65% of tests were still pending at discharge. The Joint Commission requires a discharge summary be sent to the next provider of care within 30 days; however, this study demonstrated that most primary care physicians prefer it within one week.

Less than one-third (12% to 34%) of discharge summaries were available at the first post-discharge visit, with only 51% to 77% having arrived by four weeks. The study also showed that direct communication between the hospital provider and primary care physician happened only 3% to 20% of the time.¹²

All three of these cases represent negative outcomes for the patients, their caregivers, and the healthcare system. They also demonstrate what millions of patients face because of poor transitions of care. Nearly one in five Medicare beneficiaries discharged from the hospital, about 2.6 million older adults, are readmitted within 30 days of discharge at a cost of $26 billion a year.¹ Three-quarters of these readmissions are considered potentially preventable.²

.² As the baby boomer population advances in age, we can expect a surge in the number of Medicare beneficiaries with multiple chronic conditions requiring complicated management of these conditions for persons with longer life expectancy.³

A recent analysis by the Agency for Healthcare Research and Quality (AHRQ) demonstrated that the readmission rate following a hospital stay for a chronic condition can be substantially higher than for an acute condition.⁴ Poor care transitions are not a new problem. In the 2001 Institute of Medicine report “Crossing the Quality Chasm: A New Health System for the 21st Century,” experts identified poor care transitions as a major cause of poor healthcare quality and waste. It noted “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.”⁵ Avoidable readmissions represent poor outcomes for patients and unnecessary costs to the healthcare system. In 2013, the Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program to tie a hospital’s reimbursement to its readmission rates.⁶ The program hopes to incentivize hospitals to reduce avoidable readmissions by penalizing those that exceed a national benchmark measure for readmission rates.

Initially, readmission of patients with diagnoses of heart failure, acute myocardial infarction and pneumonia were included; in fiscal year 2015, additional diagnoses of COPD and elective total hip and knee replacements were added, and in fiscal year 2017, atypical types of pneumonia and coronary artery bypass graft (CABG) were added.⁶ In its initial year, the Centers for Medicare & Medicaid Services (CMS) reported a diagnosis-related groups payment reduction of up to 1%.6 Penalties are now applied prospectively, with some hospitals receiving up to a maximum 3% penalty in fiscal year 2017.⁶

This approach, coupled with other incentives, is intended to improve hospital care, place greater emphasis on transitions of care, and result in more care coordination in the outpatient setting.

A study from The New England Journal of Medicine looked at October 2003 through December 2004 claims data for 11,855,702 Medicare beneficiaries and found that 50.2% of the patients readmitted within 30 days of a medical discharge had no bill for a physician’s office visit between discharge and rehospitalization.¹³ Efforts aimed at improving transitions of care include arranging a follow-up appointment before discharge, ideally in seven days.

A recent study of 30,136 patients from 225 hospitals examined the association between outpatient follow-up within seven days from a heart failure discharge and readmission within 30 days. They found that patients who were discharged from hospitals that have higher early follow-up rates had a lower rate of readmission within 30 days.¹⁴

The process of making a follow-up appointment before discharge may seem simple, but it’s often a manual process with unreliable results. Patients and their caregivers may not be included in the appointment-making process, which may lead to a lack of understanding about the importance of the visit, scheduling conflicts or a lack of transportation. Hospitals may struggle with the appointment process as well, finding it difficult to determine the expected discharge date, lacking resources to make the appointments, and facing outpatient providers unwilling to schedule appointments from someone other than the patient. Outpatient providers may face challenges with high no-show rates, cancellations, or lack of information.

Even in the cases when a follow-up appointment is scheduled before discharge, a period of transition exists when no one is “in charge” of the patient. The hospitalist’s responsibility may end when the patient is discharged, and the primary care physician may feel he or she is not responsible until the patient is seen back in the office at that first post-discharge visit. If the patient’s condition worsens before that outpatient visit, the patient often simply returns to the ED. A study funded by AHRQ showed that patients who have a clear understanding of their after-hospital care instructions, including how to take their medications and when to make follow-up appointments, were 30% less likely to be readmitted compared to patients without this information.¹⁵ However, patients often receive little to no education on how to care for themselves after discharge.

Hospital staff may have insufficient time or lack the dedication needed to complete education and detailed discharge instructions in the time frames afforded by today’s compressed hospital stays. Even when education does occur, patients who are under stress and overwhelmed by their illness may not remember important information given to them about their care. They may be confused about their medication regimen, lack understanding about post-discharge tests, receive conflicting information from different providers and be unclear regarding their follow-up instructions and appointments.

Health literacy and cultural background may also impact how information is received and acted on. Patient adherence may be one of the most challenging aspects of preventing avoidable readmissions. The ability for the patient to follow the recommendations for his or her prescribed therapy is the definition of adherence.¹⁶

Medication nonadherence rates have been identified at 25% and result in increased morbidity, mortality, and cost.¹⁶ Nonadherence to the treatment plan, specifically medications, has been shown to increase the risk of morbidity and mortality in cardiovascular conditions.¹⁷ Medication adherence varies greatly depending on the population studied; however, those with chronic conditions requiring long-term therapy may be more at risk.¹⁷

Factors related to medication nonadherence can be categorized into intentional and unintentional nonadherence.¹⁸ Patients intentional nonadherence is a decision made after the patient weighs their beliefs, pros and cons of treatment, review of provided educational materials, or other personal reasons. Unintentional nonadherence results from poor understanding or cognitive impairment. Practitioners play a significant role in medication adherence. Lack of communication and coordination between multiple providers can lead to complex medication regimens that may include dangerous contraindications or confusion for the patient and caregiver.¹⁹ This is especially common with chronically ill patients who may be prescribed medications from their primary care physician, specialists, and hospitalists. Failure to recognize the financial burden may preclude patients from filling prescriptions. Physicians may also fail to effectively communicate the disease process or the rationale for the medication, contributing to patient nonadherence.¹⁹ The structure of our healthcare system alone may create challenges for some patients to be successful. Poor healthcare coordination and limited access result in fragmentation of care. High drug costs and copayments prevent access to necessary medications.¹⁹ Health information technologies, although improving, lack the ability to provide healthcare providers with access to medical information from a variety of venues.¹⁹ Many of the factors for medication nonadherence also impact other aspects of disease management, such as dietary restrictions, lifestyle modification, and provider follow-up.