Care transitions from hospital to home: impact on hospital ... · 2 3 Care transition...

Care transitions from hospital to home: impact on hospital readmission rates across various disease states

Sunovion Health System Digest

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Care transition vulnerabilities

The most vulnerable care transition occurs when patients are discharged from the hospital setting to home.6 Transition failures may originate in self-care, care planning, or health literacy/communication gaps. Examples include7:

• Poor adherence to therapy• Poor access to transportation• Inability to pay for medications

• Failure to actively include the patient and family caregivers in identifying needs and resources and planning for discharge

• Lack of understanding of the patient’s physical and cognitive functional health

• Multiple care providers

• Patient/caregiver failure to ask clarifying questions about care plan

65% of patients readmitted to the hospital had a reading level below what is necessary to understand discharge plans8*

*Based on a 2016 study of patient literacy.

The high cost of readmissions

Streamlining transitions of care across health care settings remains a high priority for health systems. The weeks following hospitalization remain a particularly challenging time for patients.1 Cost drivers to health systems are often a result of readmission to the hospital after discharge, which may signal inadequate planning and transition management.2

Skilled nursing facilities will face 30-day readmission penalties beginning in 20195

of hospitalized Medicare patients are readmitted within 30 days of discharge1

Up to 20%

Total Medicare penalties assessed on hospitals for readmissions will increase to $528 million in 2017, $108 million more than in 20164

The HRRP was established in 2012 under the Affordable Care Act to reduce costly hospital readmissions. Under this program, hospitals are financially penalized for higher-than-expected risk-standardized 30-day readmission rates for4: • Acute myocardial infarction • Heart failure • Pneumonia• Chronic obstructive

pulmonary disease • Hip and knee replacement• Coronary artery bypass graft

A range of hospital-based programs has been developed in recent years to facilitate better care transitions. These programs were designed to help prevent hospital readmissions within 30 days of discharge, which is the quality measure benchmark for the Hospital Readmission Reduction Program (HRRP).1,3

Self-care

Care planning

Health literacy/communication

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* CTI (Care Transitions Intervention); Project BOOST (Better Outcomes for Older Adults Through Safe Transitions); Project RED (Reengineered Discharge); TCM (Transitional Care Model).1

Tools you can use: best practices in discharge planning

Improve discharge planning

Reduce readmissions and length of stay

Postdischarge interventions Patient follow-up

Clinical follow-up (including transportation)

Medication reconciliation

Predischarge interventions Assessment of risk of adverse events or readmissions

Patient or caregiver education

Creation of an individualized patient record

Communication with outpatient providers

Multidisciplinary discharge-planning team

Dedicated transition provider

Medication reconciliation

Core interventions of transitional care among nationally recognized programs1,6,11*

Programs designed to facilitate smoother care transitions may have effective discharge planning protocols in place, with a measurable impact on reducing readmissions.9

Some hospitals integrate plans for discharge on the date of admission as a top priority across the patient journey. Other programs focus on follow-up postdischarge either by telephone or in person with nurse advocates or allied health care providers.1,10

Safe care transitions from hospital to home and other care settings are critical to reducing avoidable readmissions and to delivering high-quality patient care.9

Providers and payers are actively investing in care transition programs as legislative changes increasingly tie reimbursement to high-quality care.1

Commitment to care transition management

Integrating best practices for care transitions and discharge management may help health systems reduce readmissions and costs while optimizing patient outcomes1


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Four care transition programs that have impacted readmission rates1

CTI, Project BOOST, and TCM have been evaluated in multiple patient populations and health care systems. Project RED has been implemented in a safety net system. In Project RED, reduction in hospital utilization by 30% was defined by combined emergency department (ED) visits and readmissions within 30 days of discharge. In Project BOOST, a study of 30 hospitals showed modest reductions in readmission rates, although only 11 hospitals provided data for the study.

ARR=absolute risk reduction; CTI=Care Transitions Intervention; Project BOOST=Better Outcomes for Older Adults Through Safe Transitions; Project RED=Reengineered Discharge; TCM=Transitional Care Model.

Project REDTeam-based program includes pharmacist outreach and medication reconciliation

• Individualized patient record• Dedicated transition provider• Facilitation of communication to outpatient providers• Multidisciplinary team• Outreach• Medication reconciliation (predischarge and postdischarge)

Project BOOSTMulticenter quality improvement program with mentored implementation

• Multidisciplinary team• Outreach• Medication reconciliation• Risk assessment

TCMNurse-led program studied in geriatric patients; intensive outreach with home and telephone follow-up

• Individualized patient record• Dedicated transition provider• Facilitation of communication to outpatient providers• Outreach• Facilitated clinical follow-up

CTIGoal is to facilitate program focused on self-management following hospitalization

• Individualized patient record• Dedicated transition provider• Facilitation of communication to outpatient providers• Outreach• Medication reconciliation

Decreased 90-day readmission rates by 48% (ARR)(follow-up at 12 weeks) and 13% (ARR) (follow-up at 6 weeks)

Decreased 30-day readmission rates up to 5.9% (ARR)

Decreased 30-day readmission rates by up to 5.8% (ARR)

Decreased 90-day readmission rates by up to 21.7% (ARR)

Decreased 30-day readmission rates by 5.8% (ARR)

Decreased 30-day ED visits by 8.0% (ARR)


SUNOVION and are registered trademarks of Sumitomo Dainippon Pharma Co., Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co., Ltd. ©2017 Sunovion Pharmaceuticals Inc. All rights reserved. 12/17 RESP243-17

References: 1. Rennke S, Ranji SR. Transitional care strategies from hospital to home: a review for the neurohospitalist. Neurohospitalist. 2015;5(1):35-42. 2. Carnahan JL, Unroe KT, Torke AM. Hospital readmission penalties: coming soon to a nursing home near you! J Am Geriatr Soc. 2016;64(3):614-618. 3. Centers for Medicare & Medicaid Services. The Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.html. Accessed September 14, 2017. 4. Boccuti C, Casillas G; The Henry J. Kaiser Family Foundation. Aiming for fewer hospital U-turns: the Medicare Hospital Readmission Reduction Program. http://www.kff.org/medicare/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/. Published March 10, 2017. Accessed September 20, 2017. 5. Department of Healthand Human Services; Centers for Medicare & Medicaid Services. Overview of skilled nursing facility value-based purchasing program. MLN Matters Number SE1621. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1621.pdf. Accessed September 28, 2017. 6. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. 7. Comprehensive discharge planning. RARE Campaign website. http://www.rarereadmissions.org/areas/compdischarge.html. Accessed September 28, 2017. 8. Choudhry AJ, Baghdadi YM, Wagie AE, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016;211(3):631-636. 9. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. 10. Schiff J. Top 10 best practices chosen by Modern Healthcare readers. Modern Healthcare. http://www.modernhealthcare.com/article/20160709/40THANNIVERSARY/307099983. Published July 9, 2016. Accessed September 5, 2017. 11. Dreyer T; Center for Healthcare Research and Transformation. Care transitions: best practices and evidence-based programs. http://www.chrt.org/publication/care-transitions-best-practices-evidence-based-programs/. Published January 15, 2014. Accessed September 14, 2017.

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