Effective Transitions of Care After Discharge Process


Getting the right transitions of post-acute care affect a patient’s well-being following their hospital stay.

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In the United States more than 20% of patients and more than 40% of Medicare patients require post-acute care following a hospital stay.

Patients transitioning to post-acute care are the most vulnerable and require high-quality care.

It’s critically important to get the transition from the hospital to another level of care right.

An efficient hospital discharge begins by involving patients and their families in the decision-making process and ensuring that patients are aware of all post-acute facilities available to them by maintaining quality, objective data about potential providers.

Getting the patient transition right drives improved clinical outcomes. When patients receive the appropriate level of care after an acute episode, results include fewer adverse events post-hospital discharge, reduced readmission rates and improved utilization of appropriate services that directly lower the cost of care.

Related: The Imapct of a Hospital Post-Acute Care Program on Value-Based Care

There are four areas of focus to ensure successful transitions from hospital bed to post-acute care facility:


  • Partner with Patients during Discharge:
    When planning for a patient’s discharge, there are several options from which hospitals and patients can choose – whether a home health agency (HHA), skilled nursing facility (SNF), inpatient rehab facility (IRF) or long-term care hospital (LTCH).

    Nearly 20% of patients experience an adverse event post-discharge and it is imperative that discharge planners, patients and families work together to find the facility that best addresses the patient’s unique needs.

    Patient choice in the discharge planning process is especially critical following the CMS’s revision to the discharge planning requirements and finalized portions of the IMPACT Act. It is now more important than ever for hospitals to focus on the patient’s goals and treatment preferences and also include the patient and his or her family as active partners in the transition process.

    The goals of the Final Rule on discharge planning are increased transparency, patient empowerment and quality care. To achieve these goals, acute providers should leverage intuitive and contextual technology, combined with strong clinical workflows, during discharge to effectively engage patients and introduce provider quality into the decision-making process.

    Knowledgeable, well-informed patients are more empowered to make educated decisions about the next step in their care journey. By thoroughly informing patients about their best post-acute care provider options, providers can help ensure patients choose the appropriate quality care settings that will best serve their specific needs.


  • Minimize Acute Length of Stay:
    Patients rely on guidance from their healthcare team to make well-informed decisions during what is often a confusing and stressful process. To expedite the discharge process and reduce hospital length of stay, acute providers should use care coordination technologies that educate patients about post-acute providers using real-time and accurate data. Technologies that allow case managers to efficiently deliver information to patients at their bedside help ensure patients are discharged in a timely manner, minimizing avoidable discharge delays, reducing acute length of stay and decreasing unnecessary hospital expenditures.


  • Reduce costly hospital readmissions and emergency room visits:
    Hospital readmissions from post-acute facilities may signify inefficiencies in the transition of care process, such as a mismatch between patient needs and post-acute care facility resources.

    JAMA found that on average, nearly 23% of SNF patients are readmitted to the hospital within 30 days. Readmissions are adverse outcomes for both the patient and the provider. When patients and their families better understand their options surrounding post-acute care facilities, they are further empowered and engaged to make the right decision – which helps reduce costly readmissions.

    Although the ultimate goal is to successfully discharge the patient to the community, patients discharged from post-acute care often turn to the emergency department because of a shortcoming somewhere earlier in the transition of care. With the right care coordination programs in place, there are ways to help reduce turning an emergency visit into another inpatient stay. It’s beneficial for the patient and the overall cost of care if a patient’s emergency visit is intercepted before it becomes an inpatient stay.


  • Implement transitional care services:
    Transitional care services – whether medical reconciliation by phone, face-to-face follow-up appointments or other services – can further prevent breakdowns or gaps in a patient’s care.

    These timely check-ins improve a patient’s successful transition to post-acute care or back into the community, and ultimately reduce hospital readmissions and unnecessary ER visits. Transitional care has been found to significantly lower readmission rates, with reductions up to 45%, as reported by American Nurse Today.

    Providers have a stake – both for the well-being of their patients as well as financially – in providing a continuation of high-quality care and aiding in communication between post-acute providers, patients and their families. Combined with quality post-acute selection, transitional care services ensure patients are on the best path to continue their care journey.

Getting the right transitions of care relies on our breaking down of health system siloes. Poor transitions of care can increase the risk of adverse events due to lack of communication – or miscommunication – between different levels of care. Providers that rely on technologies and strong workflow processes to help educate patients in their transitions can prevent readmissions and improve patient, clinical and financial outcomes. Increased transparency and communication between acute providers, post-acute providers and patients ultimately results in getting the transition of care right, not to mention reduced total cost of care and improved patient outcomes.

Michael Ipekdjian, MBA-HM, BSN, RN, director of customer success at CarePort, is a former bedside nurse, inpatient acute case manager and has also held multiple senior care management roles. He holds an MBA in Healthcare Management from Western Governors University. Prior to joining CarePort, Michael was the Corporate Chief Operating Officer of Better Health Your Way. He also served as Director of Transitional Care Management at Holyoke Medical Center.

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