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Reduce readmissions by closing transitional gaps in care


People over the age of 80 is the fastest-growing population sement in the United States, and they are also the most susceptible to falling through the cracks in the healthcare system.

On the surface, "care transitions" sounds like an area of responsibility limited to hospitals and clinicians, since those stakeholders deliver direct patient care. But insurers also have a role to play, otherwise that type of segmented thinking will likely lead to care breakdowns and hospital readmissions.

"This isn't something that can be done just by physicians and hospitals," says Mark D. Stewart, MPH, associate director of quality programs at the Washington, D.C.-based American College of Cardiology Foundation (ACC). "One of the very first ingredients in creating a good care transition plan is gaining the support of top executives, including those at payer organizations. In fact, if getting the buy-in of top non-clinical executives isn't the single most important success factor, it's close."

When insurers and hospitals find ways to work together, the quality and cost improvements they achieve can be significant. For example, an initiative developed by Aetna and Mary Naylor, MD, a professor of gerontology and director of the New Courtland Center for Transitions and Health at the University of Pennsylvania Health System, combined case management and home care, coordinated by advanced practice nurses (APNs). In the program, an APN visited Aetna members in the hospital before discharge to ensure they knew what to expect once they got home.

"The defining topic for healthcare right now is the aging population, and healthcare professionals aren't quite sure how to engage this group," says Hugh Lytle, co-founder, president and CEO of Univita Health, a Scottsdale, Ariz.-based company that integrates clinical and non-clinical services to promote a home-centered approach to independent aging. "They have a lot of healthcare needs, but they are also passionate about staying independent and don't want to repeat their parents' aging experiences. From both a cost and quality-of-life perspective, we need to find ways to allow patients to stay in their homes rather than move into long-term institutions."

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