The Importance Of Transitional Care In Achieving Health Reform

Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions—often the most vulnerable—transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions—a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments. M ore than a decade has passed since the Institute of Medicine published its landmark reports, To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. Yet the quality of health care in the United States remains suboptimal and fragmented. These shortcomings particularly affect chronically ill people, who experience frequent changes in health status accompanied by multiple transitions between care settings and care providers. Transitions, or “handoffs,” are vulnerable exchange points that contribute to unnecessarily high rates of health services use and health care spending, and they expose chronically ill people to lapses in quality and safety. It is during these transitions that mistakes commonly occur; for example, information about medication that a patient may have been prescribed while in the hospital may not be accurately communicated to the nursing home to which the patient is discharged. In addition to medication discrepancies, transitions can give rise to adverse clinical events; to patients’ having serious unmet needs; and to patients’ poor satisfaction with care. A recent multinational survey comparing the experiences of chronically ill adults from eight countries confirms these findings. Transitions have also been associated with increased rates of potentially avoidable hospitalizations. A 2009 study reported that approximately 20 percent of Medicare beneficiaries discharged from hospitals were rehospitalized doi: 10.1377/hlthaff.2011.0041