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Care Transitions: A Bridge over Troubled Water

Care transitions have been described as a bridge connecting patients from one healthcare provider or group of providers to another.  It’s easy to imagine a grand structure, like the Golden Gate Bridge in California, with awe-inspiring towers, powerful suspension, and a rock-solid foundation.  But, when patients are discharged from the hospital, the bridge they must cross looks much different: rickety, narrow, and unstable, with wide gaps between decaying boards.  Patients who haven’t fully regained physical or cognitive health, are physically vulnerable, and often times have no social support and a host of other challenges can easily end up falling through the bridge’s cracks.

  • 20% of patients suffers an adverse event within 3 weeks of hospital discharge
  • 20% of Medicare patients are readmitted within 30 days of hospital discharge
  • 2.3 million ED visits per year are from patients discharged from the hospital within the previous 7 day (Jencks, Williams, & Coleman, 2009)

To improve care transitions and prevent readmissions, the healthcare community must build a better bridge.

The Carrot and Stick

50% of potentially preventable readmissions are linked to interventions that could have been provided during hospitalization. (Abner, O’Malley, and Greenwald, 2017)

In 2012, the Centers for Medicare and Medicaid Services (CMS), through the Hospital Readmission Reduction Program (HRRP), began applying financial penalties to hospitals with above average readmission rates for select conditions.  Penalties are applied across all Medicare admissions, not just those which resulted in readmissions. For FY 2017, 79% of hospital incurred a penalty.

In addition to HRRP, other programs, such as Accountable Care Organizations, bundled-payment initiatives, medical home programs, and the Independence at Home demonstration, include incentives to lower hospital readmission rates.  Recently, CMS started allowing physicians to bill Medicare for “transitional care management” after a beneficiary’s discharge from a health care facility as an incentive to provide follow-up activities that could reduce readmissions and other complications.

Contributing Factors to Adverse Events and Readmissions

Several contributing factors have been identified in literature as causes of adverse events during care transitions and readmissions.  A good understanding of these aspects is important for assessing patient risk and determining strategies for improvement.

  • Insufficient Follow-up. A number of studies affirm that patients who are scheduled or seen for a post-hospital follow-up are less likely to be readmitted.
  • Medication-related Issues. Sixty-six percent of all care transition adverse events are due to a problem with medications. (Kripalani, Jackson, Schnipper, & Coleman, 2007).
  • Failed Handoffs. Poor information transfer from hospital-based providers to primary care providers occurs commonly. One study showed 41% of discharged patients had a test pending at discharge, but primary care providers were unaware of 62% of them – 37% of those were considered actionable. (Abner, O’Malley, & Greenwald, 2017)
  • Patient Communication Issues. In one study, 64% of patients said no one at the hospital talked to them about managing their care at home (Jencks, Williams, & Coleman, 2009)
  • Hospital-Acquired Conditions / Adverse Events. The risk of readmission doubles from 14% to 28% with an adverse patient safety event during hospitalization (Jencks, Williams, & Coleman, 2009).
  • Poor discharge planning. 81% of patients requiring assistance with basic functional needs failed to have a home-care referral (Jencks, Williams, & Coleman, 2009)
  • High-risk Clinical Factors. Patients with certain chronic conditions, a high number of co-morbidities, mental health issues, cognitive impairment, prescribed more than five medications, and taking any high-risk medication, such as anticoagulants or narcotics among others are known to be at an increased risk for adverse events leading to readmission. (Abner, O’Malley, & Greenwald, 2017).
  • High-risk Demographic Factors. Certain patient populations show higher rates of readmission, including those with prior unplanned hospitalization within the last 6 to 12 months, low health literacy, inadequate social network, lower socioeconomic status, and the elderly (Abner, O’Malley, & Greenwald, 2017).

Building a Better Bridge

An article published in the Journal of Hospital Medicine proposed key components of an ideal transition of care with each representing a structural support of the bridge patients must cross from one care environment to another during a care transition (Burke, Kripalani, Vasilevskis, & Schnipper, 2013).  “The lack of a domain makes the bridge weaker and prone to gaps in care and poor outcomes.  It also implies that the more components are missing, the less safe the bridge or transition is.”  The 10 domains described are:

  1. Discharge Planning
  2. Complete Communication of Information
  3. Availability, Timeliness, Clarity, and Organization of Information Transfer
  4. Medication Safety
  5. Patient Education and Promotion of Self-Management
  6. Enlisting the Help of Social and Community Supports
  7. Advance Care Planning
  8. Attention to Coordinating Care Among Team Members
  9. Monitoring and Managing Symptoms after Discharge
  10. Outpatient Follow-up

Authors of the article stressed that the conceptualization of an ideal transition of care serves as a guide and provides a common vocabulary for efforts.  “Hospitals and health care systems should decide on interventions customized to their organization based on workflow, resources, and culture.”

Watch our webinar on Care Transitions: Implementing Proper Transitions of Care to Prevent Rehospitalization



Abner, E., O’Malley, T., & Greenwald, J. (2017). Hopsital Discharge and Readmission. UpToDate.

Burke, R., Kripalani, S., Vasilevskis, E., & Schnipper, J. (2013, Feb). Moving beyond readmission peanlties: creating an ideal process to improve transitional care. J Hosp. Med., 8(2), 102-109. doi:10.1002/jhm.1990

Jencks, S., Williams, M., & Coleman, E. (2009, April 2). Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med, 1418-1428.

Kripalani, J. S. (2007). Promoting Effective Transitions of Care at Hospital Discharge: A Review of 5 Key Issues for Hospitalists. Journal of Hospital Medicine, 314-23.

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