Care transitions occur when a patient moves from one health care provider or setting to another, or from a health care provider to home. Effective care transitions are important for optimizing patient health and for avoiding unnecessary utilization of hospital services and related services. As CMS has noted:
Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.
The resources below provide ideas, insights, and promising practices for optimizing care transitions. These resources can be used to support collaborative learning and improvement in community models of care.