Care Transition Models.
Several models for improving transitions after hospitalization have been developed and rigorously tested. One of the most widely disseminated is the Care Transitions Intervention developed by Eric Coleman at the University of Colorado. This approach involves transitions coaches, primarily nurses, and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls over a 4-week period.
The coaches promote development of patients’ skills in four key self-care areas: managing medications; scheduling and preparing for follow-up care; recognizing and responding to red flags that could indicate a worsening condition, such as the onset of a fever or worsening breathing problems; and taking ownership of a core set of personal health 75information by having patients brainstorm and ask their providers questions about their conditions or self-care routine. In a large integrated delivery system in Colorado, the Care Transitions Intervention reduced 30-day hospital readmissions by 30%, reduced 180-day hospital readmissions by 17%, and cut average costs per patient by nearly 20%. The intervention has been adopted by more than 700 organizations nationwide.
Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of older adult patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36% and costs by 39% per patient (nearly $5000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients’ physicians and provides regular home visits with 7-day-a-week telephone availability.
What is in the Law?
The Affordable Care Act contains several provisions that could improve care transitions. These include both carrots (financial incentives) and sticks (financial penalties).
