Transitions of Care


Transitions of Care, Hospital Transition, Health Care Facility Transition, Hospital Readmission Prevention

  • Definition
  1. Transitions of Care
    1. Transitions into and out of health care facilities
    2. Example: Hospital discharge to Nursing Home
  • Precautions
  • Transitions of Care
  1. Transitions of Care are high risk periods
  2. Associated with increased medication errors
  3. Associated with 20% re-admission rate within 1 month of hospital discharge
  4. CMS will penalize hospitals and care systems for excess 30 day readmission rates
  • Approach
  • Medication reconciliation common problems
  1. Discrepancies between pre-admission medications and those during hospitalization and then at discharge
  2. Medications started in the hospital that should have been discontinued at discharge (or with set end-date or taper)
  3. Chronic medications that require re-start after being held during the hospitalization
  4. Changes in medication doses, frequency/schedule or formulation
  • Approach
  • Labs and Diagnostic common problems
  1. Pending test results following hospital discharge (occurs in 40% of patients discharged)
  2. Important results that change therapy are found in as many as 10% of pending results
  • Billing
  • Evaluation and Management Codes (E&M Codes)
  1. Code 99495: Moderately complex medical decision making
    1. Patient Communication within 2 business days of discharge
    2. Face-to-face patient visit within 14 calendar days
  2. Code 99496: Highly complex medical decision making
    1. Patient Communication within 2 business days of discharge
    2. Face-to-face patient visit within 7 calendar days
  • Prevention
  1. Communication between hospital care team and the clinic care team (sign-offs)
  2. Schedule hospital discharge follow-up prior to the patient leaving the hospital
    1. Clinic staff (e.g. triage RN) to call patient within 2 days of leaving hospital
    2. Provider visit within 7-14 days of leaving the hospital
  3. Give patients their discharge summary from hospital to bring to their follow-up appointment
  4. Educate patients and families on condition-specific home monitoring and measures
    1. Example: Daily weights in Congestive Heart Failure and what abnormalities should prompt a call
  • Disposition
  1. Median time to fullow-up after discharge: 12 days
  2. Risk factors for follow-up no-shows and same-day cancellations
    1. Medicaid insurance
    2. Black race
    3. Long admissions >15 days
    4. Discharge to home with services or to facilities
  3. Factors that make follow-up more likely
    1. Age over 65 years
    2. Living more than 40 miles from follow-up clinic
    3. Discharge from subspecialty clinic
    4. Follow-up with subspecialty clinic (in contrast with primary care)
  4. References
    1. (2017) J Hosp Med 12:618-25 [PubMed]