Care Transitions

Care transitions programs meet discharged patients in the home, to prevent readmissions and hasten a return to health

Healthcare providers have known for some time that patient outcomes are determined in large part by what happens outside the hospital – especially the home – not in it.

Today, given hospital-readmission penalties, bundled and episode-of-care payments, and concerns about population health, providers are addressing patients’ post-acute-care issues with evidence-based “care transitions” programs. Rather than allowing recently discharged patients to fend for themselves, often with a poor understanding of how to care for themselves properly, providers meet with them prior to discharge, make a home visit or two, and promote self-management through education.

The need is great. Nearly one in five Medicare patients discharged from a hospital –approximately 2.6 million seniors – are readmitted within 30 days. Readmissions cost over $26 billion every year, says the Centers for Medicare & Medicaid Services. And that’s not to mention the human suffering.

In 2012, the Centers for Medicare & Medicaid Services launched its Community-based Care Transitions Program (CCTP), a five-year demonstration project designed to study and measure the impact of transitional care arrangements on recently discharged patients. Criteria for inclusion in the program was Medicare-fee-for-service patients, 65 years of age or older, discharging home or to a skilled nursing facility, with an admission diagnosis of a chronic condition, such as congestive heart failure, acute myocardial infarction or pneumonia, with certain exclusions (dementia with no live-in caregiver, active addiction, or enrollment in Medicare hospice).

Community-based organizations have been about the task of reducing unnecessary readmissions for years, says Connie Benton Wolfe, president and CEO, Aging & In-Home Services of Northeast Indiana Inc. (AIHS), which participated in the CMS project. “Community-based organizations have a history of being in the home, assessing at-risk populations and of connecting those individuals to services across care settings – locally, regionally, and statewide,” she says. “As our clients have transitioned from one care setting to another, for example, from the hospital to home, we have been there for them – reviewing medications, determining needs, arranging services, monitoring health status.

“Today, we use the term ‘care transitions’ in a more defined way, to refer to a set of services, now evidence-based, to achieve the specific outcome of reducing hospital readmissions,” she says. “However, as we move forward in integrated care, we are adopting use of the term ‘population health management’ at the department level.”

Patient education and self-management
In 2010, AIHS partnered with Parkview Health System’s two Allen County hospitals on a Care Transitions pilot, explains Benton Wolfe. “The pilot came together quickly, as we were both focused on how health happens at home,” she says. “Parkview was aware that a significant percentage of patient outcomes were determined by factors outside of the hospital setting, and AIHS – as a community-based organization – was and had always been in the home documenting social determinants of health, such as economic stability, neighborhood and home environment, community resources, and healthcare literacy.”

With the experience and expertise gained in that pilot, AIHS successfully applied to CMS to become part of the Community-based Care Transitions Program. The project began in March 2013 and was renewed through the end of the program in January 2017.

In both the Parkview pilot, and the CMS program, AIHS followed the Coleman Care Transitions Intervention® method, explains Benton Wolfe. The evidence-based model focuses on patient education, goal-setting, primary care and specialist follow-up, medication self-management, and awareness of red flags.

The need for such intervention is clear, she says. Studies have shown that patients immediately forget 40 to 80 percent of medical information provided by healthcare practitioners. Of the information that is recalled, only about half is remembered correctly.

The CCTP program had a positive impact on 30-day hospital readmissions, says Benton Wolfe. AIHS formed a nationwide coalition of high-performing CCTP programs, who together served 254,225 individuals with an estimated net saving to Medicare of close to $87 million due to reduced readmissions, she says.

AIHS’ own results on 15,730 individuals showed a 10.8 percent readmission rate at the end of the program versus a baseline rate of 17.7 percent. Parkview Health System was selected recently for inclusion in the Truven Health Analytics/IBM Watson Health “15 Top Health Systems for, 2017,” and 30-day readmissions rate was one of the performance measures, she adds.

Break the cycle of readmissions
Another participant in the CMS project was Sun Health Care Transitions, a program of Sun Health, an Arizona nonprofit serving the community of the West Valley of metropolitan Phoenix. It owns and operates three of the 14 Life Care retirement communities in Arizona, which offer independent housing options, and health and rehabilitation facilities.

Sun Health launched Care Transitions in November 2011 after analyzing the community need for this type of assistance, says Deb Richards, MSN, RN, director of Care Transitions. “Patients don’t want to be in the hospital, and they don’t want to return, either. We all want to be well, and Sun Health was determined to find a way to provide the community seniors a way to age in place as healthy as possible.”

The Sun Health Care Transitions (SHCT) program focuses on supporting patients after hospitalization to self-manage their health conditions and break the cycle of readmissions. Sun Health partnered with Banner Boswell and Banner Del E. Webb medical centers during the five-year CMS project, employing the Coleman Care Transitions Program® model as its basis.

Sun Health nurses screened potentially eligible Medicare fee-for-service patients, then presented the program to selected patients and their loved ones while they were still in the hospital.

Sun Health modified the Coleman model based on the specific needs of its community, says Richards. For example, registered nurses – instead of non-clinical health coaches – made the initial home visits to the post-discharged patients. LPNs followed up by phone to review patients’ progress and adherence to their action plan for recovery.

Sun Health insisted on a home visit, because “that’s where the wealth of knowledge is,” says Richards. Only in the home can the nurse sit down with the patient, engage them and ask open-ended questions. He or she can see how easy – or difficult – it is for the patient to move around in the house, or how much – or how little – comprehension the patient has of the discharge plan. “Being able to provide one-to-one education and care makes a great deal of difference, no matter what the health literacy level is.” Based on those observations, the nurse can modify the action plan or connect the patient with other resources, such as meal or transportation services.

Goal-setting was an important element of the program. “And those goals don’t have to be monumental,” says Richards. “It could be, ‘By the end of the month, I want to be able to walk to the end of the block and back,’ or something as simple as ‘I want to go to my grandson’s soccer game.’ There’s a sense of accomplishment.”

For the nurses, the experience was very fulfilling, she adds. “We just had a patient call us about one of our nurses who had come to see her. She told us, ‘Now I understand what atrial fib is all about, what is going on with my body, and why it’s important to do certain things.’

“That’s the kind of thing that means everything to our team – making a difference in someone’s life.”

Lessons learned
Sun Health participated in the CMS program from May 2013 through January 2017, when the demonstration program ended. Its readmission rate was 7.72 percent, which was lower than the national Medicare average of 17.8 percent. The program resulted in a 57-percent reduction in readmissions, with an estimated savings of $16 million. The program proved to be a tremendous learning experience for Richards and the Sun Health Care Transitions team, she says. “We would have monthly calls with other CCTP teams, and would come together in Baltimore once a year. Everyone shared their expertise and ‘aha’ moments.”

Other lessons learned:

  • The interaction at the hospital proved to be invaluable in regard to patient acceptance of the program.
  • Having RNs perform the home visit was very important, because they were able to perform an assessment, identify urgent issues, and provide a medication review as well as medication education for the patient.
  • Providing the education on patients’ chronic disease helped them understand what was happening with their bodies and how to maintain or improve their current level of health.
  • Home visits also proved invaluable in identifying the true issues (some medical, some psychosocial) that can affect someone’s recovery and health status.

“Our biggest challenges would be poor discharges from the hospital, when all of the patient’s needs are not identified and addressed,” says Richards. “This is not always the hospital’s fault. We found that by going to the patient’s home, sometimes the real evaluation of needs is discovered.”

What’s next?
AIHS continues to work on care transitions with private insurance groups and a Medicaid managed care organization, and at press time was preparing to launch pilots for other payers in population health management, says Benton Wolfe.

“Beyond AIHS, I believe in the valuable role that care transitions, aka population health management, plays in improving health outcomes while lowering healthcare costs. I don’t see the need diminishing for those type of results.”

Sun Health Care Transitions is looking for partnerships with other hospitals, payers, accountable care organizations and others to leverage its expertise for the benefit of other patients, says Richards. “Our program has a proven 200 percent ROI,” she adds.

The Medicare test for care transitions

Nearly one in five Medicare patients discharged from a hospital – approximately 2.6 million seniors – are readmitted within 30 days, at a cost of over $26 billion every year.

To address the issue, the Centers for Medicare & Medicaid Services – as part of the Affordable Care Act – launched the Community-based Care Transitions Program in February 2012. The program, which ran until January 2017, tested models for improving care transitions from the hospital to other settings, and reducing readmissions for high-risk Medicare beneficiaries.

Community-based organizations that participated in the program were required to provide care transition services across the continuum of care, including at least one of the following:

  • Care transition services beginning no later than 24 hours prior to discharge.
  • Timely and culturally and linguistically competent post-discharge education to patients so they understand potential additional health problems or a deteriorating condition.
  • Timely interactions between patients and post-acute and outpatient providers.
  • Patient-centered self-management support and information specific to the beneficiary’s condition.
  • Comprehensive medication review and management, including, if appropriate, counseling and self-management support.


After surgery, what?

For patients undergoing complex abdominal operations in the United States, poor transitions from the hospital to home contribute to hospital readmission rates ranging from 13 to 30 percent, reports the American College of Surgeons. To address this situation, a research team investigated the effectiveness of a phone-based transitional care program adapted to the needs of surgical patients. The researchers found the program was feasible for hospital staff to implement and provided a positive experience for patients, according to study results published in the Journal of the American College of Surgeons.

Previously, physicians at William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, previously demonstrated that implementation of a transitional care program for hospitalized patients had led to a reduction in readmissions and cost savings. However, no evidence-based transitional care program existed for surgical patients, according to lead study author Sharon Weber, MD, FACS, professor and chief of the division of surgical oncology, department of surgery, University of Wisconsin School of Medicine and Public Health, Madison.

The needs of post-surgical patients differ from those of patients discharged with chronic medical conditions, she said. The latter typically have prior knowledge of their condition and how to treat it, whereas many surgical patients have no idea what to expect following discharge. “And today, there is a clear recognition of post-hospitalization syndrome,” she said. “The patient is sleep-deprived, possibly on narcotics, and unable to think as clearly as usual. There is a realization that the education patients in that post-operative period differ from what they need any other time in their life.”

To implement the adapted surgical program, known as sC-TraC, University of Wisconsin Hospital hired nurses, who underwent five weeks of intensive training to prepare them to counsel patients on postoperative recovery. The pilot study was conducted from October 2015 through April 2016, and included 212 patients enrolled after complex abdominal procedures, defined as colorectal, hepatobiliary, or other gastric or small bowel resections.

The nurses met patients before they were discharged from the hospital, and then contacted them 24 to 72 hours after discharge. They focused on four areas:

  • Medication reconciliation.
  • Any symptoms that would warrant direct contact between the nurse and patient.
  • Scheduling a follow-up appointment.
  • Ensuring the patient had the nurse’s contact information.

The nurses initiated phone calls every three to four days as needed. The program was completed once the patient and/or caregiver and the sC-TraC nurse mutually agreed that no further follow-up was needed, the patient had been discharged for six weeks, or the patient was readmitted to the hospital within 30 days after discharge, study authors wrote.

“Patients were unbelievably happy to have someone whom they could reach directly on the phone and they didn’t have to go through a phone tree,” said Weber.

Ninety-five percent of patients participated in the post-discharge protocol for at least one phone call. Seventy-two percent of them ended the program after mutual agreement that no further follow-up was necessary. A small percentage refused further follow-up or were readmitted to the hospital. Of all 212 patients, 17 percent were readmitted within 30 days of discharge.

Researchers also found that 46 percent of patients had medication reconciliations (meaning the patients weren’t taking medications correctly) noted on the first phone call. Study authors said this finding was concerning, because it is the hospital’s routine practice to have a pharmacist-led medication reconciliation before the patient leaves the hospital. “It reiterates that what we are providing at discharge in a routine way is not enough to meet patients’ needs,” Weber said.

“We clearly saw in the VA population this was a ‘pro’ from a cost perspective, because readmissions are so expensive, she said. “The other thing is this: Hospitals such as ours are constantly maxed out from a census perspective. If you have to turn away patients to accommodate those who have been readmitted, that’s an opportunity cost.”

Still, further study of the cost-effectiveness of a post-surgical care-transitions program is needed, she said.

A care transitions model

The Coleman Care Transitions Intervention® – used by a number of participants in the Centers for Medicare & Medical Services’ Community-based Care Transitions Program – is a self-management model, which draws from principles of adult learning and uses simulation to facilitate skill transfer. As many patients are likely to experience another transition in the near future, the Care Transitions Intervention aims to address both the patient’s current and future needs.

The program was developed by Eric Coleman, M.D., MPH, professor of medicine and head of the Division of Health Care Policy and Research at the University of Colorado Anschutz Medical Campus.

During a four-week program, comprising a home visit and three phone calls, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach® to learn self-management skills that will ensure their needs are met during the transition from hospital to home.

“The Transitions Coach is key to encouraging the patient and family caregiver to assume a more active role in their care,” according to the organization. “The Transitions Coach does not fix problems and does not provide skilled care. Rather, Transitions Coaches model and facilitate new behaviors, skill transfer, and communication strategies for patients and families to build confidence that they can successfully respond to common problems that arise during care transitions.”

According to the organization, patients who underwent the Coleman program are:

  • Significantly less likely to be readmitted to a hospital.
  • Less likely to incur further high cost utilization.
  • More likely to achieve self-identified personal goals around symptom management and functional recovery.

Furthermore, these findings are sustained for at least six months after working with the Transitions Coach®, says the organization.

Source: The Care Transitions Program®,

Three simple questions

If a discharged patient “strongly agrees” with the following three questions, there’s a good chance he or she will avoid being readmitted to the hospital unnecessarily. The questions form the basis of the Care Transitions Measure® from the Care Transitions Program®,

  1. “The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.”
  1. “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.”
  1. “When I left the hospital, I clearly understood the purpose for taking each of my medications.”

Source: © Eric A. Coleman, M.D., MPH