Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost

Transitional Care Management: Five Steps to Fewer
Readmissions, Improved Quality, and Lower Cost
KimSu Marder

© 2016 Health Catalyst
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Transitional Care Management
Transitional care management, managing
patient transitions from one level of care
to the next, is an important part of
healthcare outcomes improvement.
The National Association of Clinical Nurse
Specialists defines transitional care as
“care involved when a patient/client
leaves one care setting…and moves to
another.”
Care settings include hospitals, nursing
homes, assisted living facilities, skilled
nursing facilities, and the home
environment.

The practice of transitional care
management aims to identify and
overcome barriers to successful
transitions and prevent gaps in care.
The goals are to improve the patient
experience while saving health systems
the cost of avoidable readmissions.
Care managers are integral to
achieving successful transitions of
care and preventing unnecessary
readmissions.

This presentation outlines a pragmatic,
five-step framework for delivering successful
transitional care to avoid unnecessary
admissions and associated cost.

Reducing Readmission Rates and Lowering Costs
Under the Hospital Readmission Reduction
Program (HRRP)—which the Affordable
Care Act established in 2012—
organizations are penalized financially for
unacceptably high readmission rates
among Medicare and Medicaid patients.
According to estimates from the Medicare
Payment Advisory Commission, 12 percent
of readmissions are avoidable, and
Medicare could save $1 billion by
preventing just 10 percent of avoidable
readmissions.

After five years of the HRRP, data suggests
readmission rates are falling.
Before 2012, Health and Human Services
reported an all-cause 30-day readmission
rate among Medicare beneficiaries of
around 19 percent.
By 2013, this rate was down to around 17
percent, indicating an estimated 150,000
fewer hospital readmissions between
January 2012 and December 2013.

The Institute for Healthcare Improvement
(IHI) estimates that a structured and
comprehensive transitional care
management program can help health
systems reduce avoidable readmissions.
And because hospitalizations make up a
significant portion of annual U.S. healthcare
spending—almost one-third of the total
$2 trillion, of which the IHI observes, “a
substantial fraction” is often avoidable
readmissions—decreasing readmissions
through transitional care management is a
priority in today’s healthcare environment.

Transitional Care Management at Work
Sun Health, a non-profit community-based
organization in Arizona, implemented an intensive
transitional care management program in 2011.
The anticipated outcomes were reduced
readmissions and a decrease in medical cost,
which the program achieved after nine months.
The program also showed positive qualitative
outcomes: patients were not only satisfied with
the care management program, they also
reported that their confidence level regarding
self-care improved.
Fostering independence and self-advocacy are
key elements of any care management program.

Transitional Care Management in Five Steps
Successful transitional care management is rooted in five essential steps,
resulting in better outcomes at a lower cost.
Step 1: Start Discharge at the Time of Admission
Step 2: Ensure Medication Education, Access,
Reconciliation, and Adherence
Step 3: Arrange Follow-Up Appointments
Step 4: Arrange Home Healthcare
Step 5: Have Patients Teach Back the
Transitional Care Plan
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A care manager oversees
the transition plan and
ensures that each member
of the patient’s care team
(patient, primary care
provider [PCP], specialist,
pharmacist, social worker,
family caregiver, and any
others who will participate
in the care plan) are
included in carrying out the
care plan.

Start Discharge at the Time of Admission
When a care manager learns that a patient is readmitted, they contact the
case manager at the hospital or skilled nursing facility. This initial contact lays
the groundwork for a successful discharge that lowers risk of readmission.
The care manager should ask the case manager several questions:
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What’s the care plan?
What’s the expected length of hospitalization?
What kind of care will the patient need when
they go home?
Does the patient need to be discharged to a
facility other than home, such as a skilled nursing
facility or a rehabilitation facility?
How will the case manager communicate the
discharge plan to the patient, family, or caregiver?

Communication about discharge between the
transitional care manager and hospital or
facility case manager is particularly critical.
As hospital stays become shorter in duration,
care is best coordinated when the community
or transitional care manager collaborates on
discharge plans with the facility care manager
immediately upon admission.
The care manager, as part of discharge
planning, will communicate with the PCP and
facility care manager to coordinate visiting
nurses, or other community agencies, for
immediate home health assistance.
1

For example, if a patient is discharged on a Friday,
the visiting nurse agency may not get to the home for
an assessment until the following Monday or Tuesday.
This is an avoidable gap in care that would leave the
patient without care for up to four days, increasing risk
for readmission.
The care manager must ensure agencies
are aware of the discharge and schedule
timely visits prior to discharge.
1

A follow-up call to the patient within two days of
discharge is important to assess the patient’s
condition and understanding of prescriptions,
and to educate them on signs and symptoms
that should prompt a call to their PCP.
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Ensure Medication Education, Access,
When a person is hospitalized, either due to a chronic or a new acute
condition, it is likely that the patient will receive a new prescription or a
change in medication.
The transitional care manager must
cover the following key points
regarding medication:
Education
Access
Reconciliation
Adherence
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EDUCATION
The care manager works with the care
team to teach the patient or caregiver
about all medications—what they’re
for and how (i.e., with or without food)
and when to take them.
This includes an understanding of
the risks of missed doses and what
to do if they miss a dose.
Education should be completed prior
to discharge.
2

ACCESS
Access to medication includes both the ability
to get to the pharmacy to pick up prescriptions
and the ability to pay for them.
Prompt pick-up is particularly important with
certain medications; with antibiotics, for
example, a delay or interruption may cause an
infection to return.
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ACCESS
Before patients are discharged, the care
manager verifies with the patient or
caregiver that they can access and afford
their medications, or connects them with
resources to help (such as elder services or
a social worker from the PCP practice or
from the discharging facility).
2

RECONCILIATION
The care manager can collaborate with the
facility or practice pharmacist, if there is one
available, on medication reconciliation. The
pharmacist can play a vital role in obtaining an
accurate medication list for the patient’s
follow-up visit with the PCP.
Ideally, this reconciliation should be done at
the time of, or immediately after, discharge.
The reconciliation should be communicated to
the PCP prior to the follow-up visit (scheduled
within seven to 10 days of discharge).
2

ADHERENCE
Care managers can help patients and
caregivers understand the importance of
adhering to the medication plan.
How likely is the patient to take the
medication as prescribed?
Is there a literacy or understanding
issue that might prevent them from
taking the full course of medication or
taking it every day at same time?
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Arrange Follow-Up Appointments
Upon discharge, the care manager makes sure the
patient has a follow-up appointment with their PCP
seven to 10 days after discharge.
Patients should not skip the PCP follow-up, even if
they have plans to see a specialist.
The PCP is the continuum-of-care point person,
meaning they need stay informed of all other care
to avoid prescription contraindications, conflicting
clinical plans, confusing or contradicting patient
instructions, and other adverse events.
3

Arrange Follow-Up Appointments
Likewise, the care team pharmacist or care
manager must conduct a medication reconciliation
to obtain a current list of prescriptions, including
any new medications given in the hospital or upon
discharge.
This medication list should be given to the PCP
before the follow-up appointment.
3

Arrange Home Healthcare
The care manager determines what type of
help the patient needs at home and whether
they have someone to help. This is critical
for anyone in weakened state (e.g., elderly
patients).
After discharge, patients may need help
with cooking, dressing, and other daily
tasks, as well as someone to check in
with them and make sure they are
adhering to their medication and
follow-up care plans.
4

Arrange Home Healthcare
Care managers must ensure the home is
safe (e.g., handrails where needed and no
slippery rugs or clutter to trip on) and all
needed durable medical equipment has
been ordered (e.g., walkers and
commodes).
Visiting nurse agencies, elder services,
therapy, and/or social work interventions
are all examples of services that must
be in place prior to discharge.
4

Have Patients Teach Back the
Transitional Care Plan
The final, indispensable step in the transitional care management
framework is having the patient and caregiver teach back the care plan.
This is how the care manager confirms that
they’ve successfully educated the patient on
their discharge plans, diagnosis, medication,
and when to call their PCP.
It confirms the patient’s understanding of the
follow-up appointment with the PCP.
The care manager gives the patient a number
to call with any questions (e.g., the ED or case
manager at the hospital or skilled nursing facility).
5

Transitional Care Management Is Critical in
Today’s Healthcare Environment
Readmissions are preventable in
many cases.
This five-step transitional care
management framework can
serve as a guide for transitional
care managers.
Each step is intended to improve
outcomes, mitigate cost, and to
prevent gaps in care.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
Transitional Care Management:
Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost
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Dr. Amy Flaster, VP of Care Management Services
Is Your Care Management Program Working: A Guide to ROI Challenges and Solutions
Dr. Amy Flaster, VP of Care Management Services;
Kathleen Clary, BSN, MSN, DNP, VP of Care Management & Patient Engagement
A Guide to Care Management: Five Competencies Every Health System Must Have
Russ Staheli, VP of Analytics
The 3 Must-Have Qualities of a Care Management System
Russ Staheli, VP of Analytics
Nationally Recognized Transitional Rehabilitation Program’s Strategies
Health Catalyst Success Story

KimsSu Marder joined Health Catalyst in September 2015 as Care Manager Lead. Prior
to coming to Health Catalyst, she worked for Tufts Health Plan as Care Management
Relationship Manager. KimSu has a degree in Education from Lesley University, a
degree in Nursing from Regis College, and is currently working on a Psychiatric Nurse
Practitioner MSN at Regis College.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
KimsSu Marder

Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost

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