Evaluating the Effectiveness of Popular Care Transitions Programs

Topics: Readmissions, Quality, Performance Improvement, Outcomes, Health Care Reform, Market Trends, Strategy, Continuum Integration, Methodologies

Executive Summary

While the U.S. health care system is intrinsically fragmented, the issue of care transitions has come into the national spotlight only recently. Key drivers include: increased data transparency for accountability measures that transcend the hospital’s four walls (such as 30-day mortality and readmissions), financial penalties for 30-day readmissions, and increased funding for care transitions projects.

In addition, as more organizations engage in accountable payment models requiring higher levels of population health risk management and utilization control, care coordination will become a critical competency. Finally, the rising average age of Americans and complexity of patients is further prompting immediate action on enhanced care management across the continuum.

As such, hospitals are increasingly adopting care transitions programs designed to reduce readmissions and unnecessary utilization of costly services. Yet, evidence from many of these initiatives is not as strong as many perceive at first blush. Moreover, many of these interventions have not been tested in large scale, multicenter settings and/or successfully replicated the results in recent years.

Therefore, as providers and regulators seek solutions to reduce readmissions and improve transitions of care, a comprehensive review of the evidence base is warranted. The intent of this white paper is to review the primary outcomes of widely adopted care transitions programs (primarily readmissions and ED and hospital utilization), analyze the unified benefits and shortcomings of existing models, and provide a perspective on future strategies for enhancing care transitions programs.