Care Transformation Center Blog

The 6 key components of an effective care transition process

by Rebecca Tyrrell, MS

While the post-discharge process and readmissions prevention are by no means new concepts, increased regulatory scrutiny, financial penalties, and enhanced data transparency and accountability measures have prompted a renewed focus on improving care transitions.

Many population health leaders are now expanding transition management to tackle additional avoidable cost opportunities such improving medication reconciliation processes, monitoring medication use, bolstering patient engagement, and incorporating non-clinical risk factors into ongoing patient management. To capture these opportunities, organizations must deploy finite care management resources against a tailored set of care delivery and care coordination services.

Based on our research, there are six key steps in an effective transition process, regardless of your staffing model or even the specific tools you use:

1. Perform an initial risk stratification to identify patients at moderate or high risk of readmission

As close to initial admission as possible, determine whether a patient is low-, moderate-, or high-risk, ideally using an automated or low-effort tool. The risk designation will influence the specific services provided, with enhanced support layered on as a patient readmission risk rises. Using an acuity-based tool or predictive modeling algorithm saves time and reduces variability that may otherwise be introduced by inconsistent clinician referral patterns.

2. Conduct an in-depth patient assessment for the highest-risk patients

For patients considered high-risk based on the initial stratification, conduct a more in-depth psychosocial assessment to gain a better understanding of the patient's environment outside of the hospital to properly customize the care plan and level and type of support provided. Sample areas that might be included in a risk assessment include literacy, language, cultural needs and preferences, and housing and transportation issues.

3. Determine the next site of care and assign clear points of contact

During the discharge planning process itself, identify the next site of care, the level of support needed, and whether that support must be in person. The answers to these questions guide staffing (i.e., who is providing the support and where the handoff points are).

4. Engage the right participants, leveraging warm handoffs before discharge

Throughout this transition planning process, actively engage the patient and caregiver(s) to ensure they have a safe space to ask questions, share preferences or opinions, and address any barriers to carrying out the post-discharge plan. If the patient will be paired with a transitions coach, this meeting provides a great opportunity to meet face-to-face and for the inpatient team to transfer necessary information in a consistent manner.

5. Tailor post-discharge support to patient needs and site of discharge

Depending on patient risk level, some patients discharged home may only require a follow-up phone call, while others may need one or several home visits. Acuity and needed services influence what type of staff member should be deployed to provide services in the home. Staff may also be leveraged to surface and address readmissions drivers at specific post-acute care facilities receiving large referral volumes.

6. Connect the patient to the primary care team, ideally via warm handoff

Close the loop by connecting the patient to their primary care team after specialized transitions support concludes to provide a smooth transition.

To discuss these steps in greater depth or to see case studies highlighting these process steps in action, please feel free to contact me.

How to build a system that never discharges the patient

Providers face a mandate to deliver seamless care across settings, but with limited time and resources, it's not sustainable to perfect one transition before the next. Download an excerpt from our white paper to find out how you can start achieving care continuity.