Three Reasons Health Systems Need to Master Care Transitions Now

Sophie Leveque

The concept of care transitions in health systems is nothing new – it’s been an ongoing concern and challenge for hospitals to address for a long time. But a unique confluence of legislative and market-driven forces are now putting new pressures on health systems to evolve the way they view and execute care transitions. Penalties for readmissions, emerging payment methods, new delivery models, and the overall shift from a fee-for-service to a fee-for-value environment are some of these powerful drivers behind the shift. As a result of this perfect storm of forces, we’re seeing health systems moving from a historically laser-focused view on logistics (e.g., how do you physically move a patient to a skilled nursing facility?) to a much more comprehensive role in the overall process, execution and follow-up that a care transition entails.

However, making this kind of tidal shift in such a critical part of healthcare delivery isn’t going to be easy, especially for health systems with firmly entrenched processes and procedures. Yet hospitals that don’t realize the urgency of the need to master care transitions face significant risk and also forgo the upside that comes with doing care transitions well.

Following are three reasons why health systems need to stress the necessity of mastering care transition improvements as soon as possible:

  1. The very definition of “care transition” is changing. Historically, a care transition might have just dealt with how a hospital transported a discharged patient from its environment to another one, but now a care transition can refer to a much broader spectrum of activity and coordination. It entails any movement patients make between healthcare practitioners and settings as their conditions and health needs change during the course of a chronic or acute illness. As a result, care transition demands broader thinking: where did your patients come from? Where are they going next? Do they have a personalized discharge plan? Do they understand their medication plan, and will they adhere to it? Care transition now requires a multi-disciplinary care coordination team.

  2. New financial pressures mean that readmissions are costlier than ever. According to one analysis, one single readmission doubles the cost of a beneficiary stay of episode, which makes readmission expensive on its own. There are also new – and growing year-over-year– federal fines for readmission, which means health systems have an immediate financial interest in figuring out how to better manage care transitions beyond the traditional acute-care facility.

  3. Poor care transitions lead to negative behaviors and outcomes that drive up costs. There are a number of causes that can create poorly executed care transitions, such as lack of resources or electronic uniformity. Regardless of what’s behind a bad care transition, it can engender negative behaviors, including fragmented and uncoordinated care, non-compliance, and a breakdown of communication, all of which can lead to costly results like patient and provider dissatisfaction and inferior outcomes.
We all recognize that the current state of reactive, episodic care is simply not sustainable. That’s why hospitals should immediately address how they handle care transitions, employing a much more holistic approach that will help them stay ahead of this pivotal point in the healthcare industry.  

To find out how you can help transform your health system with a better, more sophisticated approach to care coordination, view our recent webinar recording, “Carrots and Sticks: Why Hospitals Need to Master Care Transitions Now”.