Transitions of Care from Hospital to Home

Today, the Alliance of Community Health Plans released a new report, Transitions of Care from Hospital to Home, the second in our series entitled Health Plan Innovations in Patient-Centered Care.  This new report details our members’ care transition initiatives and focuses on health plans’ roles in implementing and sustaining improvements to patient transitions from hospital to home.

The process of hospitalization is a stressful, confusing, and often traumatic experience, for both patients and their loved ones. Augmenting this anxiety are the difficulties associated with transitioning back home: poor coordination of care, confusion with instructions and medications, and a lack of communication all contribute to high hospital readmissions rates and medication errors. Every year, millions of Medicare patients are re-hospitalized within 30 days of being discharged. Not only do readmissions increase stress and health risks, they are costly – Medicare readmissions alone cost the U.S. over $26 billion annually.

Health plans play a crucial role in these transitions, as they are often the only entities that have a complete picture of a patient’s care across locations. ACHP health plans have been at the vanguard of improving care transitions for their members, assisted by close ties with their communities and partnerships with providers. Our report, conducted by independent health care analyst Avalere Health, incorporates insight and feedback from twelve different ACHP plans working to improve patient care. By identifying five key practices in care coordination amidst shifting providers and locations, these member plans can more effectively facilitate their transition programs’ success:

  • Using data to tailor care transition programs to patients’ needs.  By identifying patients most at risk for readmission, plans can ensure that these patients get the necessary help and resources for their transition to home.
  • Anticipating patients’ needs and engaging them early in the transition process.  Engaging patients prior to hospital discharge allows health plans to make sure the patient is going to an appropriate setting, prepares a patient for a home visit from a case manager or other clinician, and provides the patient with realistic expectations about their care and guidance on addressing issues that may arise.
  • Engaging providers to become program partners.  Health plans can incorporate provider feedback into the design of care transitions programs and communicate regularly with provider teams to maintain physician engagement and incentivize positive outcomes.
  • Leveraging technology to improve care transitions.  Technology, including access to a centralized and accurate patient record, plays a critical role in how health plans facilitate communication between patients and their providers during a transition of care.
  • Incorporating care transitions into broader quality initiatives.  Some plans use their care transitions programs to enroll members into other programs such as disease management, while other plans make care transitions a component of a larger program, such as a patient-centered medical home, rather than a stand-alone initiative.

In implementing these key practices, ACHP plans have developed innovative and creative solutions to connect with patients and coordinate with providers. Security Health Plan of Wisconsin collaborates with discharge planners at each of its contracted hospitals, and sends “Get Well Cards” to patients prior to discharge. These cards serve to engage patients in and provide explanation of care transitions programs.  Below is an example of one of the cards.

Technology plays a critical role in facilitating communication; in light of this, ACHP plans have improved their care coordination by utilizing telehealth solutions and maintaining electronic medical records. All of HealthPartners of Minnesota onsite case managers are equipped with laptops, which allow them secure access to their health information systems and platforms. In rural Michigan, where access to care is of vital concern, Priority Health uses telehealth solutions for heart failure patients. By using glucometers to remotely monitor glucose levels in CHF patients with diabetes, providers keep an eye on patients – if the daily data indicates a red flag, providers will telephone or conduct a home visit to check up. These are only a small fraction of the myriad ways in which our member plans are developing promising solutions to the most pressing issues of care transition.

Based on these examples and many others like them from our member plans, it is clear that we must move beyond thinking about care as individual episodes of service where one piece of the delivery system hands off a patient to another.  Successful care transitions require a patient-centered approach in which providers and health plan staff are working in partnership and utilizing their unique roles and skills to provide the best care for patients.

My hope is that this report will serve as a useful resource to health plans, providers, and policy makers, as well as consumers. Much is at stake in reducing hospital readmissions; particularly now, the sense of urgency to reduce costs and improve quality of care is intensifying. We can all benefit from taking a look at the successful initiatives of ACHP health plans, as well as the challenges they have faced, to continue to search for and implement new care transitions strategies.

– Patricia Smith
President and CEO, ACHP


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