Transitional Care Can Reduce Hospital Readmissions

age 80 or older

functional deficits

active psychiatric condition

four or more comorbidities

six or more prescription medications

two or more hospitalizations in the 6 months before the index period

inadequate social support

poor health literacy

poor adherence to medical recommendations.

Polypharmacy

Psychological comorbidities

Principal diagnosis of cancer, stroke, diabetes, chronic obstructive pulmonary disease, or heart failure

Physical or functional limitations

Poor health literacy

Poor social support

Prior hospitalization in the 6 months before the index period

Palliative care needs.

Patient receives post-acute care follow-up within 24 hours of discharge to monitor condition and reinforce and monitor transition plan.

Patient has primary-care appointment within 1 week of acute-care episode.

Sending provider is responsible for patient's care until receiving provider has communicated that he or she is assuming responsibility and acknowledges receipt and understanding of discharge information and plan of care.

Two-way communication between providers, patients, and care team includes opportunities for clarification and feedback.

Communication should include community provider, patient, and family in assessing post-discharge needs.

Telephone follow-up should be provided shortly after discharge

Use formal tools, such as Universal Discharge or Transition Checklist in patient-friendly language.

Discharge information is developed with and provided to patient and family.

Use electronic means to transfer health information expediently and securely, ideally, within 24 hours.

Patient information arrives to receiving provider or agency ahead of patient.

Use formal transitional care tools, such as Coleman personal health record, to help ensure engagement.

Inform patient in writing about "red flags" that signal worsening of condition.

Use teach-back strategies to ensure patient understands and is engaged in plan.

Discuss post-discharge care and resource needs.

Include patient goals, values, and priorities in transfer record.

Caregiver involvement is included.

Care coordinators facilitate communication between providers and settings.

Case management is communication hub.

Care coordination is provided by nurses.

Clearly identify care provider or team to coordinate and manage patient's transition.

Clearly identify primary care provider.

Primary-care follow-up visit is scheduled before hospital discharge.

Patient has 24/7 access to healthcare professionals, with access to patient records.

Sending provider sends contact name and number of individual who can respond to questions and concerns.

Reconcile discharge plan with national guidelines.

Reconcile medications, including herbal and over-the-counter products, at each stage of transition.

Provide written reconciled medication list to patient and family and review it with them.

Provide education about medications to patient and family; include teach-back.

Assess patient's polypharmacy and medication risks, allergies, drug-drug, and drug-illness interactions.

Interdisciplinary team is involved in developing and managing medication management plan.

Patient has system for managing his or her medications.