Improving Transitional Care

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Written by: Bruce Bethancourt, MD, FACP, Paige Wyer, NP, Jessica Vanderwilp, PA, Erica Shimkus, NP, Libby Peirce, NP

A landmark article published in 2009 by Jencks, et al. highlighted the high readmission rate of patients discharged from acute care hospitals. According to data analysis, 19.6% of all Medicare patients admitted to the hospital are readmitted within 30 days of discharge. The cost of readmission is $17.4 Billion annually. It is felt that with improved coordination of care that 76% of this readmission would be preventable.1 In many cases, the cause of readmission is not related to the care provided by the acute care hospital.2 Often, the cause of return to an acute care hospital after discharge is the reason for which the hospital has no influence; lack of sufficient timely follow-up, transportation, health care literacy, medication reconciliation or affordability, cognitive dysfunction or lack of community or family support. Patients discharged from hospitals are often in a vulnerable health state and are at risk of adverse events and readmissions that might be preventable with better post-discharge planning and execution. Until recently, hospitals may have under-emphasized comprehensive discharge planning and tended to view this as the responsibility of the patient’s primary care physician or specialist. A comprehensive discharge planning process is one of the key ways to reduce avoidable readmissions. However, all too often, when patients are discharged they cannot schedule an appointment or get to their primary care or referred physicians in a timely manner. Even if a timely post-discharge appointment is provided, chronically ill patients with a multisystem disease are oftentimes so vulnerable immediately following hospitalization, that they do not fare well in busy primary care office.

Intervention for the Post-Acute Care Patient

In considering an approach to improve the transitions of patients from the acute care setting to home, we relied on a systematic review published in the Journal of General Internal Medicine in 2013, mapping transitional care interventions to the “Ideal Transition in Care” framework. The most common components included were patient education (with an emphasis on promoting self-management), medication safety, and coordination of care. We utilized these most common components in designing the focus of the Dignity Health Medical Group Center for Transitional Care. We utilized a portion of other models in place across the country, Naylor’s model, the Project Reengineering Discharge (RED) and the Coleman Model, etc. that fit our demographics.3

In November of 2015, we launched the Dignity Health Medical Group Center for Transitional Care (CTC) at St. Joseph’s Hospital and Medical Center and the following year at Chandler Regional Medical Center. The goal of the CTC is to improve patient outcomes and reduce hospital readmissions through bridging gaps in the hospital to home transition. The Centers for Transitional Care serve as outpatient clinics that offer a range of transitional care services for patients who are discharged from the hospital with chronic or complex illness, or who lack adequate resources for timely follow-up. The CTC provides team-based care with Physicians, Advanced Practice Providers, Social Workers, Registered Nurses (RN), and Medical Assistants. Patients are referred to the CTC by the attending physician or nurse case managers in the hospital. Upon referral to the CTC, the patient is visited in the hospital by the clinics RN. The RN describes the purpose of the program. If the patient accepts the invitation, an appointment is made for follow-up within 72 hours of discharge. The CTC’s RN also seeks to identify any barriers to care the patient might have in transitioning home.

The initial appointment to the CTC is extensive and includes a review of the patient’s hospital course, medical history, a focused physical exam, medication reconciliation and education, disease, and self-care education, plus care coordination. The CTC takes a multidisciplinary approach to address both the medical and nonmedical needs of each patient. During each visit, the provider assesses the patient’s potential barriers to care in addition to evaluating their medical condition. In cases where there are external needs, the clinic’s social worker works alongside the provider to connect the patient with the appropriate community resources to assist in meeting those needs. The CTC also partners with entities in the community that provide various financial, social, and healthcare services. Occasionally, our social workers conduct a home visit to better assess a patient’s nonmedical needs during the transitional period.

Patients seen at the CTC are followed up by a provider for 30 to 45 days after their date of discharge. Depending on the diagnosis, some patients receive remote care monitoring until stabilized. In acute events, the patient has access to a provider 24 hours a day, and same-day appointments are available. The patient may be seen in the clinic for IV diuretic therapy, IV hydration, insulin management, thoracentesis, or paracentesis.  Patients are referred to the appropriate specialists for follow-up and set up with a long-term primary care provider if they do not already have one.  Patients are discharged from the clinic when the medical condition is stabilized. At the time of discharge, the primary care physician and/or specialist are provided with a complete summary of care.

Experience of the Centers for Transitional Care

The CTC experiences approximately 2000 visits per year. The most common diagnosis of patients referred to the CTC is DM, Heart failure, DVT, and Atrial Fibrillation (see figure #1). The typical high-risk patient seen in the CTC has greater than six medical problems, eight medications, hospital length of stay longer than predicted, and the majority do not have an active relationship with a primary care physician.

We conducted a retrospective chart review on patients referred to the CTC that were seen (797) versus those referred but not seen (238) over a six month period. The medical complexity, age, length of hospital stay, gender, and race composition were similar between the groups. Those seen and followed by the CTC had a 30 & 90 day readmission rate of 7.15 % and 11.92% respectively. Those scheduled but not seen by the CTC had 30 & 90 day readmission rate of 15.8% and 24.6% respectively (Figure 2). Utilizing the hospital’s overall readmission during this time period, a total of 60 readmissions were prevented by the CTC. Using CMS calculation that every readmission cost $12,500.00, it’s estimated that the savings for this 6 month period were $750,000.00.

Figure 2

To date, the DHMG Center for Transitional Care has decreased readmissions for high risk- complex patients, provided many with access to community services and improved the quality of care for patients discharged from an acute care setting. Hopefully, we are on our way to attaining the triple AIM of better care for the individual, population, and at a sustainable cost.


1) Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N. Engl. J. Med. 2009; 360:1418–28

2) Joynt KE, Jha AK. A path forward on Medicare readmissions. N. Engl. J. Med. 2013; 368:1175–7

3) Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The Importance of Transitional Care in Achieving Health Reform. Health Aff (Millwood). 2011; 30(4):746-754. doi:10.1377/hlthaff.2011.0041.

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