transitional care management

An In-Depth Look at Transitional Care Management

Avoidable and costly hospital admissions are a key quality and patient safety concern for patients, family, and caregivers alike. A significant cause of readmissions that are otherwise preventable is poor coordination of care during transitions. Being moved between care settings is a vulnerable period for patients, especially aging adults. Transitional care management needs to take into account a variety of elements, including admissions and discharges within acute-care hospitals; long-term care facilities; skilled nursing facilities; assisted living facilities; in-home care, and a well put together transitional care program.

Sadly, poor coordination between the primary caregiver and acute setting often results in bad planning. In fact, less than 50% of patients actually see their primary caregivers within 2 weeks of being discharged from the hospital[i]. Individualized and comprehensive programs to enhance the patient’s care during the transition between settings can significantly reduce hospital readmissions for up to a year after the initial hospitalization.

Here is what we will cover in this article:

  1. Transitional Care- Hospital Readmissions in Numbers
  2. The Risk Factors of Readmissions and Reassessment
  3. Transitional Care – What Exactly Is It?
  4. The Benefits of Transitional Care
  5. How is Transitional Care Financed?
  6. Different Transitional Care Models
    1. Research-Based Findings for Various Forms of Transitional Care Management

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Transitional Care – Hospital Readmissions in Numbers

Before we go any further, take a look at readmission by the figures[ii]:

          • As many as one in five patients are readmitted to hospital within a month
          • 75% of readmissions are preventable
          • The readmission rate for seniors discharged to nursing homes is higher with 25% being readmitted within one month
          • Readmissions cost the United Stated healthcare system more than $17 billion per year. This figure does not include readmissions to urgent-care settings or emergency departments[iii]

Before new and improved approaches to transitional care management can be implemented, we need to have an understanding of readmission risk factors.

The Risk Factors of Readmission and Risk Assessment

The problem of readmissions was highlighted in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century[iv]. The Institute has also identified weak patient instructions on discharge, including information about red flags for fading conditions, information regarding medications, and the necessary contact information for concerns and questions, as a major care-transition problem.

There are a variety of factors that seem to pose a risk for readmission[v][vi]. Some of these include:

          • Emergency department visits and previous acute-care hospitalizations
          • Being over 65 years of age
          • Comorbid medical conditions
          • Lack of social support
          • Substance abuse
          • Poor access to healthcare services
          • Functional limitations
          • Poor health literacy

Important to note here is that patients who lack a strong family support network are at greater risk of readmission to hospital. Unfortunately, family members often have little input into their loved one’s transitional care planning as they are excluded from discussions. It is common that just the patient receives self-management information, even though family members or in-home caregivers are the ones who provide the actual care.

Another major factor is patients who are discharged on weekends. There seems to be a lack of support services, such as medical equipment companies and pharmacies, that are available during weekend hours.

Transitional care management relies heavily on a broad range of resources and is more likely to be effective when targeted at seniors who are at the highest risk of readmission. In one particular study[vii], researchers undertook a methodical review of the tools available to envisage a patient’s risk for hospital readmission. The researchers evaluated 13 instruments that offered the potential to decide which patients would most benefit from transitional care services. It was found that while the risk tools had an overall poor predictive ability, both the high and the low-risk scores interrelated with readmission rates in a rather significant way.

However, another researcher criticized this study for failing to consider the intent of the tools used[viii]. The researcher, Wodchis, carried out a study of the tools designed to choose patients for transitional care programs and then assessed their relative abilities to predict both long-term and acute-care use. Wodchis reviewed five instruments and found that the patients identified by each instrument differed. That is because each tool was designed to identify a range of different risk factors. Wodchis’s finding was that while the tools did have predictive value, they predicted different outcomes. The researcher discovered that the best predictor tools of the 30-day acute-care readmissions and emergency department visits were the LACE index[ix] and Probability of Repeated Admission[x] tools. However, since the tools use risk factors that cannot be modified when assessing risk, they don’t provide lots of direction for targeted transitional care management.

Transitional Care – What Exactly Is It?

Transitional care is an umbrella term that refers to a collection of services aimed at maximizing communication and coordination of services to provide timely, safe, and high-quality care during transitions. An optimal transitional care program should include management of patient and family education, aiding communication among healthcare providers involved in the transition process, and arrangement and coordination of care in the post-acute care setting.

There has been a range of transitional care management programs that have been put through randomized controlled trials. The result is that patients experience significantly lower readmission rates. The programs typically include services such as:

          • Complete and thorough discharge planning
          • Home visits
          • Post-discharge telephonic outreach
          • Patient-centered discharge instructions
          • Medication reconciliation
          • Follow-ups with the primary caregiver

The question we need to consider is: what are the benefits of transitional care for patients and their families?

The Benefits of Transitional Care

The primary advantage of transitional care for patients is that patients can retain their sense of independence, particularly when they opt for in-home transitional care after a stay in the hospital. Patients and their families also benefit from such programs with:

          • Multidisciplinary care teams that offer personalized care and planning
          • Thorough preparation for a successful return home after hospitalization, thereby reducing their risk of readmission to an acute care hospital
          • Care teams consulting with fellow providers from referring acute hospitals to address patient and family member’s concerns and questions
          • Transitional care closer to home or at home, which makes it easier for friends and relatives to support and participate in the patient’s recovery by attending therapy sessions and learning how to assist when the patient is back at home
          • Qualified caregivers who ensure patients receive the attention and services they require

How Is Transitional Care Financed?

The Affordable Care Act[xi] does provide financial resources for providers with the aim of delivering transitional care services and reducing costly readmissions.

For the past four years[xii], Current Procedural Terminology codes for transitional care have allowed organizations to bill for transitional care management. Physicians or registered nurses are required to oversee programs that provide:

          • Coordination services, including reviews of the discharge summary, medication management, assurance the diagnostic testing and follow-up equipment are scheduled, additional patient medication
          • Face-to-face patient visits with their health care provider within two weeks of being discharged from hospital, or within seven days for complex cases
          • E-mail or telephonic contact with patients within 48 hours of being released from hospital

Now that we have discussed the basics of transitional care and what is required of physicians, carers and others involved in a patient’s care let us delve into the different transition models that have been tried and tested.

Different Transitional Care Models

Three core transitional care programs have been developed with the aim of reducing readmissions and healthcare costs. These include:

          • The care transitions intervention model
          • Transitional care model
          • Better Outcomes for Older Adults through Safe Transitions

1. The Care Transitions Intervention Model

The care transitions intervention model[xiii] was developed by Eric Coleman. The model is based on a 4-week program aimed at fostering patient engagement and promoting a smooth transition for patients from the hospital or nursing facility to their home. The model has successfully shown to decrease expensive readmissions.

The four pillars that the model rests on are:

          • Alertness to red flags
          • Self-management of medication
          • Follow-up from primary care physicians
          • The maintenance of a personal health record

A transition coach is assigned to the patient to focus on the patient’s self-determined goals and assist him or her in developing self-management skills. The relationship between patient and transition coach is short, covering just 4-week, and the coach will not assume case-management and home-care responsibilities.

Coaching the patient will start in the hospital, where the coach explains the transitional care program, ensures the patient agrees to participate, and then introduces the patient to the Coleman personal health record[xiv]. The record is used to guide patients in documenting the medical information and medication and creating a list of questions for their healthcare provider. The coach will also schedule a home visit within 72 hours of the patient’s discharge.

During the home visit, the coach will help the patient with their pre- and post-hospitalization medication review and address any discrepancies that arise. Together, the patient and coach discuss the discharge plan and update a personal health record. The coach will also discuss drug side effects and symptoms and devise an alert-and-response system.

Once the initial home visit has been done, three follow-up calls are made to address any remaining concerns and discuss the outcomes of the follow-up visits from the primary care provider. Support services will be considered, and the coach may help the patient with scheduling follow-up appointments if needed.

2. The Transitional Care Model

The transitional care model[xv] was created by Mary Naylor. The model incorporates a 1 – 3-month period of interventions with high-risk senior patients in an attempt to prevent unnecessary readmission to hospital. A pre-discharge patient assessment is performed by an advanced practice registered nurse (APRN). The APRN then collaborates with the hospital team, and a transitional care plan is developed.

The APRN undertakes to make several home visits, promote information transfer between primary-care and acute-care settings by going with the patient to their first primary care follow-up and using telephonic outreach throughout the transitional care period. Some of the cornerstones of this transitional care model include:

          • Goal setting
          • Patient engagement
          • Communication with health care team members
          • Communication with patients and their families
          • Identification of early symptoms and signs of a worsening condition so as to expedite speedy intervention and avoid re-hospitalization

This model encourages family members to play a significant role in supporting their elderly relative during hospitalization and after discharge. Up until recently, very little attention was given to family caregiver’s and their distinctive needs during their aging loved one’s transition in care. As a result, family caregivers have consistently rated their level of engagement in the decision-making process around discharge plans and the quality of the caregiver’s preparation for the next stage of care as disappointingly weak.

Overall, caregiving is rewarding, but it can also serve as a burden to family caregivers[xvi]. It is likely that the stress of caregiving is heightened during periods of acute illness, and it is up to social workers and nurses to attend to the caregiver’s emotional needs during transitional care in order to minimize their negative experiences and boost their ability to support their older relatives.

3. Better Outcomes for Older Adults through Safe Transitions (BOOST)[xvii]

The BOOST transitional care program provides a broad range of materials to help senior citizens optimize their discharge process. All the approaches and tools in this program are aimed at quality improvement and are based on the principles of evidence-based medicine and institutional and personal experiences.

The BOOST toolkit was first developed in 2008 with support in the form of a $1.4 million grant from the John A. Hartford Foundation. The program continues to be improved upon, but the 5 key elements include:

          • Longitudinal technical assistance – this provides face-to-face training and 12 months of expert coaching and mentoring to customize and implement the care program. Mentors aim to guide local teams in an attempt to build a culture supportive of safe, thorough transitions. Teams will have monthly calls with their mentors and ongoing training and support.
          • Comprehensive intervention – this is developed by a panel of experts.
          • BOOST data center – the center allows sites to store data and compare it to control units and other sites so as to generate reports.
          • Comprehensive implementation guide – the guide provides step-by-step instructions and tools to help medical teams redesign their hospital discharge workflow while also implementing and evaluating intervention.
          • BOOST online community – a space for teams to communicate with and learn from one another.

BOOST is a quality improvement collaborative that has already been implemented across the United States in a wide variety of hospital settings. The program focuses on general medicine populations, and it is up to the mentors and hospital experts to facilitate the development and implementation of this transitional care program. The BOOST toolkit contains a number of interventions, including:

          • Medication reconciliation
          • Risk assessment
          • Discharge Checklist
          • A multidisciplinary team approach to the release process

Research-Based Findings for Various Forms of Transitional Care Management

While the above three programs are the most common, it is important that we understand a wider range of transitional care models[xviii] for senior citizens in our country and the roles of caregivers within the models. A great deal of research[xix] has been conducted between 1996 and 2007. In order to understand the models, three major databases were searched (Social Work Abstracts, CINAHL, and Medline) and three auspicious approaches were identified towards improving the quality of care for older adults suffering from a chronic illness. These approaches are:

          • Improving patient handovers to and from the acute-care hospitals
          • Improving transitions within acute-care hospital settings
          • Increasing the aging adult’s access to successful community-based transitional care management

Overall, the three approaches focus explicitly on the patient and only slightly on family caregivers. Let us take a closer look at descriptions of models for each of the categories.

Patient Hand-Overs to and from the Acute-Care Hospitals

Various studies have assessed multidimensional models of care that are designed to address problems that seem to occur during the hand-over of chronically ill senior patients between the hospital and their home. It has been shown that interdisciplinary interventions[xx] led by qualified nurses have consistently improved cost savings and quality of care[xxi].

Care Transitions Coaching

An intervention that has been designed to encourage senior patients and their family caregivers to take on more active roles during care transition has been tested by a multidisciplinary team at the University of Colorado Health Sciences Center, Denver[xxii]. During testing, an advanced practice nurse acted as a transitions coach, teaching patients and their caregivers the skills required to promote cross-site continuity of care. The coaching started out in the hospital and then continued for 30 days after the patient was discharged. A controlled, randomized trial discovered that patients who received this type of transitional intervention have lower readmission rates to the hospital for up to 90 days after discharge, compared with control patients in the test. That means that at six months, hospital costs were about $500 less for senior patients in the intervention group. So, the quality of care was improved while they avoided costly readmission.

Transitions within Acute-Care Hospital Settings

Regular transitions within a hospital setting, such as from the emergency department to intensive care and then to a step-down unit followed by a move to a general unit, have been shown to have adverse effects on the health of elderly patients as well as the well-being of their caregivers. Serious medication errors seem to be common during the transition period[xxiii], and therefore several transitional care programs have been designed to address this issue.

Professional-Patient Partnership

This is a model that has been used in Baltimore with the aim of improving discharge planning and the resulting outcomes for senior patients with heart failure while taking their family caregivers into consideration. The program emphasizes the importance of engaging the patient and his or her caregiver in the discharge planning process. Upon discharge, patients and their caregivers are required to complete a questionnaire that will assess their needs. They are also given videotapes to watch on post-discharge transitional care management, and they receive information on how to access community services. With this model, patients and their caregivers have reported feeling well-prepared to manage their care after discharge.

Acute Care for Elders (ACE)

This model was developed at the University Hospitals of Cleveland, Ohio, and is aimed at avoiding functional decline while improving discharge readiness among senior citizens. Some of the core features of the model include:

          • Having daily conferences with the interdisciplinary team
          • Adapting the physical environment to meet the aged patient’s needs
          • Starting discharge planning right from admission
          • Actively involving family members in the discharge process
          • Using guidelines implemented by nurses for restorative and preventive care

Early trials have shown that ACE patients tend to have higher levels of functioning when discharged, shorter hospital stays, and fewer hospital costs.

Community-Based Transitional Care Management

After evaluating state, federal, and provider initiatives that have been designed with the aim of improving the continuity of care for high-risk seniors, it has been indicated that having better access to community-based, short-term care for managing acute episodes of chronic illness are likely to be of great benefit[xxiv]. It is the findings of these evaluations that has led to the design of community-based transitional care management.

Day Hospitals

Day hospitals have been modeled after a program implemented by the British health care system. It has proven to be an effective form of community-based transitional care management, with one such initiative being the Collaborative Assessment and Rehabilitation for Elders program (CARE)[xxv] at the University of Pennsylvania. The program was designed as a full outpatient rehabilitation facility directed by a geriatric nurse practitioner and targeted and community-based senior citizens who were deemed a high risk for hospitalization. Patients were given access to a variety of palliative, health, and rehabilitation services for several days per week for nine weeks. The study revealed that decreased hospital use and improved function among patients were significant benefits of community-based transitional care.

Hospital to Home Transitional Care

It has been determined, within community-based models, that the needs of senior patients who regularly experience acute episodes of chronic illness can be best addressed with home-based transitional care programs, like the Hospital at Home program. During one study[xxvi], researchers enrolled chronically ill older adults from a community who would usually be admitted to hospital for acute exacerbation of certain chronic illnesses. The patients were identified within the emergency department and discharged back to their homes after enrollment. Once home, the patients received physician, nursing, and a range of other services as suggested by the protocol. The findings were that patients spent shorter lengths of time in the hospital and their overall costs were reduced.

Ideally, you should check with a homecare agency for Transitional Care Programs suitable for the patient.

So, we have discussed the different transitional care management programs, with studies to back up their benefits, we need to go further into how the quality of transitional care is measured along with a few key strategies[xxvii] for transitional care.

How Is the Quality of Transitional Care Measured?

At the moment, the Care Transitions Measure (CTM)[xxviii] is the only endorsed measure of the quality of transitional care. The CTM is comprised of a 15-item survey for patients to answer.

Key Strategies and Guidelines for Transitional Care

There are a few key strategies that can and have been, implemented by hospitals and healthcare providers for transitional care. These include:

            1. Efforts to reduce readmission in the emergency department
            • Red flags for potential 30-day readmissions
            • Care continuity in the emergency department with individualized care plans
            1. Contextualize the history of present illnesses within longitudinal utilization information
            • Ask patients about emergency department visits and hospitalizations within the past 6 – 12 months
            • Obtain records from other providers
            • Adopt a longitudinal view of patients and place their hospital usage in the context of other care-seeking patterns. This information can be used to devise a transitional care plan
            1. Ask about behavioral and social health needs
            • Ask about mental health needs and whether the senior has treatment
            • Ask about legal concerns, transportation, housing
            • Ask if the patient is enrolled in Medicaid
            • Put patients in touch with the relevant referrals and resources to address their needs
            1. Listen to why the patient returned to the hospital
            • Ask why patients needed to go back to hospital
            • Understand that there may be several factors the led to readmission
            1. Engage caregivers and patients
            • Use medical interpreters to communicate with patients when necessary
            • Identify who the caregiver is
            • Ask about and address caregiver’s and patient’s priorities when discussing the patient’s post-hospital needs
            1. Customize all written information and make sure it is written at an elementary reading level
            • Include symptoms to watch out for, what to do, and who to call
            • Create printed materials at third-grade reading level, preferably in the patient’s native language
            • Provide information tailored to each patient
            1. Carefully explain medication requirements and information
            • Discuss how the patient will get his/her medication and identify any logistical and financial barriers
            • Explain what to do and who to reach out to if side effects occur
            • Explain what to take, why, how, and when
            1. Discuss post-hospital points of contact
            • Options in medical settings: transitional care teams, discharge clinics, urgent care centers
            • Choices in the community or home: home visits, visiting nurses, transitional care managers, pharmacists
            1. Make use of a checklist to make sure all transitional care factors are provided
            • Devise a transitional care checklist
            • Use the list for all patients and not only high-risk patients
            • Deploy the lists across departments
            • Monitor the patient and provide feedback regarding the utilization of the checklist

These are just some strategies that are put in place, or could be put in place by transitional care management, to improve the quality of care for senior citizens suffering from chronic or acute illnesses. They will help greatly to reduce the costs involved with readmissions while minimizing the chances of readmission to hospital. However, with any kind of program and management system, there is always room for improvement.

Transitional Care – Is There Room for Improvement?

After leaving a care setting, senior patients may not know how to take care of their health or manage their condition, or even who to reach out to should they have a question or notice their condition deteriorating. Transitional care programs that are poorly managed can result in significant emotional and physical stress for both the patients and their primary caregivers. During the transition process, the patient’s personal goals and preferences in one particular setting may not carry over to their next setting, and this could result in essential parts of their care plan being overlooked.

The Care Transitions Intervention program, as discussed earlier in this article, has been developed as a coaching intervention. It is designed to assist senior patients with self-care when they leave the hospital. The coaching techniques are aimed at ensuring the patients are able to manage their own medication and health information and understand the symptoms that could lead them to require medical assistance. The program also helps caregivers to manage patient’s medical needs and teaches both patients and caregivers to ask important questions of their healthcare providers. The coaching intervention plan is usually implanted for the first 30 days after the transition, and it has been shown to reduce hospital readmission for up to six months[xxix].


The importance of transitional care management requires a strong emphasis if the rate of readmissions for seniors is to be reduced. With proper transitional care programs in place, that are flexible enough to tailor to individual patients and their caregiver’s requirements, transitional care can go a long way to reducing the high costs that hospitals are charged when the elderly return for the same reasons.