Introduction
The period immediately following a hospital stay is often fraught with challenges for patients. Statistics reveal that approximately one in five individuals experience adverse events, such as negative drug reactions or hospital-related complications, during this vulnerable time. Alarmingly, nearly 20% of older adults on Medicare are readmitted to the hospital within just 30 days of discharge. This high rate of readmission not only signifies potential lapses in patient care but also places a significant financial burden on the healthcare system.
A significant portion of post-discharge complications stem from medication errors and related adverse drug events (ADEs). Studies estimate that ADEs lead to nearly 100,000 hospitalizations among elderly patients annually. Patients recovering from serious conditions like stroke are particularly susceptible to recurrent health issues, repeated hospitalizations, long-term disability, and even increased mortality. Therefore, ensuring smooth and safe care transitions is paramount, especially for patients managing complex and chronic conditions such as stroke, epilepsy, and neuromuscular disorders. This is a critical patient safety concern for neurohospitalists and all healthcare providers dedicated to improving patient outcomes.
Transitional care, often referred to as a “Transition Of Care Program,” is designed to bridge the gaps in healthcare as patients move between different settings and providers. These programs aim to create a seamless transition from hospital to home, or other outpatient settings, thereby preventing avoidable readmissions and adverse events. By focusing on improving communication, coordination, and patient education during these crucial junctures, transitional care programs play a vital role in enhancing patient safety and overall healthcare quality.
Recognizing the financial implications of readmissions and adverse events, healthcare policymakers have implemented national initiatives to promote improvements in transitional care. The Centers for Medicare & Medicaid Services (CMS) already publicly reports hospitals’ 30-day readmission rates for specific conditions like pneumonia, heart attack, and heart failure. It is anticipated that this reporting will expand to include neurological conditions such as stroke. Hospitals with high readmission rates face financial penalties, incentivizing them to prioritize and invest in effective transition of care programs. The Partnership for Patients initiative further underscores the importance of this area, aiming to significantly reduce preventable readmissions and healthcare expenditures by improving transitional care practices nationwide.
While targeted transitional care approaches have shown some success for conditions like heart failure and lung disease, effective strategies for neurological conditions remain less clear. Numerous studies have explored various interventions, but conclusive evidence on their impact on readmissions and post-discharge patient safety markers, such as emergency department visits and adverse events, is still needed.
Research suggests that a substantial portion of 30-day readmissions are preventable. Factors beyond the hospital setting, including limited social support, financial constraints, and access to outpatient care, significantly contribute to readmission rates. A review of stroke and cerebrovascular disease discharges revealed that over half of readmissions were potentially avoidable, often due to breakdowns in care coordination, delayed follow-up, and inadequate discharge instructions. Despite these challenges, progress is being made, with CMS reporting a decline in 30-day readmission rates for Medicare patients in recent years.
Figure 1.
Figure 1: Key factors contributing to hospital readmission rates, highlighting the complex interplay of healthcare and patient-related elements.
In today’s healthcare landscape, where value-based care is increasingly emphasized, transition of care programs represent a high-value, cost-effective approach. While these programs require dedicated resources, their focus aligns perfectly with the core values of neurohospitalists and healthcare providers: enhancing patient safety, improving the quality of care, and fostering better connections within the healthcare system. This review will delve into the specifics of transitional care strategies, examine the effectiveness of existing programs, and provide practical recommendations for neurohospitalists and other healthcare professionals seeking to implement robust transition of care programs.
Understanding Transition of Care: Definitions, Risks, and Effective Strategies
Defining Transition of Care and Post-Discharge Adverse Events
A “transition of care strategy” encompasses a range of interventions initiated before a patient leaves the hospital. The primary goal is to ensure a safe and effective shift from the hospital environment to another setting, most commonly the patient’s home. These interventions can be categorized into three main types:
- Predischarge Interventions: Actions taken while the patient is still in the hospital, such as assessing readmission risk, patient education, and medication reconciliation.
- Postdischarge Interventions: Support provided after the patient has left the hospital, including follow-up phone calls, home visits, and facilitated outpatient appointments.
- Bridging Interventions: Programs that combine both pre- and post-discharge components to create a continuous support system for the patient.
Table 1 provides a detailed taxonomy of these interventions, outlining specific actions within each category that contribute to a successful transition of care program.
Table 1. Taxonomy of Interventions for Improved Transition of Care at Hospital Discharge
| Predischarge Interventions | Postdischarge Interventions | Bridging Interventions |
|---|---|---|
| Risk assessment for adverse events or readmissions | Patient outreach (phone calls, hotlines, home visits) | Combination of at least one predischarge and one postdischarge component |
| Patient and caregiver education | Facilitated clinical follow-up appointments | |
| Personalized patient discharge record creation | Post-discharge medication reconciliation | |
| Communication facilitation with outpatient providers | ||
| Multidisciplinary discharge planning teams | ||
| Dedicated transition provider (pre- and post-discharge contact) | ||
| Medication reconciliation |
Post-discharge adverse events are defined as clinically significant issues that arise after a hospital stay. These can include new or worsening symptoms, abnormal lab results requiring medical intervention, and injuries like adverse drug events, falls, or infections linked to hospital care. Readmission to the hospital, particularly within 30 days, is also considered a major adverse event and a key indicator of transition of care effectiveness. These classifications are based on established definitions used in studies analyzing post-discharge adverse event epidemiology.
Identifying Patients at Risk of Readmission and Adverse Events
Predicting precisely which patients will be readmitted or experience adverse events remains a challenge. However, certain patient populations are known to be at higher risk. These include older adults, individuals with chronic illnesses, and those hospitalized for conditions like stroke. These patients are more vulnerable due to potential gaps in healthcare quality, transitions across multiple care settings, and frequent handoffs between different providers. Risk factors for readmission and poorer outcomes in neurological patients include functional limitations at discharge, advanced age, mental health conditions, and limited social support networks. While standardized prediction models are still under development, recognizing these high-risk groups is crucial for targeted intervention.
Elderly patients and those with multiple chronic conditions constitute a significant portion of neurology service admissions and readmissions. Stroke patients, for instance, are readmitted for a variety of reasons, including recurrent stroke, cardiac issues, and non-cardiac conditions like infections and fractures. Understanding these risk factors and patient characteristics is essential for developing effective transition of care programs tailored to the specific needs of neurological patients.
Exploring Effective Transition of Care Strategies
Several transition of care programs have demonstrated effectiveness in reducing readmissions. Four prominent hospital-based programs are highlighted below, based on evidence from controlled trials (Table 2).
Table 2. Highlighted Hospital-Based Transition of Care Programs
| Program | Key Strategies | Description and Effectiveness |
|---|---|---|
| Care Transitions Intervention (CTI) | Patient engagement, personalized health record, dedicated transition provider, communication with outpatient providers, outreach, medication reconciliation | Focuses on four core domains of self-management skills. Studied across various settings. Demonstrated significant reductions in 30-day readmission rates (ARR 3.6% – 5.8%) and 90-day readmission rates (ARR 5.8% – 21.7%). |
| Transitional Care Model (TCM) | Patient engagement, personalized health record, dedicated transition provider, communication with outpatient providers, facilitated clinical follow-up, outreach | Nurse-led program for geriatric patients, intensive outreach with home and telephone follow-up. RCT studies showed decreased 90-day readmission rates (ARR 13% – 48% across studies). |
| Project Re-Engineered Discharge (RED) | Patient engagement, personalized health record, dedicated transition provider, communication with outpatient providers, multidisciplinary team, outreach, medication reconciliation (pre- and post-discharge) | Team-based program with pharmacist outreach and medication review. RCT studies showed reduction in 30-day ED visits (ARR 8.0%). |
| Project Better Outcomes for Older Adults Through Safe Transitions (BOOST) | Patient engagement, multidisciplinary team, outreach, medication reconciliation, risk assessment | Multicenter quality improvement program with mentored implementation. Demonstrated reductions in 30-day readmission rates (ARR 2% – 5.9%). |
Abbreviations: ARR = Absolute Risk Reduction, ED = Emergency Department, RCT = Randomized Controlled Trial
Care Transitions Intervention (CTI)
Developed by Dr. Eric Coleman, the Care Transitions Intervention (CTI) is a multi-faceted program designed to empower patients and caregivers in managing their health post-hospitalization. Implemented across various hospitals, including those treating stroke and chronic illness patients, CTI centers around four key pillars:
- Medication Management: Ensuring patients understand their medications and how to take them correctly.
- Personal Health Record: Creating a portable health record for patients to track and share their medical information across different healthcare settings.
- Primary Care Follow-up: Facilitating timely follow-up appointments with primary care providers.
- “Red Flags” Recognition: Educating patients to identify warning signs that require prompt medical attention.
A “transition coach,” typically an advanced practice nurse, provides home visits and phone support, emphasizing patient engagement and self-management. CTI has consistently demonstrated statistically significant reductions in 30-day readmissions across diverse healthcare systems.
Transitional Care Model (TCM)
The Transitional Care Model (TCM), pioneered by Dr. Mary Naylor, is another nationally recognized program focused on high-risk, chronically ill older adults. TCM utilizes transitional care nurses (TCNs) who guide patients from hospital to home. TCNs facilitate communication among healthcare providers, conduct home visits, and provide telephone follow-up. This nurse-led model emphasizes a multidisciplinary approach, ensuring collaboration among physicians, nurses, social workers, discharge planners, and pharmacists. TCM has shown significant reductions in readmission rates at both 60 and 90 days post-discharge.
Project Re-Engineered Discharge (RED)
Project RED, developed for general medicine patients in urban hospitals, employs a multidisciplinary team approach coordinated by a nurse discharge advocate (DA). The DA engages patients during their hospital stay, providing clear clinical information and a personalized discharge plan. Post-discharge, a pharmacist conducts telephone follow-ups, including medication reviews and direct communication with the patient’s primary care provider. Project RED has demonstrated significant reductions in hospital utilization, including both emergency department visits and readmissions, within 30 days of discharge.
Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)
Project BOOST, supported by the Society of Hospital Medicine, is a quality improvement collaborative implemented nationwide. This program focuses on general medicine populations and provides hospitals with a toolkit and mentorship to develop site-specific transition of care programs. Key components of BOOST include risk assessment, medication reconciliation, discharge checklists, and a multidisciplinary team approach. Studies have shown that BOOST implementation leads to modest reductions in 30-day readmission rates.
Strategies Tailored for Neurological Patients
While the above programs are broadly applicable, specific strategies are crucial for neurological patients, particularly those recovering from stroke. A review of transitional care studies for stroke patients suggests that hospital-initiated interventions focusing on care coordination can improve outcomes, such as reduced hospital stay duration and improved physical activity. However, evidence regarding readmission and mortality reduction is less conclusive in this specific population from these studies.
Despite these findings, targeted interventions are crucial. Secondary stroke prevention measures (antithrombotic, antihypertensive, and lipid-lowering medications), dysphagia screening, and reducing urinary catheter use have all been shown to decrease readmissions and post-discharge adverse events in stroke patients. Neurohospitalists play a vital role in implementing these targeted strategies to improve patient care and reduce preventable readmissions and adverse events in neurological populations.
Common Elements of Successful Transition of Care Programs
Despite variations in specific approaches, successful transition of care programs share several common features. Most programs, whether general or specifically for stroke patients, utilize “bridging interventions” with a dedicated transition provider, such as a nurse or case manager, serving as a central point of contact. A strong emphasis is placed on care coordination, patient outreach, and facilitating communication across different healthcare settings. Neurological patients, similar to general medical populations, benefit significantly from strategies that enhance communication, outreach, and active patient engagement in their care transition.
Implementation and Cost Considerations
While the descriptions of various transition of care programs often detail interventions and timelines, information regarding implementation costs, resource needs, and sustainability strategies is often limited. Hospitals and healthcare systems need to carefully consider these factors when planning and implementing transition of care programs to ensure long-term success and impact.
Discussion: The Path Forward for Transition of Care Programs
This review highlights the importance of transition of care programs in reducing hospital readmissions and post-discharge adverse events. The most effective programs consistently incorporate bridging interventions and rely on a dedicated transition provider who maintains contact with patients both before and after discharge. Programs like CTI, BOOST, and TCM have been successfully implemented and evaluated across diverse patient populations and healthcare systems. While these programs require resource investment, evidence supports their effectiveness in improving patient outcomes. However, further research is needed to address implementation challenges, ensure program sustainability, and fully understand the cost-effectiveness of these interventions, particularly for patients with acute neurological illnesses.
Recommendations for Neurohospitalists and Healthcare Providers
Hospitals and neurohospitalists are challenged to develop and implement effective transition of care programs to reduce readmissions and avoid associated financial penalties. Research points towards multidisciplinary, multi-component strategies that include bridging interventions and a dedicated transitions clinician. Programs like CTI, TCM, Project RED, and Project BOOST offer valuable frameworks that can be adapted to specific hospital settings. Recognizing that a “one-size-fits-all” approach is unlikely to succeed, hospitals should tailor their programs to their unique internal factors, community context, and patient population.
Key elements of a successful transition of care program include:
- Patient Engagement: Actively involving patients and caregivers in care planning and self-management education.
- Dedicated Transition Provider: Assigning a specific individual (nurse, case manager, etc.) to oversee the transition process.
- Medication Management: Implementing robust medication reconciliation processes and patient education on medication regimens.
- Communication Facilitation: Ensuring seamless communication between hospital and outpatient providers.
- Patient Outreach: Providing post-discharge follow-up and support through phone calls or home visits.
For neurological patients, disease-specific interventions should be integrated, such as home care protocols for disease monitoring, medication adherence support, symptom management guidelines, and direct communication with rehabilitation services.
Table 3. Summary Recommendations for Neurohospitalists and Healthcare Providers
| Key Actions for Implementing a Transition of Care Program |
|---|
| Obtain hospital-specific 30-day readmission data (overall and condition-specific) |
| Assess existing quality improvement and patient safety infrastructure within the hospital |
| Establish an interdisciplinary team and identify program champions |
| Define measurable outcomes (readmission rates, adverse drug events, medication errors) |
| Implement a bundled, multi-component strategy incorporating key elements listed above |
| Integrate disease-specific interventions relevant to the patient population |
Neurohospitalists, with their expertise in neurological conditions and hospital-based care, are uniquely positioned to lead and contribute to transition of care initiatives. They can champion specific interventions like delirium and dysphagia screening for neurological patients, and collaborate with other hospitalists on broader, institution-wide programs. As consultants, neurohospitalists can provide evidence-based recommendations to reduce readmissions and adverse events, such as implementing secondary stroke prevention protocols.
Practical recommendations for improving transition of care for all patients admitted by neurohospitalists include:
- Enhancing Patient Engagement: Provide comprehensive counseling on medication management, “red flags,” condition-specific strategies, and available post-discharge resources.
- Improving Communication with Outpatient Providers: Ensure clear communication with rehabilitation facilities, skilled nursing facilities, and primary care providers regarding follow-up care, medication reconciliation, and ongoing management.
- Implementing Patient Outreach: Utilize follow-up phone calls or home visits to support patients during the immediate post-discharge period and ensure a safe transition.
By prioritizing and implementing effective transition of care programs, hospitals and healthcare providers can significantly enhance patient safety, improve healthcare quality, and reduce the burden of preventable readmissions and adverse events.
