Better coordination of patient transfers among care sites and the community could save money and improve the quality of care.
The term "care transition" describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful pending in 2011 through avoidable complications and unnecessary hospital readmissions.
Several new federal initiatives aim to encourage more effective care transitions. In addition, debate continues over how to restructure fee-for-service payments to motivate providers across care settings to work as a team to make transitions smoother.
This Health Policy Brief examines how care transitions can be made more effective and payment reforms designed to address the problem, and was published online on September 13, 2012 in Health Affairs.
This RWJF national initiative focuses on improving care transitions to reduce avoidable hospital readmissions, and how nurses, care coordinators, doctors, consumers, caregivers, patients, and others can work together to achieve this.