The Problem of Readmissions

The U.S. Government defines the term “Care Transitions” as referring to the movement of patients from one health care provider or setting to another. For people with serious and complex illnesses, transitions in setting of care–for example from hospital to home or nursing home, or from facility to home- and community-based services– have been shown to be prone to errors.

Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days. This translates to approximately 2.6 million seniors at a cost of over $26 billion every year.  Readmission rates are also high for patients covered by Medicaid and private insurance. New CMS penalties are now in force for excessive readmissions.

Medication errors, poor communication, and poor coordination between providers from the inpatient to outpatient settings, along with the rising incidence of preventable adverse events, have drawn national attention. Health care providers and community-based organizations are aware of the negative effects of poor patient care transitions. But many struggle with fragmentation and lack of collaboration across settings, limited resources, and an expanding aging population with multiple chronic conditions. New thinking about process is needed. And now, a workable solution has arrived.