By Melinda Young


A hospital’s Care Transitions Program provides patients and caregivers with care transition support.

  • The program focuses on assessment and identification of the root cause of readmission, as well as other key interventions.
  • One important feature is the post-discharge call, which is placed within 48-72 hours of discharge.
  • The program focuses on patient education with repetition and validation the patient understands the medications. Also, a medication reconciliation is provided post-discharge.

A program designed to prevent hospital readmissions and ensure best practices in transitions showed early positive outcomes and has continued to demonstrate improvements over the past eight years.

“Key indicators of readmission rates and emergency department utilization continue to decrease, and our performance improvement activities focus on this continued reduction,” says Janet Kasoff, EdD, RN, NEA-BC, senior director of care management learning and innovation with Montefiore Care Management Organization in Bronx, NY.

The program’s goals and objectives have remained the same, including the goal of reducing 30-day unplanned readmissions associated with poor transitions of care, and improving the patient experience by identifying and responding to patients’ concerns immediately during the post-discharge period — before receiving the patient satisfaction survey, she notes.

The hospital’s Care Transitions Program gives patients and their caregivers support while preparing to move from the acute inpatient setting. “We hand off patients discharged from the hospital to the post-discharge care transitions program,” Kasoff explains. “It is not the same RN who follows the patient in the hospital and into 60-days post-discharge, as we did with the [2013] research study.”

The program focuses on these key interventions:

  • Assessment and identification of the root cause of readmission;
  • Working collaboratively with the interdisciplinary team to develop the plan of care;
  • Teach-back for patient education provided by the unit staff;
  • Ensuring documentation of the transitional care plan in the electronic health record;
  • Post-discharge appointment scheduling;
  • Health home referrals;
  • Making referrals to community-based organizations;
  • Closing the loop on referrals to ensure appointments are made and kept;
  • Sharing information with providers receiving the patient in the community.

The information is shared via warm handoffs with providers when feasible. The care transitions team follows up with patients after discharge, Kasoff says.

The transitions team calls patients and caregivers to offer support during the move home. These are some of the key interventions of the care team:

  • Call within 48-72 hours after discharge;
  • Conduct transition of care screening to identify red flags, such as new or worsening symptoms, condition-specific indicators, self-management knowledge deficits, signs and symptoms of depression, and understanding the role of the primary care provider;
  • Perform medication reconciliation and assess medication self-management, including patient compliance to prescribed medication regimen and addressing medication problems due to financial issues or lack of access;
  • Post-discharge follow-up with primary care providers and specialists;
  • Evaluate psychosocial issues, including cognitive and functional deficits, caregiver gaps, and use of personal health record;
  • Determine eligibility for referral to complex care management, condition-specific management, behavioral health management, the House Call Program, pharmacy management, and applicable community resources and linkages;
  • Perform patient satisfaction screening to help mitigate negative factors affecting the patient experience of care and patient satisfaction outcomes.

Telehealth Contributes to Growth

Over time, the program has evolved with more use of telehealth services. “Technology has evolved and afforded us the opportunity to do telehealth visits with patients for care management follow-up and to schedule video visits for patients with their provider,” Kasoff says. “We can see what is going on in the home in real time. This allows us to observe the client, which is especially important during patient education teach-back sessions.”

The advantages of telehealth have contributed to the program’s continued success.

“The implementation of telehealth visits has improved the ability for patients to keep their appointments post-discharge,” Kasoff says. “The care managers track if an appointment is made post-discharge, and whether the appointment with a provider was kept. If the appointment was not kept, the care manager RN reaches out to the patient and schedules another visit.”

Other Technological Changes

Another technological advantage: The implementation and integration of care management documentation in the longitudinal electronic health record affects the provider/care manager and communication.

“This effectuates our ability to perform our care management and care coordination functions more effectively,” she says. “The implementation of the electronic personal health record capability also has improved the communication with the patient and their provider. The patient’s real-time access to key clinical and nonclinical data in one repository makes managing their transitional care more organized, effective, and collaborative.”

Program leaders plan to leverage technology further and establish a remote patient monitoring program for patients with hypertension or diabetes.

Patient education is crucial to any care transition success, but providing it within the hospital setting is difficult. “The short length of stay and acute stay care nature of the hospitalization makes it challenging for a patient to learn new skills and information,” Kasoff says. “Therefore, post-acute follow-up is extremely important.”

The timing of the education also is very important. “People may be anxious or overwhelmed, which make it a challenge to learn new information and skills,” she adds. “Repetition and teach-backs are very important for these reasons.”

Patient education also should be demonstrated. “Repetition and validation that the patient understands the medications and performs an effective medication reconciliation post-discharge is very important,” Kasoff says. “Also, patients must be engaged in their care.”

Patients should agree on their self-management goals and be active members in the care plan. “Patient education to empower patients and caregivers fosters patient engagement,” Kasoff adds.