Hospital and Health System Management

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A new study on care transition management has found that 85 percent of respondents have launched programs for older adults with complex acute or chronic conditions to close care gaps, avoid unnecessary hospitalizations, readmissions and ER visits, reduce medication errors and raise the bar on care quality.

In its second annual Managing Care Transitions Across Sites e-survey, conducted in May 2010, the Healthcare Intelligence Network documented programs and activities by 87 healthcare organizations to coordinate key care transitions. The survey results reveal slight increases from 2009 to 2010 in both the number of programs to manage transitions in care and the number of organizations conducting home visits in 2010 to improve care transitions.

Figure 1: Care Transitions Addressed by Programs

Survey Highlights

• Nearly 85 percent of respondents have adopted a care transition program this year, compared to 80.2 percent in 2009.
• The amount of organizations conducting home visits increased from 56.5 percent in 2009 to 60.3 percent in 2010.
• About 79 percent of responding organizations are focused on hospital-to-home transitions, while 49.2 percent address skilled nursing facility (SNF)-to-home, and 45.9 percent address ER-to-home.
• According to 80.3 percent of respondents, hospital to home is the most critical care transition for their population.
• Many respondents said post-transition contact with patients, such as home follow-up and post-discharge calls, is the most successful strategy to improve care transitions.
• A nurse practitioner or certified home health agency nurse is most likely to conduct the home visit, according to 37.1 percent of respondents.
• Almost 83 percent of respondents said medication review occurs during home visits. Only 22.9 percent are conducting physical therapy during home visits.

Source: 2010 Performance Benchmarks in Managing Care Transitions, September 2010