Transitional Care: Connecting the Dots of the Acute Care Continuum

Chris Clark

Chris Clark , MPA, PA-C

Published August 17, 2013

As a physician assistant working in the emergency department, one of my greatest frustrations is sending my patients out the door and into the great unknown of post-discharge care. On every shift, I encounter several who lack a "medical home" that they can rely on for follow-up care. I do my best to arm them with a few basic resources — the phone numbers and addresses for the county hospital, local clinics or their insurance carrier. But without a more comprehensive plan, I worry that in a few days or weeks, these patients will land back in the emergency room (or worse, a different emergency room where they will undergo repetitive exams and testing leading to the same diagnostic conclusion they had weeks or even days before).

The fragmented state of post-discharge care benefits no one. Patients who don’t obtain needed follow-up are at risk for poorer outcomes, which leads to more time in the hospital and higher out-of-pocket costs. Repeat ED visits also contribute to crowding and strain finite healthcare resources. And under the Affordable Care Act, "excessive" readmissions can impact hospital revenue in the form of lowered Medicare reimbursements.

Clearly something needs to be done. So you can imagine my enthusiasm when a colleague raised the idea that each ED within our system employ a transitional care director (TCD).

The transitional care director is a provider (most often a physician, physician assistant or nurse practitioner) who helps patients "connect the dots" between acute and post-acute care. One of the TCD’s key functions is to serve as a liaison between the hospital and community providers. The TCD knows who is available to deliver follow-up care, which health plans they work with, and who to contact to get things moving. In many cases, they can have the patient scheduled for follow-up appointments before discharge.

Some models take this a step further by making the TCD the coordinator of an interprofessional team. In the Transitional Care Model developed by the University of Pennsylvania, the TCD (a nurse practitioner in this case) works closely with the patient’s physician, pharmacist and other providers to ensure a safe, coordinated transition. After discharge, the TCD makes home visits, provides phone consultations, accompanies the patient to the first follow-up appointment, and continues to facilitate communication among providers for up to three months.

Results of three randomized, controlled trials funded by the NIH suggest that transitional care can be very effective at improving patient outcomes. In one study, at-risk patients participating in the Transitional Care Model had 36 percent fewer readmissions and spent significantly fewer days in the hospital over the next year. Researchers estimated that the program saved an average of $5,000 per patient in total healthcare costs. The participants, who were mostly older adults with multiple chronic conditions, showed functional gains. Patients and their families generally reported high satisfaction with the program.

The idea of coordinated transitional care has been around for decades. However, due to the upfront costs involved, relatively few hospitals have implemented it. One win-win solution is to hire a physician assistant or nurse practitioner for the TCD role. These professionals are not only cost-effective; they are also trained and experienced in interdisciplinary teaming and often practice across a wide range of specialties. This skill set allows them to liaison with a wide range of providers and effectively guide patients through the medical maze.

The time has come for healthcare systems to invest in improved transitional care, and there are resources available to help. Aetna and Kaiser Permanente have already partnered with the University of Pennsylvania to diffuse the Transitional Care Model. Several nonprofits, including The John A. Hartford Foundation and the California HealthCare Foundation, are working to translate the model into health systems. Yes, there will be costs, but hospitals will likely recoup these in the form of increased revenues and community confidence. And from a patient care standpoint, it’s simply the right thing to do.

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