Jing Li, MD, MS

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

You have spent several days checking on a patient hospitalized for an acute exacerbation of heart failure. You have straightened out her medications and diet and discussed a plan for follow-up with the patient and a family member, and now she is being wheeled out the door. What happens to her next?

Too often, not your desired plan. If she is going home, maybe she understands what she needs to do, maybe not. Maybe she will get your prescriptions filled and take the medications as directed, maybe not. If she is going to a nursing home, maybe the physician covering the nursing home will get your plan, maybe not. There is a good chance she will be back in the emergency room soon, all because of a poor transition of care.

Transitions of care are changes in the level, location, or providers of care as patients move within the health care system. These can be critical junctures in patients’ lives, and if poorly executed can result in many adverse effects—including rehospitalization.¹

Although high rehospitalization rates gained national attention in 2009 after a analysis of Medicare data,² health care providers have known about the lack of coordinated care transitions for more than 50 years.³ Despite some progress, improving care transitions remains a national challenge. As the health system evolves from a fee-for-service financial model to payment-for-value,⁴ it is especially important that health care providers improve care for patients by optimizing care transitions.

In this article, we summarize the factors contributing to poor care transitions, highlight programs that improve them, and discuss strategies for successful transitions.

TRANSITION PROBLEMS ARE COMMON

Transitions of care occur when patients move to short-term and long-term acute care hospitals, skilled nursing facilities, primary and specialty care offices, community health centers, rehabilitation facilities, home health agencies, hospice, and their own homes.⁵ Problems can arise at any of these transitions, but the risk is especially high when patients leave the hospital to receive care in another setting or at home.

In the past decade, one in five Medicare patients was rehospitalized within 30 days of discharge from the hospital,² and up to 25% were rehospitalized after being discharged to a skilled nursing facility.⁶ Some diagnoses (eg, sickle cell anemia, gangrene) and procedures (eg, kidney transplantation, ileostomy) are associated with readmission rates of nearly one in three.^7,8

The desire of policymakers to “bend the cost curve” of health care has led to efforts to enhance care coordination by improving transitions between care venues. Through the Patient Protection and Affordable Care Act, a number of federal initiatives are promoting strategies to improve care transitions and prevent readmissions after hospital discharge.

The Hospital Readmission Reduction Program⁹ drives much of this effort. In fiscal year 2013 (beginning October 1, 2012), more than 2,000 hospitals incurred financial penalties of up to 1% of total Medicare diagnosis-related group payments (about $280 million the first year) for excess readmissions.¹⁰ The penalty’s maximum rose to 2% in fiscal year 2014 and could increase to 3% in 2015. The total penalty for 2014 is projected to be $227 million, with 2,225 hospitals affected.¹¹

The Centers for Medicare and Medicaid Innovation has committed hundreds of millions of dollars to Community-based Care Transitions Programs¹² and more than $200 million to Hospital Engagement Networks¹³ to carry out the goals of the Partnership for Patients,¹⁴ aiming to reduce rehospitalizations and other adverse events.

At first, despite these efforts, readmission rates did not appear to change substantially.¹⁵ However, the Centers for Medicare and Medicaid Services reported that hospital readmission rates for Medicare fee-for-service beneficiaries declined in 2012 to 18.4%,¹⁶ although some believe that the reduction is related to an increase in the number of patients admitted for observation in recent years.¹⁷

TRANSITIONS ARE OFTEN POORLY COORDINATED

Although some readmissions are unavoidable—resulting from the inevitable progression of disease or worsening of chronic conditions¹⁸—they may also result from a fumbled transition between care settings. Our current system of care transition has serious deficiencies that endanger patients. Areas that need improvement include communication between providers, patient education about medications and treatments, monitoring of medication adherence and complications, follow-up of pending tests and procedures after discharge, and outpatient follow-up soon after discharge.^19–21

Traditional health care does not have dependable mechanisms for coordinating care across settings; we are all ensconced in “silos” that generally keep the focus within individual venues.²² Lack of coordination blurs the lines of responsibility for patients in the period between discharge from one location and admission to another, leaving them confused about whom to contact for care, especially if symptoms worsen.^23,24

Gaps in coordination are not surprising, given the complexity of the US health care system and the often remarkable number of physicians caring for an individual patient.⁵ Medicare beneficiaries see an average of two primary care physicians and five specialists during a 2-year period; patients with chronic conditions may see up to 16 physicians in 1 year.²⁵ Coordinating care between so many providers in different settings, combined with possible patient factors such as disadvantaged socioeconomic status, lack of caregiver support, and inadequate health literacy, provides many opportunities for failures.

Research has identified several root causes behind most failed care transitions:

Poor provider communication

Multiple studies associate adverse events after discharge with a lack of timely communication between hospital and outpatient providers.²⁶ One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.²⁷ Discharge summaries often lack important information such as test results, hospital course, discharge medications, patient counseling, and follow-up plans. Most adverse drug events after hospital discharge result directly from breakdown in communication between hospital staff and patients or primary care physicians.²⁸ Approximately 40% of patients have test results pending at the time of discharge and 10% of these require some action; yet outpatient physicians and patients are often unaware of them.²¹

Ineffective patient and caregiver education

The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,²⁹ noted that patients leaving one setting for another receive little information on how to care for themselves, when to resume activities, what medication side effects to watch out for, and how to get answers to questions. Of particular concern is that patients and caregivers are sometimes omitted from transition planning and often must suddenly assume new self-care responsibilities upon going home that hospital staff managed before discharge. Too often, patients are discharged with inadequate understanding of their medical condition, self-care plan,^23,24 and who should manage their care.³⁰

Up to 36% of adults in the United States have inadequate health literacy (defined as the inability to understand basic health information needed to make appropriate decisions), hindering patient education efforts.^31–33 Even if they understand, patients and their caregivers must be engaged or “activated” (ie, able and willing to manage one’s health) if we expect them to adhere to appropriate care and behaviors. A review found direct correlations between patient activation and healthy behavior, better health outcomes (eg, achieving normal hemoglobin A_1c and cholesterol levels), and better care experiences.³⁴ This review also noted that multiple studies have documented improved activation scores as a result of specific interventions.

No follow-up with primary care providers

The risk of hospital readmission is significantly lower for patients with chronic obstructive pulmonary disease or heart failure who receive follow-up within 7 days of discharge.^35–38 Of Medicare beneficiaries readmitted to the hospital within 30 days of discharge in 2003–2004, half had no contact with an outpatient physician in the interval between their discharge and their readmission,² and one in three adult patients discharged from a hospital to the community does not see a physician within 30 days of discharge.³⁹ The dearth of primary care providers in many communities can make follow-up care difficult to coordinate.

Failure to address chronic conditions

Analyses of national data sets reveal that patients are commonly rehospitalized for conditions unrelated to their initial hospitalization. According to the Center for Studying Health System Change, more than a quarter of readmissions in the 30 days after discharge are for conditions unrelated to those identified in the index admission, the proportion rising to more than one-third at 1 year.³⁹ Among Medicare beneficiaries readmitted within 30 days of discharge, the proportion readmitted for the same condition was just 35% after hospitalization for heart failure, 10% after hospitalization for acute myocardial infarction, and 22% after hospitalization for pneumonia.⁴⁰

Lack of community support

Multiple social and environmental factors contribute to adverse postdischarge events.^41–43 For socioeconomically disadvantaged patients, care-transition issues are compounded by insufficient access to outpatient care, lack of social support, and lack of transportation. Some studies indicate that between 40% to 50% of readmissions are linked to social problems and inadequate access to community resources.^44–47 Psychosocial issues such as limited health literacy, poor self-management skills, inadequate social support, and living alone are associated with adverse outcomes, including readmission and death.^48,49 Such factors may help explain high levels of “no-shows” to outpatient follow-up visits.

NATIONAL MODELS OF BEST PRACTICES

Efforts to reduce readmissions have traditionally focused on hospitals, but experts now recognize that multiple factors influence readmissions and must be comprehensively addressed. Several evidence-based models seek to improve patient outcomes with interventions aimed at care transitions:

Project BOOST

Project BOOST (Better Outcomes by Optimizing Safe Transitions)⁵⁰ is a national initiative developed by the Society of Hospital Medicine to standardize and optimize the care of patients discharged from hospital to home. The program includes evidence-based clinical interventions that can easily be adopted by any hospital. Interventions are aimed at:

• Identifying patients at high risk on admission
• Targeting risk-specific situations
• Improving information flow between inpatient and outpatient providers
• Improving patient and caregiver education by using the teach-back method
• Achieving timely follow-up after discharge.

The program includes a year of technical support provided by a physician mentor.

Preliminary results from pilot sites showed a 14% reduction in 30-day readmission rates in units using BOOST compared with control units in the same hospital.⁵¹ Mentored implementation was recognized by the Joint Commission and the National Quality Forum with the 2011 John M. Eisenberg Award for Innovation in Patient Safety and Quality.⁵²

Project RED

Project RED (Re-Engineered Discharge)⁵³ evolved from efforts by Dr. Brian Jack and colleagues to re-engineer the hospital workflow process to improve patient safety and reduce rehospitalization rates at Boston Medical Center. The intervention has 12 mutually reinforcing components aimed at improving the discharge process.

In a randomized controlled trial, Project RED led to a 30% decrease in emergency department visits and readmissions within 30 days of discharge from a general medical service of an urban academic medical center.⁵⁴ This study excluded patients admitted from a skilled nursing facility or discharged to one, but a recent study demonstrated that Project RED also led to a lower rate of hospital admission within 30 days of discharge from a skilled nursing facility.⁵⁵

The STAAR initiative

The STAAR initiative (State Action on Avoidable Re-hospitalizations)⁵⁶ was launched in 2009 by the Institute for Healthcare Improvement with the goal of reducing avoidable readmissions in the states of Massachusetts, Michigan, and Washington. Hospital teams focus on improving:

• Assessment of needs after hospital discharge
• Teaching and learning
• Real-time hand-off communication
• Timely follow-up after hospital discharge.

As yet, no published studies other than case reports show a benefit from STAAR.⁵⁷

The Care Transitions Program

The Care Transitions Program,⁵⁸ under the leadership of Dr. Eric Coleman, aims to empower patients and caregivers, who meet with a “transition coach.” The program provides assistance with medication reconciliation and self-management, a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, timely outpatient follow-up with primary or specialty care, a list of red flags to indicate a worsening condition, and instructions on proper responses.

A randomized controlled trial of the program demonstrated a reduction in hospital readmissions at 30, 90, and 180 days, and lower hospital costs at 90 and 180 days.⁵⁹ This approach also proved effective in a real-world setting.⁶⁰

The Transitional Care Model

Developed by Dr. Mary Naylor and colleagues, the Transitional Care Model⁶¹ also aims at patient and family empowerment, focusing on patients’ stated goals and priorities and ensuring patient engagement. In the program, a transitional care nurse has the job of enhancing patient and caregiver understanding, facilitating patient self-management, and overseeing medication management and transitional care.

A randomized controlled trial demonstrated improved outcomes after hospital discharge for elderly patients with complex medical illnesses, with overall reductions in medical costs through preventing or delaying rehospitalization.⁶² A subsequent real-world study validated this approach.⁶³

The Bridge Model

The Illinois Transitional Care Consortium’s Bridge Model⁶⁴ is for older patients discharged home after hospitalization. It is led by social workers (“bridge care coordinators”) who address barriers to implementing the discharge plan, coordinate resources, and intervene at three points: before discharge, 2 days after discharge, and 30 days after discharge.

An initial study showed no impact on the 30-day rehospitalization rate,⁶⁵ but larger studies are under way with a modified version.

Guided Care

Developed at the Johns Hopkins Bloomberg School of Public Health, Guided Care⁶⁶ involves nurses who work in partnership with physicians and others in primary care to provide patient-centered, cost-effective care to patients with multiple chronic conditions. Nurses conduct in-home assessments, facilitate care planning, promote patient self-management, monitor conditions, coordinate the efforts of all care professionals, and facilitate access to community resources.

A cluster-randomized controlled trial found that this program had mixed results, reducing the use of home health care but having little effect on the use of other health services in the short run. However, in the subgroup of patients covered by Kaiser-Permanente, those who were randomized to the program accrued, on average, 52% fewer skilled nursing facility days, 47% fewer skilled nursing facility admissions, 49% fewer hospital readmissions, and 17% fewer emergency department visits.⁶⁷

The GRACE model

The GRACE model (Geriatric Resources for Assessment and Care of Elders)⁶⁸ was developed to improve the quality of geriatric care, reduce excess health care use, and prevent long-term nursing home placement. Each patient is assigned a support team consisting of a nurse practitioner and a social worker who make home visits, coordinate health care and community services, and develop an individualized care plan.

In one study,⁶⁹ GRACE reduced hospital admission rates for participants at high risk of hospitalization by 12% in the first year of the program and 44% in the second year. GRACE participants also reported higher quality of life compared with the control group.⁶⁹

INTERACT tools

Led by Dr. Joseph Ouslander, INTERACT (Interventions to Reduce Acute Care Transfers)⁷⁰ is a quality-improvement initiative for skilled nursing facilities, designed to facilitate the early identification, evaluation, documentation, and communication of changes in the status of residents. Visitors to its website can download a set of tools and strategies to help them manage conditions before they become serious enough to require a hospital transfer. The tools assist in promoting important communication among providers and enhancing advance-care planning.

A 6-month study in 25 nursing homes showed a 17% reduction in self-reported hospital admissions with this program compared with the same period the previous year.⁷¹

Additional home-based care interventions

Additional innovations are under way in home-based care.

The Home Health Quality Improvement National Campaign is a patient-centered movement to improve the quality of care received by patients residing at home.⁷² Through its Best Practices Intervention Packages, it offers evidence-based educational tools, resources, and interventions for reducing avoidable hospitalizations, improving medication management, and coordinating transitional care.

The Center for Medicare and Medicaid Innovation Independence at Home Demonstration⁷³ is testing whether home-based comprehensive primary care can improve care and reduce hospitalizations for Medicare beneficiaries with multiple chronic conditions.

NO SINGLE INTERVENTION: MULTIPLE STRATEGIES NEEDED

A 2011 review found no single intervention that regularly reduced the 30-day risk of re-hospitalization.⁷⁴ However, other studies have shown that multifaceted interventions can reduce 30-day readmission rates. Randomized controlled trials in short-stay, acute care hospitals indicate that improvement in the following areas can directly reduce hospital readmission rates:

• Comprehensive planning and risk assessment throughout hospitalization
• Quality of care during the initial admission
• Communication with patients, their caregivers, and their clinicians
• Patient education
• Predischarge assessment
• Coordination of care after discharge.

In randomized trials, successful programs reduced the 30-day readmission rates by 20% to 40%,^{54,62,75–79} and a 2011 meta-analysis of randomized clinical trials found evidence that interventions associated with discharge planning helped to reduce readmission rates.⁸⁰

Methods developed by the national care transition models described above can help hospitals optimize patient transitions (Table 1). Although every model has its unique attributes, they have several strategies in common:

Engage a team of key stakeholders that may include patients and caregivers, hospital staff (physicians, nurses, case managers, social workers, and pharmacists), community physicians (primary care, medical homes, and specialists), advance practice providers (physician assistants and nurse practitioners), and postacute care facilities and services (skilled nursing facilities, home health agencies, assisted living residences, hospice, and rehabilitation facilities).

Develop a comprehensive transition plan throughout hospitalization that includes attention to factors that may affect self-care, such as health literacy, chronic conditions, medications, and social support.

Enhance medication reconciliation and management. Obtain the best possible medication history on admission, and ensure that patients understand changes in their medications, how to take each medicine correctly, and important side effects.

Institute daily interdisciplinary communication and care coordination by everyone on the health care team with an emphasis on the care plan, discharge planning, and safety issues.⁸¹

Standardize transition plans, procedures and forms. All discharging physicians should use a standard discharge summary template that includes pertinent diagnoses, active issues, a reconciled medication list with changes highlighted, results from important tests and consultations, pending test results, planned follow-up and required services, warning signs of a worsening condition, and actions needed if a problem arises.

Always send discharge summaries directly to the patient’s primary care physician or next care setting at the time of discharge.

Give the patient a discharge plan that is easy to understand. Enhance patient and family education using health literacy standards⁸² and interactive methods such as teach-back,⁸³ in which patients demonstrate comprehension and skills required for self-care immediately after being taught. Such tools actively teach patients and caregivers to follow a care plan, including managing medications.

Follow up and coordinate support in a timely manner after a patient leaves the care setting. Follow-up visits should be arranged before discharge. Within 1 to 3 days after discharge, the patient should be called or visited by a case manager, social worker, nurse, or other health care provider.

CHALLENGES TO IMPROVING TRANSITIONS

Although several models demonstrated significant reductions of hospital readmissions in trials, challenges remain. Studies do not identify which features of the models are necessary or sufficient, or how applicable they are to different hospital and patient characteristics. A 2012 analysis⁸⁴ of a program designed to reduce readmissions in three states identified key obstacles to successfully improving care transitions:

Collaborative relationships across settings are critical, but very difficult to achieve. It takes time to develop the relationships and trust among providers, and little incentive exists for skilled nursing facilities and physicians outside the hospital to engage in the process.

Infrastructure is lacking, as is experience to implement quality improvements.

We lack proof that models work on a large scale. Confusion exists about which readmissions are preventable and which are not. More evidence is needed to help guide hospitals’ efforts to improve transitions of care and reduce readmissions.

You have spent several days checking on a patient hospitalized for an acute exacerbation of heart failure. You have straightened out her medications and diet and discussed a plan for follow-up with the patient and a family member, and now she is being wheeled out the door. What happens to her next?

Too often, not your desired plan. If she is going home, maybe she understands what she needs to do, maybe not. Maybe she will get your prescriptions filled and take the medications as directed, maybe not. If she is going to a nursing home, maybe the physician covering the nursing home will get your plan, maybe not. There is a good chance she will be back in the emergency room soon, all because of a poor transition of care.

Transitions of care are changes in the level, location, or providers of care as patients move within the health care system. These can be critical junctures in patients’ lives, and if poorly executed can result in many adverse effects—including rehospitalization.¹

Although high rehospitalization rates gained national attention in 2009 after a analysis of Medicare data,² health care providers have known about the lack of coordinated care transitions for more than 50 years.³ Despite some progress, improving care transitions remains a national challenge. As the health system evolves from a fee-for-service financial model to payment-for-value,⁴ it is especially important that health care providers improve care for patients by optimizing care transitions.

In this article, we summarize the factors contributing to poor care transitions, highlight programs that improve them, and discuss strategies for successful transitions.

TRANSITION PROBLEMS ARE COMMON

Transitions of care occur when patients move to short-term and long-term acute care hospitals, skilled nursing facilities, primary and specialty care offices, community health centers, rehabilitation facilities, home health agencies, hospice, and their own homes.⁵ Problems can arise at any of these transitions, but the risk is especially high when patients leave the hospital to receive care in another setting or at home.

In the past decade, one in five Medicare patients was rehospitalized within 30 days of discharge from the hospital,² and up to 25% were rehospitalized after being discharged to a skilled nursing facility.⁶ Some diagnoses (eg, sickle cell anemia, gangrene) and procedures (eg, kidney transplantation, ileostomy) are associated with readmission rates of nearly one in three.^7,8

The desire of policymakers to “bend the cost curve” of health care has led to efforts to enhance care coordination by improving transitions between care venues. Through the Patient Protection and Affordable Care Act, a number of federal initiatives are promoting strategies to improve care transitions and prevent readmissions after hospital discharge.

The Hospital Readmission Reduction Program⁹ drives much of this effort. In fiscal year 2013 (beginning October 1, 2012), more than 2,000 hospitals incurred financial penalties of up to 1% of total Medicare diagnosis-related group payments (about $280 million the first year) for excess readmissions.¹⁰ The penalty’s maximum rose to 2% in fiscal year 2014 and could increase to 3% in 2015. The total penalty for 2014 is projected to be $227 million, with 2,225 hospitals affected.¹¹

The Centers for Medicare and Medicaid Innovation has committed hundreds of millions of dollars to Community-based Care Transitions Programs¹² and more than $200 million to Hospital Engagement Networks¹³ to carry out the goals of the Partnership for Patients,¹⁴ aiming to reduce rehospitalizations and other adverse events.

At first, despite these efforts, readmission rates did not appear to change substantially.¹⁵ However, the Centers for Medicare and Medicaid Services reported that hospital readmission rates for Medicare fee-for-service beneficiaries declined in 2012 to 18.4%,¹⁶ although some believe that the reduction is related to an increase in the number of patients admitted for observation in recent years.¹⁷

TRANSITIONS ARE OFTEN POORLY COORDINATED

Although some readmissions are unavoidable—resulting from the inevitable progression of disease or worsening of chronic conditions¹⁸—they may also result from a fumbled transition between care settings. Our current system of care transition has serious deficiencies that endanger patients. Areas that need improvement include communication between providers, patient education about medications and treatments, monitoring of medication adherence and complications, follow-up of pending tests and procedures after discharge, and outpatient follow-up soon after discharge.^19–21

Traditional health care does not have dependable mechanisms for coordinating care across settings; we are all ensconced in “silos” that generally keep the focus within individual venues.²² Lack of coordination blurs the lines of responsibility for patients in the period between discharge from one location and admission to another, leaving them confused about whom to contact for care, especially if symptoms worsen.^23,24

Gaps in coordination are not surprising, given the complexity of the US health care system and the often remarkable number of physicians caring for an individual patient.⁵ Medicare beneficiaries see an average of two primary care physicians and five specialists during a 2-year period; patients with chronic conditions may see up to 16 physicians in 1 year.²⁵ Coordinating care between so many providers in different settings, combined with possible patient factors such as disadvantaged socioeconomic status, lack of caregiver support, and inadequate health literacy, provides many opportunities for failures.

Research has identified several root causes behind most failed care transitions:

Poor provider communication

Multiple studies associate adverse events after discharge with a lack of timely communication between hospital and outpatient providers.²⁶ One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.²⁷ Discharge summaries often lack important information such as test results, hospital course, discharge medications, patient counseling, and follow-up plans. Most adverse drug events after hospital discharge result directly from breakdown in communication between hospital staff and patients or primary care physicians.²⁸ Approximately 40% of patients have test results pending at the time of discharge and 10% of these require some action; yet outpatient physicians and patients are often unaware of them.²¹

Ineffective patient and caregiver education

The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,²⁹ noted that patients leaving one setting for another receive little information on how to care for themselves, when to resume activities, what medication side effects to watch out for, and how to get answers to questions. Of particular concern is that patients and caregivers are sometimes omitted from transition planning and often must suddenly assume new self-care responsibilities upon going home that hospital staff managed before discharge. Too often, patients are discharged with inadequate understanding of their medical condition, self-care plan,^23,24 and who should manage their care.³⁰

Up to 36% of adults in the United States have inadequate health literacy (defined as the inability to understand basic health information needed to make appropriate decisions), hindering patient education efforts.^31–33 Even if they understand, patients and their caregivers must be engaged or “activated” (ie, able and willing to manage one’s health) if we expect them to adhere to appropriate care and behaviors. A review found direct correlations between patient activation and healthy behavior, better health outcomes (eg, achieving normal hemoglobin A_1c and cholesterol levels), and better care experiences.³⁴ This review also noted that multiple studies have documented improved activation scores as a result of specific interventions.

No follow-up with primary care providers

The risk of hospital readmission is significantly lower for patients with chronic obstructive pulmonary disease or heart failure who receive follow-up within 7 days of discharge.^35–38 Of Medicare beneficiaries readmitted to the hospital within 30 days of discharge in 2003–2004, half had no contact with an outpatient physician in the interval between their discharge and their readmission,² and one in three adult patients discharged from a hospital to the community does not see a physician within 30 days of discharge.³⁹ The dearth of primary care providers in many communities can make follow-up care difficult to coordinate.

Failure to address chronic conditions

Analyses of national data sets reveal that patients are commonly rehospitalized for conditions unrelated to their initial hospitalization. According to the Center for Studying Health System Change, more than a quarter of readmissions in the 30 days after discharge are for conditions unrelated to those identified in the index admission, the proportion rising to more than one-third at 1 year.³⁹ Among Medicare beneficiaries readmitted within 30 days of discharge, the proportion readmitted for the same condition was just 35% after hospitalization for heart failure, 10% after hospitalization for acute myocardial infarction, and 22% after hospitalization for pneumonia.⁴⁰

Lack of community support

Multiple social and environmental factors contribute to adverse postdischarge events.^41–43 For socioeconomically disadvantaged patients, care-transition issues are compounded by insufficient access to outpatient care, lack of social support, and lack of transportation. Some studies indicate that between 40% to 50% of readmissions are linked to social problems and inadequate access to community resources.^44–47 Psychosocial issues such as limited health literacy, poor self-management skills, inadequate social support, and living alone are associated with adverse outcomes, including readmission and death.^48,49 Such factors may help explain high levels of “no-shows” to outpatient follow-up visits.

NATIONAL MODELS OF BEST PRACTICES

Efforts to reduce readmissions have traditionally focused on hospitals, but experts now recognize that multiple factors influence readmissions and must be comprehensively addressed. Several evidence-based models seek to improve patient outcomes with interventions aimed at care transitions:

Project BOOST

Project BOOST (Better Outcomes by Optimizing Safe Transitions)⁵⁰ is a national initiative developed by the Society of Hospital Medicine to standardize and optimize the care of patients discharged from hospital to home. The program includes evidence-based clinical interventions that can easily be adopted by any hospital. Interventions are aimed at:

• Identifying patients at high risk on admission
• Targeting risk-specific situations
• Improving information flow between inpatient and outpatient providers
• Improving patient and caregiver education by using the teach-back method
• Achieving timely follow-up after discharge.

The program includes a year of technical support provided by a physician mentor.

Preliminary results from pilot sites showed a 14% reduction in 30-day readmission rates in units using BOOST compared with control units in the same hospital.⁵¹ Mentored implementation was recognized by the Joint Commission and the National Quality Forum with the 2011 John M. Eisenberg Award for Innovation in Patient Safety and Quality.⁵²

Project RED

Project RED (Re-Engineered Discharge)⁵³ evolved from efforts by Dr. Brian Jack and colleagues to re-engineer the hospital workflow process to improve patient safety and reduce rehospitalization rates at Boston Medical Center. The intervention has 12 mutually reinforcing components aimed at improving the discharge process.

In a randomized controlled trial, Project RED led to a 30% decrease in emergency department visits and readmissions within 30 days of discharge from a general medical service of an urban academic medical center.⁵⁴ This study excluded patients admitted from a skilled nursing facility or discharged to one, but a recent study demonstrated that Project RED also led to a lower rate of hospital admission within 30 days of discharge from a skilled nursing facility.⁵⁵

The STAAR initiative

The STAAR initiative (State Action on Avoidable Re-hospitalizations)⁵⁶ was launched in 2009 by the Institute for Healthcare Improvement with the goal of reducing avoidable readmissions in the states of Massachusetts, Michigan, and Washington. Hospital teams focus on improving:

• Assessment of needs after hospital discharge
• Teaching and learning
• Real-time hand-off communication
• Timely follow-up after hospital discharge.

As yet, no published studies other than case reports show a benefit from STAAR.⁵⁷

The Care Transitions Program

The Care Transitions Program,⁵⁸ under the leadership of Dr. Eric Coleman, aims to empower patients and caregivers, who meet with a “transition coach.” The program provides assistance with medication reconciliation and self-management, a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, timely outpatient follow-up with primary or specialty care, a list of red flags to indicate a worsening condition, and instructions on proper responses.

A randomized controlled trial of the program demonstrated a reduction in hospital readmissions at 30, 90, and 180 days, and lower hospital costs at 90 and 180 days.⁵⁹ This approach also proved effective in a real-world setting.⁶⁰

The Transitional Care Model

Developed by Dr. Mary Naylor and colleagues, the Transitional Care Model⁶¹ also aims at patient and family empowerment, focusing on patients’ stated goals and priorities and ensuring patient engagement. In the program, a transitional care nurse has the job of enhancing patient and caregiver understanding, facilitating patient self-management, and overseeing medication management and transitional care.

A randomized controlled trial demonstrated improved outcomes after hospital discharge for elderly patients with complex medical illnesses, with overall reductions in medical costs through preventing or delaying rehospitalization.⁶² A subsequent real-world study validated this approach.⁶³

The Bridge Model

The Illinois Transitional Care Consortium’s Bridge Model⁶⁴ is for older patients discharged home after hospitalization. It is led by social workers (“bridge care coordinators”) who address barriers to implementing the discharge plan, coordinate resources, and intervene at three points: before discharge, 2 days after discharge, and 30 days after discharge.

An initial study showed no impact on the 30-day rehospitalization rate,⁶⁵ but larger studies are under way with a modified version.

Guided Care

Developed at the Johns Hopkins Bloomberg School of Public Health, Guided Care⁶⁶ involves nurses who work in partnership with physicians and others in primary care to provide patient-centered, cost-effective care to patients with multiple chronic conditions. Nurses conduct in-home assessments, facilitate care planning, promote patient self-management, monitor conditions, coordinate the efforts of all care professionals, and facilitate access to community resources.

A cluster-randomized controlled trial found that this program had mixed results, reducing the use of home health care but having little effect on the use of other health services in the short run. However, in the subgroup of patients covered by Kaiser-Permanente, those who were randomized to the program accrued, on average, 52% fewer skilled nursing facility days, 47% fewer skilled nursing facility admissions, 49% fewer hospital readmissions, and 17% fewer emergency department visits.⁶⁷

The GRACE model

The GRACE model (Geriatric Resources for Assessment and Care of Elders)⁶⁸ was developed to improve the quality of geriatric care, reduce excess health care use, and prevent long-term nursing home placement. Each patient is assigned a support team consisting of a nurse practitioner and a social worker who make home visits, coordinate health care and community services, and develop an individualized care plan.

In one study,⁶⁹ GRACE reduced hospital admission rates for participants at high risk of hospitalization by 12% in the first year of the program and 44% in the second year. GRACE participants also reported higher quality of life compared with the control group.⁶⁹

INTERACT tools

Led by Dr. Joseph Ouslander, INTERACT (Interventions to Reduce Acute Care Transfers)⁷⁰ is a quality-improvement initiative for skilled nursing facilities, designed to facilitate the early identification, evaluation, documentation, and communication of changes in the status of residents. Visitors to its website can download a set of tools and strategies to help them manage conditions before they become serious enough to require a hospital transfer. The tools assist in promoting important communication among providers and enhancing advance-care planning.

A 6-month study in 25 nursing homes showed a 17% reduction in self-reported hospital admissions with this program compared with the same period the previous year.⁷¹

Additional home-based care interventions

Additional innovations are under way in home-based care.

The Home Health Quality Improvement National Campaign is a patient-centered movement to improve the quality of care received by patients residing at home.⁷² Through its Best Practices Intervention Packages, it offers evidence-based educational tools, resources, and interventions for reducing avoidable hospitalizations, improving medication management, and coordinating transitional care.

The Center for Medicare and Medicaid Innovation Independence at Home Demonstration⁷³ is testing whether home-based comprehensive primary care can improve care and reduce hospitalizations for Medicare beneficiaries with multiple chronic conditions.

NO SINGLE INTERVENTION: MULTIPLE STRATEGIES NEEDED

A 2011 review found no single intervention that regularly reduced the 30-day risk of re-hospitalization.⁷⁴ However, other studies have shown that multifaceted interventions can reduce 30-day readmission rates. Randomized controlled trials in short-stay, acute care hospitals indicate that improvement in the following areas can directly reduce hospital readmission rates:

• Comprehensive planning and risk assessment throughout hospitalization
• Quality of care during the initial admission
• Communication with patients, their caregivers, and their clinicians
• Patient education
• Predischarge assessment
• Coordination of care after discharge.

In randomized trials, successful programs reduced the 30-day readmission rates by 20% to 40%,^{54,62,75–79} and a 2011 meta-analysis of randomized clinical trials found evidence that interventions associated with discharge planning helped to reduce readmission rates.⁸⁰

Methods developed by the national care transition models described above can help hospitals optimize patient transitions (Table 1). Although every model has its unique attributes, they have several strategies in common:

Engage a team of key stakeholders that may include patients and caregivers, hospital staff (physicians, nurses, case managers, social workers, and pharmacists), community physicians (primary care, medical homes, and specialists), advance practice providers (physician assistants and nurse practitioners), and postacute care facilities and services (skilled nursing facilities, home health agencies, assisted living residences, hospice, and rehabilitation facilities).

Develop a comprehensive transition plan throughout hospitalization that includes attention to factors that may affect self-care, such as health literacy, chronic conditions, medications, and social support.

Enhance medication reconciliation and management. Obtain the best possible medication history on admission, and ensure that patients understand changes in their medications, how to take each medicine correctly, and important side effects.

Institute daily interdisciplinary communication and care coordination by everyone on the health care team with an emphasis on the care plan, discharge planning, and safety issues.⁸¹

Standardize transition plans, procedures and forms. All discharging physicians should use a standard discharge summary template that includes pertinent diagnoses, active issues, a reconciled medication list with changes highlighted, results from important tests and consultations, pending test results, planned follow-up and required services, warning signs of a worsening condition, and actions needed if a problem arises.

Always send discharge summaries directly to the patient’s primary care physician or next care setting at the time of discharge.

Give the patient a discharge plan that is easy to understand. Enhance patient and family education using health literacy standards⁸² and interactive methods such as teach-back,⁸³ in which patients demonstrate comprehension and skills required for self-care immediately after being taught. Such tools actively teach patients and caregivers to follow a care plan, including managing medications.

Follow up and coordinate support in a timely manner after a patient leaves the care setting. Follow-up visits should be arranged before discharge. Within 1 to 3 days after discharge, the patient should be called or visited by a case manager, social worker, nurse, or other health care provider.

CHALLENGES TO IMPROVING TRANSITIONS

Although several models demonstrated significant reductions of hospital readmissions in trials, challenges remain. Studies do not identify which features of the models are necessary or sufficient, or how applicable they are to different hospital and patient characteristics. A 2012 analysis⁸⁴ of a program designed to reduce readmissions in three states identified key obstacles to successfully improving care transitions:

Collaborative relationships across settings are critical, but very difficult to achieve. It takes time to develop the relationships and trust among providers, and little incentive exists for skilled nursing facilities and physicians outside the hospital to engage in the process.

Infrastructure is lacking, as is experience to implement quality improvements.

We lack proof that models work on a large scale. Confusion exists about which readmissions are preventable and which are not. More evidence is needed to help guide hospitals’ efforts to improve transitions of care and reduce readmissions.

You have spent several days checking on a patient hospitalized for an acute exacerbation of heart failure. You have straightened out her medications and diet and discussed a plan for follow-up with the patient and a family member, and now she is being wheeled out the door. What happens to her next?

Too often, not your desired plan. If she is going home, maybe she understands what she needs to do, maybe not. Maybe she will get your prescriptions filled and take the medications as directed, maybe not. If she is going to a nursing home, maybe the physician covering the nursing home will get your plan, maybe not. There is a good chance she will be back in the emergency room soon, all because of a poor transition of care.

Transitions of care are changes in the level, location, or providers of care as patients move within the health care system. These can be critical junctures in patients’ lives, and if poorly executed can result in many adverse effects—including rehospitalization.¹

Although high rehospitalization rates gained national attention in 2009 after a analysis of Medicare data,² health care providers have known about the lack of coordinated care transitions for more than 50 years.³ Despite some progress, improving care transitions remains a national challenge. As the health system evolves from a fee-for-service financial model to payment-for-value,⁴ it is especially important that health care providers improve care for patients by optimizing care transitions.

In this article, we summarize the factors contributing to poor care transitions, highlight programs that improve them, and discuss strategies for successful transitions.

TRANSITION PROBLEMS ARE COMMON

Transitions of care occur when patients move to short-term and long-term acute care hospitals, skilled nursing facilities, primary and specialty care offices, community health centers, rehabilitation facilities, home health agencies, hospice, and their own homes.⁵ Problems can arise at any of these transitions, but the risk is especially high when patients leave the hospital to receive care in another setting or at home.

In the past decade, one in five Medicare patients was rehospitalized within 30 days of discharge from the hospital,² and up to 25% were rehospitalized after being discharged to a skilled nursing facility.⁶ Some diagnoses (eg, sickle cell anemia, gangrene) and procedures (eg, kidney transplantation, ileostomy) are associated with readmission rates of nearly one in three.^7,8

The desire of policymakers to “bend the cost curve” of health care has led to efforts to enhance care coordination by improving transitions between care venues. Through the Patient Protection and Affordable Care Act, a number of federal initiatives are promoting strategies to improve care transitions and prevent readmissions after hospital discharge.

The Hospital Readmission Reduction Program⁹ drives much of this effort. In fiscal year 2013 (beginning October 1, 2012), more than 2,000 hospitals incurred financial penalties of up to 1% of total Medicare diagnosis-related group payments (about $280 million the first year) for excess readmissions.¹⁰ The penalty’s maximum rose to 2% in fiscal year 2014 and could increase to 3% in 2015. The total penalty for 2014 is projected to be $227 million, with 2,225 hospitals affected.¹¹

The Centers for Medicare and Medicaid Innovation has committed hundreds of millions of dollars to Community-based Care Transitions Programs¹² and more than $200 million to Hospital Engagement Networks¹³ to carry out the goals of the Partnership for Patients,¹⁴ aiming to reduce rehospitalizations and other adverse events.

At first, despite these efforts, readmission rates did not appear to change substantially.¹⁵ However, the Centers for Medicare and Medicaid Services reported that hospital readmission rates for Medicare fee-for-service beneficiaries declined in 2012 to 18.4%,¹⁶ although some believe that the reduction is related to an increase in the number of patients admitted for observation in recent years.¹⁷

TRANSITIONS ARE OFTEN POORLY COORDINATED

Although some readmissions are unavoidable—resulting from the inevitable progression of disease or worsening of chronic conditions¹⁸—they may also result from a fumbled transition between care settings. Our current system of care transition has serious deficiencies that endanger patients. Areas that need improvement include communication between providers, patient education about medications and treatments, monitoring of medication adherence and complications, follow-up of pending tests and procedures after discharge, and outpatient follow-up soon after discharge.^19–21

Traditional health care does not have dependable mechanisms for coordinating care across settings; we are all ensconced in “silos” that generally keep the focus within individual venues.²² Lack of coordination blurs the lines of responsibility for patients in the period between discharge from one location and admission to another, leaving them confused about whom to contact for care, especially if symptoms worsen.^23,24

Gaps in coordination are not surprising, given the complexity of the US health care system and the often remarkable number of physicians caring for an individual patient.⁵ Medicare beneficiaries see an average of two primary care physicians and five specialists during a 2-year period; patients with chronic conditions may see up to 16 physicians in 1 year.²⁵ Coordinating care between so many providers in different settings, combined with possible patient factors such as disadvantaged socioeconomic status, lack of caregiver support, and inadequate health literacy, provides many opportunities for failures.

Research has identified several root causes behind most failed care transitions:

Poor provider communication

Multiple studies associate adverse events after discharge with a lack of timely communication between hospital and outpatient providers.²⁶ One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.²⁷ Discharge summaries often lack important information such as test results, hospital course, discharge medications, patient counseling, and follow-up plans. Most adverse drug events after hospital discharge result directly from breakdown in communication between hospital staff and patients or primary care physicians.²⁸ Approximately 40% of patients have test results pending at the time of discharge and 10% of these require some action; yet outpatient physicians and patients are often unaware of them.²¹

Ineffective patient and caregiver education

The Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century,²⁹ noted that patients leaving one setting for another receive little information on how to care for themselves, when to resume activities, what medication side effects to watch out for, and how to get answers to questions. Of particular concern is that patients and caregivers are sometimes omitted from transition planning and often must suddenly assume new self-care responsibilities upon going home that hospital staff managed before discharge. Too often, patients are discharged with inadequate understanding of their medical condition, self-care plan,^23,24 and who should manage their care.³⁰

Up to 36% of adults in the United States have inadequate health literacy (defined as the inability to understand basic health information needed to make appropriate decisions), hindering patient education efforts.^31–33 Even if they understand, patients and their caregivers must be engaged or “activated” (ie, able and willing to manage one’s health) if we expect them to adhere to appropriate care and behaviors. A review found direct correlations between patient activation and healthy behavior, better health outcomes (eg, achieving normal hemoglobin A_1c and cholesterol levels), and better care experiences.³⁴ This review also noted that multiple studies have documented improved activation scores as a result of specific interventions.

No follow-up with primary care providers

The risk of hospital readmission is significantly lower for patients with chronic obstructive pulmonary disease or heart failure who receive follow-up within 7 days of discharge.^35–38 Of Medicare beneficiaries readmitted to the hospital within 30 days of discharge in 2003–2004, half had no contact with an outpatient physician in the interval between their discharge and their readmission,² and one in three adult patients discharged from a hospital to the community does not see a physician within 30 days of discharge.³⁹ The dearth of primary care providers in many communities can make follow-up care difficult to coordinate.

Failure to address chronic conditions

Analyses of national data sets reveal that patients are commonly rehospitalized for conditions unrelated to their initial hospitalization. According to the Center for Studying Health System Change, more than a quarter of readmissions in the 30 days after discharge are for conditions unrelated to those identified in the index admission, the proportion rising to more than one-third at 1 year.³⁹ Among Medicare beneficiaries readmitted within 30 days of discharge, the proportion readmitted for the same condition was just 35% after hospitalization for heart failure, 10% after hospitalization for acute myocardial infarction, and 22% after hospitalization for pneumonia.⁴⁰

Lack of community support

Multiple social and environmental factors contribute to adverse postdischarge events.^41–43 For socioeconomically disadvantaged patients, care-transition issues are compounded by insufficient access to outpatient care, lack of social support, and lack of transportation. Some studies indicate that between 40% to 50% of readmissions are linked to social problems and inadequate access to community resources.^44–47 Psychosocial issues such as limited health literacy, poor self-management skills, inadequate social support, and living alone are associated with adverse outcomes, including readmission and death.^48,49 Such factors may help explain high levels of “no-shows” to outpatient follow-up visits.

NATIONAL MODELS OF BEST PRACTICES

Efforts to reduce readmissions have traditionally focused on hospitals, but experts now recognize that multiple factors influence readmissions and must be comprehensively addressed. Several evidence-based models seek to improve patient outcomes with interventions aimed at care transitions:

Project BOOST

Project BOOST (Better Outcomes by Optimizing Safe Transitions)⁵⁰ is a national initiative developed by the Society of Hospital Medicine to standardize and optimize the care of patients discharged from hospital to home. The program includes evidence-based clinical interventions that can easily be adopted by any hospital. Interventions are aimed at:

• Identifying patients at high risk on admission
• Targeting risk-specific situations
• Improving information flow between inpatient and outpatient providers
• Improving patient and caregiver education by using the teach-back method
• Achieving timely follow-up after discharge.

The program includes a year of technical support provided by a physician mentor.

Preliminary results from pilot sites showed a 14% reduction in 30-day readmission rates in units using BOOST compared with control units in the same hospital.⁵¹ Mentored implementation was recognized by the Joint Commission and the National Quality Forum with the 2011 John M. Eisenberg Award for Innovation in Patient Safety and Quality.⁵²

Project RED

Project RED (Re-Engineered Discharge)⁵³ evolved from efforts by Dr. Brian Jack and colleagues to re-engineer the hospital workflow process to improve patient safety and reduce rehospitalization rates at Boston Medical Center. The intervention has 12 mutually reinforcing components aimed at improving the discharge process.

In a randomized controlled trial, Project RED led to a 30% decrease in emergency department visits and readmissions within 30 days of discharge from a general medical service of an urban academic medical center.⁵⁴ This study excluded patients admitted from a skilled nursing facility or discharged to one, but a recent study demonstrated that Project RED also led to a lower rate of hospital admission within 30 days of discharge from a skilled nursing facility.⁵⁵

The STAAR initiative

The STAAR initiative (State Action on Avoidable Re-hospitalizations)⁵⁶ was launched in 2009 by the Institute for Healthcare Improvement with the goal of reducing avoidable readmissions in the states of Massachusetts, Michigan, and Washington. Hospital teams focus on improving:

• Assessment of needs after hospital discharge
• Teaching and learning
• Real-time hand-off communication
• Timely follow-up after hospital discharge.

As yet, no published studies other than case reports show a benefit from STAAR.⁵⁷

The Care Transitions Program

The Care Transitions Program,⁵⁸ under the leadership of Dr. Eric Coleman, aims to empower patients and caregivers, who meet with a “transition coach.” The program provides assistance with medication reconciliation and self-management, a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, timely outpatient follow-up with primary or specialty care, a list of red flags to indicate a worsening condition, and instructions on proper responses.

A randomized controlled trial of the program demonstrated a reduction in hospital readmissions at 30, 90, and 180 days, and lower hospital costs at 90 and 180 days.⁵⁹ This approach also proved effective in a real-world setting.⁶⁰

The Transitional Care Model

Developed by Dr. Mary Naylor and colleagues, the Transitional Care Model⁶¹ also aims at patient and family empowerment, focusing on patients’ stated goals and priorities and ensuring patient engagement. In the program, a transitional care nurse has the job of enhancing patient and caregiver understanding, facilitating patient self-management, and overseeing medication management and transitional care.

A randomized controlled trial demonstrated improved outcomes after hospital discharge for elderly patients with complex medical illnesses, with overall reductions in medical costs through preventing or delaying rehospitalization.⁶² A subsequent real-world study validated this approach.⁶³

The Bridge Model

The Illinois Transitional Care Consortium’s Bridge Model⁶⁴ is for older patients discharged home after hospitalization. It is led by social workers (“bridge care coordinators”) who address barriers to implementing the discharge plan, coordinate resources, and intervene at three points: before discharge, 2 days after discharge, and 30 days after discharge.

An initial study showed no impact on the 30-day rehospitalization rate,⁶⁵ but larger studies are under way with a modified version.

Guided Care

Developed at the Johns Hopkins Bloomberg School of Public Health, Guided Care⁶⁶ involves nurses who work in partnership with physicians and others in primary care to provide patient-centered, cost-effective care to patients with multiple chronic conditions. Nurses conduct in-home assessments, facilitate care planning, promote patient self-management, monitor conditions, coordinate the efforts of all care professionals, and facilitate access to community resources.

A cluster-randomized controlled trial found that this program had mixed results, reducing the use of home health care but having little effect on the use of other health services in the short run. However, in the subgroup of patients covered by Kaiser-Permanente, those who were randomized to the program accrued, on average, 52% fewer skilled nursing facility days, 47% fewer skilled nursing facility admissions, 49% fewer hospital readmissions, and 17% fewer emergency department visits.⁶⁷

The GRACE model

The GRACE model (Geriatric Resources for Assessment and Care of Elders)⁶⁸ was developed to improve the quality of geriatric care, reduce excess health care use, and prevent long-term nursing home placement. Each patient is assigned a support team consisting of a nurse practitioner and a social worker who make home visits, coordinate health care and community services, and develop an individualized care plan.

In one study,⁶⁹ GRACE reduced hospital admission rates for participants at high risk of hospitalization by 12% in the first year of the program and 44% in the second year. GRACE participants also reported higher quality of life compared with the control group.⁶⁹

INTERACT tools

Led by Dr. Joseph Ouslander, INTERACT (Interventions to Reduce Acute Care Transfers)⁷⁰ is a quality-improvement initiative for skilled nursing facilities, designed to facilitate the early identification, evaluation, documentation, and communication of changes in the status of residents. Visitors to its website can download a set of tools and strategies to help them manage conditions before they become serious enough to require a hospital transfer. The tools assist in promoting important communication among providers and enhancing advance-care planning.

A 6-month study in 25 nursing homes showed a 17% reduction in self-reported hospital admissions with this program compared with the same period the previous year.⁷¹

Additional home-based care interventions

Additional innovations are under way in home-based care.

The Home Health Quality Improvement National Campaign is a patient-centered movement to improve the quality of care received by patients residing at home.⁷² Through its Best Practices Intervention Packages, it offers evidence-based educational tools, resources, and interventions for reducing avoidable hospitalizations, improving medication management, and coordinating transitional care.

The Center for Medicare and Medicaid Innovation Independence at Home Demonstration⁷³ is testing whether home-based comprehensive primary care can improve care and reduce hospitalizations for Medicare beneficiaries with multiple chronic conditions.

NO SINGLE INTERVENTION: MULTIPLE STRATEGIES NEEDED

A 2011 review found no single intervention that regularly reduced the 30-day risk of re-hospitalization.⁷⁴ However, other studies have shown that multifaceted interventions can reduce 30-day readmission rates. Randomized controlled trials in short-stay, acute care hospitals indicate that improvement in the following areas can directly reduce hospital readmission rates:

• Comprehensive planning and risk assessment throughout hospitalization
• Quality of care during the initial admission
• Communication with patients, their caregivers, and their clinicians
• Patient education
• Predischarge assessment
• Coordination of care after discharge.

In randomized trials, successful programs reduced the 30-day readmission rates by 20% to 40%,^{54,62,75–79} and a 2011 meta-analysis of randomized clinical trials found evidence that interventions associated with discharge planning helped to reduce readmission rates.⁸⁰

Methods developed by the national care transition models described above can help hospitals optimize patient transitions (Table 1). Although every model has its unique attributes, they have several strategies in common:

Engage a team of key stakeholders that may include patients and caregivers, hospital staff (physicians, nurses, case managers, social workers, and pharmacists), community physicians (primary care, medical homes, and specialists), advance practice providers (physician assistants and nurse practitioners), and postacute care facilities and services (skilled nursing facilities, home health agencies, assisted living residences, hospice, and rehabilitation facilities).

Develop a comprehensive transition plan throughout hospitalization that includes attention to factors that may affect self-care, such as health literacy, chronic conditions, medications, and social support.

Enhance medication reconciliation and management. Obtain the best possible medication history on admission, and ensure that patients understand changes in their medications, how to take each medicine correctly, and important side effects.

Institute daily interdisciplinary communication and care coordination by everyone on the health care team with an emphasis on the care plan, discharge planning, and safety issues.⁸¹

Standardize transition plans, procedures and forms. All discharging physicians should use a standard discharge summary template that includes pertinent diagnoses, active issues, a reconciled medication list with changes highlighted, results from important tests and consultations, pending test results, planned follow-up and required services, warning signs of a worsening condition, and actions needed if a problem arises.

Always send discharge summaries directly to the patient’s primary care physician or next care setting at the time of discharge.

Give the patient a discharge plan that is easy to understand. Enhance patient and family education using health literacy standards⁸² and interactive methods such as teach-back,⁸³ in which patients demonstrate comprehension and skills required for self-care immediately after being taught. Such tools actively teach patients and caregivers to follow a care plan, including managing medications.

Follow up and coordinate support in a timely manner after a patient leaves the care setting. Follow-up visits should be arranged before discharge. Within 1 to 3 days after discharge, the patient should be called or visited by a case manager, social worker, nurse, or other health care provider.

CHALLENGES TO IMPROVING TRANSITIONS

Although several models demonstrated significant reductions of hospital readmissions in trials, challenges remain. Studies do not identify which features of the models are necessary or sufficient, or how applicable they are to different hospital and patient characteristics. A 2012 analysis⁸⁴ of a program designed to reduce readmissions in three states identified key obstacles to successfully improving care transitions:

Collaborative relationships across settings are critical, but very difficult to achieve. It takes time to develop the relationships and trust among providers, and little incentive exists for skilled nursing facilities and physicians outside the hospital to engage in the process.

Infrastructure is lacking, as is experience to implement quality improvements.

We lack proof that models work on a large scale. Confusion exists about which readmissions are preventable and which are not. More evidence is needed to help guide hospitals’ efforts to improve transitions of care and reduce readmissions.