Care Transitions: Leading Practices to Achieve ‘Always’

  • Publication: Studer Group
  • Release Date: February 25, 2016

onsider for a moment how different the patient’s journey through the healthcare system is today from what it was prior to hospitalists. A physician may have practiced alone or in a small group and while a computer system may have been in use, the paper chart and the physician’s brain contained all of the information on which the physician relied. When a patient was admitted to the hospital, the physician came into the hospital and managed the patient’s care. The patient relied on his or her primary care physician to consider everything that was known about the patient when making decisions during the hospital stay.

Today’s environment is very different. Primary and specialty care groups are often large and since the patient may not see the same provider from visit to visit, the primary care providers’ knowledge of the patient is only as good as their documentation and review of the Electronic Medical Record (EMR). With the proliferation of specialty and subspecialty care, the patient is likely to be referred to a provider with more specific expertise. That person in turn may admit the patient to a hospital where care will be provided by an entirely different team of hospitalists and specialty care providers. The patient’s medications and care plan may change drastically from the original primary care team’s plan. The patient’s journey through the system includes a myriad of physical and information transfers, all of which may rely entirely on technology with no person-to-person communication between healthcare providers.

So it is no wonder that one of the most challenging aspects of healthcare today is the challenge of assuring safe and effective care transitions. Care transitions, the transition of a patient from one care environment to another or from one caregiver to another, are among the most dangerous times for our patients.


The data is staggering:

  • A study of patients discharged to home after an inpatient stay found:
    • Only 41% were able to state their diagnoses,
    • Only 37% were able to state the purpose of their medi­cations, and
    • Only 14% knew the common side effects of all their medications.1
  • Within 30 days of discharge, approximately 2.6 million Medicare beneficiaries are re-hospitalized at a cost of over $26 billion every year. It is estimated that up to 76% of these readmissions may be preventable. Of Medicare bene­ficiaries who are readmitted within 30 days, 64% receive no post-acute care between discharge and readmission.2
  • 20% of patients experience an adverse event within 3 weeks of discharge from hospital. An adverse event is defined as an injury resulting from medical management rather than the underlying disease. The most common ad­verse events are medication related which can be avoided or mitigated.3
  • 2.3 million (2%) of visits to the Emergency Department each year are by patients who were discharged from the hospital within the previous 7 days, according to the 2008 National Health Statistics Report.4
  • Direct communication between hospital physicians and primary care physicians occurred infrequently (in 3-20% of cases studied) according to a recent AHRQ literature review, and the availability of a discharge summary at the first post-discharge visit was only 12-34%, affecting the quality of care in follow-up visits.5
  • Estimated medication errors harm 1.5 million people each year in the United States, according to The Institute of Medicine, at an annual cost of at least $3.5 billion with one study finding that 60% of these medication errors occur at times of transition.6
  • The magnitude of the problem is compounded by the sheer number of care environments and extends to every type of care transition. We know that patients routinely pass from one care environment to the next not under­standing their care plan or their role in maintaining or advancing their health.
  • While 73% of admitted patients believed they had one “main” physician providing their care, only 18% of patients knew that individual’s name, let alone their care plan.7
  • A 2010 study in the Archives of Internal Medicine found that while physicians believed that 77% of their patients understood their diagnosis only 57% of patients did.8
  • When patients perceive their care provider is a poor com­municator there is a 19% higher risk of patient non-ad­herence with the follow-up plan than those who perceive their physician to communicate well.9

As healthcare has moved toward the hospitalist as the coordinator of inpatient care, it has also moved toward reimbursement for health events and health management and away from the fee for service model. Healthcare systems and providers are under ever increasing demands to improve outcomes and achieve the “holy grail” of delivering high-value care. Earning this “top tier” provider status means reimbursement that features financial rewards, including greater access to larger panels of patients and/or fewer penalties. As healthcare organizations seek new and creative ways to recover from the volume shifts away from the inpatient environment, providers are seeking ways to navigate the ever- changing array of regulatory requirements and billing and coding system changes. The imperative to survive through size and scale has fueled an explosion of new healthcare delivery models (integrated health systems, accountable care organizations, mergers, acquisitions) and a transition from environments of intermittent change to continuous change.


In 2012, the Centers for Medicare and Medicaid Services (CMS) began to levy excess readmission penalties against those inpatient providers whose readmission rates exceeded expected rates. These penalties are substantial and have increased each year since they began to be assessed.

CMS began reporting patient experience with transitions of care for the first time in December of 2014, increasing both the industry’s and the public’s attention to this area. The Care Transition dimension gives us a window into a hospital’s discharge process, and highlights problems that lead to adverse events such as medication errors and avoidable readmissions. It is included as part of Value-Based Purchasing for the FY2018 Program. The Baseline Period was January - December 2014, and the first Performance Period was January 1 – December 31, 2016.

Similarly, Medicare Spending per Beneficiary, a comparative, price-standardized, risk adjusted value assesses the cost for an episode of care—the period from three days prior to admission to 30 days post discharge—is factored into the Value-Based Purchasing incentive payment within the Efficiency Domain.

Perhaps most noteworthy is the way in which private insurers and self-insured organizations are following suit. Several large insurers now direct their insured individuals to a few carefully selected care providers for high-cost procedures without regard to where the insured individual lives. These fortunate few providers enjoy a significant patient volume increase at the expense of the providers back in the insured person’s home town. And even after reimbursing the insured and a support person for the travel costs, the insurer is able to save cost and spend fewer premium dollars.

Ask yourself, if you were an insurance company with obligations to your subscribers, your Board of Directors, and your stockholders, wouldn’t you want to partner with healthcare systems and providers that deliver the best health outcomes at the most affordable rate?


So how can you navigate this virtual sea of change with wave after wave of new demands from patients, the government, and insurers? By starting at the heart or your commitment to your patients:

“Today we are caring for 41 patients here on the unit and 8 who are recovering at home.”

“Mrs. Jones, this is Kate at Dr. Roehl’s office calling to check on you. Dr. Roehl wanted me to check on you because she knows you are just getting used to your new glucose monitoring regimen and she wanted me to make sure everything is going well so you’ll stay safe and under control. Do you have a few minutes to chat?”

“Mr. Smith, it’s been my privilege to care for you while you were in our Emergency Department. I’d like to take a few minutes and introduce you to my colleague Shelly who will be your nurse here as we get you settled into your inpatient room. She’s been with us for over 10 years now so I know you are in good hands. While we get you settled, I am going to share information with Shelly about what we’ve done in the Emergency Department. I want you to listen and to help me do a good job in sharing the information as I hand-on your care to her.”

When we take steps such as these to assure safe transitions of care, we are honoring our sacred responsibility to patients and we truly live our mission and values. At Studer Group, we’ve studied care transitions in all environments. Through our work with more than 900 partner organizations in our national and international learning lab, we’ve identified leading practices that allow us to better connect with our patients and their families at the many points of care transition. These field-tested practices show us how to create care transitions that are safer, more effective, and that both lessen patient anxiety and increase their adherence to treatment plans and follow-up regimens. When executed well, Studer Group’s Evidence-Based LeadershipSM strategies for care transitions, yield a higher level of patient engagement in the care process.

The strategies include a framework to drive execution and a wide array of tools customized to specific care transitions spanning movement of patients back and forth between primary and specialty care, office-based care and hospital-based care, urgent care, emergency, and inpatient environments, inpatient to post-acute care and inpatient to home. Whatever your challenge, Studer Group has proven strategies to assist you.


Care Transition Calls—(or as we frequently refer to them “the best four minutes in healthcare”). These calls, made once the patient has gone home after a care encounter or inpatient stay, allow a touch point with the patient to assure the patient is progressing safely by adhering to the treatment plan and follow-up recommendations. The calls also demonstrate empathy, offer an opportunity for service recovery, reassure caregivers as to the patient’s safe progress, and help improve the patient’s health. Studer Group’s software accelerator, Patient Call Manager: The Clinical Call SystemTM, is designed to provide quality touch points along a patient’s continuum of care, both before and after we care for them within our four walls.

Key Words at Key Times for Hand-ons—combining the AIDET® communication framework with proven standardized communication such as SBAR (Situation, Background, Assessment, Recommendation) ensures that caregivers and patients understand the care that preceded the patients’ transition and expected outcomes from the transition.

Discharge Folders—a superior discharge plan begins when the patient first enters the care environment. This essential feature of a patient’s discharge assures the patient a well-organized view of post-care instructions. When the care team reviews this information prior to discharge, the patient is more successful and safer at home.

Nurse Leader Rounding/Leader Rounding on Patients—rounding on patients demonstrates to patients and families the organization’s commitment to deliver quality care and to validate that this level of care is occurring with every patient, every time. Through rounding on patients, leaders validate the work of the caregiving team in preparing the patient for care transitions.

Bedside Shift Report—one of the most critically important transitions in the inpatient environment is from nurse caregiver to nurse caregiver at time of shift change. This leading practice prevents organizations from “dropping the baton” with a change in caregiver. It engages the departing and arriving nurse in conversation with the patient to achieve a real-time exchange of information to increase patient safety, improve quality of care, increase accountability, and strengthen teamwork. Teach-back is a key element of this process to confirm patient understanding and help drive patient engagement.

M in the BoxSM—a visual communication tool to help care providers enhance their dialogue with patients about new medicines. The tactic also helps serve as a reminder for care providers to cascade information to the patient about the new medicines that have been ordered for them, including the name, purpose, any possible side effects, and what the patient should do if they experience these side effects. As above, teach-back is a key element of this process to confirm patient understanding and help drive patient engagement.

Visit Guides—a customizable document given to medical practice patients at the time of check-in that follows the patient throughout the visit to facilitate discussion of the patient’s concerns and questions, highlight objectives for the visit, and capture highlights of the encounter. Once at home, the patient and the patient’s family can refer to the guide.

Visit Summaries—Meaningful Use criteria define a visit summary as an understandable summary for the patient of everything that occurred in the clinical encounter, including the information the patient must act on to optimize his health. Engaging staff, care providers, and patients in the review of this information is critically important to the patient’s health.

And the good news is that through the Evidence-Based LeadershipSM model, Studer Group leads the country in helping our partners improve care transitions. In fact, our work has delivered some of its highest impact for our partners within the care transitions area:

Average difference in national percentile rank between Studer Group partners and non-partners

Whether your work is focused in the physician office, the emergency room, the inpatient environment, post-acute care, or home care, the time to improve care transitions is now. Studer Group is committed to helping you ensure that healing continues beyond the walls of your hospitals and offices, that patients truly understand and follow their treatment plans, fill their prescriptions, take their medications, and keep their follow-up appointments. We offer our partners a proven suite of tools and tactics to improve all care transitions.

Download the Whitepaper

1Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-841.
2Medicare Payment Advisory Commission. A data book: Healthcare spending and the Medicare program. June 2007. Available at: http://www.medpac.gov/documents/Jun07DataBook_Entire_report.pdf.
3Centers for Medicare & Medicaid Services (CMS) website: http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html.
4Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from US hospitals. National Health Statistics Reports, July 24, 2008; Number 6.
5Journal of Clinical Outcomes Management, 2001. Kripalani et al, JAMA 2007.
6Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: http://www.nytimes.com/2006/07/21/health/21drugerrors.html?ex=1311134400&en=8f34018d05534d7a&ei=5088&partner=rssnyt&emc=rss.
7Olsen, DP et al, Arch Intern Med. 2010 Aug 9;170(15):1302-7. Communication discrepancies between physicians and hospitalized patients.
8Olson, DP and Windish, DM; Communication Discrepancies Between Physicians and Hospitalized Patients” Arch Intern Med 2010; 170 (15): 1302-1307.
9Med Care. 2009 Aug;47(8):826-34. Physician communication and patient adherence to treatment: a meta-analysis. Zolnierek, KB et al.

  • Lynne Mahony

    Lynne Mahony, MBA, MFA

  • Don Dean

    Don Dean, BSRT

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