Avoidable hospital admissions are a key patient safety and quality concern. A significant cause of preventable readmissions is poor communication and coordination of care during transitions. Transitions between care settings are vulnerable periods for all patients, but especially older adults and those with multiple comorbidities. Transitions include admissions and discharges within and between acute-care hospitals, skilled nursing facilities, long-term care facilities, long-term acute-care hospitals, assisted living facilities, and home.

All too often, poor coordination between the acute setting and primary care provider results in poor longitudinal care planning. Fewer than 50% of patients see their primary care providers within 2 weeks of hospital discharge. Comprehensive programs to enhance care during transitions between settings can reduce not only 30-day hospital readmissions but also readmissions for the entire year after the initial hospitalization. This article reviews the rationale for administrative implementation of high-quality transitional care initiatives and provides tools to help nurses implement these initiatives.

Readmission by the numbers

One in five Medicare enrollees is readmitted to the hospital within 30 days, and up to 75% of these readmissions are preventable. The readmission rate for patients discharged to skilled nursing homes is even higher: 25% are readmitted within 30 days. Such readmissions cost the U.S. healthcare system approximately $17 billion annually, not including readmissions to emergency departments (ED) or urgent-care settings.

The Institute of Medicine (IOM) highlighted this problem in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century. Yet readmission rates remained stable between 2004 and 2011. The IOM identified poor patient-discharge instructions—including information about medications, red flags for worsening condition, and contact information for questions—as a care-transition problem.

Effect of the Affordable Care Act

In 2012, the Affordable Care Act (ACA) established the Medicare Hospital Readmissions Reduction Program (HRRP), giving hospitals incentives to reduce readmission rates. Financial penalties are imposed on hospitals whose adjusted 30-day readmission rates for patients with acute myocardial infarction, heart failure, and pneumonia are significantly higher than the national average. These rates are adjusted according to patient demographics and risk factors. (In 2015, the Centers for Medicare & Medicaid Service (CMS) is expanding this program to cover COPD and hip and knee arthroplasties.) Since HRRP implementation, the 30-day readmission rate for Medicare patients has decreased from 20% to 17.8% overall, with the most significant reductions in the targeted diagnostic groups.

Understanding transitional care

Transitional care refers to a collection of services aimed at ensuring optimal communication and coordination of services to provide continuity of safe, timely, high-quality care during transitions. Optimal management of care transitions includes patient and family education, coordination and arrangement of care in the post-acute care setting, and aiding communication among healthcare professionals involved in the patient’s care transition.

Several transitional-care programs have gone through randomized controlled trials and been found to significantly lower readmission rates, with reductions up to 45%. These programs incorporate such services as comprehensive discharge planning, post-discharge telephone outreach, home visits, patient-centered discharge instructions, follow-up with a primary care provider, and medication reconciliation.

Specific care transition models

Transitional care programs that reduce both healthcare costs and readmissions include the care transitions intervention model (Coleman model), transitional care model (Naylor model), and Better Outcomes for Older Adults through Safe Transitions (BOOST) model.

Care transitions intervention model

Eric Coleman’s care transitions intervention model is a 4-week program designed to foster patient engagement and promote a smooth transition from the hospital or skilled nursing facility to the home. It has been shown to decrease rehospitalizations. This model rests on four pillars:

• medication self-management
• maintenance of a personal health record
• primary care physician follow-up
• alertness to red flags.

A transition coach focuses on the patient’s self-identified goals and helps the patient develop self-management skills. The relationship is relatively short, spanning only the 4-week intervention period, and the coach doesn’t assume home-care or case-management responsibilities. Coaching starts in the hospital, where the coach describes the transitional care program, obtains the patient’s consent to participate, and introduces the Coleman personal health record (www.caretransitions.org/documents/phr.pdf).This record
guides the patient in documenting medication and other medical information and generates a list of questions for the healthcare provider. A home visit is scheduled within 72 hours of discharge.

During the home visit, the coach assists the patient with a pre-/post-hospitalization medication review and addresses any discrepancies. The patient develops his or her own list of questions for the primary care provider. The coach and patient review the discharge plan and update the personal health record. Finally, the coach discusses symptoms and drug side effects and establishes an alert-and-response system.

After the home visit, three follow-up calls take place to address the patient’s remaining medication questions, discuss the outcomes of follow-up primary care provider visits, describe available support services, and assist with scheduling additional follow-up appointments (as needed).

Transitional care model

Mary Naylor’s transitional care model involves a 1-to-3 month period of interventions with high-risk older adults to prevent hospital readmission. An advanced practice registered nurse (APRN) performs a predischarge patient assessment, and then collaborates with the hospital team to develop a transitional care plan.

The APRN makes multiple home visits, uses telephone outreach throughout the transitional care period, and promotes information transfer between the acute-care and primary-care settings by accompanying the patient to the first primary care follow-up visit. Cornerstones of this model are patient engagement, goal setting, and communication with patients, families, and healthcare team members. The APRN helps the patient identify early signs and symptoms of a worsening condition to expedite prompt intervention and avoid future hospitalization.

Patients with specific risk factors are good candidates for this care model. (See Patients who can benefit from the transitional care model.)

Project BOOST

An initiative of the Society of Hospital Medicine, Project BOOST was developed by a team of payers, regulators, and leaders in healthcare transitions and hospital medicine to improve the quality of care transitions. This model focuses on discharge processes and communication with patients and receiving providers. It uses a systemic approach to enhance the quality of transitions and gives clinicians tools to help them standardize, initiate, and improve hospital practices. Evidence-based tools are available in a toolkit available free of charge to healthcare professionals with an interest in transitional care. Project BOOST also provides technical support and education to project management teams and helps develop a community of organizations that freely share strategies and struggles with program implementation.

Project BOOST involves discharge planning, medication reconciliation, patient and family communication, and primary care provider communication before discharge. It includes post-discharge telephone follow-up (including facilitating appointment scheduling). Patient-centered discharge instructions actively involve the patient in his or her own care.

The BOOST Risk Assessment Tool, called the “8 P’s,” identifies modifiable risk factors that guide discharge planning. (See “8 P’s” of the BOOST Risk Assessment Tool.)

Project BOOST aligns evidence-based interventions with specific problems identified by the “8 P’s” tool. It maximizes patient involvement in the plan of care through concise patient-centered discharge instructions tailored to the patient’s literacy level. The instructions include the reason for hospitalization, red flags signaling complications, follow-up appointments, post-discharge care, key contact information, and space for the patient to list questions for the primary care provider. Before discharge, nurses use the teach-back method to review this information with the patient.

INTERACT program

Interactions to Reduce Acute Care Transfers (INTERACT) is designed to improve care in long-term care (LTC) and skilled nursing facilities (SNFs), with the goal of reducing preventable hospital readmissions. It includes multiple quality-improvement strategies and tools to help healthcare professionals in LTC and SNFs identify, document, and communicate early changes in the patient’s condition so interventions can begin before the condition becomes serious enough to warrant rehospitalization. INTERACT tools and strategies aid effective advance care planning; communication between LTC, SNF, and hospital providers; and management of changes in the patient’s condition.

An evaluation of 25 LTC facilities that incorporated INTERACT quality-improvement methods found readmission rates decreased an average of 17%. Facilities with a greater commitment and resources allocated to implementing the model saw greater reductions than those with a minimal commitment.

Guidelines and key strategies for transitional care

The American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine have worked together to develop consensus standards for transitional care. Practice standards have been developed based on this framework of guiding principles. Both the National Transitions of Care Coalition and the Institute for Healthcare Improvement’s State Action on Avoidable Rehospitalizations specify standards of care and provide transition guides in these consensus standards. For a summary of all key recommendations from leading transitional care organizations, (see Transitional care principles.)

Other recommendations for improving care transitions have been developed by the National Transitions of Care Coalition (www.ntocc.org), Care Transitions Program (www.caretransitions.org), and Institute for Healthcare Improvement’s State Action on Avoidable Hospitalizations program (www.ihi.org/offerings/Initiatives/STAAR/Pages/default.aspx.) Using standardized forms aids implementation of these recommendations. (See Transitional Care Toolkits.)

In a 2014 meta-analysis of 26 randomized controlled trials involving 7,932 subjects, one research group found 30-day readmissions were reduced only by high-intensity transitional care programs that included most of the activities listed in Transitional care principles. They found that a home visit within 3 days of hospital discharge, care coordination by an APRN or RN, and communication between the hospital team and primary care provider within 1 week of discharge were essential to transitional care programs that reduced 30-day readmissions.

Targeted care transition: Readmission risk factors and risk assessment

Patient factors that pose a risk for readmission include comorbid medical conditions, previous acute-care hospitalizations and ED visits, older age, lack of social support, poor access to healthcare services, substance abuse, poor health literacy, and functional limitations. Patients who lack strong family support also are at risk for readmission, and family members commonly have inadequate input into transitional care planning because they’re not included in discussions. Too often, only the patient receives self-management education, even though family caregivers provide the actual care. Also, weekend discharges can put patients at risk for readmission due to lack of available support services, such as pharmacies and durable medical equipment companies, during weekend hours.

Transitional care programs are resource-intensive and are most likely to be effective when they target individuals at highest readmission risk. In one study (Kansagara, et al), researchers conducted a systematic review of currently available tools used to predict a patient’s risk for readmission and evaluated 13 instruments with potential use in deciding which patients would benefit most from transitional care services. They found that although risk tools overall had poor predictive ability, high- and low-risk scores correlated with readmission rates in a clinically significant manner.

Another researcher (Wodchis) criticized the Kansagara study for not considering the intent of the tools in its review. Wodchis studied tools designed to select patients for transitional care interventions and assessed their comparative abilities to predict acute- and long-term care use. This study included five tools. The author found that patients identified by each tool differed significantly, because each tool was designed to identify different risk factors. Wodchis found the tools have predictive value but predicted differing outcomes. The Probability of Repeated Admission (Pra) tool and the LACE index were the best predictors of 30-day acute-care readmissions and ED visits. But because these tools use unmodifiable risk factors to assess risk, they provide little direction for targeted transitional care activities.

Pra tool and LACE index

A three-study meta-analysis involving five cohorts of subjects (n = 8,843) evaluated the validity of the Pra tool. The researchers found Pra to be a good predictor of hospital admission in subjects who achieved high scores on the assessment. Unfortunately, this tool has poor sensitivity, so many patients with low scores not identified as high risk for readmission may be categorized inaccurately and thus fail to receive the transitional care services they need. The Pra tool is easy and quick to administer and considers age, gender, presence of diabetes and cardiac disease, hospital and primary care use, self-rated health, and caregiver availability to assess risk for hospital admission. Scores range from 0 to 1; a score of 0.5 indicates a 50% risk for two or more hospitalizations within the next 4 years or one or more admissions in the following year.

The LACE index is a valid algorithm useful in identifying patients likely to benefit from post-discharge care. LACE scores range from 0 to 19; patients scoring 10 or above are at high risk for readmission or death and are likely to benefit from post-discharge services. Like the Pra tool with its cutpoint of 10, the LACE tool accurately identifies high-risk patients but misses a significant number with low scores who will be readmitted. Administered during hospitalization, the LACE tool considers:

• Length of the hospital stay
• Acuity on admission to the hospital
• Comorbid conditions
• Emergency visits in the 6 months before hospitalization.

Patient activation

Patients with the essential skills and confidence to engage actively in their own healthcare discharge planning are far less likely to be readmitted to the hospital and less likely to overuse the ED. The term patient activation describes six key components of engagement—self-management of symptoms and health problems, engagement in health-promoting activities to optimize function, involvement in treatment decisions, collaboration with healthcare professionals, active identification of high-quality healthcare organizations and providers, and ability to navigate the healthcare system.

A developmental process, patient activation has four identifiable stages.

• Stage 1: Patients don’t realize the importance of taking an active role in their own health.
• Stage 2: They lack the knowledge and confidence to participate effectively in their own health care.
• Stage 3: They begin to take an active role in their care but may lack confidence to assert themselves adequately in care planning.
• Stage 4: They generally play an active, effective role in maintaining their own health but may struggle during times of excessive stress or illness.

Patients in stages 3 and 4 have lower levels of 30-day readmission rates than those at lower activation levels.

PAM measure

The Patient Activation Measure (PAM), a 13-item survey with good validity and reliability across multiple demographic groups, can be used to determine a patient’s activation level before hospital discharge. It also can be used to identify readmission risk and guide specific tailored interventions based on the patient’s activation level.

In 2013, URAC (formerly called the Utilization Review Accreditation Commission) proposed using PAM to identify at-risk patients, appropriately direct interventions and resources to high-risk patients, and enhance patient activation. Unfortunately, PAM is copyrighted and its use requires purchase of a licensing agreement. Costs vary with organization size, and licenses must be purchased every 12 months. Costs vary from $2,000 for use with up to 1,000 participants to $7,500+ for organizations planning to use the tool with more than 2,000 patients in 12 months.

Financing transitional care

The ACA provides financial resources for providers to deliver transitional care services to reduce readmissions. Since 2013, Current Procedural Terminology codes related to transitional care allow organizations to bill CMS for this care. APRNs or physicians must oversee programs that provide:

• phone or e-mail contact with the patient within 48 business hours of hospital discharge
• a face-to-face patient visit with the healthcare provider within 14 days of hospital discharge (7 days for high-complexity patients)
• coordination services, such as review of the discharge summary, assurance that follow-up equipment and diagnostic testing are scheduled, medication management, and additional patient education.

If all of these services are provided to patients who require moderate- or high-intensity decision-making based on their physical or mental condition, transitional care codes 99495 or 99496 may be billed.

Making progress

No single specific transitional care activity has been shown to decrease hospital admissions effectively, but a bundle of activities linked to transitional care principles can reduce short- and long-term readmission risk. High-quality transitional care programs have been shown to enhance patient safety and reduce hospital readmissions for high-risk patients. The Pra tool, LACE index, and PAM measure are useful tools for identifying patient risk.

Several well-established transitional care programs have shown consistent benefit in reducing hospital readmissions. These programs provide tools and best practices on which new programs may be modeled. The ACA offers a carrot-and-stick approach to transitional care by offering opportunities for reimbursement for transitional care programs and imposing penalties on hospitals with high readmission rates.

Your role

As a hospital nurse, you can help ensure your patients are assessed for readmission risk and referred for transitional care services as appropriate. Engage patients (and families) as partners in planning and managing their care. Use effective educational strategies, including teach-back and other methods of assessing understanding, with instructions written at the patient’s health literacy level. Education should include basic information about the reason for hospitalization, red flags that signal complications of the patient’s condition, and instructions on what to do if symptoms worsen or red flags occur.

Conduct careful planning for post-discharge care and explore barriers to receiving needed services with the patient and family. Make sure the patient has a primary care provider; if not, work with Medicaid or community resources to match the patient with a provider and arrange for follow-up care. A discharge summary should be faxed to the patient’s primary care provider at the time of discharge.

If you’re a primary care nurse, reconcile your patient’s medications immediately after discharge and ensure a timely follow-up visit in the primary care office. Also make sure durable medical equipment, follow-up testing, and home care have been scheduled and received. Finally, work with patients and families to mitigate preventable factors that triggered hospital admission.

Selected references
Bixby MB, Naylor MD. The transitional care model (TCM): hospital discharge screening criteria for high risk older adults. Medsurg Nurs. 2010;19(1):62-3.

Coleman EA. Infusing true person centered care into improving the quality of transitional care. Paper presented at: Transitions of Care: Improving Care Across Settings; November 2, 2011; Greater Cincinnati Health Council, Cincinnati, Ohio.

Dreyer T. Care transitions: best practices and evidence-based programs. Home Healthc Nurse. 2014;32(5):309-16.

Gruneir A, Dhalla IA, van Walraven C, et al. Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm. Open Med. 2011;5(2):e104-11.

Hansen LO, Young RS, Hinami K, et al. Interventions to reduce 30-day hospitalization: a systematic review. Ann Intern Med. 2011;155(8):520-8.

Hibbard JH, Mahoney ER, Stockard J, et al. Development and testing of a short form of the patient activation measure. Health Serv Res. 2005;40(6 Pt 1):1918-30.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press; 2001.

INTERACT. Interventions to Reduce Acute Care Transfers. https://interact2.net/

James J. Medicare hospital readmissions reduction program. Health Affairs; Health Policy Briefs. November 2, 2013. www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102

Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306(15):1688-98.

Naylor MD, Aiken LH, Kurtzman ET, et al. The care span: the importance of transitional care in achieving health reform. Health Aff (Millwood). 201;30(4):746-54.

Quartarolo J. Project BOOST: Improving hospital care transitions. February 12, 2014. http://legacy.hospitalmedicine.org/Source/ondemand/2014-02-12-13-04_Project_BOOST_Fall_2014_Informational_Webinar.cfm

Snow V, Beck D, Budnitz T, et al; American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine: American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-6.

Transitional Care Model. http://www.nursing.upenn.edu/ncth/transitional-care-model/index.php

Joan M. Nelson is an associate professor in the College of Nursing at the University of Colorado in Aurora. Amy L. Pulley is manager of the community-based care transitions and case management program, Denver Regional Council of Government, Area Agency on Aging in Denver.