Five Ways to Ensure Your Transition of Care is Successful

Transition of Care for Medicare

Being discharged from the hospital is a critical point in a patient’s care. Medicare estimates that nearly one in five Medicare patients discharged from a hospital stay are readmitted within 30 days, at a cost of over $26 billion every year. The major cause of unplanned readmissions is an ineffective transition of care.

“Transition of care is the movement patients make between health care practitioners and settings of care as their condition and needs change, during the course of a chronic or acute illness,” Network Health Quality Coordinator Carol Hirn said.

“For example, if a patient has been seeing their personal doctor and then starts seeing a specialist for a condition/illness or if a patient is transferred from an inpatients hospital to a skilled nursing facility.”

The most frequent factors that contribute to a breakdown within the transition of care are the following.

• Poor communication between providers
• Incomplete transfer information
• Inadequate education of the patient and/or caregiver
• Limited access to essential services needed for recovery
• The absence of a single point person to ensure continuity of care

These factors can lead to adverse events for patients and result in avoidable rehospitalization. Here are five ways you can ensure successful transition of care.

1. Ask facilities about access to a case manager. Case managers are usually registered nurses or social workers who specialize in coordinating patient care. They can assist you and your family in navigating the transition. Discussing your concerns and options as early as possible can ensure you’re making informed decisions regarding your care.
2. Check if your insurance offers care management services. At Network Health, we offer care management services to assist many of our members, at no cost. These services help effectively navigate the available options during transition of care. To find out if these services are available to you, visit our website or call 800-826-0940.
3. Bring a family member or friend with you during discharge. It can be vital to have another person listen to discharge instructions and ask questions. They can help you remember details and ask questions that you might not have thought to ask.
4. Request a written copy of discharge instructions. Most facilities offer a written copy of your visit that includes recommended follow-up care. If they don’t offer it, make sure you request it. If you are unclear, ask further questions for clarification. Keep the summary as a reference during your transition of care.
5. Set up a follow-up appointment with your personal doctor. Most hospitals automatically set up a follow-up appointment with the admitting provider. If the admitting provider is not your personal doctor, make sure your personal doctor receives a copy of the medical records and medication changes from your hospitalization or hospital visit. If the hospital doesn’t set up a follow-up appointment, make sure you ask for one.

Effectively navigating a transition of care empowers you to maintain your health, independence and quality of life to meet your healthcare needs.