Healthcare News & Insights

Study: Hospital-based care transition programs may have better patient outcomes

A new study finds that hospital-based programs for care transition may play a role in shortening patients’ hospital stays and improving their outcomes overall.

In a report issued by the Annals of Internal Medicine, a review of several care-transition strategies for those who were hospitalized after a stroke found that hospital-based interventions produced the best results.

Since stroke patients have a variety of complex needs after discharge that make coordination of care essential, examining their outcomes paints a good picture of the effectiveness of various care-transition programs.

After analyzing several different studies, researchers found stroke patients who participated in a program coordinated by their hospital upon discharge had the shortest hospital stays.

The report also found some evidence that hospital-initiated care support for stroke patients contributed to a reduced risk of mortality.

Less evidence for different approaches

Other alternate transitional care strategies reviewed include community-based support programs, similar to those proposed by the Centers for Medicare & Medicaid Services (CMS), and education programs focused on patients and their families.

The authors of the report did caution there’s not much info about these alternate transitional care strategies, which made comparison difficult. Ultimately, they said, more research needs to be done before a full determination can be made about the best strategy for coordinating patient care.

But taking a more proactive approach to patients’ care can only be beneficial in your hospital’s quest to improve patient outcomes, especially given federal efforts to make care transitions more effective by tying hospital reimbursement to meeting various quality-of-care measures.

Making your care-transition program work

Having an effective care-transition program at your hospital may also have the effect of reducing readmissions, another measure CMS will be focusing on in the coming months.

To help guide hospitals in their decision-making, the Congressional Research Service released a report of its own detailing some goals hospitals should have for improving care transitions and reducing readmissions. Its suggestions include:

  • Strengthen hospital infrastructure.  Identify the issues in your hospital that contribute to readmissions and work to address them. Explore different strategies for improvement, such as participating in collaborations with other hospitals or with payors.
  • Improve post-discharge planning. Incomplete documentation and an unclear treatment plan can contribute to major breakdowns in the care transition process. Make sure patients receive a detailed discharge plan, including info about any follow-up tests or medications needed.
  • Improve post-acute follow up and patient support. Schedule follow-up appointments and coordinate any necessary referrals before discharge so patients won’t have to worry about doing so later. Remind patients to keep their appointments and encourage them to stick with their care plan.

For more tips on improving care transition and reducing readmissions in your hospital, click here.

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