Transitions of Care (TRC)

The percentage of discharges for persons 18 years of age and older who had each of the following. Four rates are reported:

  1. Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission through 2 days after the admission (3 total days).
  2. Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).
  3. Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
  4. Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

Why It Matters

The Medicare population includes older adults and individuals with complex health needs who often receive care from multiple providers and settings, and thus experience highly fragmented care (1). This population is at particular risk during transitions of care because of higher comorbidities, declining cognitive function and increased medication use (2). Suboptimal care transitions from the inpatient setting to home often results in poor care coordination, including communication lapses between inpatient and outpatient providers, intentional and unintentional medication changes, incomplete diagnostic workups and inadequate understanding of diagnoses, medication and follow-up needs (3). High quality transitions can improve patient safety and care coordination as well as improve patient satisfaction (4, 5, 6). In particular, quality transitions can lower the risk of readmissions, adverse events, and drug-related errors (3, 4).

Although there are no specific clinical guidelines for transitions of care, best practice standards have been developed by several organizations including The American Case Management Association (ACMA) (7), Centers for Healthcare Research & Transformation (8), and the American College of Physicians (ACP) (9). A consensus standards statement was also developed by the ACP, Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) (10). These best practice standards include several key actions: clear communication regarding treatment plans and follow-up; timely sharing of information including discharge summaries and instructions; involvement of the individual and family; appropriate and timely follow-up care; and appropriate management and review of medications, which emphasize the importance of well-coordinated care.

Notification of inpatient admission

In order to effectively treat patients and engage in transition of care coordination, providers need access to accurate and timely information; often, primary care providers are not aware of patient admissions (11). While transition of care best practice standards do not directly address notifications of admission, they all indicate communication is important. One study suggested readmissions can be reduced through better communication which can be accomplished by a provider’s use of event notifications (i.e., admission, discharge and transfer notifications) (12). Another study that specifically looked at event notifications for veterans receiving care outside of the Veteran’s Administration (VA) system found that providers felt the notifications were a useful overview of patient information and were a helpful first step to initiate follow-up care (13). Generally, notification of admissions can support initiating care coordination, improve patient safety and allow for communication across care teams.

Receipt of discharge information

Inpatient discharge processes are often not standardized and lack information despite being one of the most critical components to provider communication and care transitions (14, 15, 16). Studies have found that discharge summaries are also often delayed in being sent to other care providers (17, 18). One study found that discharge summaries were completed and available to PCPs within 48 hours only 55% of the time (17).

There is also evidence that quality and timely discharge summaries lower the risk of re-hospitalization (18, 19). However, discharge summaries often lack sufficient administrative and medical information including diagnostic test results (missing 40% of the time), discharge medications (missing 22% of the time), and test results pending at discharge (missing 75% of the time) (17).

Patient engagement after inpatient discharge

Research shows that timely follow-up care after hospitalization leads to lower risk of readmissions and minimized disparities in readmission rates (20). A 2018 study including around 50,000 patients examined the association between having a scheduled follow-up appointment or no follow-up appointment and readmissions and found that patients with an appointment scheduled and who had arrived at the appointment were readmitted less often than those with no scheduled appointment (21). Another study of 2018 Medicare patients shows that timely follow-up after discharge is an important measure for reducing readmissions for all beneficiaries (20).

Medication reconciliation post-discharge

Medication reconciliation is critical post-discharge for all individuals who use prescription medications. Prescription medication use is common among adults of all ages. Data from the National Health Interview Survey found that about 60% of adults aged 18 and older reported taking at least one prescription medication in 2021 and 36% reporting taking three or more (22). Older adults typically consume even more; Estimates indicate that almost 90% of older adults regularly take at least one prescription drug, 80% take at least two prescription drugs and 36% regularly take at least five different prescription drugs (23). Moreover, 95% of older adults have at least one chronic condition and around 80% have two or more (24). The more chronic conditions older adults experience, the higher the number of providers that are involved in their care. The risk of medication errors increases as the number of drugs, comorbidities and multiple prescribers increase (25).

Changes often occur to a patient’s medications during hospitalization. Studies have shown that when older adults are hospitalized, they are often discharged on different medication regimens than at admission (26). Medication errors are also common (27). Medication errors are 30% higher in patients who are prescribed five or more drugs and 38% higher in those 75 years and older (27). Performing medication reconciliation after hospitalization can reduce the number of medication errors and improve patient safety (28; 29).

Historical Results – National Averages

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References

  1. Barnett M.L., Bitton A., Souza J., & Landon, B.E. (2021). “Trends in outpatient care for Medicare beneficiaries and implications for primary care, 2000 to 2019”. Ann Intern Med.;174(12):1658–1665. Doi: 10.7326/M21-1523
  2. Chippa, V., & Roy, K. (2023, April 16) “Geriatric Cognitive Decline and Polypharmacy.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2024. http://www.ncbi.nlm.nih.gov/books/NBK574575/.
  3. Bajorek, S.A., & McElroy, V. (2020, March 25). “Discharge Planning and Transitions of Care”. Patient Safety Network. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
  4. Earl, T., Katapodis, N., & Schneiderman, S. (2020, March).”Care transitions. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices”. https://www.ncbi.nlm.nih.gov/books/NBK555516/
  5. Gurses, A. P., Sousane, Z., & Mossburg, S. (2024, March 27). “Communication During Transitions of Care”. Patient Safety Network (PSNet). https://psnet.ahrq.gov/perspective/communication-during-transitions-care#:~:text=Patient%20understanding%20of%20care%20decreases%20readmission%20rates,video%2Dbased%20patient%20education%20and%20counseling%20before%20discharge%2C
  6. Wang, Z., Vikram, P., Gallion, C., Lakshman, N., Motla, V., & Coffin, J. (2024, September 28). “Transitional care management improves patient outcomes, reduces healthcare costs and meets the quadruple aim.” Medical Group Management Association (MGMA). https://www.mgma.com/articles/transitional-care-management-improves-patient-outcomes
  7. American Case Management Association (ACMA). Transitions of Care Guiding Principles. (2024). https://transitionsofcare.org/standards/guiding-principles/
  8. Center for Health & Research Transformation (CHRT). (2021, April 16). “Care transitions: Best practices and evidence-based programs”. https://chrt.org/publication/care-transitions-best-practices-evidence-based-programs/
  9. American College of Physicians (ACP). (2023, April 26). “Beyond the Discharge: Principles of Effective Care Transitions Between Settings”. https://www.acponline.org/acp-newsroom/acp-makes-recommendations-to-improve-transitions-between-health-care-settings
  10. Snow V., Beck D., Budnitz T., Miller D.C., Potter J., Wears R.L., Weiss K.B., Williams M.V.; 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. (2009, April 3). “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-Society of Academic Emergency Medicine.” J Gen Intern Med;24(8):971-6. doi: 10.1007/s11606-009-0969-x. Epub 2009 Apr 3. PMID: 19343456; PMCID: PMC2710485.
  11. Jones, C. D., Maihan V.B., O’Donnell, C.M., Anderson, M.E., Patel, S., Wald, H.L., Coleman, E.A., & DeWalt, D.A. (2015, April). “A Failure to Communicate: A Qualitative Exploration of Care Coordination between Hospitalists and Primary Care Providers around Patient Hospitalizations.” Journal of General Internal Medicine 30, no. 4: 417–24. https://doi.org/10.1007/s11606-014-3056-x.
  12. Unruh, M. A., Jung, H. Y., Kaushal, R., & Vest, J. R. (2017). “Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York.” Journal of the American Medical Informatics Association : JAMIA, 24(e1), e150–e156. https://doi.org/10.1093/jamia/ocw139
  13. Franzosa, E., Traylor, M., Judon, K. M., Guerrero Aquino, V., Schwartzkopf, A. L., Boockvar, K. S., & Dixon, B. E. (2021, May 10). “Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial”. Journal of the American Medical Informatics Association : JAMIA, 28(8), 1728–1735. https://doi.org/10.1093/jamia/ocab074
  14. Chatterton, B., Chen, J., Schwarz E.B., & Karlin, J. (2024, June 1). “Primary Care Physicians’ Perspectives on High-Quality Discharge Summaries.” Journal of General Internal Medicine 39, no. 8: 1438–43. https://doi.org/10.1007/s11606-023-08541-5.
  15. Robelia, P.M., Kashiwagi, D.T., Jenkins, S.M., Newman, J.S., & Sorita, A. (2017, November 1) “Information Transfer and the Hospital Discharge Summary: National Primary Care Provider Perspectives of Challenges and Opportunities.” The Journal of the American Board of Family Medicine 30, no. 6: 758–65. https://doi.org/10.3122/jabfm.2017.06.170194.
  16. Valverde, P.A., Ayele, R., Leonard, C., Cumbler, E., Allyn, R., & Burke, R.E. (2021, August 1). “Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: A Comparison of Hospital and SNF Clinicians’ Perspectives.” Journal of General Internal Medicine 36, no. 8: 2251–58. https://doi.org/10.1007/s11606-020-06511-9.
  17. Kattel, S., Manning, D.M., Erwin, P.J., Wood, H., Kashiwagi, D.T., & Murad, M.H. (2020, March) “Information Transfer at Hospital Discharge: A Systematic Review.” Journal of Patient Safety 16, no. 1: e25. https://doi.org/10.1097/PTS.0000000000000248.
  18. Mohammed, S.A., Dzara, K., Hodshon, B., Punnanithinont, N., Krumholz, H.M., Chaudry S.I., & Horwitz, L.I (2015, January 13). “Hospital Variation in Quality of Discharge Summaries for Patients Hospitalized With Heart Failure Exacerbation.” Circulation. Cardiovascular Quality and Outcomes 8, no. 1: 77. https://doi.org/10.1161/CIRCOUTCOMES.114.001227.
  19. Jack, B.W., Veerappa C.K., Anthony, D., Greenwald, J.L., Snachez, G.M., Johnson, A.E., Forsythe, S.R., O’Donnell, J.K., Paasche-Orlow, M.K., Manasseh, C., Martin, S., & Culpepper, L. (2009, February) “A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial.” A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. 150, no. 3 . https://psnet.ahrq.gov/issue/reengineered-hospital-discharge-program-decrease-rehospitalization-randomized-trial.
  20. Anderson, A., Mills, C.W., Willits, J., Lisk, C., Maksut, J.L., Khau, M.T., & Scholle, S.H. (2022, March 30). “Follow-up Post-Discharge and Readmission Disparities Among Medicare Fee-for-Service Beneficiaries, 2018.” Journal of General Internal Medicine 37, no. 12: 3020. https://doi.org/10.1007/s11606-022-07488-3.
  21. Coppa, K., Kim, E.J., Oppenheim, M.I., Bock, K.R., Conigliaro, J., & Hirsch, J.S. (2021, January 19). “Examination of Post-Discharge Follow-up Appointment Status and 30-Day Readmission.” Journal of General Internal Medicine 36, no. 5: 1214. https://doi.org/10.1007/s11606-020-06569-5.
  22. National Center for Health Statistics (NCHS). (2023, June). “Characteristics of Adults Aged 18–64 Who Did Not Take Medication as Prescribed to Reduce Costs: United States, 2021.” NCHS Data Brief. https://www.cdc.gov/nchs/data/databriefs/db470.pdf
  23. Ruscin, J. M., & Linnebur, S. A. (2023, August). “Aging and Medications.” Merck Manual Consumer Version. https://www.merckmanuals.com/home/older-people%E2%80%99s-health-issues/aging-and-medications/aging-and-medications
  24. National Council on Aging (NCOA). (2024, August 16). “Get the facts on Healthy Aging. Aging in America.” https://www.ncoa.org/article/get-the-facts-on-healthy-aging/
  25. Rasool, M.F., Rehman, A.U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I, Shakeel, S., Hassali, M.A.A., & Hayat, K. (2020, November 19). “Risk Factors Associated With Medication Errors Among Patients Suffering From Chronic Disorders.” Frontiers in Public Health 8. https://doi.org/10.3389/fpubh.2020.531038.
  26. Weir, D.L., Lee, T.C., McDonald, E.G., Motulsky, A., Abrahamowicz, M., Morgan, S., Buckeridge, D., & Tamblyn, R. (2020) “Both New and Chronic Potentially Inappropriate Medications Continued at Hospital Discharge Are Associated With Increased Risk of Adverse Events.” Journal of the American Geriatrics Society 68, no. 6: 1184–92. https://doi.org/10.1111/jgs.16413.
  27. Tariq, R.A., Vashisht, R., Sinha, A., & Scherbak, Y. (2024, February 12). “Medication Dispensing Errors and Prevention.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2024. http://www.ncbi.nlm.nih.gov/books/NBK519065/.
  28. Kreckman, J., Wasey, W., Wise, S., Stevens, T., Millburg, L., & Jaeger, C. (2018, April 20). “Improving Medication Reconciliation at Hospital Admission, Discharge and Ambulatory Care through a Transition of Care Team.” BMJ Open Quality 7, no. 2: e000281. https://doi.org/10.1136/bmjoq-2017-000281.
  29. Patient Safety Network (PSNet). (2019, September 7). “Readmissions and Adverse Events After Discharge.” https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge

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