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Care Transitions, Patient Health, and System Performance in the United States

Abstract and Keywords

Transitions in care occur when a patient moves from an institutional setting, such as a hospital or nursing home, to home or community, often with the hope or expectation of improving health status. At the very least, patients, clinicians, and caregivers aim to achieve stability and avoid complications that would precipitate a return to the emergency department (ED) or hospital. For some groups of vulnerable people, especially the very old and frail, such transitions often require specific, targeted coaching and supports that enable them to make the change successfully. Too often, as research indicates, these transitions are poorly executed and trigger a cycle of hospital readmissions and worsening health, even death. In recognizing these perils, organizations have begun to see that by improving the care transition process, they can improve health outcomes and reduce costs while ensuring safety, consistency, and continuity. While some of this improvement relies on medical care, coaching, social services and supports are often also essential. Lack of timely medical follow-up, transportation, inadequate nutrition, medication issues, low health literacy, and poverty present barriers to optimal health outcomes. By addressing social and environmental determinants of health and chronic disease self-management, social workers who make home visits or other proven timely interventions to assess and coach patients and their caregivers are demonstrating real results. This article describes care transitions interventions, research into barriers and opportunities, and specific programs aimed at improvement.

Keywords: care transitions, readmissions, discharge planning, social work, community-based care transitions, Coleman model, CTI, HomeMeds

Why Care Transitions?

People who are discharged from the hospital after an acute health crisis or routine surgery, but who are otherwise in good health, can generally manage going home with some support from family and friends. But for people who are more vulnerable, either because of age, frailty, multiple chronic conditions, mental illness, poor social supports, a challenging environment, or limited resources, hospital discharge represents a real risk to health and healing. Canadian researchers (Forster, Clark, Menard, Dupuis, et al., 2004) examined such events among patients who were discharged home or to a care facility during a 14-week interval in 2002. The average patient age was 71. After discharge, 76 of 328 patients experienced at least one adverse event. The severity of these events ranged from symptoms only (68%) to symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common were adverse drug events (72%), therapeutic errors (i.e., contraindicated medications, medication interactions, failure to provide appropriate care) (16%), and hospital-acquired infections (11%).

Many factors can undermine these patients’ recovery, and often lead to complications and decline and thus end in trips to emergency departments, rehospitalizations, ongoing or worsening disease, and, too often, death. Coaching the patient to recognize complications early and seek (and access) appropriate medical care is key. Better coordinated and targeted care during the transition is one avenue toward changing this course.

In their ability to interact with individuals in their own homes, social workers are well-suited to assess and coach patients in strategies that help them to better manage their own diseases, access supportive services (e.g., nutrition and transportation), and adapt complex treatment regimens to their own circumstances. In the realm of care transitions, skill at self-care and disease-management has a direct effect on outcomes, as do social and environmental factors. Social workers can help to anchor teams that deliver comprehensive, patient- and client-centered coaching and long-term supports and services.

This article examines the impact of readmissions and poor care transitions on health systems and outlines the contributing factors to increased avoidable readmissions to better understand what components are necessary for a successful care transitions program. Policy developments that support care transitions programs are explored, and several innovations, including the Coleman model of care transitions, Bridge Model of Transitional Care, and HomeMeds, a medication management intervention, are discussed. The article closes with a case example showing a successful transition and provides a brief outline of non-social work based interventions.

Impact of Avoidable Readmissions on Health Systems

Poor care transitions can be harmful and costly for not only for individuals, as described above, but also for the healthcare system. Avoidable readmissions are typically a symptom of poor care transitions. In 2009, a major study of Medicare’s fee-for-service patients revealed the magnitude of those costs: Of the nearly 12 million patients discharged from hospitals over the course of one year, nearly 20% were readmitted within 30 days, and an additional 14% were readmitted within 90 days. (Jencks, Williams, & Coleman, 2009) Half of the fee-for-service Medicare beneficiaries who were re-hospitalized within 30 days of a medical discharge (that is, their first hospitalization had been for a medical problem, not for surgery) had not visited a physician’s office between the time of discharge and the time of re-hospitalization. Researchers estimated that as many as 10% of these readmissions might have been avoided: In 2004, Medicare paid $17.4 billion for these “revolving door” hospitalizations—readmissions (Jencks, Williams, & Coleman, 2009). In one study, potentially avoidable hospitalizations of dually eligible costs amounted to $3 billion for Medicare, and $463 million to Medicaid (Walsh, Wiener, Haber, Bragg, et al., 2012).

Characteristics of Readmissions and Contributing Factors

In understanding readmissions, it is helpful to understand more about patients who are hospitalized in the first place: who they are and why they are being hospitalized. This section outlines the research done to better examine this issue. A 2012 study of claims from 2005 for 1.6 million persons eligible for both Medicare and Medicaid, sometimes referred to as “dual eligibles,” found that one-third of this group was hospitalized at least once over the course of a year. These dually eligible beneficiaries experienced nearly one million hospitalizations. An expert panel judged that nearly 40% (382,846) of these hospitalizations might have been preventable. Avoidable readmissions were found to vary by the patient’s location, race, and diagnosis. For example, African Americans had a higher rate of avoidable admissions and higher healthcare costs than did Whites. Just a few conditions—pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma—caused 78% of the potentially avoidable hospitalizations (Walsh et al., 2012).

In 2013, the Robert Wood Johnson Foundation released its report, The Revolving Door: A Report on U.S. Hospital Readmissions, which includes an analysis by the Dartmouth Atlas Project, as well as individual patient stories (Goodman, Fisher, & Chang, 2013). Dartmouth researchers conclude:

The burden of readmissions falls unevenly on Medicare beneficiaries, and is closely linked to their place of residence and the health system providing their care. Patients with similar illness have very different chances of hospital readmission depending on where they live. The variation in the quality of care is hard for patients and doctors to see, but the differences are substantial. Many patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care for illness, leading to both higher initial admissions and higher readmissions.

The study goes on to note that understanding these variations in care is vital: “because even though hospitals are places where life-saving heroics are routine, they can also be costly and dangerous places to receive care. People who do not need to be in the hospital should not be there.”

Canadian researchers (Bell et al.) reported on the incidence of potentially unintentional medication discontinuation among patients over the age of 65. The study group of 396,380 patients was assessed continuously using one of five selected medication classes for at least one year. Half of the patients were hospitalized at some point during the study period, and the rest were matched controls.

The study concluded that medication errors, especially unintentional stopping of a medication, led to hospitalizations: For the 5 medication classes studied, hospitalization was associated with medication discontinuation at rates that ranged from 4.5% to 19.4% Hospitalized patients were at increased risk for discontinuing medication from all five classes, with the highest risk among those patients admitted to intensive care units (ICU).

Such errors may be compounded by the fact that only half of all adults take medications as prescribed: they do not get prescriptions filled, stop taking them or do not follow instructions. (Fischer, Stedman, Lili, et al., 2010) Further, many take other over the counter medications or herbal or other supplements which can interact with prescribed medications but be unknown to the prescriber. This behavior has real consequences for patient health, and many patients improve when coached to understand and follow instructions for medications.

Furthermore, early research into the causes of readmissions revealed common themes in patient experience and hospital practices. The most frequent issues were:

  • failure of the hospital to share information with patients and with other sites of care, especially home health providers and skilled nursing facilities;

  • inadequate patient and caregiver preparation for what to expect next and how to recognize worsening health;

  • absence of coaching to improve patient understanding of disease and self-management strategies;

  • failure to empower patients to know when and whom to call for help when needed—to catch complications early; and

  • inadequately staffed facilities receiving discharged patients, and a concomitant dearth of knowledge about each patient’s condition, values, and preferences (Parry, Coleman, Smith, Frank, & Kramer, 2003).

Identifying patients who are at greatest risk for errors during care transitions is essential to delivering tailored and effective interventions to reduce readmissions. The Partners in Care Foundation has worked with a large academic medical center to deliver multiple care transitions interventions that address key risk factors. These were identified in a shared intensive root-cause analysis of avoidable readmissions and defined which patients being discharged from hospital are eligible to participate. They meet two or more of the following criteria:

  • readmission within 30 days of hospital discharge

  • two or more hospital admissions within prior 12 months

  • two or more emergency department visits within prior six months

  • more than 10 day length of stay

  • if being discharged with eight or more medications, or if, during hospitalization, two or more medications were adjusted

  • discharge home with little caregiver support

  • cognitive impairment, especially with little caregiver support

  • two or more chronic conditions

  • depression as a secondary diagnosis

  • cognitive impairment, especially with little caregiver support

  • new tracheotomy or ostomy.

Knowledge of who is at risk for readmissions and why they may be readmitted provides a solid foundation for care transitions program development and highlights potential policy implications for maximizing the health of this fragile population.

An Opportunity to Improve Care Transitions: The Affordable Care Act and Policy Considerations

National and local efforts to improve patient and population health, limit costs by improving health and recovery, and reduce overuse and overtreatment, are among the vanguard of healthcare changes. These changes build on a shift from volume of care—that is, care driven by interventions that can lead to overtreatment and overuse—to value of care—that is, care that contributes to improved health. Healthcare leaders and providers increasingly understand the importance of addressing the social, environmental, and lifestyle determinants of health (i.e., where and how people live, work, play) that can either compromise or bolster individual and population health. Changes in care approaches now underway are an opportunity for social service providers and leaders to become more engaged and integrated with the healthcare delivery system.

Section 3026 of the Patient Protection and Affordable Care Act (ACA) created a platform to test the value and effectiveness of home and community-based services, typically led by a community-based organization (CBO, such as Area Agencies on Aging and other social service organizations) to reduce the rate of hospital readmissions for fee-for-service Medicare patients within the first 30 days of discharge. The law established the Community-based Care Transitions Program (CCTP), which has led to a major learning opportunity for communities nationwide, primarily through its requirement that hospitals partner with CBOs to achieve their shared objective. The program mandates that CBOs provide post-acute services and receive and manage the funding. The learning curve has been steep, as fully engaging hospital staff in new approaches and the extra work of targeting and referring is a major challenge. Nevertheless, much is being learned about strategies needed to work with hospitals, and a number of sites nationwide are demonstrating success. In addition, the Act authorized the Centers for Medicare and Medicaid (CMS) to penalize hospitals for achieving or missing specific readmission goals.

Reducing 30-day hospital readmissions is a short-term goal, but one that represents an opportunity for CBOs and payers to identify patients most at risk for readmission who are likely to benefit from an intervention. The interventions being tested are typically brief (up to 30 days in duration) yet visionary: It is a new concept to follow and coach patients in their homes immediately after hospital discharge as a way to address social determinants of health such as timely access to follow-up physician visits, access to transportation, special diets, or affordability of medications. The value proposition is clear: interventions help people stabilize and avoid readmissions, thus reducing significant individual suffering and social and financial costs. Deploying the savings can fund this new work and thus represents a promising new way to bring social work services to much larger populations.

While a first effort, CCTP serves as a starting point for federal funding of community-based and—led health improvement activities, testing a possible new Medicare benefit. CCTP funded 102 groups as part of its five-year, $300 million initiative that was launched in 2011. Awardees must lead, organize, implement, and evaluate their work, and commit to a 20% reduction in Medicare fee-for-service hospital readmissions. The CBOs in the lead in each community are paid an all-inclusive negotiated case rate per eligible discharge only once in any 180-day period for any given beneficiary (Centers for Medicare and Medicaid, 2014).

CMS continues to direct broader efforts at preventing 30-day hospital readmissions—those that could have been avoided or prevented, had care coordination or coaching strengthened the transition from hospital to home or other care facility. A 2012 article in the New England Journal of Medicine (Berenson, Paulus, & Kalman, 2012) notes the increasing attention being paid to hospital readmissions “as a largely correctable source of poor quality of care and excessive spending.”

CCTP uses reductions in preventable readmissions as a metric of improvement. Joynt and Jha (2012) note that a key flaw with the readmission metric as a way to monitor care transitions may be that “much of what drives hospital readmission rates are patient- and community-level factors that are well outside the hospital’s control.” This clearly points to the promise of social work solutions to address this important problem.

A systematic review of 37 studies dealing with unplanned, avoidable, or early readmissions (Vest, Gamm, Oxford, Gonzalez, & Slawson, 2010) found such variation in the literature that it could not cite any reliable determinants of such readmissions. The study’s authors write that the studies they reviewed include “evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions.” However, there was such variation in definitions and methodologies, that no conclusions could be generalized.

Berenson writes that financial penalties for avoidable readmissions are not a sufficient deterrent nor incentive to preventing them. The penalties simply do not affect hospital finances, and “may be too weak to overcome the substantial counterincentives inherent in DRG-based payments . . . [and] tries to change hospitals’ behavior with a stick but no carrot, failing to reward hospitals that improve” (Berenson, Paulus, & Kalman, 2012).

In 2014, first-year results were released from an implementation evaluation of the CCTP projects (Econometrica, 2014). At first glance, those results do not seem terribly promising: just four of the 46 programs evaluated had achieved any reductions in readmissions. These results, however, are misleading. The evaluation focused more on the actual implementation of projects—the administrative details, such as launching the effort with a specified period of time—rather than on the ultimate goal of the work to reduce readmissions. Although the report sheds some light on the complexity of establishing these programs, it may be too early in the process to really know whether or not the approaches work, and whether nationwide policy should be guided by these preliminary results.

CMS has tracked the results and most recent results reported for work at three California sites did demonstrate the ability to target and serve the required footprint of 30% of Medicare discharges and showed the following strong, positive results. Across three sites, Partners in Care Foundation has assisted 21,669 individuals. The participant baseline readmission rate averaged across the three sites was 20.7%. For participants in CCTP, a readmission rate of 14.6% was achieved—a 29.4% change due to the success of the CCTP intervention. Preliminary results have shown a net Medicare savings of $3,574,613 due to prevented readmissions.

While not a RCT, these results come from full claims data for the six months following discharge and are thus a solid base of information for early program review that show the power of the evidence-based social work/coaching interventions highlighted in this article.

The Role of Social Workers in Improving Care Transitions

Social work services bring key perspectives and skills to a healthcare system that, to date, has not succeeded in addressing the whole of each person’s complex life and the many factors beyond medical care that contribute to or undermine good health. The very nature of social work makes it ideal for social workers to lead and partner in programs to solve challenges faced by frail elders and their caregivers at home. Social workers can help to address and minimize the effects of some of the key drivers that contribute to failures in care transitions.

In addition, the social work skills in counseling for behavior change are a natural fit. Because social workers are not hampered by the role constraints of their physician and nurse colleagues, they are able to make patient-centered, comprehensive home visits to engage the person, evaluate their capacities and caregiver/social supports and resources, connect them with essential services, and coach to build new self-management skills. These brief, one-on-one relationships with patients and caregivers enable social workers to reach out to people who are identified as most at risk for readmissions or poor transitions and provide them with effective interventions.

Practice Innovations to Address Poor Care Transitions

CCTP requires grantees to implement evidence-based care transition interventions; these vary in their focus, their delivery, and their results. Among the most widely used is the Coleman Model, developed by Dr. Eric Coleman, which focuses on patient engagement and activation to become partners in managing their own disease and recovery. While several other models rely on physicians or advanced practice nurses to anchor the approach, the Coleman model, also known as the Care Transitions Intervention (CTI), further encourages social workers to coach patients in better self-monitoring and in communicating concerns and updates to their physicians.

CTI, widely adopted now in more than 500 healthcare settings, must be implemented within 24-to-72 hours of discharge and delivered for 30 days. It includes a hospital visit to the hospitalized patient, a home visit, and several follow-up telephone calls. CTI is based on four pillars, which were developed in response to what was learned in focus groups with patients and caregivers. These conceptual domains include assistance with medication self-management, a patient-centered record owned and maintained by the patient for cross-site information sharing, timely follow-up with primary and specialty care, and a list of “red flags” that indicate a worsening situation and how to address it.

A 2006 report on a year-long randomized controlled trial found that intervention patients had lower rehospitalization rates at 30 days and at 90 days than did controls. They also had fewer rehospitalizations at 90 days for the same condition that had precipitated the original hospitalization. Finally, their mean costs were lower ($2058 vs. $2546) at 180 days (Coleman, Parry, Chalmers, & Min, 2006). Early results from Partners in Care Foundations CCTP are promising, as outlined in the above section.

Two other effective interventions are also being implemented, both developed by and for social workers. One is the Bridge Model of Transitional Care (Bridge), developed by Robyn Golden, LCSW, Director of Health & Aging at Rush University Medical Center. Bridge addresses the needs of patients and their families as they transition from an inpatient hospital stay to the community. It is becoming increasingly clear that patient engagement, connection to community resources, and other social determinants of health play an enormous role in health outcomes. Bridge uses master’s-prepared social workers in a care coordinator role to place greater emphasis on these challenges, while partnering closely with medical providers to help ensure medical stability.

The model consists of three phases: pre-discharge, post-discharge, and termination. Pre-discharge, Bridge Care Coordinators (BCCs) review the medical record, visit patients with inpatient and outpatient providers, and meet one-on-one with patients and their families. Post-discharge services consist of a biopsychosocial assessment designed to capture gaps in care that lead to poor health outcomes, such as avoidable readmissions and unnecessary ED visits. During the post-discharge phase, BCCs provide case management and care coordination services, while integrating psychotherapeutic techniques to increase patient engagement and decrease patient and caregiver stress. Services are generally terminated within 30 days after discharge.

Bridge can be delivered in person or telephonically. There are on average 20–25 patient, family, and/or provider contacts per case. The largest analysis of Bridge outcomes to date by CMS through their quarterly reporting of claims for the Bridge program, found a 30.7% decline in 30-day readmissions from baseline (n = 5,753). The traditional target population has been largely comprised of Medicare beneficiaries. Two recent Bridge adaptations include a focus on super-utilizers and Medicaid patients at risk for nursing home placement.

Partners in Care Foundation’s implementation of Bridge as an alternative to CTI has proven promising. It is a powerful extender of services as it permits an evidence-based intervention with patients who refuse a home visit or live too far from the service center to be practical for a home visit. It has proven to provide dramatically increased engagement of the targeted population. In the CCTP population served by Partners in Care Foundation, 8,896 patients were contacted with the Bridge intervention from May 2013 through September 2015. This intervention is increasingly useful in reaching participants who might not have otherwise engaged with CCTP.

The other intervention is HomeMedssm, developed in 1993 by Partners in Care Foundation. HomeMedssmcan serve as a key element in a home visit, such as that included in CTI. The HomeMeds program is licensed to 41 sites in 20 states across the country and can be used in many kinds of home visits.

CTI focuses on coaching, but HomeMeds can serve as an additional tool with CTI if coaches take care to use a coaching approach. During the CTI home visit the patient develops a Personal Health Record including all medications and is coached to take this to all physician visits. Social workers trained in the HomeMeds program can also use its web-based protocols to screen older adults who are being discharged from an institutional setting for potential medication-related problems. During the home visit the social worker assesses the patient and environment, inventories all medications, determines how medications are really being taken, and works to strengthen the patient’s ability to manage his/her health. The social worker enters data into the HomeMeds program and then transmits the record to a consultant pharmacist for review. The pharmacist verifies the appropriateness of medications being taken and follows up with the health care clinician, patient, and/or social worker to make any recommended changes in prescriptions.

The average patient enrolled in the HomeMeds program across national sites is over the age of 79, frail, and a Medicaid or Medicare beneficiary. HomeMeds allows social workers to identify a range of targeted problems, selected by a national consensus panel chaired by Mark Beers, MD, originator of the Beers Criteria. Problems included in HomeMeds were selected for their likelihood of being resolved by collaboration between home health, pharmacist, patient/family, and prescriber. The targeted problems are: falls and confusion related to psychoactive medications, cardiovascular medication problems such as low blood pressure or pulse, non-steroidal anti-inflammatory drugs prescribed to patients with high risk for gastrointestinal bleeding, and unnecessary therapeutic duplication. Therapeutic duplication has proven to be the most common error, one that is costly to the healthcare system and dangerous for patients. Too often, a patient already has a medication at home for a particular condition and is then prescribed a similar drug for the same condition while hospitalized. Once home, the patient continues to take both the old and new medications. Another contributor to duplication happens when two doctors, a primary care physician and a specialist, prescribe medications for the same condition.

An adaptation known as HomeMedsPlus was recently deployed as a pilot in a readmissions reduction private contract with a managed care medical group. Early results demonstrated that HomeMedsPlus, when compared to the usual practice outcomes for similar patients, was very effective in reducing emergency department visits and readmissions. ED visits within 30 days post discharge were 12% lower than usual care, and the readmissions within 30 days post were 2% lower.

Previous external evaluations of the HomeMeds program (a randomized controlled trial by Vanderbilt University (Meredith, Feldman, Frey, et al., 2001) in home-health programs and a follow-up pre–post study the University of Southern California (Alkema, Enguidanos, Wilber, et al., 2009) in Medicaid waiver programs found substantial and significant improvement in medication use. Among program participants in the Vanderbilt study who had issues of therapeutic duplication, 71% were resolved by HomeMeds, compared to only 24% of those receiving usual home health care. In addition, half of program participants in the home health study experienced improvement in overall medication regimens, compared to just 38% of those receiving usual care. In the USC study, 61% of pharmacist-confirmed problems were resolved. With respect to cardiovascular medications, 55% of participants had improvements, compared with only 18% of those receiving usual care.

Case Example from Partners in Care Foundation’s CCTP

What follows is a case example from a CTI-trained social worker assisting with a transition and utilizing HomeMedsPlus in that process. An older man with recent mild cognitive impairment who, after a recent hospital discharge to home, mentioned that he was anxious about missing a dose of his many medications. He lived alone and his adult children were scattered throughout the country. He did not have the resources to pay for home health care; what he really needed most was help to sort through his prescriptions and take them properly. His medications included clonazepam, trazodone, amlodipine/olmesartan, and metoprolol.

While in the hospital, the man was enrolled in HomeMedsPlus. Upon discharge a social worker transitions coach visited the man in his home for follow-up. In this case, the client told the visiting social worker that in the two days following his hospital discharge he had fallen twice and was very dizzy. The social worker learned that the client had been taking all of his prescriptions at once each morning instead of throughout the day, so he would not miss a dose. Unfortunately, this routine included his sleep medication, causing drowsiness and increasing his already high risk of falls. The social worker also learned that the client enjoyed a drink in the evening. Without realizing it, the client’s own “solutions” and habits endangered his safety and well-being. The social worker contacted the consultant pharmacist immediately. Together with the patient, they established a dosing schedule that the patient could follow. They also helped him to understand the risks of his medication interacting with alcohol, and the problems of alcohol for people with mild dementia.

Without the social worker’s visit and discovery, this patient likely would have fallen again and, with the combination of medications and alcohol, experienced even worse complications. These insights came from a home visit by a non-medical professional focused on the person and his self-management and not distracted by the duty to provide medical services.

The social work role in improving care transitions—and health—seems clear. A home visit and careful evaluation of the patient’s own environment and habits is a way to really ascertain what is happening and thus target how to prevent avoidable rehospitalizations. For individuals not available for a home visit, the Bridge intervention provides broadened methods for engagement and post-acute support with successful results. Social worker participation in healthcare teams can promote patient empowerment, while also tapping other resources needed to assure that basic needs are met.

This example illustrates the challenges and dynamics of care transitions, which can be a time of great risk for error, in part because of the ever-changing factors and the interactions (or failed communications) across multiple providers and settings. As HomeMeds has shown in its 20-year course of operations, engaging social workers in care transitions has real benefits for patient outcomes. HomeMeds has become one of several evidence-based or promising practices now being used nationwide in social-work-led programs that are working to improve the care transitions process and, from that, improve systems, coordination, collaboration, and population health. Bridge is a more recently developed intervention, and it brings a strong new tool to permit a more extensive portfolio of interventions to deploy, customized to individual patient needs/preferences.

Non-Social-Work Evidence-Based Interventions

The 2010 Remington Report on Care Transitions summarizes seven multidimensional interventions to improve transitions, along with evidence that supports their implementation. Although these seven have been widely described and evaluated, participants in the CCTP were not limited to these interventions and could propose to use any intervention that had proven to be effective. In addition to CTI and Bridge, described above, the Report highlights six other prominent (and promising) models:

  • Bridging Nursing Support/Transitional Care Model (TCM), which focuses on in-hospital planning and follow-up care led by a specially trained nurse practitioner

  • Better Outcomes for Older Adults through Safe Transitions (BOOST), which features a toolkit for improving hospital discharge

  • Best Practices Intervention Package (BPIP), a manual for leaders and staff in home health agencies to identify effective tools and processes

  • Interventions to Reduce Acute Care Transitions (INTERACT), a toolkit for staff in skilled nursing facilities (SNFs) to reduce readmissions to hospitals

  • Transforming Care at the Bedside (TCAB), a hospital intervention focused on themes of safety and reliability, care team vitality, patient centeredness, and value

  • Re-engineered Discharge (RED), standardized discharge intervention (Ventura, Brown, Archibald, Goroski, & Brock, 2010).

These are valuable approaches that social work can support and participate in but are not distinctly social work developed or driven. Nurse-led care transitions programs may have proven efficacy as well, but there could be several challenges to them that demonstrate the benefit of a more flexible social worker model. Some nurse-led models may struggle with finding nurses that can successfully take on a role as care manager to empower patients and to work beyond typical clinical care. Additionally, nurse-led programs may be less cost-effective due to the salary difference of a nurse transitions coach and a social worker transitions coach (California Healthcare Foundation, 2008). Of course the social work ecological framework permits a broad expertise in environmental and self-management assessment and coaching that reflect profession-specific strengths as well.


Left unchecked or unaddressed, the failures and costs of poor transitions, which are a common element in the lives of older adults who are frail and/or who live with multiple chronic conditions, will simply increase by magnitudes as millions of Boomers live very long lives. This represents avoidable suffering as well as avoidable medical services and costs.

Further, complex populations, such as the homeless, those with multiple chronic conditions and others, have similar challenges. Correcting those failures is an opportunity to improve the healthcare system at a local level: for groups that now do not communicate to integrate services, for communities to assess and respond to the needs of the aged and other with complex needs, and for services to be developed and delivered that serve those needs effectively and well.

This is a major opportunity for new social work leadership in healthcare. In many larger communities there is a move for non-profit community agencies to form into regional delivery systems, working as a network. With the focus on patients who are dually eligible (i.e., for Medicare and Medicaid) and other broader populations, the need to stabilize people at home, avoid institutional care, and reduce avoidable readmissions and inappropriate emergency department use is essential.

At the time of this writing, a few national for-profit companies are seeking to take the lead in bringing services to improve care transitions. As Medicaid moves from fee-for-service to managed care, financial risk for long-term nursing home placement is increasingly shifting to managed care plans. Generally, the cost to Medicaid for nursing home placement is substantially greater than the cost for providing long-term services and supports (LTSS) in the person’s own home. Traditionally, LTSS have been provided by not-for-profit community-based organizations (CBOs) with deep local connections. Medicaid managed care organizations (MCOs) tend to be large regional or statewide organizations that go beyond the local borders served by CBOs. This creates a business opportunity for large, national for-profits with highly developed infrastructure—such as electronic health records, insurance, and systems—to provide managed long-term services and supports (MLTSS). This trend could threaten the long-term viability of local social services organizations and area agencies on aging/senior centers, which are all non-profit or governmentally sponsored. The for-profits envision seizing the opportunity to lead by winning major federal and state contracts with the new payers—health plans and medical groups.

Social workers, who bring to this effort core in-home services, are truly the eyes and ears in the home and are critical to helping the patient voice be heard and respected. Social work skills also work well through Bridge to reach into the home without an actual home visit. All programs must consider and develop strategies that bring more social services and supports to the endeavor. Indeed, one call should create a “no wrong door” access to the full range of resources and services.

Plans and medical groups will not be able to practically contract with many entities, so the local agencies must join together in a shared business structure to create a new regional delivery system approach as a network. The network teams can then provide care transitions and other home- and community-based services efficiently while also bringing the unique expertise in local culture, language, and resources. Regional network member agencies can avoid competing with each other and move together to achieve greater strength, taking the opportunity to bring their services to many more people, albeit, if only for brief-service interventions.

Improving care transitions can lead to important benefits for systems and for patients. In focusing on community-based programs and services, health care leaders have an opportunity to engage more members of the community in caring for its vulnerable people and build stronger community-based efforts. Improved transitions can reduce problems that lead to poor health outcomes and increased healthcare costs, and social workers are well equipped to offer assistance to improve transitions.


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