What’s in a care transition? The key to population health.

By Leigh Ann Myers  /  26 Mar 2015

It’s a common scenario: a patient is admitted to the hospital, treated, and discharged from the hospital with discharge instructions and a reminder to follow-up with their doctor in two weeks. This transition process is far from perfect and patients are often confused about what they should be doing when they are discharged. There’s more at stake, too:

With the shift to value-based care and population health, it’s becoming even more critical for providers to improve their patient care transitions. Why? Simply put, care transitions are happening more frequently and with larger care teams. Patients are now receiving care in a multitude of care settings, including within hospitals, skilled nursing facilities, and in the home through telehealth, which puts even greater emphasis on the need to move patients seamlessly from one care setting to the next.

To reach the benefits of population health, expanded care teams must collaborate with one another to transition patients seamlessly across the healthcare continuum. It’s not an easy fix. Healthcare organizations need to undergo a cultural change to place the patient at the center of the care model, and must collaborate more frequently to ensure all members of the care team are all aligned on patient status, treatment plans and next steps.

Later this month, we’ll dig into the steps providers must take to improve their transitions of care. In the meantime, tell us in the comments below: what are you doing to make care transitions better?

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