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What are Care Transitions?
What does care transitions mean?
The term “care transitions” refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
For example, in the course of an acute exacerbation of an illness, a senior patient might receive care from a Primary Care Provider in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Once it has been determined that a patient should return home, they may receive care from a visiting nurse and or a non-skilled home care provider. Each movement between settings and providers is referred to as a transition in care.
Our Solution
By supplementing and providing extra care throughout the whole process, and by working with healthcare providers, patients and their families, we are able to ensure a safe transition home from a facility. The extra care is designed to allow patients to recover faster and get back to their normal life. The services provided by Preserve Home Care in these circumstances are for those who lack some degree of physical or cognitive function. Home care services typically consist of assistance with activities of daily living. Some recipients receive a few hours of care a day while others receive 24 hour service. The goal of the extra care is to reduce readmissions. One in five Medicare patients who leave a hospital will be readmitted within 30 days. However most of those readmissions are preventable with a little extra care.
More Info
Through healthcare reform and new initiatives, the federal government aspires to save $26 billion in the coming years by leaning on hospitals to lower their preventable readmission rates. According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[ii] The Medicare Payment Advisory Commission estimates that up to 76% of these readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200. With cuts to Medicare spending, hospitals with high readmissions are motivated to develop solutions within their community as their performance (of reducing readmission rates) will impact how much they will be paid by Medicare.
Care transitions programs allow hospitals to focus on reducing those numbers by improving the care coordination for patients between settings, which in turn lessens the likelihood that they will return for a related readmission. The core benefits of these programs for hospitals are to improve patient outcomes and reduce costs.