Discharges and Readmissions: Advancing Appropriate Transitions of Care

Presented by Nancy Skinner and Colleen Morley

Video Runtime: 48 Minutes; Learning Assessment Time: 29 Minutes

Achieving effective transitions of care has been a consistent goal of healthcare providers over the past decade, yet the movement of patients from one healthcare setting to another continues to represent a vulnerable exchange point that may prompt negative healthcare outcomes, leading to unnecessary increases in healthcare utilization and spending. Most importantly, a lack of coordinated care across the healthcare continuum exposes patients to lapses in the delivery of quality healthcare services and may compromise patient safety.

This program will present an opportunity to review the current state of transitional care in America and offer information regarding the creation and maintenance of care coordination strategies to support the delivery of safe transitions of care. Effective and efficient transitions not only advance the ability of a patient to experience a safe healthcare journey but also support the appropriate reimbursement of provided healthcare interventions and services. This course is applicable to physical therapists, occupational therapists, speech-language pathologists, nurses, social workers, and case managers.

Meet your instructors

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Nancy Skinner

Nancy has, for the past 30 years, served as a case manager, director of case management, and international case management educator. In her current role as principal consultant for Riverside HealthCare Consulting, she advances programs that promote excellence in care coordination and other transitional care strategies. She…

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Colleen Morley

Dr. Colleen Morley has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for more than 12 years and piloting quality improvement initiatives focused on readmission reduction and…

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Chapters & learning objectives

1. Transitions of Care

In this chapter, we will define the concept of transitions of care and discuss the impact that transitional care has on the healthcare delivery system. The impact of good and poor transitions on healthcare outcomes, costs, and patient experience is explored.

2. Transitions of Care: Quality Metrics

Continuing the discussion on transitions of care, we study the metrics that are closely associated with transitions of care (readmissions, patient outcomes, patient satisfaction, financial outcomes). An in-depth discussion of the Medicare Hospital Readmissions Reduction Program features prominently. This chapter begins a discussion on defining transitional care gaps and the risks/effects of each on the transition plan.

3. Transitional Standards

We will continue the discussion of transitions in healthcare delivery with a review of the Transitions of Care Standards from the American Case Management Association. Following established standards of care can decrease the impact of the care gaps and create a better overall transitional experience. The standards are explored in detail in this section, and examples are used as illustration.

4. Advancing Appropriate Transitions of Care

In previous sections, the concept of readmissions has been discussed. This chapter will introduce the readmission prevention concept. We will discuss the available tools and resources that clinicians can use with their patients to enable each patient to more effectively self-manage through the transition process. Examples from leading transitions-of-care organizations are highlighted.