Frequent "handoffs" of chronically ill patients from one health care provider or setting to another make this population especially vulnerable to treatment errors, adverse clinical events, and low levels of patient satisfaction, resulting in disproportionately high health care costs and rates of hospital readmission. Under the Patient Protection and Affordable Care Act (PPACA) of 2010, lawmakers added programs and services designed to improve outcomes and lower costs at these crucial transition points. Now, a recent study by leading nurse researchers has identified a dozen effective strategies that improve transitional care.

Figure. Kyla Sears, RN, examines stroke patient Elvira Tesarek in her Warren, Rhode Island, home. Her visits are covered under a pilot program in which Medicaid pays for older, disabled adults to have home care, rather than the more costly institutional care. Since the start of this program, nearly 1,300 elderly and disabled adults have been able to leave nursing facilities or avoid them altogether. Photo by Jay Reiter / MCT via Getty Images.

Mary D. Naylor and colleagues at the University of Pennsylvania School of Nursing, conducted a systematic literature review and analyzed 21 randomized clinical trials of transitional care interventions used in the care of chronically ill adults. Nine interventions had positive effects related to hospital readmission. All nine relied on nurses as clinical leaders or care managers.

The three most effective interventions reduced all-cause readmissions for six or 12 months. Two of these had multiple components that combined comprehensive discharge planning with follow-up visits and included "patient and caregiver goal setting, individualized care planning, education and behavioral strategies, and clinical management." The third, a "telehealth-facilitated" intervention, relied on daily home videophone or telephone monitoring.

According to the authors, these findings demonstrate which interventions should serve as prototypes for programs receiving support through the PPACA. Effective interventions should be promoted as best practices by the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and other private and public organizations. The authors call for the development of new measures of transparency and accountability in evaluating and reporting on transitional care, as well as workforce development programs to ensure effective delivery.-James M. Stubenrauch

REFERENCE