Years ago, while working as a hospital-based case manager, I was part of a team that explored how to improve and support transitions of care. Some patients already had multiple readmissions, and we wanted to break the pattern of cycling back to the hospital because of problems such as medication errors, failure to follow-up with primary care physicians, and/or poor health literacy that compromised self-care.

Our practice was to check in with patients telephonically within the first week after discharge. To improve outcomes, we proposed extending follow-up for several weeks, particularly for high-risk patients. The idea never gained traction, however, because the hospital determined that there were not enough resources.

Although this experience occurred earlier in my career, it is still relevant today as transitions remain a challenge across the care continuum. When care transitions do not go as planned, there is a greater likelihood that patients will end up in the emergency department or be readmitted to the hospital. According to the Centers for Medicare & Medicaid Services (CMS, 2019a), nearly one in five Medicare patients discharged from a hospital, or approximately 2.6 million older Americans, is readmitted within 30 days, at an estimated cost of $26 billion a year. When avoidable hospital readmissions occur, penalties result. CMS's Hospital Readmission Reduction Program reduces payments to hospitals that have excess readmissions, and the 21st Century Cures Act assesses penalties based on a hospital's performance relative to other facilities with similar Medicare populations (CMS, 2019b).

We cannot let the intense focus on hospitals and avoidable hospitalizations lead us to assume that acute care organizations, alone, are responsible for improving care transitions and reducing readmissions. As CMS observed, "...It is clear that there are multiple factors along the care continuum that impact readmissions and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions" (CMS, 2019a, p. 1). This raises an urgent question for professional case managers and every member of patient-centered, transdisciplinary teams of how to achieve and support successful care transitions.

In the article "Improving Care Transitions to Drive Patient Outcomes: The Triple Aim Meets the Four Pillars," appearing in this issue, my coauthors and I explore what professional case managers can do to improve transitions of care. A framework for action is Coleman's Four Pillars of care transition activities, spanning medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (Coleman, Parry, Chalmers, & Min, 2006). Hospital-based case managers, as well as case managers in every practice setting and specialization, should be aware of the Four Pillars and other best practices to promote successful transitions of care. By improving care transitions, case managers also further the pursuit of the Triple Aim to improve patient health, improve population health, and reduce the per capita cost of care (Berwick, Nolan, & Whittington, 2008).

Care transitions can occur intrainstitution, unit to unit, such as from emergency department to medical/surgical unit, or interinstitution, such as from one acute care hospital to another, from acute care to subacute, or discharge from hospital to a skilled nursing facility or home. Ample information on care transitions is available through a variety of health and human services sources, including The Joint Commission's Transitions of Care Portal, the National Transitions of Care Coalition, the Commission for Case Manager Certification's Case Management Body of Knowledge, and the American Case Management Society's Transitions of Care Standards. Yet, the fact remains that, even with evidence-based best practices, care transitions remain problematic because they are not solvable with easy solutions.

When patients are discharged from a hospital, so many factors can undermine even a thorough discharge plan. Transitioning across networks (e.g., from a hospital that is "out of network" for a patient's health plan to outpatient care with its "in-network physician") can be particularly problematic. In addition, patients today are leaving the hospital sooner, with multiple (and often new) medications. This puts more emphasis on self-care and medication management, as well as follow-up with primary care doctors and specialists. For individuals and their caregivers, this can be overwhelming.

Speaking at the Commission for Case Manager Certification's New World Symposium earlier this year, Dana Deravin Carr, DrPH, MPH, MS, RNC, CCM, care manager at Jacobi Medical Center in New Rochelle, NY, stressed the importance of warm handoffs, with thorough documentation and medication reconciliation. Nonetheless, lapses still occur. "It's unfortunate that some of our colleagues don't get it yet," Carr said in her presentation. "Some patients can be so challenging that, when they exit the premises, it's easy to say, 'I'm done with that.' But we can't be done with it."

As advocates, case managers have an ethical obligation to let people know who we are and what we do. If there is a problem, a misunderstanding, a question that needs answering, we want to hear from them. Otherwise, that unresolved problem or misunderstanding or unanswered question can become a breakdown in communication or a misperception that leads to a failed care transition. Postdischarge follow-up helps, but such interventions tend to occur only in the first week. The reality is patients remain vulnerable to risks of hospital readmission for far longer than the first week (Carr, 2007).

This is our call to action as professional case managers across the care continuum. Improving care transitions requires all of us, regardless of specialization or practice setting, to do all we can to improve these outcomes. Each step of the case management process helps ensure that the patient is informed and educated, promoting better self-care and follow-up postdischarge. At every juncture along the care continuum, professional case managers need to practice at the top of their license and/or certification. In addition, case managers need to urge hospitals and other organizations to implement extended follow-up postdischarge. Whatever the cost in terms of money or case management personnel will be well worth the investment to reduce failed care transitions and avoid the penalties of avoidable readmissions.

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