Implementing Successful Transitional Care:
A structured move from Acute to Sub-Acute or Ambulatory Care

Introduction
Transitional care is defined as a set of actions designed to ensure the coordination and conti- nuity of health care as patients transfer between different locations or different levels of care. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing homes, the patient’s home, primary and specialty care offices, and long-term care fa- cilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.1

Contents

1 Introduction 1 Historical Problems 2 Attempted Solutions 3 AmerisourceBergen Solution
3 Benefits
5 Outcomes
5 Summary

Historical Problems with Transitional Care
Despite considerable attention focused on improving 30-day readmission rates to hospitals, only modest change has been achieved according to the Centers for Medicare & Medicaid Services (CMS).
Medicare Readmission Penalties

Max Penalty 278 Hospitals
8.3%

No Penalty

fiscal year 2013 and rising to 3 percent in 2015—penalties that could reach into the millions of dollars for some hospi- tals. Patient outcomes from July 2008 to June 2011 dictated the penalties leveraged in 2013. Health experts say high re- admission rates for pneumonia, as well as other conditions, are mainly driven by lapses in post-discharge planning and