Care management

Aligning Transitional Care With Quadruple Aim: What Healthcare Needs to Do?

Abhinav Shashank
Fri 05 October 2018

“I don’t know where I am headed. Repeating the same things every time I am referred to a new facility has become a new pain for me.”

This is the story of a 60-year-old diabetes patient, John Doe. John is also suffering from acute kidney failure and has to go through constant weekly dialysis procedures. His doctor recently referred him to another care facility which was much closer to the dialysis center.

It seems great, isn’t it?

Well, it was not. John had to go through the same procedures again— detailing every single detail again to his new physician. His every visit to his new hospital now comes with an additional problem of carrying information, relaying it, most of all, explaining the entire situation, again and again, every time.

Most patients who go through such transitions in care are experiencing the same dilemma. Often marked by uncertainty and confusion, transitioning from one care facility to another such as a hospital or a home care facility could be exhausting for providers and patients alike.

So, is this situation really bad? Where do we stand in terms of providing proper care to patients during their transition process?

The present of healthcare— The real state of transitional care

According to the report published by the United Health Foundation based on the source data from the Dartmouth Atlas of Health Care, the percentage of Medicare enrollees aged 65 and older who were readmitted within 30 days of hospital discharge was 14.8% in the year 2017, and is expected to rise to 14.9% by the end of year 2018.

Inefficiencies in the process of care transition of patients do not just result in a few setbacks but they are among the primary reasons behind raised hospital readmissions, frequent ED visits, and many more. As per the study published in the American Journal of Managed Care, patients who receive post-discharge care have a 28% lower risk of readmission in 30 days.

Now, the big question is why are we not able to provide patients with the care they want during transitions?

The 3-level barrier to a smart care transition

The health care system often fails to meet the needs of patients during transitions because care is rushed in and responsibility is fragmented. Poor communication among the care facilities during transitions can lead to confusion about the patient’s health conditions, duplicative tests, inconsistent patient monitoring, medication errors, and lack of proper follow-ups through referrals.

The barriers to proper care transition process can be summarized in three levels:

  • Delivery system-level: Care settings often work as ‘silos’ that do not interact and share information effectively. In the present scenario, even though nearly every record is computerized, they are not standardized and compatible across systems.
  • Physician-level: There is a wide gap among providers, care teams, and multiple healthcare organizations. Consultation among them is a problematic process with generally a single care manager providing longitudinal care across the settings.
  • Patient-level: Patients are at the receiving end of the care, and suffer the most due to lack of proper information, inability to communicate with physicians efficiently, limited understanding of their health condition, and little involvement in the decision-making procedure.

With these barriers, what is the solution?

Roadmap to an efficient transition of care

The coordination of care across multiple care settings is crucial for the proper implementation, management, and evaluation of a patient’s care during the entire transitional care journey. Healthcare organizations need to identify the blind spots at every step to ease the process for the patients:

  • Building an integrated environment of care

The first step towards achieving a seamless transition of care should be the development of an ecosystem of connected care across multiple care settings. There should not be a situation where a physician is struggling for patient medical data once he is referred to that doctor.

  • Identifying at-risk patients

The next step should be to identify the at-risk and high-risk patients who are at a greater risk of falling ill or getting lost during the entire process of transition. Providers should leverage advanced analytics to stratify the patient population to provide apt support to drive transitional care with accurate care plans.

  • Building an efficient delivery network

The organizations should focus on building a network where providers and patients do not struggle to traverse across the care continuum. While assigning any patient to a care team member, it is important to ensure that patients know who each care team member is and what purpose they serve. Patients should not feel that they are being passed off to the person who does not have the expertise to deal with his/her medical problem.

  • Devising patient-centric care plans

Once the providers learn about the patients requiring transitions in care, they can take a data-driven approach to plan care protocols and strategies that could drive a difference. The care teams can study the gaps in the network and prioritize patients who need care with smart algorithms.

  • Engaging patients with post-discharge follow-ups

With available insights on the gaps in care of the patient during their transitional journey, care teams and providers can conduct the process of follow-up with patients up to their respective discharges, and keep them engaged to promote 24X7 care access. Providers should make sure that discharged patients are getting the care they need to prevent any unnecessary hospital readmissions.

Can healthcare organizations improve factors such as hospital readmissions and ED visits by enhancing transitional care? Is streamlining the transitional care processes enough?

Efficient transitional care— The key to better outcomes

Patients cannot be perceived as the passive respondents of the care-delivery process. The outcomes of healthcare organizations are driven by the patients themselves. If the patients receive the care they need, hospitals can automatically improve their outcomes.

Providing effective and timely care to patients, especially the ones suffering from chronic diseases, reduces their chances of falling sick again and, thereby, reduces their chances of getting readmitted or rushing to the emergency departments. The goal is to enable and equip patients to be an active member in their transitional care journey.

The road ahead

The care-delivery process does not just end after leaving the gates of the hospital or the physician’s clinic. Holistic care defines the all-around care which a patient receives before the treatment, during the treatment, and especially, after the treatment. Patients sometimes suffer more due to inefficient processes rather than the illness itself. There is no time like now to bring the future of healthcare to the present and old methods are not going to help. The US healthcare needs an innovative approach towards the existing problems to develop an efficient and smooth care experience for every patient.


To know more how a unified healthcare data platform can streamline the transitional care processes in your network, get a demo.

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