Maya Peters is a Research Associate with the Michigan Value Collaborative.

Transitions of care out of the acute care hospital setting are a hot topic, and for good reason.  Ineffective care transitions can lead to undesirable outcomes for both the patient and the hospital, including avoidable readmissions1. As payment policy moves away from fee-for-service and toward episode-based payments, there will be a necessity for greater connectivity between acute-care hospitals and post-acute care providers.  With readmission payment penalties of up to 3%, Medicare’s Hospital Readmission Reduction Program (HRRP) is already putting additional pressure on hospitals to improve these transitions2.

Luckily, hospital discharge planning tools can help improve the transition from an acute-care hospital to home or another post-acute care setting.  These tools help assess patient demographic and clinical characteristics, risk of readmission, acute care needs and level of resource use3.  Here are three ways these tools can help improve your hospital’s care transitions:

  1. Appropriate post-acute care placement

Discharge planning tools can help ensure that a patient receives care in the correct setting.  By taking into account patient demographics, activities of daily living, medical/clinical needs, and basic functioning (mobility) status, these tools help therapists and discharge planners better allocate therapy resources to the appropriate patients.  They also help identify when post-acute care may be unnecessary, thereby avoiding excess cost.

  1. Management of the transition of care itself

Discharge planning tools can assist in a smooth transition of care out of an acute-care setting, by identifying high risk or more complex patients.  This lets providers know that a patient’s transition to the next care setting should be more highly managed.  Interventions that can help manage a transition include: in-depth discharge summaries and instructions, teach-back method training on potential complications and appropriate responses, post-discharge phone calls, and a PCP follow-up visit within 7 days.

  1. Readmission reduction

Discharge planning tools can help reduce readmissions by taking into account a patient’s current conditions and procedures, length of stay, discharge disposition, and any social issues.  This information can help a provider determine what a patient’s risk of readmission may be, and therefore decide on the right post-acute care and placement.  The right move here can reduce the risk of inappropriate care leading to a readmission.

Many of the discharge planning tools available for hospitals to use require little to no staff time for completion.  Rather, many can pull available health data from a patient’s electronic health record, and may require just a few additional fields.  If your hospital isn’t already using a discharge planning tool, maybe it’s time to look into your options!

For more information on this topic, as well as a more in-depth look at a number of discharge planning tools in use around the country, read this helpful AHA report.



Questions or comments? We’d love to hear from you!  You can comment on this article, or fill out the contact form at the bottom of the page.