Assessment of the Performance of Transitions of Care

Assessment of the Performance of Transitions of Care

One of the most frequent yet challenging duties in the healthcare industry is moving a patient’s care from the hospital to their home or another institution.
Phase 2: Care Transition Document
Because the patient must be handed off to many providers, ensuring a safe transfer of care is not an easy process.

According to studies, one in five patients have a negative incident during the transition of their care that results in re-hospitalization or even death (McCarthy et al., 2018). Even for the elderly and those with chronic diseases that call for close and ongoing monitoring, care transition poses risks.
Assessment of the Performance of Transitions of Care

Costs and other factors that can prevent the safe delivery of patient care must be taken into account when moving patient care to other institutions. The Centers for Medicare and Medicaid Services (CMS), which focuses on the problem of healthcare costs, has shown interest in lowering costs related to care transitions. The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based buying initiative that pushes hospitals to enhance care coordination and communication in order to better involve patients and caregivers in discharge plans and, as a result, lower avoidable readmission rates (CMS, 2020). By tying payment to the caliber of hospital care, this policy helps the country achieve its objective of improving healthcare for Americans. Acute Myocardial Infarction (AMI), one of the several illnesses covered by HRRP, is the topic of this discussion.

Assessment of the Performance of Transitions of Care

A heterogeneous group of patients with a range of heart damage triggering events comprise the acute myocardial infarction cohort. The most frequently seen myocardial infarction types to result in readmissions to the hospital are types 1 and 2. As an illustration, AMI made a $528 million contribution to the HRRP in 2017. Additionally, it has been noted that 10% of all readmitted patients who contribute to the HRRP penalties have AMI (McCarthy et al., 2018). The excess readmission ratio (ERR) is used to evaluate hospital performance in order to determine whether there are too many AMI readmissions that could have been avoided. The payment adjustment factor is calculated for qualified hospitals to estimate the percentage of reimbursements that will be cut based on the ERR ratings.

Readmissions after AMI discharge can occur for a number of reasons. First off, comorbidities including diabetes, renal failure, and chronic lung disease are examples of non-cardiac causes of readmission. The spread of infection is one of the most commonly noted reasons for readmission. Readmission rates for AMI patients are approximately 8.8%, and this has a substantial negative influence on the fines assessed to related healthcare facilities (Kwok et al., 2020). Discharged against medical advice is another observed risk for unexpected readmission. The majority of patients return with progressively severe symptoms, sometimes necessitating extended hospital stays.


Assessment of the Performance of Transitions of Care

The hospital readmission reduction initiative is significant because it addresses concerns about providing patients with high-quality care. The program places a strong emphasis on patient and provider involvement following discharge to aid in the creation of a strategy that can lower readmission rates. Additionally, HRRP is an essential step in achieving value-based buying, which rewards institutions based on the caliber of care they provide. With different readmission rates across the nation, HRRP offers each institution an equal chance to save public money by giving patients standardized, high-quality care.

Clinical Synopsis Assessment of the Performance of Transitions of Care

Donald, a 55-year-old man who had a myocardial infarction, is being released from the hospital after a 5-day stay. Upon admission, two cardiac stents and an angioplasty were performed as interventions. Donald’s discharge plan calls for him to see a cardiologist in two weeks, begin cardiac rehabilitation in one, and have lab work done in five to seven days. The following tactics will be used to keep this patient from being readmitted:

ensuring that Donald follows his cardiologist’s follow-up schedule.
make follow-up phone calls to check on ambulation at home.
regular monitoring to make sure he is properly taking all of his meds.


Strategies Based on Research Assessment of the Performance of Transitions of Care

Following discharge from the hospital, a number of things can happen that will have an impact on the patient’s status, ranging from complete recovery to rehospitalization. Disengagement from primary care providers, which results in non-compliance with the initial treatment plan, is one of the factors that leads to rehospitalization (Kwok et al., 2020). The likelihood of readmissions rises when follow-up schedules are not followed and communication with healthcare providers is poor. Second, the condition’s consequences, particularly those following surgery, may lead to readmission. People with long-term illnesses like myocardial infarction and CCF may require hospitalization again because of complications. The ineffective transition of care is another issue that frequently results in rehospitalization. Readmission is influenced by poor communication, insufficient information delivery at discharge, and poor care coordination.

There are numerous evidence-based tactics available to lower hospital readmissions after home release. The first tactic entails giving patients nurses or primary care doctors to monitor their pharmaceutical regimens (Pugh et al., 2021). To ensure prompt follow-up and care communication, each practitioner only treats a set number of patients or patients with a particular ailment. Second, collaborating with neighborhood doctors and medical groups is a tactic that shows enhanced patient care after discharge (Pugh et al., 2021). In order to facilitate prompt referrals and consultations and stop the patient’s condition from getting worse, hospitals need to establish communication with the doctors. Another key tactic is the teach-back technique, in which the patient is asked to reiterate information provided regarding their condition and subsequent at-home care (Pugh et al., 2021). And finally, the application of contemporary technology offers a chance to lower readmissions. Without the direct engagement of their primary care physicians, patients can use a variety of educational films and software to help them through normal treatment.

In addition to the patient’s health, a number of other factors can influence readmissions. Poor social planning, for instance, especially among the elderly, might make the patient’s condition worse. The person who will care for the patient at home should be mentioned in the discharge plan; failing to do so has an impact on later home care. The factors in the surroundings where individuals are born, live, learn, work, play, worship, and age that have an impact on a variety of health, functional, and quality-of-life outcomes and hazards are known as social determinants of health (McCarthy et al., 2018). In terms of hospital readmission, a patient’s level of poverty may have an impact on how they seek out medical care, including whether they buy drugs that worsen their health. An client is more likely to return with increased symptoms and require readmission if they are unable to purchase medications.

The Patient’s Experience Assessment of the Performance of Transitions of Care

Donald is a patient who underwent surgery for AMI and was then sent home. Failure to follow the follow-up plan is one of the things that can lead to the patient being readmitted. Donald had a primary care physician, as stated in the patient’s history, and his most recent appointment was seven months ago. He is currently required to visit a cardiologist every week, and failing to do so could result in readmission. Donald’s lifestyle choice, which has contributed to his obesity and hyperlipidemia, is another potential aspect to take into account. Despite taking Artovastatin, the patient eats primarily fast food. Lack of dietary change at home may be a factor in his condition getting worse.

Donald’s case study shows that a number of social determinants have an impact on his health. The following actions can be utilized to enhance his health and avoid readmission.

Personal level: Low-fat health diet instruction to prevent obesity The patient needs to become more literate in matters of health.
Social/community level: Assure that Donald’s family is involved in his treatment and follow-up schedule. Wife should go with the patient during follow-up appointments to increase compliance.
Level of the system: Donald’s treatment plan entails long-term care, including frequent visits and the use of over-the-counter drugs. To encourage pharmaceutical assistance, call Blue Cross Blue Shield, his insurance provider.

STEP 4: Individual, social/community, and system-level interventions in the hospital prevention plan

Primary Defense

Primary prevention refers to measures taken to stop illness or injury before it happens (Karunathilake & Genegoda, 2018). Exercise and physical activity are two of the most effective preventative methods for people with cardiovascular problems. To treat the patient’s AMI, the key preventative techniques listed below can be applied.

Individual level: Take part in regular exercise and physical activity. Exercise will assist in maintaining a healthy weight, reducing obesity, and lowering your risk of developing AMI.
Social/Community level: Adoption of legislation to limit the sale of fast foods that cause obesity and weight gain.
Systems level: Public education on the dangers of cardiovascular disease and the services offered in medical facilities.

Second-Line Defense

Early detection increases the likelihood of beneficial health outcomes, which is the focus of secondary prevention (Karunathilake & Genegoda, 2018). The interventions listed below can be utilized to improve Donald’s health.

Ensure medication compliance and regular exercise for personal health enhancement. Additionally, the patient needs to see his cardiologist frequently.
Social/Community: Population-based screening for obesity and overweight to identify diseases early. creation of support services for routine screening, such as dyslipidemia screening, in hospitals.
Systems level: Prescription drug assistance through insurance approval. The plan will expand the number of people who can afford to buy drugs for AMI therapy.

Third-Level Prevention

aims to improve the quality of life for those who have already been afflicted by a disease by lowering impairment, limiting or delaying consequences, and regaining function (Karunathilake & Genegoda, 2018). Donald’s tertiary preventative measures could consist of:

Individual level: Regular cardiologist appointments for checking on problems after angioplasty and the implantation of two heart stents.
Social/Community: Establishing community-based support networks for those dealing with heart disease. Support groups, especially those with members who have experienced AMI, might be helpful to Donald.
At the system level, make sure the patient’s insurance will cover any additional care, including pricey surgery. improving emergency and telecommunications services after AMI calls.


Centers for Medicare and Medicaid Services. (2020). Acute inpatient PPS: Hospital readmissions reduction program (HRRP).

Karunathilake, S. P., & Ganegoda, G. U. (2018). Secondary prevention of cardiovascular diseases and application of technology for early diagnosis. BioMed Research International2018, 5767864.

Kwok, C. S., Capers, Q., 4th, Savage, M., Gulati, M., Potts, J., Mohamed, M. O., Nagaraja, V., Patwala, A., Heatlie, G., Kontopantelis, E., Fischman, D. L., & Mamas, M. A. (2020). Unplanned hospital readmissions after acute myocardial infarction: A nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014. Coronary Artery Disease31(4), 354–364.

McCarthy, C. P., Vaduganathan, M., Singh, A., Song, Z., Blankstein, R., Gaggin, H. K., Wasfy, J. H., & Januzzi, J. L., Jr (2018). Type 2 myocardial infarction and the hospital readmission reduction program. Journal of the American College of Cardiology72(10), 1166–1170.

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research21(1), 189.

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