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Advancing Successful Care Transitions to Improve Outcomes

Why Is It Important to Improve Care Transitions?

Ineffective care transition processes lead to:

  • Adverse outcomes for patients, including medication errors, clinical progression of illness, lack of post-discharge follow-up and avoidable emergency department visits
  • Decreased patient and staff satisfaction
  • Inappropriate use of resources
  • Financial penalties through reduction in reimbursement from the Centers for Medicare & Medicaid Services (CMS) and other insurers

SHM’s Center for Quality Improvement provides hospitals and care teams with comprehensive resources and implementation tools that enable hospitalists to improve and enhance their care transitions.  

Enhancing Care Transitions to Reduce Readmissions

Reducing readmission rates through improved care transitions requires an evidence-based approach that incorporates adequate communication, optimized workflows, and institutional commitment to improving patient outcomes.

By initiating the discharge planning process early in a patient’s hospital stay, the care team can appropriately identify risks to a successful discharge.

SHM has developed a suite of resources that may assist hospitals with:

  • Identifying patients at high risk for re-hospitalization
  • Developing specific interventions to mitigate potential adverse events
  • Reducing 30-day readmission rates
  • Improving patient satisfaction and H‐CAHPS scores related to discharge
  • Improving flow of information between hospital and outpatient physicians and providers
  • Improving communication between providers and patients

SHM's care transition tools help hospital teams to:

  • Identify opportunities for improvement
  • Redesign workflow practices
  • Incorporate improvements into existing workflows to ensure a safe care transitions and improve patient outcomes.

SHM's resources also emphasize the importance of a "patient-centered" approach, incorporating input and engagement from patients and their families/caregivers about the care transition process.

Care Transitions in Pediatric Hospitals

SHM has adapted its care transitions guide and resources to meet the unique needs of the pediatric hospital setting. 

View the Pediatric Transitions Implementation Guide.

Care Transitions for Minority-Serving Institutions

PArTNER: PATient Navigator to rEduce Readmissions 

PArTNER is a PCORI funded transitional care model that is specifically targeted to Minority-Serving Institutions (MSIs). It encourages increased support to patients and caregivers at the hospital through the transition home to reduce readmission rates and patient anxiety.

PArTNER provides patients visits in the hospital and at home from a community health worker acting as a patient navigator and access to a peer-led telephone support line.   

While transitional care strategies are primarily designed for and implemented by clinicians,
PArTNER has been designed with the collaboration and involvement of patients and caregivers to address their specific needs.

View more information on PArTNER