Future Directions in Research to Improve Care Transitions From Hospital Discharge

Abstract

T journey from hospital to home is hazardous and frustrating for many patients and caregivers. As they navigate the transfer of care from one provider to another, they are often unprepared for the transition, with incomplete information, unreliable access to timely advice, and a distressing burden of symptoms. Researchers and clinicians have been studying and trying to mitigate the adverse events that occur after hospital discharge, and the readmissions they are associated with, for > 20 years. Attention to care transitions has become super-charged by policies promoting value-based payment models, incentivizing performance based on patient experience surveys, and penalizing providers for high hospital readmission rates. As we approach the 10-year anniversary of the Hospital Readmissions Reduction Program (HRRP), surely every hospital provider in the country has had to consider ways to improve posthospital care transitions. Recognition of care transitions challenges and opportunities is now pervasive. We no longer need to convince anybody that the care and self-management that occurs between and outside of medical settings is important. We know that people experience multiple gaps in care after hospital discharge, and there is something close to consensus on the most important factors leading to those gaps.1,2 Multifaceted care transition interventions have been shown by research trials to both improve patient experiences and reduce unplanned readmissions.3 These evidence-based intervention models share common elements, such as robust medication reconciliation, improved hospital discharge processes, engagement of patients and families in care planning and preparation, and use of bridging strategies that promote patient self-care capacity and continuity between providers. Government policy mandates national measurement and public reporting of patient care transitions experiences most associated with readmission risk4 through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey. Yet progress has been slower than might be expected given the concerted focus on the challenges, defined improvement strategies, and financial incentives. Readmission rates have decreased, but are still nearly 16%,5 and care transitions experience scores have improved minimally since 2013, and remain the lowest scored HCAHPS measure.6 Research and improvement initiatives have demonstrated that positive patient experience scores are often, but not always, associated with lower readmission risk7,8 highlighting the need to better understand, measure and address the social and contextual factors unassociated with hospital care that influence patients’ capabilities to manage their health after discharge. Replicating evidence-based models has been challenging, and results vary across studies of the effectiveness of the same model.9 Pragmatic effectiveness and adaptation tests often demonstrate incomplete implementation of model components,10,11 leading to uncertainty about whether intervention models are less effective in “real life” scenarios, or whether such models are just difficult to implement within the current