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Care Transitions and Accountable Care

Apr 03, 2012

Every person that has ever spent a day as an in-patient in a hospital has experienced a care transition.  And every person that has stayed in a hospital in the last several years has seen changes in the way in-patient stays and discharges are handled.  Some of these changes are better than others.  Did you know that:

  • Among hospitalized patients 65 or older, 21 percent are discharged to a long term care or other institution,
  • Approximately 25 percent of Medicare skilled nursing facility (SNF) residents are readmitted to the hospital, many within 30 days,
  • Individuals with chronic conditions-a number expected to reach 125 million in the U.S. by 2020-may see up to 16 physiciansin one year.

As the Patient Protection and Affordable Care Act becomes a reality, hospitals and other skilled care providers are being held accountable for "preventable readmissions".  This is generally good news for patients, as more attention will be paid to a patients status at the time of discharge, as well as to a plan for a coordinated transition back into the home.  There are three specific conditions for which the Centers for Medicare & Medicaid Services (CMS) are already publicly reporting:  pneumonia, acute myocardial infarction (AMI) and Heart Failure (CHF), and a fourth—Chronic Obstructive Pulmonary Disease (COPD) that is being considered.  The research is showing that about 1 in 5 Medicare patients are being readmitted within 30 days after hospital discharge. In 2013, in addition to the "shame" of public reporting, the CMS will start holding hospitals accountable by decreasing their reimbursements.