An unplanned readmission to the hospital within 30 days of discharge is seen as a failure by the healthcare team to appropriately plan for a safe and effective discharge to the next level of care. According to The Center for Medicare & Medicaid Services (CMS), the national average readmission rate in 2012 was 18.4%. As CMS shifts to a pay for performance strategy, a readmission rate higher than the national average for specific disease processes will result in a financial penalty. Many organizations have identified the need to improve the current discharge planning processes and to provide patients with a safer transition to the next level of care to prevent readmissions. Evidence demonstrates that there is value in reconfiguring the current discharge processes toward interventions that demonstrate a reduction in readmission rates. The discharge process should incorporate a multidisciplinary, multicomponent transition of care intervention that starts while the patient is in the hospital and continues with some type of home-care follow-up. Transition of care is a relatively new term that is used to describe a set of interventions designed to coordinate a patient's care during the movement between healthcare settings. Implementing a well-designed transition of care program allows hospitals to provide a safe Environment of Care to patients during their care transitions. Environment of Care is a term coined by The Joint Commission that is used to describe the environment in which the patient is being cared for. The term usually involves three components: the people, the equipment and tools, and the building. As healthcare changes, it will become increasingly important to provide patients with care management throughout the continuum of care, which means thinking of the patient's Environment of Care in much broader terms. How do transition of care processes affect the patient's Environment of Care? Does a well-implemented transition of care program lead to a positive impact in the patient's overall Environment of Care? This article provides an overview of how implementing a formalized transition of care process can lead to a safer Environment of Care.

Background: Failure to appropriately plan for a safe and effective transition to the next level of care leads to greater use of hospital and emergency services, often measured by rates of readmission. Despite a focus to develop programs to reduce readmissions, the 30-day all-cause readmission rate for Medicare patients in 2011 remained essentially unchanged. Purpose:The objective of this qualitative systematic review was to synthesize the evidence for interventions aimed at reducing readmissions through a transition of care program. Methods:We searched PubMed and Medline (OVID) with search terms including home care services, continuity of patient care, patient discharge, patient-centered care, health planning, and patient readmission. Selection criteria included quantitative studies, qualitative studies, and expert opinion articles in which a transition of care intervention, was implemented. The outcome of interest was readmission rates.Results: Thirty-three articles met inclusion criteria. The data were synthesized into two categories: primary studies in which the readmission rate was measured as an outcome, and studies that systematically reviewed interventions aimed at improving the discharge process. In all studies reviewed, a transitional care intervention resulted in a statistically significant reduction in readmission rate, or a rate trending lower, or the rate remained the same. Several studies evaluating an intervention occurring during and after hospitalization demonstrated significant results. Conclusion:There is value in reconfiguring discharge processes toward interventions that are more likely to reduce readmissions. The discharge process should incorporate a multidisciplinary, multicomponent transition of care intervention that involves hospital and home-care follow-up.

Background and objective: Failure to appropriately plan for a safe and effective transition to the next level of care leads to a greater use of hospital and emergency services, often measured by rates of readmission. A large academic medical center located in Houston, Texas, USA consistently achieves an overall University Health System Consortium (UHC) ranking for most benchmarks in the top decile (90th percentile) except for 30-day all-cause readmission rate, which ranks in the bottom decile. The objective of the study was to implement changes in Midas+, the system used by Houston Methodist Hospital for quality and case management activities, select a formal transition of care plan and implement the process on a pilot unit to reduce the 30-day readmission rate and improve the discharge planning process. Methods: Setting: Cardiovascular Intermediate Care Unit (CVIMU), a 30-bed cardiovascular surgery unit within an academic medical center in Houston Texas. The project intervention included the addition of a readmission risk screen in the Hospital Case Management (HCM) and intervention screens based on the Coleman Model in the Community Case Management (CCM) module of Midas+. The clinical improvement involved three components spanning from hospital to home: (1) Screening patients for readmission risk upon admission and assigning those identified as high-risk for readmission (with a planned discharge to home) to a Transition Coach, (2) A visit by the Transition Coach during the patient's hospital stay to assess the patient and provide coaching, and (3) Providing five follow-up phone calls from the Transition Coach post-discharge. Results: The system changes in Midas+ were implemented and were effective in tracking the interventions. Of the 258 patients admitted from July through August 2014, 226 or 87.5% of the patients were screened using the readmission risk assessment tool. Of the patients' screened, 49 were considered high risk with 26 discharged home, 22 or 45.8% discharged to another level of care and one patient expired. During the pilot, of 19 patients were followed by a transition coach only one patient readmitted to the hospital. Conclusions: The project demonstrated that utilization of a computer system to record the readmission risk screen, track the assessment of the pillars (medication management, continued care, red flags to report, and personal health record) over the six time intervals of the pilot transition program was effective in tracking the intervention. The data collected through information technology was easily retrieved for tracking progress and evaluation. The outcome of this pilot has shown that a well-defined transition of care program may decrease the 30-day readmission rate.

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