Study highlights transitional care importance in health reform

A new study, conducted by Ellen Kurtzman, R.N., M.P.H., FAAN, assistant research professor in the GW School of Nursing, and colleagues, published in the April 2011 issue of Health Affairs, highlights the importance of transitional care in reaching the goals of health reform, and provides evidence-based strategies to guide its implementation.

"Our study revealed nearly a dozen interventions that have demonstrated some positive affect on hospital readmissions, a key focus of health reform," said Kurtzman. "More critically, we have identified three proven strategies that have effectively reduced all-cause readmissions through six or twelve months. We recommend these strategies serve as prototypes to guide the implementation of transitional care under the Affordable Care Act."

Kurtzman and colleagues conducted a systematic review of the research literature analyzing the effectiveness of twenty-one randomized clinical trials of transitional care interventions or models on quality and efficiency. The programs targeted chronically ill adults transitioning from acute care hospitals to other settings, including patients' homes or skilled nursing, rehabilitation, and long-term care facilities. Based on their analysis, the researchers identified nine interventions that demonstrated positive effects on measures related to hospital readmissions— total all-cause readmissions, time to first readmission, or length of readmission stay. Many of the successful interventions share similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients.

Based on these findings, the researchers were able to recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, including:

•Encouraging the adoption of the most effective interventions identified from their synthesis through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments;
•Expanding transparency and accountability measures, including standard, precisely specified measures that address patients and family caregivers' experiences with transitional care and potentially avoidable readmissions;
•Expand training and education programs to address the expanded roles health care professionals will assume in the delivery of transitional care and align licensure, certification, and accreditation requirements to reflect these accountabilities.