ACOs and Transitional Care

Series 1 Paper 1

“The researchers concluded that, although hospitals are being penalized for excessive readmission rates, the strategies that an individual hospital can implement to improve transitional care remain largely undefined.” This study was supported by AHRQ (Contract No. 290-07-10062). [1]

The most commonly used interventions included patient engagement, ranging from general patient education to more specific instruction on symptom management, and medication counseling. Other interventions included postdischarge outreach to patients by telephone and/or home visit. One of the strategies used by some hospitals, the Care Transitions Intervention, has been successfully implemented and evaluated in multiple patient populations and health care systems. A similar intervention, Project RED (Re-Engineered Discharge), has been implemented in a safety net system. Although these strategies are relatively intensive and probably require considerable resources, information on the cost of transitional care strategies was lacking.

As an Accountable Care Organization (ACO) and Transitional Care Team, we all see our roles as important. However, if the only approach to patient adherence you are using is Teachback, you won’t get very far.  If you are using Transitional Care in addition to Teachback, you won’t get far enough.  Long term habit change requires a clear understanding and the application of applied behavior science.  Adherence Management Coaching is an evidence-based tool for augmenting what you are doing and improving patient behavior.

This is the first in a series of White Papers looking at an applied behavioral approach to reducing readmissions by improving patient adherence.  Unlike traditional chess, adherence management is a readmissions reduction strategy in which the pieces are not competing to beat the other players on the board.  The competition is non-adherence and the complex nature of today’s health services system.  The competition is morbidity, mortality and financial unhealth to the providers.  Health care and patient adherence is more like the multi-dimensional chess board, introduced in Star Trek back in the 1980s, where the aspects of the playing field is the competition.

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[1]  “Hospital-initiated transitional care interventions as a patient safety strategy,” by Stephanie Rennke, M.D., Oanh K. Nguyen, M.D., Marwa H. Shoeb, M.D., and others in the March 5, 2013, Annals of Internal Medicine 158(5) Part 2, pp. 433-440.


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