Care Transitions (Readmissions)

Why improve care transitions?

Improving care transitions is important for three main reasons:

  • Failed care transitions result in patient harm.Click to expand
  • First, and most important, failed care transitions result in patient harm. Research in the past 10 years documents that up to 49% of patients experience at least one medical error after discharge,1 and one in five patients discharged from the hospital suffers an adverse event.2,3 It is important to note that up to half or more of these adverse events are preventable or ameliorable, primarily through improved communication among providers. Information transfer and communication deficits at the time of hospital discharge are common, with direct communication between physicians occurring less than 20% of the time, and discharge summaries often lack important information and/or are unavailable when patients present for post- hospitalization follow-up with their primary physicians.4 Additionally, many patients are discharged with test results pending, and left with loose ends such as additional testing after discharge.5,6 Furthermore, many patients lack understanding of their hospitalization diagnosis and treatment plans,7 resulting in patients not being able to care for themselves after discharge. Eventually, these mistakes result in about one in five Medicare patients being rehospitalized within 30 days of hospital discharge.8


  • Healthcare reform aligned financial incentives to stimulate system improvements in care transitions.Click to expand
  • Second, healthcare reform implemented by the Patient Protection and Affordable Care Act of 2010 has better aligned the financial incentives to stimulate healthcare systems to work on improving care transitions. The new law does so by both penalizing hospitals with excessive rates of rehospitalization, and supporting programs to help healthcare systems improve care transitions. As in the case of Ms. Jones in the story at the beginning of this section, a common result of a “failed” hospital discharge is subsequent rehospitalization resulting from harmful events after discharge. Such unnecessary rehospitalizations cost billions of dollars annually. Reacting to these unnecessary costs, the Medicare Payment Advisory Commission (MedPAC) recommended to Congress in June 2007 that hospitals should publicly disclose their own risk- adjusted readmission rates.9 This suggestion became official policy with the passage of the Affordable Care Act on March 23, 2010. Since the beginning of 2013, those hospitals with higher-than-expected readmission rates for the diagnoses of pneumonia, heart failure and acute myocardial infarction have begun receiving a reduction in Medicare reimbursement of up to 1% for all Medicare diagnosis-related group (DRG) payments.10 This maximum financial penalty is 2% in FY2014, and 3% in FY2015, resulting in potential loss of reimbursement for some hospitals in the millions of dollars. Beyond the penalties, though, hospitals and physicians can now receive reimbursement for care coordination for discharged patients. Physicians can use Current Procedural Terminology (CPT) codes 99495 and 99496 when they arrange for an early post- discharge follow-up appointment or make contact with a patient shortly after discharge. Combined with an increasing emphasis on patient-centered care, hospitals’ desire for high-quality patient care and patient satisfaction is now aligning with reimbursement for quality instead of quantity.


  • Optimized care transition processes improve outcomes, including patient satisfaction and reduced readmission rates.Click to expand
  • Third, beyond the financial penalties, the Patient Protection and Affordable Care Act created programs to help hospitals and providers improve care transitions. The Centers for Medicare & Medicaid Services (CMS) started one of these programs, the “Partnership for Patients,” creating a “nationwide public-private partnership that offers support to physicians, nurses, and other clinicians working in and out of hospitals to make patient care safer and to support effective transitions of patients from hospitals to other settings.”11 In fact, CMS recommends Project BOOST® as one of the care transition models for the community-based care transitions program. Following the principles and standards set forth by the Transitions of Care Consensus Policy Statement, medical home providers can ensure a safe transition for patients and help them navigate our complex health system.12

    Read more about reducing unnecessary readmissions and improving the discharge process by visiting the Project BOOST implementation toolkit.



   Programs & Tools