Exploring Post-Discharge Spaces Designed to Eliminate Gaps in Care

Exploring future spaces to further ease transitions in care

As long as readmission rates around the country remain high, the search for the most effective transition from healthcare to home will continue.

“I think it’s good that people are experimenting with different models and different patient populations because, in the end, what you really want to do is focus your attention on those most vulnerable populations who stand to gain the biggest benefit from some type of transitional care clinic or model,” Robertson points out.

Research is currently underway at the federal level to further explore transitional care models. The Project ACHIEVE clinical trial was launched in 2016 to examine diverse high-risk Medicare patient populations—people with several potential triggers for hospital readmissions. These include having multiple chronic conditions, having mental health issues, possessing low health literacy or low income, and living in rural areas (Li et al., 2016).

“These are very different populations with very different clinical needs and very different kinds of risks. It’s great to see at the federal level a study being funded like this to look at so many variables and types of transitional care models and to assess their impact on patient outcomes,” Robertson says.

As the Project ACHIEVE researchers state, “Problematic transitions occur from and to virtually every type of health care setting, but especially when patients leave the hospital to receive care in the post-acute setting (e.g., independent rehabilitation or skilled nursing facilities) or at home. Systems issues need to be addressed, including: communication of unresolved problems among providers, patient education regarding medications and treatments, monitoring medication reconciliation and adherence, arranging appropriate follow-up and monitoring the status of patients soon after discharge including adverse drug events.”

Hospitals’ less-than-stellar readmission rates—and the resulting HRRP penalties—are promoting a new wave of exploration in program effectiveness. However, this attention to readmission rates also seems to be driving worldwide interest in improving the overall quality of care.

“Interestingly these [transitional care models] have emerged in other countries too—Brazil, Switzerland, Singapore, all over—because people are trying to look at the gaps in care and where patient safety is compromised by those gaps,” Robertson says.

Although evidence remains mixed thus far, many patients are being better served by today’s commitment to sending them home not just healthy, but also well educated.

Megan Headley is a contributing writer to PSQH and owner of ClearStory Publications. She has covered healthcare safety and operations for several publications. Headley can be reached at megan@clearstorypublications.com.



The Dartmouth Institute for Health Policy & Clinical

Practice. (2011, September 28). After hospitalization: A Dartmouth Atlas report on post-acute care for Medicare beneficiaries. Retrieved from www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf

DiNardo, A. (2016, March 15). Moving service: Improving the patient discharge process. Healthcare Design. Retrieved from www.healthcaredesignmagazine.com/article/moving-service-improving-discharge-process

Distel, E. Casey, M., & Prasad, S. (2016, March). Reducing potentially-
preventable readmissions in critical access hospitals. Retrieved from www.flexmonitoring.org/wp-content/uploads/2016/03/PB43-

ECRI Institute. (2015). 2015 top 10 hospital C-suite watch list. Retrieved from www.ecri.org/Resources/Whitepapers_and_reports/Top_Ten_C-Suite_Watch_List_2015.pdf

Lack of pharmacy access sends some patients back to the hospital (2016, August 3). Pharmacy Practice News. Retrieved from www.pharmacy

Li, J., Brock, J., Jack, B., Mittman, B., Naylor, M., Sorra, J., … Williams, M. (2016). Project ACHIEVE – using implementation research to guide the evaluation of transitional care effectiveness. BMC Health Services Research, 16(70). Retrieved from http://rd.springer.com/article/10.1186/s12913-016-1312-y

Rice, S. (2015, August 3). Most hospitals face 30-day readmissions penalty in fiscal 2016. Modern Healthcare. Retrieved from www.modern

Roy, C., Poon, E. G., Karson, A. S., Ladak-Merchant, Z., Johnson, R. E., Maviglia, S. M., & Gandhi, T. K. (2005). Patient safety concerns arising from test results that return after hospital discharge. Annals of Internal Medicine, 143(2), 121–128. Retrieved from http://annals.org/article.aspx?articleid=718580

Zuckerman, R. (2016, February 24). Reducing avoidable hospital readmissions to create a better, safer health care system [Blog post]. Retrieved from www.hhs.gov/blog/2016/02/24/reducing-avoidable-hospital-readmissions.html