HJNO Mar/Apr 2024

48 MAR / APR 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS COLUMN MEDICAID program fosters interdisciplinary collaboration that is informed by consistent and coordinated efforts, established relationships, complementary perspectives, and a common goal. The how What makes a successful care transition program you may ask? If you don’t already know or suspect you know but are strug- gling with what you have in place, here are a few suggestions: • Utilizing evidence-based transition models: Research-based models such as BOOST (Better Outcomes by Op- timizing Safe Transitions), CTI (Care Transitions Intervention), and TCM (Transitional Care Model) help orga- nizations employ a structured frame- work to address outcome deficiencies across the continuum of care. Though rigorous, these models can be adapt- ed to targeted patient cohorts. • Engaging a multidisciplinary care team: The adage “it takes a village …” takes on new meaning in the world of care transitions. Representing mul- tiple perspectives (e.g., physicians, IN THE DYNAMIC landscape of health- care, moving individuals from one care setting to another is known as “transition of care,” or sometimes “care transition” or “transitional care”. 1 As research has evolved to study this coordination step and ways to improve patient care during these transient events, transitions of care encompass various factors to include multiple provider types, different levels of care — think acute vs. sub-acute — and even various shifts during community re- source utilization, for example, waiver ser- vices. Regardless of the type of transition, individuals require support to ensure they are safe and that their needs are met at the most appropriate level of care. There is a plethora of care transition data available to anyone needing a good read before bed, but here’s the skinny: Care transitions are challenging to healthcare entities, costly to payers, and frustrating to patients and families. In other words, care transitions remain a pervasive, sys- temic issue that is no closer to achieving a replicable formula than we are to colo- nizing Mars — though this may seem more achievable! And with regard to hospital-based tran- sitions in particular, answers to the why, how, and what’s-in-it-for-me questions around care transitions demonstrate pos- itive impacts on patients, families, hospi- tals, health systems, and practically every- one else in between. The why Outside of regulatory mandates, accreditation requirements, public scrutiny, and inclusion in Centers for Medicare and Medicaid Services (CMS) programs, implementing a comprehensive care transition program supports financial stability by reducing costly readmissions, avoiding penalties associated with increased readmission rates, and maximizing reimbursement opportunities through value-based arrangements. Relative to population health, it addresses social determinants of health gaps, promotes health literacy, and connects patients to essential community resources. Moreover, a successful care transition TRANSITION OF CARE Why effective coordination in hospital-based settings is essential to achieving improved outcomes — for the bottom line and for the patient.