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Care Transitions F.A.Qs

Q: What does the term “care transitions” mean?

A: “The term care transitions refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, a patient might receive care from a Primary Care Provider (PCP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse.  Each of these shifts from care providers and settings is defined as a care transition.”[i]


Q: What is the average cost to Medicare per preventable readmission?

A: The Medicare Payment Advisory Commission estimates that up to 76% of hospital readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200.


Q: How will new health regulations impact hospital readmissions?

A: The penalties imposed for preventable readmissions should incent hospitals to improve the quality of care patients receive and reduce costs to Medicare.


Q: Should all hospital readmissions be prevented?

A: No, not all readmissions are preventable. If the cause for the readmission is not tied to the original admission then a patient should not be prevented from returning to the hospital. It may also be necessary to readmit a patient even if the cause is tied to the original cause for admission. The objective for reducing preventable readmission is to increase the patient’s well being while also reducing the hospital’s cost but one should not occur at the expense of the other.


Q: What are the critical timeframes associated with reducing readmission rates?

A: According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[iii]  This 30 day timeframe is the period on which most care transitions programs are focusing their efforts; however, the first 72 hours after a patient is discharged from the hospital is especially critical as this is when seniors are typically most frail and overwhelmed. 


Q: What are some of the problems associated with poor transitions between settings?

A: The following are some of the outcomes associated with poor transition management:

  • Information is  often fragmented in silos and there is poor communication between settings;
  • There is often misunderstanding or confusion on the part of the patients and their family caregivers about how and who should manage their care;
  • Medication errors may occur due to misunderstanding of instructions, medication adherence, drug-drug interactions and duplicate prescriptions;
  • Inadequate or poor follow up with Primary Care Provider (PCP);
  • There is a general lack of knowledge about alternatives (i.e. home care providers) in many communities.


Q: How can Right at Home services help improve transitions of care to effectively reduce the number of preventable readmission rates?

A: Right at Home caregivers may be able to assist patients at home in the following ways:

  • Observe red flags, provide documentation and report back to the hospital (or Physician) on the patient’s progress to avoid an adverse event;
  • Transport patients to and from Doctor’s visits to assure appropriate follow up;
  • Assist clients with medication reminders to deter medication errors;
  • Offer meal preparation to adhere to a patient’s dietary restrictions;
  • Provide ambulatory assistance to lessen the likelihood of a fall.

[i] The Care Transition Program:


[iii] Department of Health and Human Services Press Release

[iv] The Care Transition Program:

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