National Care Transitions Awareness Day Calls Attention to Transitions of Care Practices

Efforts to reduce hospital readmissions have increased the focus on care transitions (also referred to as transitions of care), when a patient moves from one healthcare setting to another, such as from a hospital to a long-term care facility, from a skilled nursing facility to home with home health care, or from an inpatient rehabilitation facility to a hospital. Improving care transitions helps prevent patients from having to come back to the hospital soon after discharge.

Ten years ago this month, awareness of the high rate of hospital readmissions among people with Medicare became widely recognized with the publication of the New England Journal of Medicine article “Rehospitalizations among Patients in the Medicare Fee-for-Service Program” by Jencks, Williams, & Coleman (2009).  That analysis of Medicare claims data from 2003-2004 found that 19.6% of Medicare fee-for-service beneficiaries discharged from an acute care hospital were readmitted to the same or another hospital within 30 days. Additionally, there was substantial variation in the readmission rates across states, ranging from 13.3% in Idaho to 22.0% in Maryland. That finding suggested that there were excess avoidable readmissions in states with high readmission rates.
The Affordable Care Act (ACA), which was passed a year later, included the Hospital Readmissions Reduction Program, which currently reduces reimbursement for all Medicare fee-for-service admissions to hospitals with excess readmission rates for discharges in any of six conditions (acute myocardial infarction, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, hip/knee replacement, and coronary artery bypass grafting). Shortly after the passage of the ACA, and before the readmission penalty went into effect, readmission rates began to fall (Zuckerman, Sheingold, Orav, Ruhter, & Epstein, 2016), but nationally the readmission rate has decreased by just over one percentage point since then, from 19.7% during 2010 to 18.5% through mid-2018 (Quality Insights Quality Innovation Network, 2019).
Unfortunately, the American healthcare system is generally not strong in providing the components that produce good care transitions. Areas in which there are opportunities for improvement include:
  • Comprehensive and timely discharge planning that addresses patient needs during the post-acute care period
  • Improved communication between providers at different settings, such as phone calls between nurses and/or physicians at sending and receiving facilities at the time of transfer
  • Improved interoperability of EHRs to allow better to access to information about care received by the patient in the previous setting
  • Better education of patients and family caregivers about their medical condition(s) and what they need to do to keep themselves as healthy as possible, along with more engagement of patients/families in managing their chronic conditions
  • Improved medication reconciliation (and medication management in general, such as reducing polypharmacy when appropriate)
  • Addressing end-of-life planning and patient wishes
The Centers for Medicare & Medicaid Services has designated Tuesday, April 16, 2019 as the 1st annual National Care Transitions Awareness Day in order to bring more attention to the importance and value of safe and effective care transitions and care coordination. Please use that day and the week of April 15-19 to examine what you and your organization can do to improve care transitions and prevent hospitalizations of your patients. The goal is not zero readmissions, but better care transitions that lead to fewer hospitalizations and better quality of life for patients. If you would like to share initiatives that you have undertaken to improve care transitions or would like assistance in implementing interventions, please feel free to contact Quality Insights’ Care Coordination Network Task Lead, Dr. Andy Miller at

Jencks, Stephen F, Williams, Mark V, and Coleman, Eric A.  “Rehospitalizations among Patients in the Medicare Fee-for-Service Program.” New England Journal of Medicine. 360:1418-1428.  2 April 2009.
Zuckerman Rachel B, Sheingold, Steven H, Orav, John, Ruhter, Joel, & Epstein, Arnold M. “Readmissions, Observation, and the Hospital Readmissions Reduction Program.” New England Journal of Medicine. 374:1543-1551. 21 April, 2016.
Quality Insights Quality Innovation Network Scorecard. Prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. Data available upon request. 2019.