Inpatient Care Transitions: Best Practices and Measures of Success

The medical home, by any of the many current definitions, includes care coordination as an essential characteristic. The flow of patients from the inpatient setting to either the home or another clinical setting is one critical component of care coordination. When this transition is handled effectively, patients continue on a trajectory to restored function, improved health, or at least comfort and appropriate treatment. When this transition is handled efficiently, improvements in patient health and well-being are made at the lowest levels of additional expenditure. In particular, effective inpatient care transitions reduce or eliminate avoidable hospital re-admissions along with their associated costs and negative impact on patient well being and satisfaction.

This project, under the auspices of HRET's Center for Health Management Research, and lead by Cindy Watts, PhD of the University of Washington, will explore the transition of patients out of the inpatient setting. It will seek to address the following questions:

• What are the settings to which patients are most often discharged?
• What processes do hospitals use in determining to which setting patients will be discharged?
• What follow-up processes are used to assure that patient continue to make progress toward the desired state (e.g., return to health, restored function, comfort and palliative care)?
• What processes are used to track patient re-admissions?
• What actions result from the re-admissions data?
• What characteristics of patients and hospitals affect the transition process?
• What measures are/can be used to track the effectiveness and efficiency of patient transition out of the inpatient setting?
• What are the best practices for inpatient transitions?

These questions will be addressed in a mixed method approach applying a literature review, case studies, key informant interviews, and conceptual analyses.

For more information about this project, contact Debbie Pierce at (312) 422-2635 or dpierce@aha.org.