Brief Supporting Transitions of Care

Transitions of care occur when a patient moves from one health care setting to another. Transitions may be from a higher acuity care setting to a lower acuity care setting, or vice versa. Settings can range from hospitals, primary care practices, specialty care practices, long-term care facilities, home health, and rehabilitation facilities. 

For example, transitions of care may include moving a patient from:

• A hospital to a long-term care setting.
• A long-term care setting to a hospital.
• One unit to another within the same facility, such as a transition from the intensive care unit to a general inpatient unit.

Transitions of care are necessary to help patients receive the right care in the right place and at the right time and in the most cost-effective environment. Transitions of care are necessary to help patients receive the right care in the right place, at the right time and in the most cost-effective environment. However, many challenges exist to ensuring safe and effective transitions for patients.

Transitions of care from hospitals to home-based care settings are associated with increased risk of adverse events including diagnostic errors, medication errors, medical errors and hospital readmissions. Adverse events during transitions of care also disproportionately affect patients with low socioeconomic status, limited English proficiency or complex health and social needs.

Placing patients in the most appropriate setting is also challenging due to workforce shortages, increasing demand for certain settings and limited provider availability. During the COVID-19 pandemic, 44 states reported that workforce shortages led to permanent closures of home- and community-based service providers. A 2023 white paper using proprietary data from a care coordination and discharge planning software platform found that hospitals are finding it harder to refer patients to nursing facilities and home health agencies and are facing higher rejection rates.

State Actions to Improve Transitions of Care

Despite the complexity and challenges of this issue, states are taking actions to improve transitions of care.

Addressing patient social needs, supporting caregivers, using interdisciplinary care teams to plan and manage transitions of care, implementing telehealth and virtual care interventions, and exploring payment policy changes may contribute to better health outcomes for patients and yield cost savings.

Addressing patient health-related social needs like housing or nutrition may decrease certain adverse events associated with care transitions. An evaluation of a program that screened high-needs patients for unmet social needs found that addressing health-related social needs were associated with a 2% to7% reduction in readmission rates and 0.5% to 1.5% decrease in certain mortality rates.

• California is taking steps to improve access to housing to help patients transition from facilities like hospitals and nursing homes back into the community. requires the state Medicaid agency to cover one-time community transition services up to $5,000 for security deposits, essential furnishings, utility deposits and other services to help nursing facility residents or hospitalized individuals transition into the community. also requires the state Medicaid agency to expedite home- and community-based waiver processing for patients in acute care hospitals to divert hospital discharges from nursing facilities into the community. 
• Arizona’s Housing and Health Opportunities Medicaid demonstration provides housing supports to individuals in long-term care who are medically able to reside in their own home and require affordable housing to transition out of an institutional setting.

Involving caregivers in the discharge planning process may help improve transitions of care for older adults transitioning from hospitals or nursing homes into community settings. A literature review of 11 randomized controlled trials found that integrating informal caregivers into the discharge planning process for this population was associated with a 25% reduction in hospital readmissions at 90 days and statistically significant reductions in length of hospitalization and costs of post-discharge care. 

• States have taken action to support informal caregivers, family caregivers and the broader direct care workforce. For example, some states like Arizona and Hawaii have appropriated funds to directly support unpaid caregivers and others, such as Wisconsin, provide resources to assist caregivers for people with dementia.
• During the COVID-19 public health emergency (PHE), states were given flexibility to pay family caregivers who provide services to Medicaid home- and community-based services beneficiaries. In a survey of 27 state developmental disability services agencies, more than 77% reported that they intend to continue PHE flexibilities to pay family caregivers, and 13 states allow legally responsible family members to provide services to Medicaid beneficiaries that receive home- and community-based services.

Interdisciplinary care teams may help patients with complex health and social needs navigate transitions of care, address social needs, and avoid adverse events. Hospital at home programs provide interdisciplinary care both in-person and via telehealth to deliver a hospital level of care in the patient’s home instead of in a hospital setting and have been associated with reduced costs, readmissions and complications. An evaluation of an interdisciplinary home-based primary care program in Asheville, N.C., reported fewer emergency department visits, fewer inpatient hospitalizations, and $1,500 decrease in per member per month costs compared to the year prior for enrolled patients. An evaluation of an interdisciplinary model in the San Francisco Veterans Affairs Health Care System found a 40% reduction in the number of patients with a length of stay longer than 30 days after six months.

• Both North Carolina and South Carolina passed legislation permitting hospitals to operate federally approved hospital at home programs through 2024.
• California requires the state to incorporate care management and care coordination into interdisciplinary care teams for certain children and youth, as part of its Whole Child Model program, in part to help children and families navigate transitions among levels of care.

Some states are ensuring telehealth coverage to improve transitions of care. Telehealth services like store-and-forward services can be used for consultations between providers when a patient needs specialty care following a transition. Remote patient monitoring can be used to monitor a patient’s condition following a transition and alert providers to activity outside of expected ranges.

• Texas legislation covers telehealth services, including store-and-forward services for Medicaid beneficiaries, including for case management services and nursing assessments provided under certain state home- and community-based services waiver programs.
• Virginia legislation updated Medicaid coverage of remote patient monitoring for certain patients with chronic or acute health conditions, when there is evidence that use of remote patient monitoring is likely to prevent readmission of the patient to a hospital or emergency department.

States have also acted to address broader payment and provider availability challenges. Payment policy can either pay providers for services associated with transitions of care that are not currently paid or hold providers financially at risk for outcomes associated with safe, effective transitions of care through alternative payment models or penalties.

• Oregon created a task force to develop recommendations to address challenges faced by hospitals in discharging patients to appropriate post-acute care settings, including the post-acute care workforce, facilitating timely discharge, and supporting innovative care and payment models for patients with complex health or housing needs.
• Nebraska requires the state to pay hospitals at 100% of the nursing facility per-diem rate for individuals who no longer require acute inpatient care and are unable to be transferred to a nursing facility due to a lack of available beds. In the same bill, Nebraska also appropriated $1 million to establish a pilot program to facilitate the transfer of patients with complex health needs from eligible acute care hospitals to appropriate post-acute care settings. 
• Washington provides payment to acute care hospitals for difficult to discharge Medicaid patients who do not need acute care but who are waiting in the hospital to be appropriately and timely discharged to post-acute and community settings. Washington separately appropriated $160 million per biennium from its Medicaid safety net provider assessment program to be used for post-acute hospital transitions.