Care Transitions

Hospitals are faced with the task of preparing patients and families to provide ongoing care at home and by ensuring they understand how to self-manage the clinical condition. Unfortunately, patients often go home, where, with little or no professional assistance, family members must provide complex and difficult care.

This brief highlights the most common failure points associated with hospital discharge, offers practical tools and effective strategies for hospital staff and caregivers, and shares valuable insights from the patient perspective.

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The disproportionate concentration of health care consumption and expenditures among a small portion of the population is a well-documented facet of the health system in the U.S. The top 1 percent of the population consistently consumes more than one-fifth of health care resources, the top 5 percent account for half of all spending and half of the population accounts for 97 percent of health care utilization and expenditures.

Because of new paradigms in accountable care and population health management, one particular segment of high-cost patients — hospital “super-utilizers”— has been the focus of emerging models of patient-centered care delivery that concentrate on both medical and socioeconomic conditions. The foundational elements of these models include robust data analysis and patient-centered transitions of care from the hospital to patients’ communities.

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