ACA incentives driving healthcare transition improvements in hospitals

Regardless of one's views on the Affordable Care Act, it has succeeded in placing long-overdue attention on improving management of patient transitions from one care setting to another, according to a leading health care policy analyst speaking today at the National Quality Summit, sponsored by the National Association for Healthcare Quality (NAHQ, www.nahq.org).

For its first-ever National Quality Summit, NAHQ assembled a roster of leading experts in healthcare quality management to discuss an increasingly significant concern - how to assure favorable outcomes when transitioning patients from one clinical environment to another or to the home. Speakers at the Summit will cover clinical, social, economic and public policy influences on healthcare transition quality.

"The Affordable Care Act has advanced provider accountability for care transitions through penalties and incentives, but focusing on preventing hospital readmissions to avoid penalties misses the point that improving care transitions is the right thing to do for patients," said Cheri Lattimer, RN, executive director, Case Management Society of America and National Transitions of Care Coalition. "For too long, care transitions have been have been the weakest points in the chain of care, causing inefficiency, fragmentation and poor outcomes. I'm pleased that CMS is recognizing the need to support transitions of care and care coordination, but the policy landscape will continue to shift as Congress deliberates various measures to amend the ACA."

Lattimer stressed that in the public policy arena, health care providers historically have been their own worst enemies. "We've been very good at defending our turf, but in the current health policy debate, providers need to speak in a unified voice, especially in lobbying to align desired health care outcomes with appropriate financial support for care coordination," she said. "Lawmakers need to know the evidence clearly shows that properly managed care transitions improve overall population health, enhance the patient's care experience, and reduce per-capita cost of care."

While debate continues on various ACA provisions and ways to achieve needed policy fixes, Lattimer said healthcare professionals can demonstrate their commitment to improving care transitions by focusing on interventions that are proven effective. "For now, let's identify what works and move forward. There's no need to start from scratch because research has shown us what's effective."

Lattimer stressed that improving communication among various providers involved in managing care transitions may be the most critical element for successful care transitions. "Ensuring clear communication with the patient, within the care team and across locations can make a significant difference in the patient's recovery. Poor communication can lead to multiple negative outcomes, most notably medication errors," she said.

Successful communication requires accountability and Lattimer explained that providers must have a clear understanding of their roles. "Accountability is promoted by identifying who is responsible at each point in a care transition and establishing communication links with patients and families, as well as other providers," she said. "Case managers should take the lead in coordinating care transitions and be the hub to which all involved parties are connected. Case management has always been about patient-centered care."

Moving forward, an ongoing major challenge, Lattimer noted, is demonstrating the value of smooth care transitions to health policy makers and payers by showing the financial benefits of coordinated care and making sure that patients and families are engaged and educated. "The current fragmented approach to health care delivery puts patients at risk and is very inefficient, which increases costs," she said. "We have to be united and active in the public policy arena in promoting the value of care-transitions management and relating successful outcomes in patient and family engagement, medication management, and assuring seamless, coordinated care across the health care continuum."