From a population health standpoint, a hospital admission identifies someone in the community who needs more health care and support. A re-admission is even a greater indication. Our country cannot have a health care system where nearly 20% of its senior citizens who are hospitalized, return for re-admission within 30 days. It demonstrates a need for our delivery system to adjust, and transitions of care are an obvious focus for change.
Most often the physicians and other providers who care for a patient inside the hospital are not the same as those who take over outside the hospital. The handoff between them needs to be coordinated better, with more complete information integrated in the process. Often as well, the patient has limited resources – physical or financial – to assist in their recovery. The hospitalization itself, particularly for the elderly, is debilitating. In some cases, skilled nursing facilities and rehabilitation units need to be better leveraged. Certainly home care services for many of these vulnerable patients needs to be deployed. By focusing on a more comprehensive transition of care process for their patients who are most at risk for readmission, hospitals can reduce readmissions and at the same time provide appropriate support for their communities of patients and providers.
Ray Fabius MD
Chief Medical Officer