Transitions of Care: From Vulnerabilities to Value Drivers

Welcome to the first article in our transitions of care series. Here, we’ll provide an overview of:

• Why transitions of care matter
• Where there’s room for workflow improvement
• What patients and providers stand to gain from optimizing transitions of care

In our next installments, we’ll dive deeper into specific technology solutions designed to support care teams in effectively managing these vulnerable moments along the healthcare journey.

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High Stakes for Patients, Providers and Payors

Transitions of care — moments when a patient moves from one healthcare setting to another are among the most vulnerable and costly points in the patient journey. In fact, patient readmissions account for more than $26 billion in Medicare spending each year.

Despite the frequency of these events, optimizing transitions of care is far from routine. According to the Centers for Medicare & Medicaid Services (CMS), nearly one in seven Medicare patients discharged from a hospital is readmitted within 30 days, often due to poor communication or lack of follow-up care.

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Why Transitions of Care Break Down

When patients transfer facilities or return home, coordination often falls through the cracks. Incomplete or delayed records, inadequate post-discharge care — and even lack of visibility into the fact that a transition has occurred can stand in the way of care continuity and patient support.

Many care teams rely on admission, discharge and transfer (ADT) alerts for real-time visibility into transitional care events. However, ADT data feeds typically only connect to individual healthcare facilities, meaning care events that occur outside of those systems fail to trigger alerts. To achieve broader coverage, many organizations stitch together multiple ADT connections. Yet this patchwork approach still leaves gaps — while creating poor data standardization, adding vendor management costs and complicating downstream workflows.

ADT notifications also often lack the deep clinical context care teams need to inform more effective interventions. Care teams frequently find themselves reacting to events without clinical context, or searching for the documents they need to deliver safe, seamless care.

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The Value of Improving Transitions of Care

Better Patient Outcomes, Healthier Populations and Stronger Organizational Performance

Transitions of care are often confusing and stressful for patients. When they lack information, they may miss follow-up appointments, struggle with medications or disengage from their care.

By contrast, when patients and caregivers are engaged in collaborative discharge planning by compassionate providers using effective communication, actionable information, and anticipatory guidance— satisfaction improves, adherence rises, and caregivers voice more self-confidence. This improved patient experience often extends to CAHPS® scores, enhancing providers’ reputation and performance under value-based care models. 

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Reduced Readmissions, Lower Costs

Each hospital readmission costs on average $15,000, and reducing avoidable readmissions is key to improving patient outcomes and lowering overall healthcare costs. Additionally, payors increasingly tie readmission metrics to value based care Star ratings and penalties. Certain reimbursement frameworks—such as CMS’s TCM program—support post-discharge follow-up, given the proven impact of effective care transitions in lowering readmission rates. A 2018 study showed that 30-day readmission odds decreased by nearly 85 percent among patients receiving full TCM services compared with those who did not.

Beyond improved outcomes, these services can unlock distinct CPT code revenue streams tied to coordinating care, managing medications, and addressing community support and social needs.

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Higher Quality Measures, Stronger Reimbursement

Across payment models, there are a range of quality measures, such as Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU) or HEDIS Transitions of Care (TRC), which focus on timely post-discharge care. Many of these measures require follow-up within just days of a hospital discharge. 

With access to near-real-time health records, discharge summaries and care plans, providers can act quickly on complete information rather than delaying care or supporting patients without the pertinent context. Closing care gaps can not only improve patient outcomes, but can also strengthen payor contracts, raise performance scores and drive financial upside.

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The Bottom Line

Transitions of care are pivotal moments that shape patient outcomes and organizational success. While inherently complex, they also represent major opportunities when supported by the right infrastructure and workflow. 

As the healthcare system continues to evolve, providers and payors must shift from seeing transitions as vulnerabilities to treating them as value drivers.

In our next installments, we’ll explore the transitional care technology landscape and how innovative solutions are helping care teams close critical gaps.