Older adults who receive direct support for up to 90 days after a care transition have lower odds of hospital readmission and better medication continuity, according to a new meta-analysis. The most effective support is medication reconciliation, telephone follow-up and patient education that led to self-management activities, reported investigators from the University of Bradford, United Kingdom. The longer the transition care intervention and the more components it had, the better the outcomes, they found.

  • Shifting care between healthcare facilities or to the patient and their family or caregivers is difficult, especially for those managing complex health conditions and multiple medications.
  • One study estimates that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.
  • Nearly half of all American adults have difficulty understanding and acting upon health information.
  • People affected by multiple chronic conditions are at risk of early mortality, poor functional status, and hospitalization. They also face significant out-of-pocket expenses for healthcare and prescription drugs.
  • Continual communication among the patient, their providers and their caregivers ensure individual medical needs, health status, and personal values are addressed, especially during care transitions. Promoting shared decision-making methods, discharge protocols and risk assessments would ensure patient safety and improve the overall patient experience.

Source: McKnight’s Long-Term Care News 

Visit the Great Plains QIN Quality of Care Transitions and Medication Management pages of our Web site for tools and resources.