4/06/2017

How Care Coordination Can Help Create High-Quality, Cost-Saving Care Transitions

Healthwise Care Coordination Team

Editor’s Note: In these posts, we’ll explore six steps for developing a care coordination program that increases revenue, cuts costs, and enhances the quality of patient care. Managing care transitions is an urgent need. Nearly 1 out of 5 Medicare patients discharged from a hospital—approximately 2.6 million older adults—are readmitted within 30 days of discharge, at a cost of over $26 billion every year. In this post, we’ll look at five ways to begin managing care transitions.


Nearly 1 out of 5 Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year. It’s a huge cost to everyone involved, and an avoidable detour on a patient’s journey to their best possible health. Patients are particularly vulnerable when transitioning from one level of care to another. When Ben suffered a stroke, he and his wife, Suzie, learned firsthand how complicated it can be to navigate the transitions in care levels.


Ben was in an acute care hospital to recover from the stroke. Then he was admitted to a sub-acute unit where he could get the care he needed to improve enough to go home. Once he was home, he continued with his outpatient rehabilitation. Because there was a solid plan for his goals and transitions, Ben avoided another acute care admission.

Here are a few ways that care coordination teams can influence and improve care transitions so people like Ben can focus on health.

One: Strengthen communication during transitions between clinicians, patients, and family.

Care transitions can be fraught with miscommunication and a lack of information sharing. In fact, researchers have estimated that inadequate care coordination was responsible for $25 billion to $45 billion in wasteful spending in 2011 alone, due to avoidable complications and unnecessary hospital readmissions.

Communication is key for patients in a transition phase. For Ben and Suzie, knowing that someone is there to help them through these transitions is priceless. They can trust that the care coordination team members are all tuned in to the same channel. Ben and Suzie can stay engaged and focused on what to do to get Ben home.

Two: Share information between settings by automating the exchange process with EHRs.

When we automate some of the information exchange, we can reduce errors and miscommunication in the care coordination process.

Errors are expensive. Automating through an EHR reduces errors and keeps patients on the best track to health, which in turn helps keep costs down.

Ben’s team members know how to use the technology they have to streamline management of his case. His provider can communicate with his therapists, pharmacists, and others to ensure that Ben’s getting the care he needs.

Three: Educate patients and caregivers by equipping them with tools to manage their own care.

It didn’t take long for Ben and Suzie to feel overwhelmed by information. The stroke was something they couldn’t plan for. They had to start at the beginning and learn everything they could about Ben’s medical condition.

The care coordination team definitely helped. The team gave Ben and Suzie patient education and health information written in plain language. The team used standardized processes that helped Ben move from one phase of his care to the next, without missing a step.

Four: Facilitate access to care by using telehealth technology.

Access to care is a common sticking point for some patients and their families. Ben and Suzie got a lot out of using telehealth technology. It helped smooth Ben’s transitions by giving him more opportunities to connect with his care coordination team.

Ben and Suzie didn’t have to stay in one place in order to get the best care—they could connect via video chat, text messaging, and phone. Information in Ben’s electronic health record could be updated in real time, communications between people on the team were faster and smoother, and workflows were more efficient. They could access information they needed from anywhere and have peace of mind knowing they were the center of the care team.

Five: Identify the areas in the clinical workflow that need interventions.

Analyze and evaluate the care that patients receive at each setting and where they spend the most time in order to identify obstacles and quality issues in the clinical workflow.

Medicare Transition Care Management (TCM) codes can be billed for interactive contact with patients and family members during the 30 days’ post-acute stay. This includes providing education to the patient, family, guardian, and/or caregiver to support self-management, independent living, and activities of daily living.

For Ben and Suzie, the biggest keys to his successful recovery were staying engaged in the care transition process and continuing to learn as much as they could about Ben’s new health challenges. They are looking forward to many more years together.

Read our eBook, The State of Care Coordination: 6 Illuminating Strategies You Should Know, for more information on best practices in care coordination to facilitate change.

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