Health Education: The Golden Key to Successful Care Transitions

Healthwise Communications Team

Many patients inadvertently fall through the cracks during care transitions—the point at which someone changes location and environment for the next phase of their treatment or recovery.


This typically doesn’t happen because of incompetence or lack of compassion, but rather because most healthcare organizations simply aren’t set up to effectively provide continuity of care after someone leaves. Often, a lapse in care happens because one care setting thinks another has picked up the ball and run with it.

Supporting patients across care settings is one of the most difficult issues in healthcare—and one of the biggest opportunities to improve outcomes and reduce costs.

Why Do Gaps Occur After Care Transitions?

There are many reasons why a patient might fall off the radar or get conflicting information after transitioning to another setting:

  • Ineffective or insufficient health education. Patients who receive all their education on the day of discharge will struggle to remember it later.
  • Communication breakdowns. Health professionals are overworked, which creates breakdown opportunities between providers and/or caregivers.
  • A lack of timely follow-up in the outpatient setting. A follow-up call or telehealth appointment 24 to 72 hours after discharge is needed to touch base and answer questions.
  • Accountability “dead zones.” Accountability dead zones happen when a patient leaves one clinical entity’s “jurisdiction” and enters another’s, such as a teen transitioning from a pediatrician to an adult provider, or a surgery patient being discharged from the hospital to an assisted living facility.


Health Plans Can Make the Difference

Because health plans are the one constant throughout a member’s journey, payers are perfectly positioned to help coordinate care across every healthcare environment.

Think about it. Care managers and coaches already handle every one of the focus points common across the most-used care transition models.

Reduced Healthcare Costs and Better Outcomes
Improve medication adherence Identify potential problems early Provide written care instructions Educate the patient and their family Focus on patient-centered care Schedule follow-up phone calls Reduce hospital readmissions
Health Education


When all of the “pillars” in these models are strong, everyone gets what they want:

  • Lower costs for health plans
  • Lower readmissions
  • Better outcomes
  • Happier, healthier people


But success can only happen if the health education is conveniently incorporated into the care managers’ existing workflow. This way, coaches have the right content at their fingertips and members receive consistent information.

You’re already perfectly poised to take on care transition—and we can help you make it happen. Stop in for our upcoming webinar on March 18 to see how CareOregon teamed up with Healthwise to improve quality and reduce overutilization of services.