The quality of transitional care is shaping up to be a critical factor in value-based reimbursement. For example, under CMS's readmissions penalty program, one-third of a hospital's HCAHPS score, which comprises 30 percent of its overall value-based purchasing score, rests upon three transitional care questions added to the Experience of Care survey.

As demonstrated by the myriad pilots in this area, many hospital bouncebacks can be avoided and inpatient quality items addressed by good transitional care planning — by making sure that all medications, tests, procedures and education that patients need are in place when they leave a hospital's care and transition to the next setting of care.

33 Metrics for Care Transition Management is HIN's graphic compendium of performance benchmarks in key areas impacting care transitions — from key tasks performed at hospital discharge to the prevalence of home visits in programs to improve medication adherence.

Carefully curated to inspire innovation in transitional care and eliminate cross-system breakdowns, this 50-page resource dives deep into several years of market research to identify key influencers and tactics related to the improvement of care transitions:

• Medication Adherence
• Care Transitions Management
• Reducing Readmissions
• Case Management
• Patient-Centered Medical Home
• Health Coaching

Accompanying each metrics grouping is a relevant best practice or case study from industry thought leaders, as well as a list of most effective tactics, workflows and practices for improving transitions of care from survey respondents, in their own words.

In all, respondents contribute more than 100 ideas to improve the handoff of patients from one site of care to another.

Transitions of care — the movement of patients from one care site to another, such as from hospital to home or hospital to skilled nursing facility — are key opportunities for healthcare organizations to strengthen care coordination and reduce avoidable hospitalizations, particularly among the Medicare population.

As Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation, stated during a recent conference on reducing hospital readmissions: "Every patient needs to have a seamless journey back to their community."

Table of Contents: 33 Metrics for Care Transition Management

• Medication Adherence (MA)
  • Medication Compliance During Transitions of Care
  • Targeted Populations for MA Initiatives
  • Components of MA Programs
  • MA Tools and Technologies
  • Opportunities to Initiate MA
  • Primary Responsibility for MA
  • Top Tools to Improve Medication Adherence
• Reducing Readmissions
  • Considerations for Transitional Care in a Penalty-Based System
  • Targeted Health Conditions
  • Strategies to Prevent Readmissions
  • Hospital Discharge Checklist
  • Tools to Identify 'At-Risk' Individuals
  • Barriers to Reducing Readmission Rates
  • 10 Tools for Reducing Readmissions
• Case Management
  • Case Management in Home Health, SNFs and Care Transitions
  • Populations Targeted for Case Management
  • Conditions Targeted for Case Management
  • Typical Duties of Case Management
  • Identification of Individuals for CM
  • Top Transitional Care Tools from CMs
• Patient-Centered Medical Home
  • Standards in HRHC's Enhanced Care Model
  • Health IT Tools in the Medical Home
  • Patient Engagement and Education Strategies
  • Health Professionals on the Medical Home Team
  • Impact of Medical Home on Operational Metrics
• Health Coaching
  • Integrated Health Coaching Spans Risk Continuum with Health Behavior Change Management
  • Health Risk Levels Included in Coaching
  • Health Areas Addressed by Health Coaching
  • Identification of Individuals for Health Coaching
  • Techniques and Models of Behavior Change
• Care Transition Management
  • Hospital Discharge as 'Tipping Point'
  • Care Transitions Addressed by Program
  • Most Critical Care Transition
  • CT Model for Program
  • Transition Management Program Components
  • Training for Care Transitions Team
  • Frequency of Home Visits
  • Home Visit Checklist
  • Top Strategies for Strengthening Care Transitions

33 Metrics for Care Transition Management is an essential desktop reference for the healthcare professional charged with the movement of patients between care sites and improving the overall patient experience.