Improving care transitions means more than reducing hospital readmissions

Hospital readmissions are not only expensive, avoidable, and dangerous, but are also indicative of the most dysfunctional elements of US health care. The Patient Protection and Affordable Care Act places great emphasis on reducing preventable readmissions by building care systems that are patient-centered and that remove arbitrary silos of care. Hospitals that perform poorly on this measure will experience significant financial penalties beginning this fiscal year. In the short term, decreasing readmission rates will eliminate waste and enhance patient recovery from major illness. However the real vision is to ensure that vulnerable patients, particularly the chronically ill, benefit from coordinated, patient-centered systems that maintain functional independence, improve quality of life, and provide comfort without the trauma, expense, and displacement that unnecessary hospitalization often entails. The commentaries published in this issue of the NCMJ portray some of the most significant barriers to smooth transitions and reducing readmission rates and describe some of the nascent North Carolina and national solutions that demonstrate promise in real world situations.