Care transitions programs: a review of hospital-based programs targeted to reduce readmissions

An emphasis on a value-based payment model is expected to provide motivation for developing effective care transitions programs. For such programs to succeed, organizations must adopt an evidence-based, financially feasible model that enables improved coordination with providers, alignment of incentives, and measurement of key performance metrics, both clinical and operational. Evidence of cost-effective care transitions programs is important for deploying successful models broadly.

Hospital-based programs.

Current literature on care transitions programs highlights different strategies, patient populations, settings, and outcomes; however, it lacks sufficient supporting financial evidence that these programs are operationally sustainable and cost-effective within current and projected reimbursement schemes.

Care transitions interventions need to be further studied in different settings with different patient populations to identify the optimal approach(es). An additional opportunity for future investigation lies in translation of interventional programs targeted at readmission diseases in line for penalty by Medicare.