Table 1 Transition services program intervention components
Transition services components | Transition recommendations [10] and drivers of readmissions addressed |
|---|---|
Referral to transition services program and introduction by patient navigator while patient is still hospitalized | • Dedicated transition personnel • Spanning inpatient and outpatient • Engagement • Discharge plan confusion |
Comprehensive postdischarge evaluation by internal medicine physician | • Dedicated transition personnel • Spanning inpatient and outpatient • Access • Timely follow-up of items outstanding at discharge • Early identification of change in patient status |
Postdischarge medication reconciliation by a pharmacist | • Dedicated transition personnel • Medication errors, misunderstanding, adherence |
In-home virtual appointments | • Home-based interventions • Integration of IT • Access |
24/7 availability of dedicated paramedicine team for in-home visits | • Home-based interventions • New types of transitional care personnel • Dedicated transition personnel • Access • Coordinated service between home and clinic |
Multidisciplinary team (internal medicine, pharmacist, paramedicine, behavioral health, and care management providers) | • Dedicated transition personnel • Access to comprehensive follow-up services |
Regular care management contact starting with discharge follow-up call and weekly thereafter | • Dedicated transition personnel • Coordinated care • Engagement |
Real-time population health dashboards for clinic staff | • Integration of IT |
Coordinated transition to the next appropriate care location after 30 days | • Spanning inpatient and outpatient • Coordinated care • Intraprovider communication |