Consider transitional care programs

By Zack Budryk

Transitional care, which involves intensive follow-up with high-risk patients, has been floated as a solution since before the readmissions penalties were even implemented.

For example, beginning in 2008, Community Care of North Carolina launched a transitional care program that cut readmissions among the state's sickest and poorest patients by 20 percent. Eight hundred nurses and social workers conducted follow-ups, sometimes shadowing patients for months to ensure medication adherence. Research found patients receiving transitional care were 20 percent less likely to be readmitted within the subsequent year.

In August of this year, Global Transitional Care, the first third-party transitional-care provider approved by Medicare, took its first patients. The provider gives its patients a month of unlimited face time with a nurse practitioner and a registered nurse after discharge, CEO Rani Khetarpal told FierceHealthcare in an exclusive interview. Transitional care, she added, differs from the home healthcare because it provides clinical oversight and care coordination during the period of greatest patient vulnerability.

"At the end of the day, we are really dealing with what is most impactful for the patient to ensure the patient doesn't go back to the hospital for things that can be cared for as an outpatient," she said. 

Consider transitional care programs