By John Torontow, Medical Advisor, Zus Health
LinkedIn: John Torontow
LinkedIn: Zus Health
It’s time to exhale.
After emergency surgery and a brief hospital stay, a patient battling deep vein thrombosis that sent a blood clot to his lungs is finally on the mend. Everything went as planned, the pulmonologist is pleased, the vitals are where they need to be, the family is relieved, and the discharge is scheduled for a few days out.
But the real risk is just beginning. From medications to follow-up appointments to therapy demands, there are any number of vulnerabilities that could land him right back in a hospital bed. Every clinical decision can be correct. And this patient can still be readmitted.
It’s a dangerous time for not only the patient, but also for the clinician. Without real-time visibility into the transition of care, potential issues come to light too late for any real meaningful follow-up.
But transition of care isn’t just one of healthcare’s most overlooked operational gaps. It’s also one of the biggest opportunities in value-based care.
Why? Because when receiving care teams have the right data at the right time, they can intervene before small problems become readmissions and dramatically improve patient outcomes. Here’s how to flip that switch.
Why Transitions of Care Create the Perfect Conditions for Readmissions
No matter how many times I see some variation of the above example play out, I’m still amazed by it. For all the serious medical peril patients may face as they come through the hospital doors, they’re actually at their most vulnerable when responsibility shifts between care teams.
On the patient side, discharge can be a chaotic time. Patients often leave the hospital overwhelmed by all of the information they’ve been given – and therefore without a full understanding of their discharge instructions. This can lead to common issues like medication confusion, which is surprisingly not one of the leading drivers of preventable readmissions.
On the clinician side, meanwhile, receiving providers frequently begin follow-up without a complete clinical picture, their efforts plagued by frequently missing or delayed critical information, including…
- Discharge summaries
- Medication lists
- Pending labs and imaging
- Outstanding referrals
- Hospital course and treatment decisions
In most cases, this information exists, but it’s scattered across hospital portals, ADT notifications, EHRs, and paper records. That means care teams spend valuable time hunting for information instead of caring for patients.
Right-time Data Transforms Transitions From Reactive to Proactive
These days, I don’t hear many clinicians asking for more patient data. What they need is usually out there. But their ability to deliver better patient outcomes depends on faster, more unified access to all of that information.
For example, today’s common transition workflow probably looks something like this:
- The patient is discharged.
- A care team receives the ADT notification (maybe).
- Staff manually investigate hospitalization.
- A follow-up is scheduled after significant delays.
Compare that with a more optimized transition that provides clinicians with:
- Visibility into hospital admissions as they occur.
- Early access to discharge summaries and medication lists.
- One consolidated view instead of multiple hospital portals.
The first 48 to 72 hours after discharge are a critical intervention window, so which of the above two scenarios is more likely to result in a successful transition of care?
A safer patient experience isn’t the only upside here. For hospitals and other healthcare providers, the potential operational benefits of a more orderly transition include:
- Reduced administrative burden.
- Better coordination between hospital and primary care.
- Faster medication reconciliation.
- Improved patient engagement.
Of course, even perfect information won’t ensure a smooth transition if organizations can’t determine which patients need immediate attention.
The Future of Transitions is Predictive Care Management
Part of the problem with today’s system is a continued reliance on retrospective care management.
Most healthcare organizations simply don’t have the staff or the capacity to provide intensive follow-up for every discharged patient. What clinicians need is a system of risk stratification that can easily and reliably identify who needs intervention first and which type of intervention is most appropriate.
Uncovering this key information and moving beyond retrospective reporting means embracing predictive approaches such as readmission risk scoring. A LACE score, for example, calculates a patient’s risk for readmission based on length of stay, acuity of admission, comorbidities, and emergency department visits in the six months prior. That type of insight can help:
- Care managers prioritize outreach.
- Pharmacists focus on medication-related risks.
- Care teams intervene before complications develop.
In other words, it can help value-based care organizations better direct their limited clinical resources to where they’ll produce the greatest impact.
Transitions of Care Is The Next Frontier in Digital Health
The scenario I laid out at the start of this piece is all too common in healthcare today. A patient survives the seemingly most dangerous period of a medical emergency, only to fall victim to a readmission down the line that puts them right back in harm’s way.
Why? Because despite huge advances in digital health, transitions of care remain one of healthcare’s weakest and most stubborn operational links. Too many providers are still documenting what happened instead of equipping receiving care teams with complete, actionable information at the moment they need it.
But it doesn’t have to stay this way. By combining timely data, coordinated workflows, and predictive prioritization, value-based care organizations can reduce readmissions to improve both patient outcomes and their own operations.
It’s how better patient data can lead to better performance under risk. And it’s how the most dangerous moment in healthcare becomes an exciting new opportunity.