1. Powell, Suzanne K. RN, MBA, CCM, CPHQ

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I can't believe it! I have not had "themed issue" since January 2003, my first issue as Editor-in-Chief. Long overdue, the May/June 2011 issue of Professional Case Management does have a theme: Hospital Case Management. The title of this editorial may seem a bit misleading, but it is not. As you read the articles in this issue, you may come to realize that case managers in all levels of care are in this together: the quality of patient care, the communication through the continuum, the regulations, and the future of healthcare. And as Dr. Jencks stated in a recent editorial, "Rehospitalization may be better viewed as a healthcare system problem than a hospital problem, because care fragmentation is a property of the whole system" (Jencks, 2010, p. 757).


It is a common fact that avoidable readmissions to the hospital are quite an expense. In the landmark 2009 study, almost 20% of Medicare beneficiaries who were discharged from hospitals were readmitted within 30 days. Of the medical discharges/readmissions, there was no bill for a follow-up visit to a physician in over half of the cases; of the surgical discharges/ readmissions, more than 70% were readmitted for a medical condition. And by the way, more than one third of Medicare beneficiaries who were discharged from hospitals were readmitted within 90 days. Translated into 2004 dollars, Medicare unplanned admissions cost $17.4 billion (Jencks, Williams, & Coleman, 2009). Not surprisingly, the estimated cost of avoidable rehospitalizations within 30 days of discharge has soared to a massive waste of $44 billion (Jencks, 2010).


In the early years, we tried to blame poor hospital care given at the index hospitalization as the reason for rehospitalizations. Medicare Peer Review Organizations, the earlier forerunners of Quality Improvement Organizations (QIO), were tasked with reviewing the medical records of these index admissions. The process did not provide constructive information that could be translated into sound interventions for improvement. Later studies demonstrated that "rehospitalization" was an unreliable metric for poor quality in the inpatient setting.


So what are the critical elements that may change the trajectory of unnecessary hospitalizations? Current demonstration projects have gleaned important information. This journal has had the privilege of highlighting some of the most successful processes, authored by their developers. Large institutions such as the Centers for Medicare & Medicaid Services and the Institute for Healthcare Improvement have supported some of the most fruitful. And most recently, Health Services Advisory Group, Inc., the Quality Improvement Organization for Arizona, and the National Transitions of Care Coalition (NTOCC), chaired and coordinated by the Case Management Society of America (CMSA) in partnership with sanofi-aventis, U.S., compiled a set of essential categories for successful care transitions. Titled, "Care Transitions Bundle: Seven Essential Intervention Categories," hundreds of articles were thoroughly examined for the most relevant categories leading to successful transitions. Although the full document can be found at, the seven essentials are summarized below.


1. Medications Management: Ensuring the safe use of medications by patients and their families and based on patients' plans of care:


Assessment of patient's medications intake


Patient and family education and counseling about medications


Development and implementation of a plan for medications management as part of the patient's overall plan of care.


2. Transition Planning: A formal process that facilitates the safe transition of patients from one level of care to another including home or from one practitioner to another:


Clearly identified practitioner (or team dependent on setting) to facilitate and coordinate the patient's transition plan


Management of patient's and family's transition needs


Use of formal transition planning tools


Completion of a transition summary


3. Patient and Family Engagement/Education: Education and counseling of patients and families to enhance their active participation in their own care including informed decision making:


Patients and families/caregivers are knowledgeable about condition and plan of care


Patient- and family-centered transition communication


Developing self-care management skills


4. Information Transfer: Sharing of important care information among patient, family, caregiver, and health care providers in a timely and effective manner:


Implementation of clearly defined communication models


Use of formal communication tools


Clearly identified practitioner to facilitate timely transfer of important information


5. Follow-up Care: Facilitating the safe transition of patients from one level of care or provider to another through effective follow-up care activities:


Patients and families timely access to key healthcare providers after an episode of care as required by patient's condition and needs


Communicating with patients and/or families and other health care providers posttransition from an episode of care


6. Healthcare Provider Engagement: Demonstrating ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times:


Clearly identified patient's personal physician (primary care provider)


Use of nationally recognized practice guidelines (evidence-based guidelines)


Hub of case management activities


Patient and family education and counseling activities


Open and timely communication among health care providers, patients, and families


7. Shared Accountability Across Providers and Organizations: Enhancing the transition of care process through accountability for care of the patient by both the health care provider (or organization) transitioning the patient and the one receiving the patient:


Clear and timely communication of the patient's plan of care


Ensuring that a health care provider is responsible for the care of the patient at all times


Assuming responsibility for the outcomes of the care transition process by both the provider (or organization) sending and the one receiving the patient



As we have said before, some things are simple-but they are not easy. Whenever the number of details involved is as complex as what is described in the "care transition bundle," there is an opportunity for important pieces to fall between the cracks. Establishing standardized discharge processes and using checklists that, at a minimum, address the "essential seven," will likely impact avoidable readmissions more than retrospectively reviewing medical records for poor care in the index hospitalization ever could. It is our time to shine and change these statistics! We have the knowledge, experience, energy, and passion. We can do this!




Jencks S. F. (2010). Defragmenting care. Annals of Internal Medicine, 153(11), 757-758. [Context Link]


Jencks S. F., Williams M. V., Coleman E. A (2009). Rehospitalization among patients in the Medicare fee-for-service program. 314(14), 1418-1428. [Context Link]



* National Transitions of Care Coalition at


* Institute for Healthcare Improvement (IHI) at


* The Colorado Foundation for Medical Care at


* Society of Hospital Medicine's Project BOOST at


* Care Transitions Intervention (CTI) under the leadership of Eric Coleman, MD at


* PCM Journal's web site (use the search engine for care transitions, readmissions) at