How to Optimize Patient Care Transitions through Whole Person Care

Article Summary

Whole person care during care transitions is an innovative strategy to reduce hospital readmissions and improve care affordability. A robust analytics platform can stratify high-risk patients and provide the data needed for action-driven improvements in care delivery and quality outcomes.

male patient talking with doctor

This article is based on a healthcare conference presentation by Emily Downing, MD, System Clinical Officer, Allina Health, titled, “Innovative Approach to Care Transitions: An Evolution of Whole Person Care” at the 2022 Healthcare Analytics Summit.

Robust data insights create opportunities for healthcare organizations to care for their patients in innovative ways while containing unplanned costs in care delivery. Whole person care looks beyond a single issue or diagnosis to recognize that all factors of a patient’s health- mind, body, spirit, and community- are connected. Healthcare organizations launch a whole person care initiative to incorporate enhanced care transitions and data strategies for reducing hospital readmissions, a common and costly scenario where patients return to the hospital within 30 days of their discharge.

A whole person care strategy integrates a patient’s stakeholders post-discharge who combine efforts for individualized care and higher quality, patient experience, safety, and access. Whole person care can improve affordability by retaining patients within the healthcare system and shift payment models from fee-for service (FFS) to pay-for-performance (P4P). Payer contracts are likely to incentivize for improved care transitions, and that makes launching a whole person care strategy now a critical step in long-term financial viability.

Incorporate Community Needs in Whole Person Care

There are many strategies a health system can incorporate into patient care transitions to support whole person care. For preventative care, conducting comprehensive assessments such as disease screening and diagnosis can uncover potential health issues. Chronic conditions can be addressed by delivering consistent, evidence-based, and longitudinal chronic disease management. A healthcare provider may offer universal screening and navigation to address a patient’s health-related social needs. Healthcare organizations focusing on health equity as a system objective should expand mental health and addiction services for all patients and employees, which reinforces a commitment to healthier communities. Care transitions are most effective through reliable, coordinated care transition support throughout the healthcare system so that high-value and accessible care is available for the whole population.

Improve Patient Outcomes through Coordinated Care Transitions

Reduce, align, and provide are guiding principles for improving patient outcomes. Healthcare organizations that adopt this structured approach with established goals realize the importance of caring for the whole person and will accelerate their care transition improvement results.


Reduce acute care crises for chronic disease exacerbations so patients can experience more days at home, increase convenient access to care, and achieve optimal disease management. Goals may include reducing emergency department (ED) visits, inpatient (IP) hospitalizations, and skilled nursing facility (SNF) stays.


Consistently align care with evidence-based best practice and patient’s goals to ensure patients receive appropriate screenings, shared decision making, and care aligned with their preferences. Reducing preventable surgical procedures, eliminating unhelpful imaging studies, and reducing the reliance on polypharmacy become achievable goals.


Provide care at affordable sites resulting in less out-of-pocket expenses. Examples of targeted sites of affordable care to consider are home-based primary care, home-based hospital care, ambulatory surgery centers, and urgent care.

Incorporate an Analytics Framework into Care Transition Pathways

Continuum-based care transitions improvement tactics that match the right level of care upon discharge will improve clinical outcomes and reduce costs. When action is derived from accurate patient analytics insight, whole person care is a measurable strategy to reduce readmissions, inpatient mortality, and unwarranted care utilization. Adopting a sophisticated analytics framework will guide the care team to effectively identify care transitions improvement opportunities. In addition, whole person care that is supported by analytics:

  • Matches patient needs with services
  • Standardizes care pathways
  • Reduces unnecessary utilization
  • Addresses equitable healthcare delivery

Leverage Analytics to Effectively Identify Care Transition Improvement Opportunities

Healthcare providers must move past previous siloed performance improvement for measures and sites of care to an integrated approach of care transition measures across a connected continuum. An integrated approach intertwines readmissions, inpatient mortality, and length of stay (LOS) to provide a reliable and effortless post-discharge transition that matches the right level of care for patients and clinicians.

When considering care transitions performance measures, here are three leading performance indicators with types of data in an analytics platform, such as the Health Catalyst Data Platform, for reducing unwarranted care utilization.

  1. Readmission
    • 30-day all-cause
    • 30-day potentially preventable readmissions
    • 60-day return to hospital
  2. Inpatient Mortality
    • Actual to expected (A/E) ratio
    • All hospitalized patients over age 65
    • Excludes hospice patients
    • Expected risk predicted by APR-DRG mortality risk model
  3. Hospital LOS
    • Geometric mean length of stay (GMLOS)
    • Medicare Severity Diagnosis Related Groups (MS-DRG) driven%
    • GMLOS articulated as LOS actual to expected ratio
    • Focus on optimizing LOS for disease-specific populations

An integrated platform across the care continuum unifies teams and action plans to improve care transition performance measures. For example, measuring readmissions across the entire healthcare system versus a single hospital is possible when sophisticated analytics can break down the siloed data reporting for a global view in whole person care.

Population assessments align with performance measures, enabling further action through data and analytics. Understanding the patient population will uncover opportunities to identify targeted patients, communicate measure connectivity, and leverage performance reporting for results tracking. Population assessment examples include:

  • Discharge disposition. Analytics can be used to identify improvement opportunities for those patients readmitting and discharging to home with self care, discharges to home health, and discharges to SNF.
  • Serious illness population. Diagnosis factors, patient-specific factors, and utilization factors can be combined to establish a serious illness category score. This score can then be assessed through analytics to identify patients most at-risk, or with a maximum score in mortality rates with serious illness score category reports.
  • Race, ethnicity, and language evaluation. Health equity opportunities can be identified using mortality analysis from population assessments for potentially preventable readmissions and actual/expected (A/E) rates by race category.

Structure Performance Improvement Teams and Tactics for Better Engagement

A performance improvement infrastructure that is designed to provide whole-system support at discharge will produce meaningful, coordinated care transitions and better clinical outcomes. There are several types of organizational committees and support that feed into a care transitions value team:

  • A transitions measurement team
  • Serious illness care program committee
  • Steering committee for inpatient (IP) mortality review
  • Ecosystem-based care transitions committee

Tactics for performance improvement will be most effective if they are population-focused with a defined approach. The ability to measure outcomes and communicate the effort across the performance improvement team makes the tactical effort coordinated and in-sync for optimal results. Patient populations can be stratified and targeted in the following ways.  

Standardized Discharge Huddles

Patients with serious illness and those discharged to home with self care to community support programs could be assessed by an interdisciplinary team meeting for discussion regarding their discharge disposition, barriers, transportation, serious illness, and other transition care planning needs.

Serious Illness Care Program

This program could be for patients categorized as diagnosed with a serious illness, like heart failure. Serious illness conversations led by providers and program referrals to support services will transition patients to the appropriate care setting with kindness and compassion.

Home Hospital Care

Patients included in home hospital care focus could be identified as those with COVID-19, sepsis, heart failure, and patients who are post-procedural. Patients in this population may benefit from in-home community paramedic and nursing visits, virtual provider visits, biometric monitoring with 24/7 oversight, nurse triage, and in-home lab and imaging.

Primary Care Transition Support

In this type of support, healthcare organizations can target specific discharged patient populations and those more at-risk based on their ethnicity. Goals could include assigning a registered nurse transition call within 48 hours of discharge. In addition, the patient may need to establish a primary care visit within seven days of discharge supported by standard discharge communication.

Data tools that healthcare providers can utilize for performance improvement include communication reports, key metrics and trends from analytics reporting, and driver measure reports. Aligning performance improvement data with performance improvement teams will produce maximum effort and results.

Implement Success Strategies for Whole Person Care During Care Transitions

A whole person care strategy has countless benefits for patients, providers, and the entire health ecosystem. Beyond clinical advantages, healthcare providers are turning to whole person care to align financial incentives across successful community-wide partners who work together to reduce costly hospital readmissions. Establishing the framework to leverage data and analytics for risk-stratification, identify outcomes improvement opportunities, and implement a coordinated care transition strategy connects patients to the right support at discharge for meaningful guidance.

To effectively launch a whole person care strategy, the following are must-have components for optimizing care transitions and reducing care costs.

  • Organizational alignment and unified leadership
  • A robust data and analytics platform
  • Effective engagement and patient focus
  • Adequate access to care for patients and employees

Additional Reading

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