Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:
- Start discharge at the time of admission.
- Ensure medication education, access, reconciliation, and adherence.
- Arrange follow-up appointments.
- Arrange home healthcare.
- Have patients teach back the transitional care plan.