Seamless Care: Safe Patient Transitions From Hospital to Home

Abstract

Background: “Seamless care ” is a smooth and safe transition of a patient from the hospital to the home. Our goal was to identify ways to maximize improvement in postdischarge patient outcomes. This research targeted patients at risk for unscheduled readmissions, examined delivery system processes, and identified possible interventions for providing more seamless care. Methods: This pilot study included three phases. In the first phase, we examined selected readmissions using extant administrative databases for fiscal year 2001 at two facilities, a Department of Veterans Affairs (VA) hospital and a private, nonprofit hospital. We identified patient characteristics that were associated with a high risk of unscheduled readmission within 30 days of discharge for three Diagnosis Related Groups (DRGs) (127–Heart Failure, 89–Pneumonia (> 17 years), and 109– Coronary Artery Bypass Graft without catheterization). Survival analyses and other statistical techniques were used. An expert panel focus group provided insights into discharge planning processes. Finally, patients in these DRGs at the