"Transitional care has emerged as a huge, evidence-based approach to aligning care teams with the needs and goals of patients," Naylor says. "We have an opportunity to have people's needs met in their home rather than in a more intensive setting."
The transitional care model that Naylor helped develop at UPenn has 10 essential elements, featuring highly skilled transitional care nurses who help guide patients through an entire acute episode of care, from hospital admission to home care. Other elements of UPenn's transitional care model include in-hospital assessments and evidence-based plans of care, TCNs conducting regular home visits, engagement of patients and family caregivers, and a holistic approach to patient care that not only addresses the acute care episode but also other factors impacting a patient's health such as home safety and medication management.
"Medicare pays for 30 days of clinical transitional care postdischarge from a hospital or skilled nursing facility," says Rani Khetarpal, CEO of Global Transitional Care, a Newport Beach, California–based third-party specialty group provider organization dedicated to providing comprehensive transitional care. "We know what the needs are. We know the situation at home. And we can talk about all of that with the patient and all of the members of the patient's care team. It provides for a seamless transition from the hospital or the SNF to the home."
The organization is only working with California patients this year, but it has applied to CMS for the ability to operate in all 50 states.
"As a provider, we now have the ability to make decisions on behalf of the patient. However, we prefer to collaborate with the patient's physician care team on any medical decisions," Khetarpal says. "Patients can self-refer to our care. We do not require a physician's order to provide services. Our focus is the patient. We are independent. That's the beauty of being a third-party provider."
GTC's third-party status distinguishes the organization from AHN and other health systems that are offering transitional care services, she says. "Health systems with transitional care are only managing their own patients. However, the capacity to provide transitional care to all their patients is somewhat limited due to the lack of necessary resources. But I don't want to disparage any healthcare provider that is offering transitional care. Any transitional care program is fantastic. There are so many patients who need this service. We cannot serve all of them."
Naylor says she is pleased with the rise of transitional care and the decline of silo-based approaches to healthcare service delivery, particularly for older patients.
"It is tremendously exciting," she says. "We cannot ignore that major drivers in this change are the patients and their family caregivers. They have been watching. They are saying, 'This cannot be the way we treat our most treasured citizens.' "
Christopher Cheney is the senior clinical care editor at HealthLeaders.