Transition to where?

People with chronic disease bear the full brunt of the medical system’s fragmented care. This balkanization is encouraged by the way health-care providers are paid. Usually, no one is paid to manage a patient’s overall condition. Providers are paid for procedures, visits and dispensing prescriptions. There is no direct relationship between how much physicians earn and whether the patient improves. Chronic-disease patients see health-care providers in a number of unrelated venues, many of which do not communicate with each other.

Transitional care, which patients receive after discharge from a hospital or other health-care facility, occurs during an especially vulnerable period. Patients often do not understand the purpose of their medications or receive a detailed care plan. These oversights are especially critical in chronic-disease care because the conditions are managed largely by patients and their caregivers. As a result, nearly 1 in 6 is readmitted to the hospital within 30 days of having left a health-care facility. Hospitals are paid when again the patient is readmitted.

About 1 in 7 does not make a follow-up doctor appointment within four weeks of discharge. Patients’ physicians often are not informed about the details of the care provided in the hospital. About 1 in 5 chronic-disease patients say their physicians did not do a good job of communicating about their care.

Nearly 1 out of 4 was a victim of a medical error, and nearly two-thirds of those errors created a major problem.

Cheri Lattimer, executive director of the Case Management Society of America, does not like the term “discharge,” referring to when a patient leaves the hospital.

Hospitals should call their discharge paperwork a “transitions summary,” implying that it is a proactive care plan for the patient and provider.

“That summary must be sent to the next level,” Lattimer said. “The Joint Commission says 39 percent of documentation does not get sent to the next level. Transitions of care are not just from hospitals. It is an ongoing process. They say health care is a team sport, but we don’t know who’s on the team or who to throw the ball to.”

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