Care Transitions F.A.Qs

Q: What does the term “care transitions” mean?

A: “The term care transitions refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, a patient might receive care from a Primary Care Provider (PCP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse.  Each of these shifts from care providers and settings is defined as a care transition.”[i]


Q: What is the average cost to Medicare per preventable readmission?

A: The Medicare Payment Advisory Commission estimates that up to 76% of hospital readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200.


Q: How will new health regulations impact hospital readmissions?

A: The penalties imposed for preventable readmissions should incent hospitals to improve the quality of care patients receive and reduce costs to Medicare.


Q: Should all hospital readmissions be prevented?

A: No, not all readmissions are preventable. If the cause for the readmission is not tied to the original admission then a patient should not be prevented from returning to the hospital. It may also be necessary to readmit a patient even if the cause is tied to the original cause for admission. The objective for reducing preventable readmission is to increase the patient’s well being while also reducing the hospital’s cost but one should not occur at the expense of the other.


Q: What are the critical timeframes associated with reducing readmission rates?

A: According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[iii]  This 30 day timeframe is the period on which most care transitions programs are focusing their efforts; however, the first 72 hours after a patient is discharged from the hospital is especially critical as this is when seniors are typically most frail and overwhelmed. 


Q: What are some of the problems associated with poor transitions between settings?

A: The following are some of the outcomes associated with poor transition management:


Q: How can Right at Home services help improve transitions of care to effectively reduce the number of preventable readmission rates?

A: Right at Home caregivers may be able to assist patients at home in the following ways:

[i] The Care Transition Program:


[iii] Department of Health and Human Services Press Release

[iv] The Care Transition Program:

We started working with Right at Home about a month ago to provide services for my mother who has Alzheimer's and to provide support to my father (her primary caregiver) six days a week. So far we have had an excellent experience. The caregivers are supportive, caring people and have given my Dad a much deserved break as well as providing knowledgeable care for my Mom. I have also been impressed with the structures and processes put in place to insure that we get consistent, reliable care. Our relationship with Right at Home is still new but we couldn't be happier.