Are too many patients today “lost in transition?”
Since 1983 when Medicare launched the prospective payment system (PPS), the average inpatient hospital stay has declined from 10.0 to 4.5 days. During this same period, Medicare discharges to skilled nursing increased four-fold. Health care providers are well aware that patients are being discharged at a higher acuity and with far more significant needs for continuing care. What often is not recognized is how vulnerable patients are during transitions between care settings, especially older adults and those with multiple comorbidities. Poor communication and coordination during care transitions can contribute to adverse events and preventable hospital readmissions. As health care providers and systems are incentivized to manage episodes of care beyond the inpatient stay, hospitals increasingly are under pressure to transform the traditional discharge planning paradigm