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Improve Transition of care

Nearly 20% of patients are hospitalized again within 30 days, preventing these events is a priority for healthcare organizations


Being discharged from the hospital can be bad for your health. Nearly one in five adult patients experience an adverse event within three weeks of leaving the hospital, and roughly 20% of Medicare patients discharged from a hospital—approximately 2.6 million older adults—are rehospitalized within 30 days, at a cost of over $26 billion every year (1,2).

Managing “transitions of care”—when a patient moves from one care setting to another as their condition and needs change—is the key to avoiding many of these adverse events. Adverse drug events are a common driver of negative outcomes; studies have shown nearly one in three discharges had medication discrepancies, with 51% having the potential for serious harm.³ In reality, multiple modifiable factors contribute to readmissions, including poor medication reconciliation, hospital-acquired infections, post-procedural complications, provider discontinuity, inaccurately assessing patients' abilities to care for themselves, and failing to enlist the necessary resources (3,4).

Size of the Problem

  • $58.6 billion was the total Medicare FFS spending in 2018 on post-acute care services (9).
  • 32% of patients in a clinical study of medication reconciliation were discharged with at least one medication-related error (10).
  • More than 50% of adverse events due to insufficient transitional care following discharge are drug related (11).

Why it matters

With nearly 20% of Medicare patients being rehospitalized within 30 days, preventing these events is a priority for healthcare organizations (HCOs). As HCOs pursue new solutions, experts are keen to point out that patients are readmitted for reasons that vary on a case-by-case basis and stress that interventions must be carefully tailored to each patient’s individual circumstances (5).


AI can help HCOs improve care transitions by identifying patients at risk for post-discharge adverse events before they are discharged. Armed with this insight, organizations can implement individually-targeted interventions to improve health outcomes. Patient-centered interventions that prioritize engagement, patient self-care education, and persistent caregiver relationships can cut hospital readmissions following discharge by more than 30% (6,7). Additionally, comprehensive transitional care programs that include home follow-up visits have the potential to reduce average hospital costs by up to $14,150 per episode of care (8).


  • Medical Claims: Data extracted from health insurance medical claims with details about dates and place of service, diagnosis codes, key procedures, use of medical equipment, and provider specialties.
  • ADT Records: Data from Admit, Discharge, and Transfer feeds and patient data notification services that synchronize patient demographic, diagnostic, and visit information across healthcare systems.
  • Health Risk Assessments: Self-reported data from health questionnaires that assess a person’s individual medical history, health risks, lifestyle, health behaviors, and quality of life.


  1. Misky, Gregory J., et al. “Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up"" Journal of Hospital Medicine, vol. 7, no. 5, Sep. 2010, pp: 392-397.¡hm.666.
  2. “Community-based Care Transitions Program.” Centers for Medicare and Medicaid Services. https://innovation.ems.gow/innovation-models/cctp. Accessed on 12/09/2020.
  3. Kreckman, John et al. “Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team.” BMJ open quality vol. 7, no. 2, Apr. 2018. DOli: 10.1136/bmjog-2017-000281.
  4. “Hot Topics in Health Care - Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care.” The Joint Commission, vol. 8, 2012. Accessed 12/09/2020.
  5. “Readmissions and Adverse Events after Discharge”” Agency for Healthcare Research and Quality, 7 Sept. 2019, Accessed 22 Mar. 2021.
  6. Burton, Rachel. “Improving Care Transitions: Better coordination of patient transfers among care sites and the community could save money and improve the quality of care.” Health Affairs—Health Policy Brief, Sep. 2012. doi: 10:1377/hpb20120913.327236.
  7. Labson, Margherita C. “Innovative and successful approaches to improving care transitions from hospital to home" vol. 33, no. 2, Feb. 2015, pp: 88-95. doi:10.1097/NHH.0000000000000182.
  8. Sezgin, Duygu et al. “The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review” European geriatric medicine vol. 11, no. 6, Aug. 2020, pp: 961-974. doi:10.1007/541999-020-00365-4.
  9. “Report to the Congress: Medicare Payment Policy” Medicare Payment Advisory Commission, Mar. 2020. Accessed on 12/8/2020.
  10. Belda-Rustarazo, S et al. “Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors” International journal of clinical practice vol. 69, no. 11, Jul. 2015, pp: 1268-74. doi:10111/ijep.12701.
  11. Farhat, Nada M., et al. “Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates.” The American Journal of Managed Care, vol. 25, no. 7, Jul. 2019. Accessed on 12/09/2020.

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