Improve Transition of care

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).

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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).

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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).

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• 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.