Health Policy Brief
Transitional care is the coordination and continuity of healthcare by a patient. This happens during movement from one health care setting to another or home. When there is a poorly managed transition on the patient, it results in increased costs and deterioration of health on the patient, leading to negative results. According to previous research, in the United States, around $25 to $45 billion goes into waste because of inadequate care coordination with the patient and poor management during the transitions. This is because people are forced to have other hospital readmissions and complications. However, there have been efforts to develop federal initiatives that will encourage effective health care transitions among patients. There should also be motivations for health care providers to make sure that the changes are safer. The data used in the evidence that informed the policy brief are previous research studies, journals, and articles.
Existing research shows that amongst the major contributors of a low-quality health care system is poor care transitions. According to a report issued by the Institute of Medicine, the healthcare system in the United States is poorly organized and complicated, which makes the patients and their families uncomfortable, while the personnel views the system as wasteful. Patients receive less or no information about how they should manage themselves during transitions, especially when resuming normal activities. The patients lack knowledge of the side effects to look out on and know that one is progressing well. As a result, patients end up feeling unwell again or deteriorating to worse conditions. The Medicare program indicates that most United States beneficiaries end up being readmitted, which costs about $12 billion in a year to cater for the expenses. This leads to a need to come up with preventable measures to improve health care transitions.
The contributing factors that have resulted in the majority of hospital readmissions include poor communication among the health care providers. The health care providers fail to communicate about what is expected of the patient. The health care team in one hospital fails to communicate with outpatient physicians upon discharge of a patient. Also, the health care providers fail to follow up on the patients’ progress, thus easy for the latter to lose track of what is expected.
The medical records might also be a root cause when there are problems in the computer systems. In addition, the payment policies employed by the Medicare group make it difficult for smooth transitioning. For example, Medicare fails to allow hospitals to bill for readmissions within a day of discharge. In some cases, one is forced to pay high rates in some hospitals upon readmissions. Lastly, the medical personnel lacks adequate knowledge and risk management strategies to handle health care transitions.
It is vital to develop strategies in transitional care and management to ensure the quality of life of a patient, save on money and avoid readmissions. In this case, the medical personnel ought to establish and sustain solid interpersonal relationships with the political institutions to ensure the success of the strategies. The medical team must be involved in the policy process and bring deliberations of the health policy issue affecting clinical care and the patient’s wellbeing.
In response to the law, affordable care has several provisions meant to improve transition care and cater to the financial penalties and incentives. The law has made efforts to ensure that hospitals receive increase Medicare payments whenever there are quality care transitions among patients. The health care providers will receive increased payments whenever an improvement is noted. In some cases, Medicare has also made efforts to ensure that costs are reduced for readmission of patients with certain conditions. For the readmission penalties, the hospitals in the United States are also increasing in Medicare payments. The State Medicaid agencies have provided reimbursements on monthly care management payments, which cover costs for transitional health care. The United States law has also authorized paying healthcare providers in the medical homes who manage patients after transitions.
To solve communication and conflict management, hospitals should be tracked on whether they transmit records to physicians. There should be a policy option added in the care transitions, which will ensure quality reports about a patient are handed over to the other health care providers expected to handle the patient during the transition. This will provide better communication between hospitals and physicians According to Timely transmission of transition record, measures on how often a hospital sends a transition record to the to a patients physician has been formed. This type of strategy helps thee physicians know patients who need a follow up care. The Medicare should also increase money to hospitals to cater for the processes required during a transition.
Research, which has shown the pool health care system in terms of providing transitioning care, has been vital. It has played a powerful level both in politics and in policy making. Research has helped come up with policy declarations in nursing and health in general. Research has helped come identify the problem and the factors leading to the poor management and coordination in transitioning care. It has also helped identify the harsh policies for example that the Medicare does not offer payments upon readmission of patients within 24 hours. This is harsh and a disadvantage to majority of the hospitals. This type of research has resulted to decision making where policy makers have come up with a current policy of not paying for Medicare readmissions which occur within 24 hours of a hospital discharge. There should be an increase of days to make it more favorable. It will also be vital for Medicare to emphasize on the readmissions they cater for which should be neutral amongst all hospitals in the United States.
Also, several models for improving the transitions after a patient has been hospitalized are crucial. One is the care transition mode. Through research, then strategies will be put into practice in the healthcare system. The care transition model ensures that the nurses who first handled the patient in the hospital have made a follow up through home visits and also use of phone calls often. Through the model, the coaches in charge are able to manage medications and schedule for follow up care. They are also able to respond to red flags that show the condition may worsen and take charge. In addition, another transitional care model has also emerged whereby there is invention of a health care follow up plan to be used by the coaches and nurses to manage conditions of the students.
Lastly, the policies made to solve the problem must have an aim to make life better for both patients and the medical team. The policy concerning Medicare must contain equal financial penalties and disbursements in all hospitals in the United States. The primary care providers are also expected to conduct their duties during the transition in a professional manner and articulate the values in their practice. Although some policies and health care transition models have proved efficient and have helped save costs, there is still need to research on how best to encourage medical health care providers to use the approaches. The changes to be made in the Affordable Care Act should fill the gaps in the health care system to provide quality and improved transition care.
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