There are multiple descriptions and definitions of transition of care, and a wide variety of models designed to improve the process.

In Part 1 of The Post Hospitalization Conundrum, I noted that research consistently shows that ineffective management of care transitions poses risks to patients. In Part 2, we look at three models and approaches to care management and their outcomes.

Good communication between hospitalists and primary care physicians at the time of discharge is critical to patient safety and to the reduction of risk. Historically, this communication has been “one-way” in the form of a discharge summary. Studies have shown that "[F]ollowing hospital discharges nearly half (49 percent) of hospitalized patients experience at least one medical error in medication continuity, diagnostic workup, or test follow-up."

The CMS Hospital Readmissions Reduction Program (HRRP) was effective for Medicare discharges beginning on October 1, 2012 and reduces payments to IPPS hospitals with excess readmissions.

Good communication between hospitalists and primary care physicians at the time of discharge is critical to patient safety and to the reduction of risk. Historically, this communication has been “one-way” in the form of a discharge summary.