The Affordable Care Act (ACA) and subsequently the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), through the Hospital Value-Based Purchasing Program (VBP), reward acute care hospitals for quality outcomes and cost efficiency through the hospitals’ Total Performance Scores (TPS) based on Clinical Outcomes, Person and Community Engagement, Safety, Efficiency and Cost Reduction. Transitional Care effectiveness is becoming critical for hospitals and value-based care organizations as a means of providing quality, safe, and cost-effective patient care to address the TPS challenges. Readmissions to hospitals can be costly and undesirable, with negative implications for both major payers and the public. Hospitals participating in the Inpatient Prospective Payment System (IPPS) and bundle-payer systems are publicly accountable for their costs and outcomes. Furthermore, value-based care organizations that utilize risk-based payment systems are significantly impacted by high readmission rates, motivating them to invest in robust post-acute care initiatives.
High-risk patient populations and complex medical cases are often associated with increased readmission rates and poor outcomes, necessitating timely intervention to reduce the need for costly inpatient services. However, even patients with lower complexity can be affected by adverse events, such as medication errors and poor adherence to medical regimens, which can contribute to preventable readmissions. Communication breakdowns, information lapses, and unintended consequences frequently contribute to misperception and decrease shared decision-making by patients and families, medication nonadherence, decreased disease management, limited follow-up on test results or treatment plans, and missed post-discharge follow-up visits. Addressing these factors can significantly reduce the likelihood of preventable readmissions or emergency department return visits while increasing post-hospitalization access to outpatient primary care. We developed and implemented a multifaceted approach to evaluating patient needs and delivering transitional care, considering patient needs, risk stratification, referral providers, institutional processes, major internal stakeholders, transitional care to primary care providers (PCPs), care coordination, data analysis, and financial considerations. The Post-Discharge Clinic functions as a dedicated transitional innovation for individuals who have received care within the UChicago Medicine Healthcare System.

Our research aims to understand patient perceptions of care, knowledge and drivers of their own care, root analysis of medication adherence, and factors that drive patient experience while decreasing the rate of readmissions, return visits, and length of stay that impact quality and cost-effectiveness. There is no more opportune time to motivate inquiry and curiosity for transitional care than during the early years of medical education. Our Pre-Med Transitional Care program recruits these future medical students not only to immerse in research activities but to discover and acquire knowledge of basic medical education.

Gilmer Rodriguez, MD, MPH, MMM, FACP, FAAPL, CPE

Director, Post-Discharge Clinic and Transitional Programs