Thinking Seriously About Readmissions—and Care Transitions

But the bottom line is that there’s no magic bullet or magic combination of things to do, so the hospital is left trying to figure out what magical things to do for each patient. So you have to organize programs that try to address the various risks, whether it’s the typical risks for a fragile COPD patient, the typical risks of someone going home to poor supports, the typical risks involved if someone doesn’t have a primary care provider with whom to arrange follow-up care. So it really is individualized, and it’s a very complicated problem without a magic bullet-type solution. So that says to me that you have to customize your solutions.

Obviously, you need to have a really strong IT foundation for this.

Yes, and what I talk about on page 9, and I italicize the things that meaningful use does, I try to talk about it at a fairly high level, on page 9.

I think the opening statement in that section says it well: “Tracking patients will be essential to ensuring planned post-discharge care and support actually occurs in time to address gaps. This will only be possible with the assistance of health IT to accomplish communication and close loops.”

Thank you.