Care Transitions FAQs

Q: What does the term “care transitions” mean?

A: “The term care transitions refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, a patient might receive care from a Primary Care Provider (PCP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse.  Each of these shifts from care providers and settings is defined as a care transition.”[i]


Q: What is the average cost to Medicare per preventable readmission?

A: The Medicare Payment Advisory Commission estimates that up to 76% of hospital readmissions may be preventable and the average cost to Medicare per preventable readmission is $7,200.


Q: Why are hospitals interested in care transitions programs?

A: Impending cuts to Medicare spending will likely motivate hospitals to seek solutions within for reducing readmission rate since those rates will start to impact the Medicare payments they receive. 


Q: How will new health regulations impact hospital readmissions?

A: While health reform is still very new, experts have speculated that they will impact hospital readmissions in the following ways; “in 2012 the Department of Health and Human Services (HHS) will publish each hospital's readmission track record and Medicare will stop paying hospitals for preventable readmissions tied to health conditions such as heart failure or pneumonia. In 2014, HHS will expand that policy to cover four additional health conditions.”[ii]


Q: Should all hospital readmissions be prevented?

A:  No, not all readmissions are preventable.  If the cause for the readmission is not tied to the original admission then a patient should not be prevented from returning to the hospital.  It may also be necessary to readmit a patient even if the cause is tied to the original cause for admission. The objective for reducing preventable readmission is to increase the patient’s well being while also reducing the hospital’s cost but one should not occur at the expense of the other.

Q: What are the critical timeframes associated with reducing readmission rates?

A: According to the Department of Health and Human Services, “one in five patients who leave the hospital will be readmitted within 30 days”.[iii]  This 30 day timeframe is the period on which most care transitions programs are focusing their efforts; however, the first 72 hours after a patient is discharged from the hospital is especially critical as this is when seniors are typically most frail and overwhelmed. 


Q: What are some of the problems associated with poor transitions between settings?

A:  The following are some of the outcomes associated with poor transition management:


Q: How can Right at Home services help improve transitions of care to effectively reduce the number of preventable readmission rates?

A: Right at Home caregivers may be able to assist patients at home in the following ways:

 Q: Who pays for care transitions programs?

A:  Some hospitals may have access to alternative funding sources like foundations, grants or government funded studies.  Some hospitals may also be willing to appropriate funds for such a program because by creating these programs they will save them money in the long run.  Still other hospitals using certain intervention or care transitions models are compatible with both Medicare Advantage and traditional Medicare fee-for-service payment systems.  In this instance, the hospital likely pays for the program upfront and then is later reimbursed based on the success of their program. [iv] Hospitals may use some combination of all three funding options.  If hospitals are not willing to pay for the program themselves, they may encourage patients to pay for and use the services through another care provider (like Right at Home).


[i] The Care Transition Program:


[iii] Department of Health and Human Services Press Release

[iv] The Care Transition Program:

I would recommend Right at Home to anyone looking for a home health aide. They were very professional and each person who helped along the way - from the owners to the nurse in charge of our care to the home health aides themselves, were kind and caring. My father was well-cared for each day.

Suzi C.