This investigation had three specific aims: (1) to describe the patterns and prevalence of care transitions among a sample of Medicare beneficiaries during a 30-day time period following an acute hospitalization; (2) to characterize the complexity of these care transitions; and (3) to develop and test two predictive indices designed to identify Medicare beneficiaries who are at greatest risk for complicated care transitions. With respect to the first aim, 46 distinct care patterns were observed among the Medicare beneficiaries in the study sample 30 days after hospital discharge. Sixty-one percent of beneficiaries experienced one transfer (among these 93 percent were discharged home), and 31 percent of beneficiaries experienced more than one posthospital transfer during the 30-day posthospitalization time period. With regard to the second aim, approximately one in eight 30-day care episodes in the 1998 sample were classified as complicated when rigidly applying the criteria evaluating transfers from lower- to higher-intensity care environments. When this criteria was broadened to include “lateral” transfers and “plateaus” in care, approximately one in four 30-day care episodes were deemed complicated. Regarding the third goal of the study, both of the indices designed to identify those beneficiaries at greatest risk for complicated care transitions (that is, the index based on administrative data only and the index based on administrative and self-reported data) were found to have acceptable predictive accuracy.
Few prior studies have addressed the three aims of this investigation, whether separately or collectively. In fact, little attention has been paid to the tracking of care transfers over time. Using the National Long Term Care Survey, Murtaugh and Litke (2002)
found a prevalence rate of 24 percent for potential transition-related problems over a two-year time period, defined as emergency department visits, hospital admissions, and returns to an institutional setting following discharge to the community. Fairchild and colleagues developed a predictive index designed to identify patients who may require the use of postdischarge medical services; however, the index was constructed using a single study population (i.e., patients hospitalized at an urban teaching hospital) and relied on predictor variables that are not routinely available in the hospital setting (Fairchild et al. 1998
). Prior studies have demonstrated that indices that utilize administrative or self-reported data have similar rates of predictive accuracy (Coleman et al. 1998
; Roblin et al. 1999
; Fethke, Smith, and Johnson 1986
; Anderson and Steinberg 1985
; Mukamel et al. 1997
; Roos et al. 1988
The findings from this investigation need to be considered within the broader context of improving the quality of care transitions among Medicare beneficiaries. This study provides important insights into the nature of post-acute care episodes and suggests that the needs of Medicare beneficiaries who are discharged after an acute hospitalization are both complex (requiring care from different practitioners in multiple settings) and ongoing (lasting 30 days or more). This understanding may help guide current attempts to modernize the Medicare program through the creation of financial incentives designed to improve posthospital care, such as bundling payments for acute and post-acute care services across episodes of care. At present, there is no uniformly accepted definition of an episode of care for Medicare beneficiaries.
Furthermore, the fact that over 30 percent of patients in this investigation underwent more than one posthospital transfer is significant since the potential for mismanagement or medical errors increases as patients undergo more care transitions (Coleman 2003
; Institute of Medicine 2001
; Murtaugh and Litke 2002
). In addition, the significant number of care patterns in this study characterized as complicated (one in eight, and one in four episodes, depending upon the classification approach utilized) strongly emphasizes the need for both the system-level and patient-level approaches outlined in the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the Twenty-first Century
(Institute of Medicine 2001
Finally, this study has demonstrated that Medicare beneficiaries who are at risk for complicated care transitions can be identified with reasonable accuracy using either Medicare administrative data alone or a combination of administrative and self-reported data. Given the number of evidence-based interventions that are being tested to improve the quality of transitional care, the indices developed and tested in this study have immediate practical applications (Naylor et al. 1999
; Rich et al. 1995
; Philbin 1999
; Townsend et al. 1988
; Parry et al. 2003
). Specifically, the instruments can be used to target specialized care coordination programs tested or implemented in health delivery systems.
This study has a number of strengths. First, the investigation utilized a nationally representative sample of Medicare beneficiaries to investigate three areas of posthospital care transitions that have previously received little to no attention. Second, in contrast to most studies reported in the literature, the findings from this study are contemporaneous—that is, the time period examined in this study (1997–1998) coincides with the implementation of the Balanced Budget Act that is believed to have influenced patterns of post-acute care service delivery (Angelelli et al. 2002
). Third, the study tracked transfers over a 30-day time period and thereby extended our understanding of posthospital care beyond the initial discharge location. Finally, since hospital discharge planners and utilization managers often develop discharge plans based upon their clinical judgment, the application of an empirically derived instrument may provide a more reliable means for identifying patients in need of additional services and monitoring.
The findings of this study need to be considered in light of a number of limitations. First, this study was not able to evaluate all possible care transitions. The results reported in this study were heavily influenced by return to the hospital or emergency department because data on transfers to assisted living facilities, primary or specialty care, or home health care were not readily available from the MCBS. Second, the patterns of care in this study that resulted in recidivism may not have been due to transition-related problems. Collectively, the patients studied had a high burden of illness and some of the recidivism may have been attributable to the natural progression of moderate-to-advanced chronic illnesses. Third, in order to ensure that the functional status measurements used in the predictive indices were current, the Medicare samples were restricted to those patients with care episodes that occurred within four months of the annual MCBS functional assessment that takes place in September. It is unknown whether a temporal effect may have influenced the results of this study. Prior studies have demonstrated an association between transfers to and from acute care settings and functional status (Covinsky et al. 2003
; Gill, Williams, and Tinetti 1999
). Fourth, different health conditions have different periods of recovery that a 30-day episode may not fully encompass. Finally, it could be argued that identifying high-risk Medicare beneficiaries at the time of hospital discharge is a relatively “downstream” perspective that is more reactive than proactive. Nevertheless, hospital discharge was targeted in this study because it is unquestionably a time of great patient vulnerability and because there is a growing number of evidence-based interventions that show potential for significantly improving posthospital care transitions (Naylor et al. 1999
; Rich et al. 1995
; Philbin 1999
; Townsend et al. 1988
; Parry et al. 2003
In summary, these findings demonstrate that posthospital transitions are common among Medicare beneficiaries and that the associated patterns of care vary greatly overly a relatively short time. Furthermore, the finding that a significant number of Medicare beneficiaries experience complicated posthospital care transitions has important implications for both patient safety and cost-containment. Finally, this study shows that Medicare beneficiaries who are at risk for experiencing complicated care transitions can be identified using data available at the time of hospital discharge. Thus, the predictive indices developed in this study may have direct application in matching high-risk patients with evidence-based interventions designed to improve posthospital care transitions.