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Position Paper: Technologies for Improving Post-Acute Care Transitions (Discussion Draft)

2010 | Download

The recent focus on improving post-acute care transitions (the process by which a patient moves from hospital to home or other settings) is being driven by an interest in reducing hospital readmissions. The United States has an 18% rate of hospital readmissions within 30 days of discharge—and as many as 76% of these are preventable. According to Medicare data, over half of readmitted patients received no care or follow-up in the 30 days after hospitalization. Patients that do receive care after a hospital stay often experience care that is fragmented and uncoordinated, which results in duplication of services, inappropriate or conflicting care recommendations, medication errors, patient/caregiver distress, and higher costs of care.

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Recent studies by Coleman, Naylor, and others suggest that interventions targeted toward postacute care transitions can reduce readmission rates by one-third. These interventions focus on improving the care transitions process, providing direct patient support, improving selfmanagement capabilities, and increasing access to needed information and tools. The Care Transitions Intervention and the Transitional Care Model are two commonly used care process improvement interventions that focus on post-acute care transitions. The Guided Care and Geriatric Resources for Assessment and Care of Elders are promising care coordination intervention models that have care transitions elements.

Several types of technologies have potential to support post-acute care transitions interventions and are discussed in this position paper. Technologies that can assist in improving medication adherence, medication reconciliation, patient monitoring, communications between and among clinicians, patients, and informal caregivers, risk assessment, and other important aspects of care transitions are widely available, but often underutilized. Studies suggest that use of such technologies can lead to fewer hospitalizations and emergency room visits, high patient satisfaction and acceptance, and reductions in cost of care.

Created by PHI's Center for Technology and Aging, this position paper illustrates some of the technology applications the Tech4Impact grant aims to encourage. The paper is a starting point for consideration and is not meant to describe all possible technologies for improving post-acute care transitions ("PACT" technologies).