The terms care management, case management and care coordination are beginning to receive the recognition they so rightfully deserve, though the terms have been around for decades. The phrase “care coordination,” as a role associated with transitional care, is spoken by a number of individuals including legislators and regulators in Washington D.C.; leaders of both payer and provider systems; case management professional colleagues; and patients who were previously lost in complex and often confusing healthcare system. The phrase is found 14 times in the Accountable Care Act. The interest in care transitions is causing policy makers, care providers, advocacy groups, and families to want a measurement of how well entities do in care transition. As an example from a hospital perspective, patient satisfaction surveys—commonly identified as the Hospital Consumer Assessment of Hospital Providers and Systems—for 2014 are anticipated to include the following care transitions measures (Centers for Medicare and Medicaid 2013a, b):

So exactly what is transitional care management and why the increased interest in it? Fundamentally transition of care or care transitions, is the movement of patients from one health care practitioner or setting to another as their condition and care needs change. Care transitions can occur within a setting (intensive care to medical surgical floor); between setting (acute care to skilled nursing facility); across health states (curative care to hospice); or across health providers (pediatric to adult setting). The majority of studies and work related to care transitions have focused on the elderly, as they are a population with complex care needs, including admissions and readmissions. However, transitional care program development may be applied to all populations and is increasingly being seen in advanced in research (Taylor et al. 2013). One specific area of interest has been in the safe discharge transition of infants from the neonatal intensive care unit (NICU) and the coordination and education needed to prevent readmissions and gain compliance with a first pediatrician visit (Moyer et al. 2010).

The Committee on Healthcare Quality in America, formed by the Institute of Medicine, investigated quality of care beginning over 15 years ago. This Committee’s initial report, Crossing the Quality Chasm provided a concerning and comprehensive review of the overall quality of the health care system, including an assessment of its safety and effectiveness and recommendations for a comprehensive strategy for improvement (Institute of Medicine 2001). The Committee still exists today with one of their concerns being safe and efficient care transitions. In 2031, they have additionally formed a subcommittee on Improving the Health, Safety, and Well-Being of Young Adults (age 18–26) due to the issues of chronic condition care and lack of access to health care, exacerbated by poor transition to the adult care community, placing these individuals at risk, or vulnerable to poor health care outcomes (http://​www.​iom.​edu/​Activities/​Children/​ImprovingYoungAd​ultHealth.​aspx).

Tip for Families: Ask the case manager at your child’s hospital to explain what measures they have in place to ensure a successful discharge without readmission? Do they offer a home visit to support medication reconciliation?

Tip for Health Care Professional: Making sure that communication from hospitalists and specialists occurs at discharge with the receiving community pediatrician requires a solid protocol. Make sure to connect with the hospital case management department and are informed of the communication protocol in effect.

Section 3025 of the Affordable Care Act added Section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program (http://​www.​cms.​gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPP​S/​FY-2012-IPPS-Final-Rule-Home-Page-Items/​CMS1250103.​html), which requires CMS to reduce payments to inpatient prospective payment system (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. CMS has also established an Improving Care Transitions program in Medicaid. The recognition that transitions between care settings is critical to improving outcomes, and quality of care has initiated a Program focus on transition issues of:

Care coordination was defined to be necessary in the coordination of medical and long term supports and services (LTSS) when an individual is:

In April 2011, CMS announced the development of the Community-Based Care Transition Program (http://​innovation.​cms.​gov/​initiatives/​CCTP) created by Section 3026 of the Patient Protection and Affordable Care Act (PPACA). The CCTP provides funding opportunities for acute-care hospitals with high readmission rates that partner with community based organizations (CBOs). This initiative is part of the Partnership for Patients, a public public-private partnership charged with reducing hospital-acquired conditions by 40 % and hospital readmissions by 20 % by 2013. The Department of Health and Human Services agreed to invest up to $1 billion in PPACA funds in the Partnership to reduce millions of preventable injuries and complications. There are currently 102 organizations participating in the CCTP. Participants will use process and outcome measures to report on their results. Multiple studies have shown there are many factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions for patients of all ages. The Hospital Readmissions Reduction Program and the Improving Care Transitions Program has potentially significant financial impacts for hospitals and has caused an increase in attention on the development of transitional care management programs in an attempt to reduce hospital readmission rates.