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Would like to see development of metrics around care transitions. This will be especially important as ACO's come into being.

The primary aim of this

The primary aim of this endeavor is to initiate a measure that is consistent with the concept of patient-centeredness, and useful for the purpose of performance measurement and subsequent public reporting. There are many issues in the way, one of which is avoidable re-admissions. Re-admissions are individuals who have had to revisit a medical center soon after leaving one. Re-admissions are a fairly large part of what the national health care system has to deal with. I found this here: Preventable re-admissions a growing problem for hospitals, newstype.com. Therefore, this poses a great challenge to the health care team to exert extra effort in rendering care to all patients to avoid readmission after hospital discharge.

care transition measures

NCQA and others are starting to focus on care transition measures, but frankly, it's not clear these process measures will be useful.  In our work on episodes, we've focused on avoidable complications as a means to track care coordination failures.  So, for example, if a patient is readmitted post discharge for a co-morbidity that might not have been managed well during the original hospitalization or post-discharge, then that readmission counts as a potentially avoidable complication.

Ultimately, outcomes -- fewer ED visits, fewer hospitalizations -- will be the mark of good care coordination and transition.