Even with all the industry focus on improving discharge planning, the process of helping a patient safely transition from the hospital to a new care setting continues to be fraught with challenges.

2011 report on reducing 30-day readmissions estimated that poorly coordinated care transitions cost providers approximately $12 to $44 billion per year. They also result in a significant uptick in adverse health outcomes.

Many organizations have sought ways to improve discharge planning and patient care transition planning, including those that participated in the Community-based Care Transitions Program (CCTP). This five-year initiative focused on promoting better transition models and strategies, thus improving patient safety and quality of care, and reducing healthcare costs.

So, just what did the CCTP research identify as best practices? And what is missing from your case transitions strategy? Here’s a checklist for how to improve your hospital’s care transitions strategy in 2021.


The goal of any care transitions process should be to ensure the continuity and safety of every patient. The key to that? Implementing discharge readiness policies and procedures, which establish protocols and standards addressing all major issues of the transition process.

Effective discharge planning must be an organization-wide initiative, and one that starts at the top. Leadership needs to set the example. By taking the discharge process seriously, the leadership team can instill a hospital-wide ethos about the importance of discharge planning.

Additionally, this process should be continuously updated and modified to create the best results. Frequent and ongoing staff training is critical to reinforce procedures and create a culture that prioritizes the value of strong discharge planning.


Do you know why patients are being readmitted to your hospital? That insight is critical in identifying patients who may be at higher risk for readmission.

Does your care transition strategy evaluate the most common factors that increase the risk of readmission after discharge? According to the Joint Commission, these include:

  • Diagnoses associated with high readmissions
  • Comorbidities
  • The need for numerous medications
  • A history of readmissions
  • Psychosocial and emotional factors
  • The lack of a family member, friend, or another caregiver who could provide support or assist with care
  • Older age
  • Financial distress
  • Deficient living environment

Other common factors to consider are communication and patient education:

  • How well are your nurses educating patients in preparation for discharge?
  • Are they relying on old-school, paper-based materials (that patients rarely read)?
  • Do they have digital checklists that the patient AND the nurse can view and discuss together?
  • Can the nurse assign video education to the patient room TV — and see through the EMR if the patient has viewed it?
  • Is the nurse able to provide language-appropriate education to non-English speaking patients?

Insert a callout here: Related Article: 5 Things You Need Now to Improve Discharge Planning


Not every patient faces the same risk of readmission. Some have significant risk factors, whereas others don’t require the same level of concern.

The goal is to identify high-risk patients.

In pursuit of that goal, case managers or discharge planners should conduct a formal assessment of each patient, their transition needs, and discharge instructions. This will consider the patient’s:

  • Medical condition
  • Daily living situation and habits
  • Cognition
  • Ability to walk
  • Risk factors

By assessing and addressing the patient’s functional status, clinicians and staff can better prepare the patient and the receiver for handoff. Additionally, it increases the hospital’s ability to pair the individual patient with the best post-acute care setting for their specific condition.


Countless studies have shown that most patients are confused about their post-discharge healthcare plans, with the majority of the medical information they received being forgotten immediately upon leaving the hospital (if not sooner). Nurses can no longer rely on bedside conversations or pamphlets to convey this information, especially given their heavy caseloads and limited time.

It’s critical that both the patient and family are taught about their role and responsibility in managing post-acute care. During this training, staff can also gain a greater understanding of the social determinants of health that g both the patient and the family may face.

Recently, researchers have also discovered that “health information that was focused on individual needs not only increased patients’ understanding of their health needs and improved their health literacy, but supported self-management and promoted health outcomes.”

This is where automation can help hospitals improve patient outcomes. By embracing patient education technology, nurses can provide patients with visual, interactive discharge planning materials that focus on the patient’s individual needs while empowering the patient to review and access these instructions at any time.


A significant number of hospital readmissions are caused by medication-related issues. According to researchers at NEHI, “Up to 19 percent of discharged patients experienced an adverse event after discharge, of which roughly two-thirds were attributed to medications.”

Clearly, medication reconciliation is a critical piece in successful care transitions – and one that is often missing.

Where to start?

Hospitals must create an accurate medication list at hospital discharge, which includes: the patient’s pre-admission medication list, a list of the medications the patient is taking at the time of discharge, and medication changes made during the hospitalization.

Share that list with both the patient and their new caregiver, whether that is a family member at home or skilled nursing facility staff. Be sure the handoff clearly conveys all of the important details, including:

  • What each medication is
  • What each medication does
  • Side effects to watch for
  • How to take the medications
  • When to take the medications

Simply handing the patient a sheet of paper with fine print medication jargon won’t do. Give patients jargon-free information written in layman’s terms. Make it visually appealing, easily digestible, and accessible.

Does a medication reconciliation process really matter in lowering readmissions? The short answer is yes. According to a 2020 report, “In a systematic review of 26 studies, the medication reconciliation process consistently reduced medication discrepancies, as well as actual and potential adverse drug events.”

Related Article: Two Proven Ways to Reduce Readmissions


Technology can make the care transitions handoff process infinitely more accessible and seamless for both patients and their new care teams.

According to a recent CCTP Evaluation of the Community-based Care Transitions Programs: “Sites whose participants exhibited lower participant readmission rates than the comparison group of beneficiaries implemented communication and operational approaches that promoted solid integration between community-based organizations and their partners.”

Put simply, without easy access to all of the patient’s data, the new care team is forced to operate blindly or on partial information.


To create a harmonious transition of care, there must be an open line of communication between the sender (the hospital) and the receiver (the family or new post-acute care facility). If a patient is going to a new treatment center, it’s essential that the hospital care team knows the organization and starts a dialogue that emphasizes the patient’s strict admission and discharge requirements.

Once more, technology can assist with this aspect of the care transition, helping hospitals identify the best possible post-acute care settings for each patient according to their diagnosis, care needs, personal preferences, and personal situation.

In other words, they can help with the tracer method, which is:

“An evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through an organization to assess and evaluate the organization’s compliance with selected standards and the organization’s systems of providing care and services.”

Collaboration across the care continuum is key. Both sides can benefit from this relationship, especially when technology can simplify the process.


By automating and integrating the discharge planning readiness process, you can ensure that your patients leave your hospital better educated and prepared for their post-acute care setting, with less likelihood for readmission. In fact, hospitals using Sentrics’ interactive patient engagement platform have significantly outperformed national averages in HCAHPS improvement and achieve lower readmission rates and penalties than their peer groups..

Contact us today to learn how you can leverage technology to improve your care transition strategy.


  1. NIH. Interventions to reduce 30-day rehospitalization: a systematic review. https://pubmed.ncbi.nlm.nih.gov/22007045/
  2. CMS.Gov. Community-based Care Transitions Program. https://innovation.cms.gov/innovation-models/cctp
  3. The Joint Commission. Transitions of Care: The need for collaboration across the entire care continuum. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/assetmanager/toc_hot_topicspdf.pdf?db=web&hash=771E68DC706144E8A23553D961F9D12E
  4. NIH. Do patients understand discharge instructions? https://pubmed.ncbi.nlm.nih.gov/21397126/
  5. NCBI. Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590951/#b1-fp-36-06-284
  6. NEHI. Improving Medication Adherence and Reducing Readmissions. https://www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf
  7. UpToDate. Hospital discharge and readmission. https://www.uptodate.com/contents/hospital-discharge-and-readmission
  8. CMVS.Gov. Evaluation of the Community-based Care Transitions Program. https://downloads.cms.gov/files/cmmi/cctp-final-eval-rpt.pdf