For older adults, inpatient hospital stays are costly, representing nearly one-fifth of all Medicare payments. 1 In 2019, Medicare spent $109.8 billion for 8.7 million inpatient hospital stays.1 Medicare beneficiaries also have the longest length of stay—5.3 days versus 3.9-4.6 days for other payors. 2

After a hospital stay, the transition from hospital to home is often complex, fragmented, and can be challenging for many patients. Without proper planning, care coordination, and patient engagement, patients have a higher risk of poor outcomes, adverse events, and unnecessary hospital readmissions.

As a result, transitions of care and readmissions management have become even more important especially for Medicare Advantage Plans as CMS continues to focus on how to evaluate the quality of care through measures such as Transitions of Care (TRC) and Plan All-Cause Readmissions (PCR).

The Impact of Unmanaged Transitions of Care

Unmanaged transitions of care are costly. Members who are sent home without any follow-up care make up 50% of all readmission costs.3 What’s more, 76% of readmissions are potentially avoidable—driving up to $12 billion in healthcare expenditures.4

Additionally, transitions of care that are not well-planned and managed can lead to:

  • gaps in care
  • poor health outcomes
  • unnecessary hospital readmissions
  • increased SNF utilization and length of stay (LOS)

When transitions of care are well-planned and managed, outcomes improve and costs are reduced. A 2020 study5 found identifying complex patients at high risk for readmission and supporting them during transitions from hospital to home potentially decreases lengths of stay and prevents short-term ED revisits and long-term readmissions.

Identifying the Next Site of Care

Among the most important decisions patients make with the help of their physicians and discharge coordinators at the hospital is where they will move after their stays.

Some may need constant monitoring or intensive nursing support, and need a sub-acute care facility such as a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), long-term care hospital (LTCH), or assisted living facility.

For most, however, the home may be the best option with the right support. When patients are transitioned to the home, the discharge team will set up appropriate home services such as home nursing needs, including durable medical equipment (DME) and visits from specialized nurses, physical therapists (PTs), occupational therapists (OTs), and palliative care support.

In addition, a patient’s and caregiver’s preferences should be taken into account when deciding on the next site of care.

Eliminating Barriers for a Smoother Transition of Care

Whether the patient has moved to a SNF or home, it’s important to ensure the right level of support to address and close gaps in care, including emotional or psychological support, and provide community resources for meals, transportation, and other SDoH challenges.

To set up patients for a successful transition:

  • confirm follow-up appointments.
  • ensure the patient understands all discharge instructions.
  • review instructions for prescribed medications.
  • provide contact information for any questions they may have once they are discharged from the hospital.

Moving Members Back Home Sooner

While some members will need to move to a SNF, home is often the best care setting for members to recover and heal. In fact, research shows 80% of members sent to a sub-acute facility could recover at home with the same or better outcomes.3

The path to moving patients from hospital to home in a timely manner requires a transition of care strategy that includes:

Analytics: AI/ML-driven analytics that leverage outcomes and population health data can inform and enable recommendations for the optimal site-of-care and transition plan for each member for their post-acute care.

Collaboration: providers, discharge managers, and the care transition teams must work together to optimize care, improve discharge planning decisions, and provide recommendations for the most effective and appropriate level of care. The results are better outcomes and lower total cost of care for payors.

Engagement: communication with members is key. Engagement teams comprising of nurse liaisons, hospital discharge care managers, and care management teams should take the time to learn about members’ preferences for the care setting. They should also understand patient goals, social determinants of health (SDoH) challenges, and level of caregiver support to determine the right site of care, provider, and time to transition.

With CareCentrix’s PAC Site Optimization and Readmissions Management solutions, members can get home sooner and stay there.

To learn more about our approach and how it can improve transitions of care for your members, request a consultation.


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  1. S. Department of Health and Human Services
  2. Agency for Healthcare Research and Quality
  3. 2022 CareCentrix book of business performance data
  4. CMS
  5. BMJ Open Quality