qlēr Transition

a clear problem…

On an annual basis, over 34 million patients are discharged from hospitals.  For many, they are on the mend and going home.  For others, particularly the elderly Medicare beneficiaries, they are transitioned to skilled nursing facilities to continue their treatment plans.

Unfortunately, as hospitals are increasingly pressured to reduce patient length of stay, the hand-off is often hastened before a final clinical review and intervention is completed.

The result?  According to a CMS report produced in March 2015:

  • 20% of Medicare beneficiaries discharged from hospitals to skilled nursing facilities are poorly executed care transitions that negatively affect patient's health
  • 41% of discharged patients had a test pending at discharge
  • 10% of those patients required a possible medical intervention
  • 65% of responsible aftercare providers were unaware that a test was outstanding
  • 25% of discharge plans fail to include all pending tests

Hospital readmissions are seen as an important indicator of care quality and account for billions of dollars in annual Medicare spending.  Medicare's Readmission Reduction Program and the associated readmission penalties have placed transitions of care at the center of the national discussion around healthcare quality.  In 2012, 17.8% of Medicare patients discharged from the hospital were readmitted at a cost of nearly $18 billion.  

The result?

  • 80% of hospitals have established interdisciplinary teams to target reducing readmissions
  • 70% of hospitals share their readmission rates with their Board of Directors
  • 60% of hospitals have established goals to reduce readmissions
  • 50% of hospitals provide post discharge follow up calls to support and reinforce the discharge plan and aide in problem solving

Although hospitals have lofty goals of reducing readmissions, they often fail to accomplish them.  Our qlēr Transition solution is a targeted approach to achieve our clients' goals.  We help hospitals reduce avoidable readmissions by providing the processes, tools and resources to establish better communication with patients and among hospital and primary care physicians, appropriately assess patient readiness for discharge, and ensure a smooth transition from the hospital to the post-acute care setting.

Using our qlēr Path approach to Transitions of Care, we can make an immediate impact in these metrics without adding cumbersome, disruptive processes.

qlēr Path: seamless transition

qler path