Q&A: Care transitions in the population health model
Q. Within a population health model, which patient populations should case managers focus on with regard to care transitions?
A. Patients face significant challenges when moving from one care setting to another (transitions of care). Transitions involve multiple caregivers and professionals. There exists significant evidence that poor transitions place a burden on patients, families, and caregivers through inefficiencies. Poor transitions also increase costs to patients, providers, and payers. Standardizing communication across settings will improve care transitions by improving the consistency of the patient care plan and decreasing errors.
The case manager working within a population health model creates a transfer plan of care for all patients; however, patients with the highest risk level or an emerging risk level require our greatest scrutiny and planning, including the following patient types:
- The elderly
- Patients with two or more chronic diseases
- Dual-eligible beneficiaries of Medicare and Medicaid
- Dual-diagnosed patients
These patients are also prime candidates for transfers to and from extended care facilities and skilled nursing facilities (SNF).
For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.