Preventing hospital readmissions: A transitions of care coordination framework

Hospital readmissions (HRAs) have attracted significant worldwide interest because of the high associated costs. In the United States, HRAs have additional financial and legislative connotations, including monetary penalties to facilities across the nation. The transitions of care programmes are one of the most innovative hospital management initiatives in the current century to combat HRAs during the first month of discharge, increase customer satisfaction and facilitate a quicker and safer patient recovery in the community. Researchers around the world have been studying the implementation of similar programmes to tackle the problem. However, multiple studies have produced distinctive, controversial and conflicting outcomes following partial initiatives. The need for a customisable standard model is evident. This study discusses the scholarly justifications and international experiences for reducing HRAs and attempts to fill this gap proposing a transitions of care coordination framework (TCCF). The conceptual framework promotes the consolidation and standardisation of a series of organisational, financial and managerial initiatives and represents the first step towards the development, implementation and evaluation of transitions of care programmes in multiplayer health systems. The TCCF summarises important general strategies for the design of a transitional health programme and the barriers and challenges that anticipate its implementation. Additional investigation will facilitate the identification of and validate the necessary strategies, tools, metrics, processes and procedures to operationalise the concept.