Residential and Health Care Transition Patterns Among Older Medicare Beneficiaries Over Time

Transitions between different residential and health care settings represent vulnerable periods for older adults (Coleman, 2003; Coleman & Berenson, 2004; Naylor et al., 2004). The subsequent care transitions that result from the movement of persons from one setting to another require effective coordination as care is transferred across providers (Coleman, 2003). There is growing evidence that suboptimal care transitions may generate unnecessary spending (e.g., emergency department utilization, avoidable rehospitalizations, duplicative laboratory tests; Coleman, 2003; Jencks, Williams, & Coleman, 2009), medical errors (e.g., medication discrepancies; Coleman, Smith, Raha, & Min, 2005; Moore, Wisnivesky, Williams, & McGinn, 2003), and poor health outcomes (e.g., adverse events, relocation stress, uncontrolled chronic conditions, avoidable rehospitalizations; Arbaje et al., 2008; Boockvar et al., 2004; Forster, Murff, Peterson, Gandhi, & Bates, 2003; Intrator, Schleinitz, Grabowski, Zinn, & Mor, 2009). Care transitions are common among older adults (Coleman, Min, Chomiak, & Kramer, 2004). Coleman and colleagues identified 46 distinct types of care transition patterns within the first 30 days after hospital discharge of older adults and that more than 30% experience at least two or more care transitions during that time frame (Coleman et al., 2004). Between 13% and 25% of care transition patterns after hospital discharge were “complicated”—representing movement from a lower to a higher level of care. A recent study found that a fifth of Medicare patients who had been discharged from the hospital were rehospitalized within 30 days after discharge and a third were rehospitalized within 90 days (Jencks et al., 2009). The number and complexity of transition patterns in Coleman's posthospital discharge study suggest that older adults do not experience a single predominant transition pattern but rather a collection of a few primary patterns followed by many unique and complex ones. Policymakers, health care organizations, and providers are paying increased attention to care transitions because they represent an essential element in optimal continuity of care and subsequent reduction of rehospitalizations. Programs to improve care transitions are difficult to implement under the current payment system. A 2008 recommendation by the Medicare Payment Advisory Commission (MedPAC)—that hospitals with relatively high rehospitalization rates should be subject to reduced payments as part of a plan to increase efficiency and improve quality of care—also illustrates the interest in this area (Jencks et al., 2009; Medicare Payment Advisory Commission, 2009). The Centers for Medicare & Medicaid Services (CMS) has initiated a Care Transitions Project that involves 14 Quality Improvement Organizations to improve care coordination and reduce unnecessary hospitalizations and rehospitalizations (CMS, 2009; Colorado Foundation for Medical Care, 2010). The recent passage of the Patient Protection and Affordable Care Act (PPACA) includes numerous examples of efforts intended to increase care coordination and improve care transitions (PPACA, 2010; Kaiser Family Foundation, 2010). Guidance on where to target such efforts is hampered by the scarcity of information on national care transition patterns of older adults. Prior work examining care transition patterns among older adults has focused solely on care transitions to and from hospitals or on care transitions that occur shortly after discharge. The earliest depiction used 1992–1994 data from the National Long-Term Care Survey and presented the proportion of individuals having distinct types of transitions across four settings: home, hospital, skilled nursing facility (SNF), and other institutional settings (Murtaugh & Litke, 2002). The study by Coleman and colleagues (Coleman et al., 2004) examined transitions in 1997 and 1998 originating after a hospitalization and occurring during the first 30 days after discharge. The most recent study by Jencks (Jencks et al., 2009) also examined postdischarge transitions but specifically focused on rehospitalizations and only those occurring during the first 30 days after discharge. It did not describe residential settings encountered after the initial hospital discharge. Though these studies examined transition patterns nationally, they did not describe (a) transitions experienced by community-dwelling beneficiaries without hospitalizations, (b) transitions occurring beyond 30 days after discharge, (c) transition patterns over several years, or (d) transitions involving long-term care settings other than SNFs. In summary, the extent to which transitions happen and how they are encountered is found in the literature but is often restricted to specific sub-populations, specific transitions, or limited time periods. Knowledge of care transition patterns across residential and health care settings can help provide a broader context not only to understand health care utilization among older beneficiaries, but also potentially inform health care organizations on the types of scenarios regarding transitions of older individuals across different settings. Such understanding also may help identify potential issues related to quality of care and identify areas for improvement in patient safety and outcomes. To address the knowledge gap of the patterns of transitions for individuals over the course of a year, we designed a study to (a) describe the natural history of care transitions among Medicare beneficiaries across residential and health care settings, (b) assess whether annual care transition patterns are consistent over time, (c) characterize repeated/multiple transitions, and (d) report variations in transition patterns across demographic characteristics.