If you ask how effective an organization is when it comes to transitions of care, the response may vary depending on the setting and whom you ask. A hospital may say they are highly effective because they have a program in place and it’s efficient. However, if you ask the patient, they may say otherwise, feeling the frustration from moving to different facilities, navigating their benefit coverage under potentially different payers, or seeing different providers. Addressing the “how to transition” question is critical, but of equal or may be even greater importance, is the question of “where to transition?” Regardless of where patients receive care, in an inpatient, outpatient, post-acute care facility, skilled nursing home, or at home, many of these institutions don’t share data or operate on the same platform, making the process even more complex.

Addressing system-wide interoperability gaps is only one part of the solution. A transitions of care survey conducted by NEJM Catalyst in January 2023 showed that the biggest barriers to successful patient care transitions in the US were fragmentation of care delivery (54%), social determinants of health (SDOH) challenges (44%), and poor communication between providers (37%)1  When asked about home-based care, 54% of US clinicians said it would improve patient care transitions.1 In addition, clinical work shortage issues impact an organization’s ability to provide good transitions in care. If there are not enough trained staff, the transition process may not be completed, or not completed well. Finally, clinical care acuity is a factor as well, and may have some patients cycling between all of these settings as part of their health journey, further complicating communication between settings.

What are payers doing?

The challenges of a fragmented health care system, disparate operating systems, health care inequities, poor provider communication, workforce shortages and acknowledging the severity of a patient’s health are not exclusive issues facing transition of care models. However, to address the challenges around patient transitions within the health care system, the Centers for Medicare and Medicaid Services (CMS) enacted a final rule outlining discharge planning requirements for home health agencies and providers. The rule supports interoperability between health care settings and creates an environment where members are active participants and can make informed decisions in their discharge planning process.2 While this rule is laudable for its efforts to address fragmentation, it is not a total fix.

Investments like CVS Health’s purchase of Signify Health marries CVS’s community footprint with Signify Health’s nationwide provider network.  Signify Health’s model puts clinicians in a patient’s home to identify chronic conditions, close gaps in care, and address SDOH issues. The alignment helps to address some of the issues patient experience, but there is still room for other innovators to help address the more complex patients or those in need of urgent care.

Market disruptors like Amazon Pharmacy, GoodRx, or Mark Cuban’s Cost Plus Drug Company have challenged traditional payer models, forcing industry leaders to think differently not only on how to deliver care but also how to improve the quality of a patient’s experience. A broken transition of care process and poor continuity of care present both clinical and financial issues for insurers. Payers have processes in place to help in care transitions, but face very real issues in execution. The consolidations and vertical integrations of health care entities have allowed organizations to evaluate their combined assets, review new capabilities and access resources to address unique challenges such as transitions of care. With the industry as a whole demanding a more quality-focused, transparent model, payers are likely to evaluate unique ways to engage providers to improve patient outcomes.

What role does pharma play?

For pharmaceutical manufacturers, poor transition planning can lead to lower adherence or discontinuation of therapy. Helping develop care plans, specific to a therapeutic area or brand, may help providers identify unique needs associated with keeping patients from being lost in the system. Educating case managers or provider care teams with materials to ease patients through transitions and ensure continuity of care can help improve the overall patient experience. Tools to help patients navigate drug coverage as they transition from one setting to another can help alleviate some of the financial stress that comes with change.

The biggest challenges for both payers and pharma are being able to keep the patient in the center, understanding what SDOH factors may be preventing them from continuing care, and providing services to help them through their treatment journey. The need for transparency, the focus on improving health disparities and pending legislation is focused on putting patients back in the center of the US health care system.