Key Takeaways

One of my first jobs in healthcare was at a palliative care practice where I was responsible for managing our oncology business. I worked closely with a team of physicians and nurse practitioners who saw cancer patients in community clinics to address their physical symptoms, psychosocial and emotional needs, and facilitate conversations about advanced care planning and end of life. 

My clinical colleagues experienced some of the most difficult scenarios when managing care for individuals who were admitted and discharged from the hospital. Despite investing in care coordination to help people manage their conditions at home, the clinic saw their patients often landing in the ED — sometimes being admitted for days or even weeks. Following up with them and providing necessary support after discharge was equally challenging.

Transitions of care are vulnerable stages along care journeys for patients. If conducted successfully, they can lead to better outcomes. But poorly managed transitions present significant challenges to patient health, jeopardize the member experience, and lead to billions of dollars in unnecessary costs to both patients and plans. Let’s explore the importance of transitions of care and how the right digital health tools can help payors give their members best-in-class service.

Why transitions of care are important for payors

Effective transitions of care require a multidisciplinary team effort. Hospital-based providers including nurses, physicians, and case managers do much of the legwork to get patients ready to go home — providing education and instructions about steps to take during the weeks after hospital discharge. 

But once patients leave the hospital, responsibility switches to outpatient providers, including PCPs and their staff as well as care navigators and other team members. While direct patient care is provided by clinicians, health plans play an essential role in supporting their members throughout their care journeys and ensuring that members receive the services and guidance needed to effectively manage their care.

1. Continuity of care and health outcomes

Shifting care settings or switching providers can impact the continuity of care members receive. Disruptions in care may lead to gaps in treatment, medication errors, or delays in accessing necessary healthcare services. 

These interruptions can negatively affect health outcomes — and they persist in the face of continued investments in care coordination and navigation. In a study conducted among 400 patients at an academic hospital, nearly 20% of them experienced an adverse health event within three weeks after discharge. These types of scenarios not only increase the risk of readmission, but they require individuals to know where and how to access the care they need within a fragmented healthcare system. Unfortunately, this leads people to fall between the cracks and into avoidable escalations in care given how complicated our system is to navigate — especially for people with complex care needs.

2. Cost implications for health plans

Haphazard shifts can contribute to increased administrative costs for health insurance plans. These may include expenses related to duplicate tests, inefficient use of resources, and additional administrative efforts to manage fragmented care. 

One study conducted for a population of high-risk patients found that implementing a pharmacy-based transitions of care program helped control costs for health plans — reducing expenses by an estimated $1.8 billion. This and other real-world examples point to discerning investments in transitions of care not only benefiting member experience and health outcomes, but also helping payors control costs.

3. Member experience and satisfaction

Smooth transitions of care contribute to a positive patient experience and increased satisfaction with the healthcare system. But when individuals encounter challenges during transitions — such as difficulty obtaining timely information, accessing medications, understanding their care plans, or coordinating follow-up appointments — it can lead to frustration and dissatisfaction. 

Facilitating successful transitions of care and providing timely, comprehensive support present opportunities for health plans to differentiate themselves. If a member gets quick access to care, medications, and other benefits post-discharge thanks to their health plan, they’re more likely to understand that their insurance provides assistance beyond paying bills. Care transitions are arguably some of the biggest moments to positively influence members’ experiences and increase their likelihood of staying with their plan. 

4. High-risk members and chronic care management

Transitions of care are particularly critical for individuals with chronic conditions who require ongoing care management. Inadequate transitions, such as gaps in medication management or a lack of communication among healthcare providers, can lead to exacerbations of chronic conditions and increased use of healthcare resources. 

Health plans that manage transitions in the context of chronic disease management can ensure that individuals receive ongoing support following discharge from the hospital or ED. By facilitating care coordination and surfacing relevant benefits, health plans can help support better outcomes and reduce overall costs by preventing avoidable readmissions. A McKinsey study found that individuals with similar risks and demographics who saw a primary care physician within seven days of discharge had a decreased likelihood of readmission from 23% to 15%.

How can innovation support better transitions of care?

Health plans are increasingly adopting innovative digital health platforms to enhance the member experience and facilitate greater member engagement with health plans.

Intelligent care enablement — scalable technology that supports members and care managers through complex clinical episodes — provides payors with a platform that facilitates personalized, proactive, and coordinated care. Health plans can use this innovative technology to:

1. Proactively and reactively support members through their care journeys

Two-way communication can help facilitate successful transitions of care. Proactive messaging — in the form of consistent post-discharge education, appointment reminders, and assessments — helps patients adhere to their care plans. Creating a channel for patients to ask questions and report how they feel is also important for rapidly addressing arising concerns.

Memora Health’s intelligent care enablement platform facilitates two-way communication using text messaging, which is a proven channel for reaching members across demographic groups and all ages. The platform also leverages conversational AI to interpret messages, ask for clarifying context, and triage information and questions from members to their care teams. For care managers, intelligent care enablement augments routine outreach and tasks so they can focus more time on actively supporting members. For members, it acts as an always-on and dynamic assistant that guides them through the fragmented healthcare system.

Learn how to unlock better care management operations with intelligent automation.

2. Reinforce care plan adherence to help prevent readmissions

A low rate of readmissions is a key metric for successful transitions of care programs. Although there is no single solution to keeping patients out of the hospital, evidence suggests that readmissions are less likely to occur when individuals understand their care plans and have access to resources required to follow them. 

Making transitions of care programs more effective is a key focus for Memora Health. Memora’s platform automates a series of proactive messages that include clinical education and information related to expected symptoms and side effects. Through user experience research, the content and spacing of these messages have been optimized for readability and engagement. By helping patients understand what to expect, they’re more likely to be prepared for any issues that arise and reach out for support before needing to visit the ED.

When individuals respond to messages they receive or reach out unprompted with questions, the platform uses AI to automatically retrieve answers from a pre-approved clinical database to respond. When the conversational AI doesn’t know the response to a question or identifies a concern as urgent, a care manager is notified to provide personal support.

3. Promote longitudinal access to care for high-risk members with chronic conditions 

Chronic care management is complex. It requires frequent specialist appointments, medication adherence, and continuous monitoring. With all of these moving parts, it’s easy for mishaps to occur — and even small mistakes can have big health and cost consequences.

Memora’s technology can be configured for ongoing care journeys that require long-term support. The platform is built using evidence-based guidelines to engage members with chronic conditions to assess how they feel, prompt them to take their medications, and identify any barriers to accessing care. Memora Health’s Care Programs surface relevant resources to members based on their needs and can help individuals overcome barriers inherent to our complicated healthcare system.

Successfully managing transitions of care is difficult and requires a commitment to facilitating access to high-quality care for patients. While there’s no simple solution to guiding individuals through their personal care experiences, intelligent care enablement can help by providing always-on support.  

Want to see how Memora Health’s platform can help your health plan improve the member experience? Speak with one of our experts!