title: Care transitions in a changing healthcare environment.
abstract: Readmissions are a significant element in the ongoing healthcare debate, and new evidence suggests that high readmissions can be a surrogate marker for poor quality healthcare. Additionally, although readmissions can offer a financial incentive for some hospitals, that model is being phased out; readmissions in a pay-for-performance or bundled payment model represent significant financial risk for providers and hospitals. Although no specific strategy at discharge has proven to be effective in reducing readmissions, practices that include good posthospital communication to the patient and care team, access to follow-up, and attention to mobility and self-care deficits are important factors in limiting readmissions. PAs play a key role in assessing for high readmission risk and implementing prevention strategies in real time.
authors.affiliation: Kathryn E. Callahan is an assistant professor in the Section on Gerontology and Geriatric Medicine at Wake Forest School of Medicine in Winston-Salem, N.C. Zachary Hartsell is director of the PA program at Wake Forest School of Medicine and director of PA services at Wake Forest Baptist Medical Center. The authors have disclosed no potential conflicts of interest, financial or otherwise.
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: Callahan
authors.forename: Zachary
authors.initials: Z
authors.lastname: Hartsell
mesh_terms: D003266:Continuity of Patient Care / Q000592:standards*; D006801:Humans; D006278:Medicare; D010351:Patient Discharge; D010359:Patient Readmission / Q000191:economics*; D010823:Physician Assistants; D024382:Professional Role; D011787:Quality of Health Care; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States