Care Transitions solutions encompass technological platforms and systems designed to help healthcare organizations optimize the coordination and movement of patients between different care settings. These solutions streamline and optimize the process of transitioning patients between different care settings, enabling seamless coordination among providers, real-time information sharing, personalized care planning, and proactive interventions.
Care transitions framework
Post-acute network management | Specializes in connecting hospitals with post-acute providers through curated networks of high-quality facilities with digital connectivity. These solutions enhance visibility into post-acute options, provide analytics on provider performance, and streamline the referral and placement process to help match patients with the most appropriate care settings for their needs. Example companies: WellSky, Aidin, Optum |
Patient flow management and discharge planning optimization | Centralizes and automates patient movement logistics within and between facilities through digital command centers that manage bed capacity and transfers. These platforms optimize patient flow to standardize handoff communications so patients move timely throughout the care continuum. Example companies: TeleTracking, LeanTaaS, Qventus |
Predictive risk analytics | Empowers healthcare organizations to identify at-risk patients and determine optimal next-care settings through sophisticated algorithms that predict readmission risk, complications, and other adverse events. These solutions provide evidence-based care setting recommendations based on patient data and outcomes, while generating intervention triggers that notify care teams when patients require additional support during transitions. Example companies: Health Catalyst, Innovaccer |
Care collaboration platforms | Delivers comprehensive platforms that streamline communication and care management as patients move between care settings. These solutions support cross-organizational care team coordination, promote information sharing at transition points, and enable more seamless handoffs between providers involved in a patient’s care journey. Example companies: WellSky, Bamboo Health, TigerConnect, Pulsara |
Longitudinal patient record and care continuity | Creates a unified view of patient information across care episodes and settings through interoperable data platforms that aggregate information from disparate EHRs. These solutions enable care plan persistence across transitions, medication reconciliation tools that reduce adverse drug events, and structured clinical documentation sharing that improves handoffs between providers. Example companies: Bamboo Health, Arcadia, Innovaccer |
These are example companies, and not meant to be comprehensive. Did we miss your company? Schedule some time to connect.
The case for digital in care transitions
The fragmented nature of healthcare delivery creates significant challenges as patients move between care settings. Traditional transition processes—relying on paper documentation, phone calls, and manual coordination—frequently result in communication breakdowns, medication errors, unnecessary readmissions, and poor patient experiences. These care gaps impose substantial clinical, operational, and financial burdens on healthcare organizations while undermining patient outcomes. Digital care transition solutions address these challenges by creating connected ecosystems that promote information sharing, standardize workflows, and enable proactive care management.
Bridge care gaps to improve clinical outcomes
The transition between care settings represents one of the most vulnerable periods in a patient’s healthcare journey. Gaps in care persist as providers struggle to connect disparate pieces of data and information with one another. This communication gap leads to medication discrepancies affecting up to 70% of patients during transitions and contributes to 80% of serious medical errors.1 Digital care transition solutions address these challenges through structured communication protocols and patient engagement tools. Organizations implementing these technologies have the ability to reduce information gaps during handoffs, decrease post-discharge adverse drug events, and improve patient satisfaction scores related to discharge processes.
Streamline operations to maximize resource efficiency
Care transitions impose significant operational burdens on healthcare organizations, with discharge planners reporting significant time constraints and delays, with studies showing that approximately 25% of hospital days for Medicare beneficiaries could have been avoided with more efficient care transitions.2 Digital platforms streamline these workflows through automated discharge planning, real-time post-acute provider directories, and digital handoff tools. This enables providers to perform at the top of their license by giving them more time for high-touch patient interactions along the care journey.
Drive financial success in value-based care models
As growing interest in value-based payment models persists, effective care transitions become increasingly important financial drivers. Medicare’s Hospital Readmissions Reduction Program penalizes hospitals with excessive readmissions, while bundled payment programs include post-acute care in the episode cost. Digital care transition solutions directly address these financial imperatives. One health system was able to save $3.2M annually by improving how they support patients in their care transitions.3 As reimbursement models continue to evolve, the financial return on these solutions will only increase as payers increasingly reward coordinated, high-quality care across the entire continuum.
Sources
- https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-26-transitions-of-care-managing-medications/#:~:text=Issue:-,Safe%2C%20quality%20transitions%20of%20care%20can%20serve%20as%20safety%20nets,result%20in%20adverse%20drug%20events.&text=The%20most%20vulnerable%20patient%20populations,discrepancies%20at%20transitions%20of%20care:&text=3.4%2D97%25%20of%20adult%20patients,hospital%20medication%20changes%20at%20discharge.
- https://www.qventus.com/resources/blog/why-hospital-discharges-take-so-long-and-what-we-can-do-to-shorten-them/, https://pmc.ncbi.nlm.nih.gov/articles/PMC4104507/#:~:text=The%20most%20common%20categories%20of,successfully%20reduce%20readmission%20(Table).
- https://www.healthcatalyst.com/learn/success-stories/care-transitions-allina-health
