However, Jackson says it's harder to pinpoint exactly why transitional care works on a larger scale. "That is a very challenging question to answer because the transitional care program is tailored to the individual," he says.
"If you have a patient who doesn't have a lot of needs, they only need a little support. Whereas somebody who is high risk and high need you have to give them a lot of support. Sometimes in the evaluation it may show that that person you have given a lot of support to still shows up back at the hospital but maybe you've kept them in the hospital a little bit longer. Those kinds of things are hard to tease out."
Anecdotally, Jackson believes that a key component of transitional care is the home visit by a medical professional. "A lot more comes out in the home. You learn a lot more than you would with a phone call," he says. "They are telling you one thing, but you clearly see that they are not. Maybe there are mobility issues, transportation issues, there may be environmental or nutrition or health issues. A picture paints a thousand words."
Jackson says patients appreciate the voluntary home visit too. "They like having the extra support and having a nurse come and check in on you and make sure you are OK and have what you need," he says. "They love the clarification and the support they need when they come out of the hospital."
Let's review: Transitional care reduces readmissions, improves patient outcomes, saves money, and engages patients to become an active partner in their own care plan. With every new study, the statistics and other objective evidence are lining up behind the common sense.