Bridging the Gaps: Actionable Strategies for Improving Transitions of Care and Reducing ED Admissions
In value-based care, it’s not just what you track—it’s how you act on it.
For ACOs and MSOs, one of the most critical—and underleveraged—opportunities to improve outcomes and reduce costs lies in the transitions of care. Poor transitions don’t just lead to fragmented care—they lead to avoidable ED visits, unnecessary hospitalizations, and missed shared savings.
With the Texas Association of ACOs Annual Conference around the corner (March 31–April 2), now is the perfect time to reexamine how we move patients from hospital to home—and what we can do differently to keep them from bouncing back into the system.
Where Transitions of Care Break Down
When transitions fall apart, it’s rarely for lack of good intention. It’s usually due to process gaps like:
- Patients discharged without clear follow-up
- Medication confusion or lack of reconciliation
- Primary care teams unaware of hospitalizations
- One-touch follow-ups that don’t go far enough
- No stratification of who needs the most support
The solution isn’t more documentation. It’s smarter systems, clearer workflows, and timely insights that drive action.
Here’s how to do it:
1. Strengthen Discharge Coordination with Real-Time Alerts
Build workflows that trigger immediate outreach from care managers the moment a patient is discharged. The faster you engage, the better the outcomes.
💡Example: A Texas-based ACO embedded ADT (admission, discharge, transfer) alerts directly into its workflow. As soon as a patient was discharged, the care team received a notification, prompting a next-day follow-up call and scheduling a primary care visit. In one quarter, this reduced preventable ED visits by 20%.
2. Implement Medication Reconciliation Within 48 Hours
Medication confusion is one of the top drivers of readmissions. Assign a dedicated team member to review prescriptions with the patient within 48 hours of discharge.
💡Example: After a string of readmissions tied to heart failure mismanagement, one ACO had its pharmacist call each discharged patient within 48 hours to review medication changes. A 74-year-old patient avoided readmission when the pharmacist flagged a dosing error—catching the issue before it became critical.
3. Use Predictive Analytics to Identify High-Risk Patients
Not every patient needs the same level of intervention. Use risk scoring and predictive modeling to focus your resources where they’ll make the biggest impact.
💡Example: Using AaNeel’s risk stratification tool, an ACO flagged a patient with COPD and multiple chronic conditions as high-risk. The care team provided home visits and remote monitoring, preventing a flare-up that would have otherwise led to an ED visit.
4. Increase Patient Engagement Through Multi-Touch Follow-Ups
One call is easy to miss. Build a post-discharge cadence of communication that keeps patients engaged and supported for the first 7–14 days.
💡Example: An IPA launched a three-point contact system: a phone call within 24 hours, a text at day 3, and a follow-up call on day 7. The result? Improved appointment adherence and a measurable drop in post-discharge ED use.
5. Ensure Seamless Coordination Between Hospitals and Primary Care
If the primary care team doesn’t know a patient’s been discharged, they can’t help. Ensure real-time visibility across the care continuum.
💡Example: One South Texas PCP was often left out of the loop until patients returned with complications. After her ACO implemented real-time discharge alerts through AaNeel, she was able to proactively reach out to patients and adjust care plans—reducing ED visits and improving continuity.
How AaNeel Supports Smarter Transitions
AaNeel’s platform is built to operationalize insights—turning alerts, analytics, and patient data into meaningful interventions that reduce preventable ED admits. We do this through:
- Real-Time ADT Alerts to trigger follow-up workflows
- Predictive Risk Stratification for targeted support
- Medication Reconciliation Tools to avoid post-discharge complications
- Multi-Touch Engagement Plans that keep patients connected
- Care Coordination Dashboards that align hospitals, PCPs, and case managers
We’ll be at the Texas Association of ACOs Annual Conference March 31–April 2. If you’re attending, come talk to us about how AaNeel helps ACOs reduce unnecessary ED utilization and deliver seamless, value-based care transitions.
Want to see how our transitions of care solution fits into your ACO strategy?
🔗Request a Demo Today
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