Transitional care aims to provide patients with alternative healthcare solutions outside of the tertiary care system that are more suited to quality-of-life interventions and support long term healing. An aging population in 2025 coupled with a surge of various chronic diseases, as well as greater acceptance and focus on mental health treatments will call for a higher demand for transitional care given the importance of reducing readmissions into hospitals, enhancing patient experience, and reducing healthcare costs.
The Need for Transitional Care
The growing need for transitional care is mainly driven by the increase in awareness of physiological and comprehensive solutions for rehabilitation needs across the population from congenital paediatric conditions to post surgical needs to the requirements of an aging population. Let’s look at each of these contributory aspects in turn.
The prevalence of Autism in India has been increasing steadily with IJP publishing that 1 in 68 children were on the spectrum in 2021. Similarly, ADHD is estimated to impact between 5 – 8% of children in our country (WHO). Most cases go undiagnosed and untreated due to social stigma but with great awareness campaigns and movies such as Taare Zameen Par – there has been greater acceptance of the disorders and consequently much greater demand for integrated solutions in this space. In parallel, conditions such as club foot and congenital deformities that were once considered permanent disabilities are now largely understood to have surgical and non-surgical remedies and across the board early intervention and comprehensive solutions are in high demand. Transition care supplements the diagnosis, treatment and provides long term care facilities that traditional hospitals cannot as they are focused on saving lives.
Older patients with complicated medical conditions often have difficulty in making the transition from hospitals to home care or rehabilitation. These handoff transitions are also some of the highest risk periods for patients who can be susceptible to medication errors, miscommunication, or failure to follow discharge directions. Poor transitional care also results in increased readmission rates due to infections, disease recurrence, repeated falls amongst others and therefore, increased adverse health outcomes for these patients.
Chronic disease management is driving the need for effective transitional care. Individuals with chronic medical conditions such as diabetes, heart disease, and lung disease often need similar types of monitoring and care across multiple settings. Transitional care makes certain that these patients get the correct, ongoing care they need, reducing the risks since their health conditions don’t get worse and avoiding unnecessary hospital visits.
Shifting Toward Value-Based Care
As healthcare systems shift from fee-for-service to value-based delivery, transitional care will become even more important. Value-based care models give financial incentives to healthcare providers to focus on patient outcomes and reduce avoidable costs. Transitional care programs reduce readmission rates and complications. By 2025, more healthcare providers will offer value-based care models, where a patient’s outcome takes priority over how many services a provider offers. For example, these models incentivize health systems to invest in comprehensive transitional care programs, for which there is evidence that they reduce long-term outcomes and are cost-saving.
Technological Advancements in Transitional Care
There are many tools available today such as telehealth, remote monitoring, and EHRs that work in tandem to fuel better care coordination. They also enable real-time contact between patients and providers, helping to ensure continuity of care across transitions.
Providers will use telemedicine, for example, to conduct virtual consultations and monitor patients remotely and in real-time to address concerns. Remote monitoring tools — such as wearables — will be used to help track patients’ health data and alert providers to potential problems. Eliminating barriers to timely coordination and retrieval of information prevents complications and readmissions, and improves outcomes.
AI and data analytics can help augment transitional care when risk is identified earlier. AI tools pour over the data of patients to catch when medications ordered have been given or not, or when they may be showing signs of deterioration so that care teams can intervene before things worsen. These technological advancements will play an essential role in guaranteeing a timely and appropriate transition in the care of patients.
Virtual and Gaming rehabilitation is another upcoming area of care innovation where gross and fine motor skills development and neurological stimulation are provided in an engagement led manner. This leads to greater adoption of the treatment plans by patients and therefore better long term results. There are very few centres that have any infrastructure in this space in India but it is one to watch out for.
Coordinated Care Across Settings
Transitional care requires coordinated communication among multiple healthcare providers. When patients move from hospital to rehabilitation institution or homecare, it’s essential healthcare teams stay in touch so that care remains integrated. Fragmented care leads to missed follow-up appointments, uneven treatments and medication errors. In addition, long term care requires multi-disciplinary coordination which are the foundation of transitional care centres.
In 2025, even more advanced technologies will be responsible for improvements in care coordination in healthcare organizations. Inspired by the practice of using patient-centered platforms, these EHRs are integrated with communication systems that give healthcare teams access to patient information in real time and can be used all on their devices or smartphones. This will enable better decision-making and in turn guarantee that patients receive the right care, the right way, in every context.
Patient-Centered Care During Transitions
Transitional care will be about the individual patient’s specific needs by 2025. A patient-centered approach will lead to care plans that are tailored to the individual, one that responds not only to medical needs but to complex and extremely personal factors such as emotional, psychological, and social needs.
Transitional care programs also have the flexibility to include integrative care such as art and music therapy where more clinical evidence is emerging on efficacy especially in the areas of stress and anxiety reduction and this allows faster recovery and better experience for the patients.
Reducing Healthcare Costs Through Transitional Care
Transitional care saves healthcare costs due to the prevention of expensive readmissions from hospitals. Most readmissions can be prevented through proper transitions of care. Health systems can effectively minimize readmissions if they invest in better coordination during transitions and ensure that patients receive necessary support services. By properly managing chronic conditions through transitional care, healthcare organizations reduce complications and avoid expensive interventions later on. This places transitional care in a good position as a valuable investment at a time when the industry is changing toward value-based models.
In addition, there are many cases where patient families feel unable to cope with the care burden at home and either choose to keep the patient in hospital to avoid complications or compromise by taking the patient home. Coordinating multiple therapy sessions, a day, IV medications, feeding tubes etc in most homes for the elderly or for one of the primary breadwinners results in caregiver burnout and high costs. Transitional care provides for all this in one safe setting with easy access to the family thereby providing a solution that suits the entire family while never compromising on patient care.
The Future of Transitional Care
By 2025, transitional care will become recognised as the essential cornerstone of the health care system. With a growing proportion of health systems embracing evolving technology, coordinated care, and patient-centered approaches, transitional care will evolve to care for the diverse emerging needs of the Indian population, including our rapidly aging population. By ensuring patients receive continuous, high-quality care during transitions, healthcare providers will improve patient outcomes, reduce readmissions, and lower costs. As the Indian transitional care framework continues to grow this holds the potential to become the beacon for how quality of life interventions should be served on the world stage.
