Description

Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90 days after discharge. The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting.