Transitions of care in people with pain represent a period of increased vulnerability due to potential disruptions in pain management, which could result in worsened quality of life, function, and other adverse patient outcomes. In addition, people with pain are often discharged on opioids; such patients may be at risk for opioid-related adverse events or withdrawal if opioids are discontinued or tapered abruptly. The Medicare population is particularly vulnerable during transitions of care due to higher medical complexity, presence of disability, older age, or (in the case of dual eligibility) socioeconomic status. Evidence indicates that transitional care interventions reduce risk of readmission in patients with congestive heart failure and in general medical populations. Therefore, if effective in people with acute or chronic pain, transitional care interventions represent a potential opportunity to optimize management and reduce adverse outcomes in this population.
- Overall, a review of 10 systematic reviews found that successful transitional care interventions are comprehensive, extend beyond hospital stay, and have flexibility to respond to individual patient needs. However only one systematic review focused on patients with pain (specifically postsurgical patients) and found no difference in readmission rates between the Enhanced Recovery After Surgery (ERAS) model and usual care. The other nine systematic reviews did not report pain outcomes.
- One cohort study of patients with postsurgical pain and a usual provider prior to surgery found an association between early return visit to the usual provider and decreased likelihood of receiving opioid prescriptions from multiple providers.
Chou R, Kansagara D, Dana T, Pappas M, Hart E. Care Coordination and Care Plans for Transitions Across Care Settings. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006). AHRQ Publication No. 21- EHC018. Rockville, MD: Agency for Healthcare Research and Quality; April 2021. doi: https://doi.org/10.23970/AHRQEPCCARECOORDINATION. Posted final reports are located on the Effective Health Care Program search page.
