How to Measure Real Transitional Care Success

Effective transitional care services are more than just a handoff between hospitals and homes. Yet, the way we measure success in these programs has long been flawed. The traditional approach to transitional care measurement is broken—focused almost entirely on lagging indicators like 30-day readmission rates, initial follow-up visits, and medication reconciliation. While these measures matter, they tell us only what has already happened, often when it is too late to intervene.

To truly improve health outcomes, reduce healthcare costs, and strengthen care coordination, health systems must move toward upstream, proactive indicators that provide real-time insights into risks before they become problems.

Why Are Metrics Vital in Transitional Care Programs?

Transitions of care are high-risk moments for patients—especially older people, those with chronic conditions, or Medicare beneficiaries—where miscommunication and gaps in discharge planning can lead to adverse events and poor outcomes. Traditional metrics such as readmission rates and completed follow-up appointments highlight these failures but only after the fact.

Clear, upstream metrics ensure care teams across multiple care settings—from acute care to skilled nursing facilities to home care—are aligned around preventing risk earlier. Without defined lead indicators, even the strongest model of care risks being reactive rather than proactive.

Traditional Metrics: Still Necessary, But Not Enough

Readmission Rates (30-Day, 90-Day)

Hospital readmission has long been the “gold standard” of transitional care management (TCM programs). Tracking both 30-day and 90-day rates helps primary care clinicians and case management staff assess lasting effects on the patient population. While valuable, this is the ultimate lag measure—by the time a readmission occurs, harm has already been done.

Patient Satisfaction and CAHPS Measures

CAHPS surveys and related measures highlight the patient voice, showing whether individuals felt supported and prepared during medical care transitions. These are critical to understanding experience but are still retrospective, offering little warning before issues escalate.

Medication Reconciliation and Management

Ensuring medication reconciliation within 48 hours of discharge reduces errors and adverse events. It is one of the most widely adopted transitional care interventions, but again, it is measured after discharge, offering little foresight into whether patients will even have access to or take the medications they need.

ED Visits Avoided

Tracking avoidable ED use provides insight into how well care coordination and discharge planning prevent crises. Yet this too is a lagging indicator—it tells us a failure occurred only once the patient is already in the emergency department.

Follow-Up Appointment Adherence

Measuring whether patients attend follow-up visits is essential for continuity. But if a patient misses the visit, the system only discovers the problem afterward, sometimes when poor outcomes have already taken root. According to CMS Transitional Care Management requirements, timely follow-up—within 7 to 14 days depending on patient complexity—is not optional but fundamental to reducing readmissions. While CMS defines the clinical timelines for TCM services, broader policy considerations shaping transitional care management highlight how reimbursement rules and compliance requirements influence care delivery models

Member Engagement Benchmarks

Metrics like answered care team calls or participation in home care visits help assess patient engagement. Still, they reflect past behavior rather than predicting future risks.

Lead vs. Lag Indicators: Why Actionability Matters

Not all metrics are equally useful when it comes to driving timely action. In transitional care, the distinction between lag indicators and lead indicators is critical:

• Lag indicators reflect outcomes that have already happened. Examples include readmission rates, ED utilization, and follow-up adherence. While they are valuable for accountability and retrospective analysis, they are reactive—by the time the data is available, the opportunity to prevent the event has already passed.
• Lead indicators predict or signal risk before an adverse event occurs. Metrics like medication access rates, caregiver confidence, and quality of life surveys provide early warning signs, allowing care teams to intervene proactively.

The limitation of lagging measures is that they are poorly actionable in real time. They validate performance but offer little guidance for immediate course correction. For example, knowing that a patient was readmitted within 30 days helps explain failure but does not prevent the next readmission.

In contrast, leading measures are directly actionable. If a patient has not picked up new prescriptions within 48 hours, or if a caregiver reports low confidence, the care team can mobilize resources immediately to close those gaps. This distinction is why Presidium Health has redesigned its transitional care measurement model to blend both lagging and leading indicators.

The Illusion of Readmission Reduction: Changing Disposition Practices

While hospital readmission rates have long been treated as the gold standard in measuring transitional care efficacy, emerging evidence suggests that reductions in these numbers may not always signal genuine improvements. Instead, hospitals may modify how patients are categorized when they return for acute care—admitting them under “observation status” or discharging them directly from the emergency department in lieu of coding their status as an admission.

This practice, sometimes called “changing disposition,” can make readmission rates appear lower without actually reducing the total burden of post-discharge instability. For example, JAMA Network Open study on readmissions and overall acute revisits found that while 30-day readmissions declined for conditions targeted under Medicare’s Hospital Readmissions Reduction Program, overall acute revisits—including ED visits and observation stays—actually increased. Similarly, a landmark NEJM analysis of HRRP and rising observation stays observed significant growth in observation stays after HRRP implementation, raising concerns that part of the apparent progress with respect to hospital reductions reflects reclassification rather than true recovery.

These findings underscore a critical flaw in relying solely on readmission rates: they may reflect shifts in reporting or hospital thresholds more than actual patient stabilization. This reality makes it clear that transitional care success cannot be defined by hospital readmission rates alone. True effectiveness requires a broader view—one that captures not just where patients land after discharge, but whether they are genuinely stabilizing across care settings. That is why Presidium Health has redefined how success is measured, blending traditional indicators with upstream metrics that reveal risk earlier, account for post-acute recidivism, and track outcomes that matter most to patients and caregivers.

How Presidium Measures Transitional Care Success

At Presidium Health, transitional care is more than a checklist of discharge tasks — it is an integrated, patient-centered model designed to intervene early, prevent complications, and support long-term stability. Our program blends traditional quality indicators with innovative upstream measures to give a more complete and predictive picture of success.

To ensure these measures drive real-world change, each program is supported by a custom dashboard. These dashboards are tailored to the unique priorities, populations, and partner goals of each program, bringing together both lagging and leading indicators into a single, actionable view. This allows care teams to track stability, close social determinant gaps, and evaluate patient progress in real time. Our model builds on lessons from integrating transitional care services with enhanced care management, ensuring care coordination spans both clinical and social needs.

Engagement with Peer Support Specialists

We track patient and family engagement with peer support specialists who serve as trusted guides during the vulnerable post-discharge period. Measuring the percentage of patients who actively connect with these specialists provides insight into the strength of our patient engagement model and ensures that emotional, social, and cultural needs are addressed alongside medical care.

Peer support engagement is particularly significant because transitions are not just clinical but also emotional. Patients often feel overwhelmed after a hospitalization. Having a peer who has “been there” improves trust, boosts adherence to care plans, and increases confidence in managing conditions at home. For Presidium, this metric demonstrates how well our model is closing the gap between medical interventions and real-world patient experiences.

Skilled Nursing Facility (SNF) Recidivism Rates

Beyond hospital readmissions, we monitor returns to skilled nursing facilities within 7–14 days of discharge. This early marker helps identify instability before it escalates into a hospital event. By tracking SNF recidivism rates, Presidium can adjust care plans rapidly, deploy additional case management, and strengthen continuity across care settings.

It is important to note that simply blocking patients from the hospital is not the answer. True success means ensuring that care is still accessible, monitored, and delivered at the right level, not just diverting patients from one setting to another. If hospitalizations decrease but SNF admissions rise inversely, it may signal that risk has merely shifted rather than been resolved. These metrics must be evaluated together to understand whether patients are truly stabilizing in their preferred care setting.

This measure is significant because SNF recidivism often reflects breakdowns in discharge planning, care coordination, or family readiness. By catching trends early, Presidium prevents “silent failures” that may not appear in hospital readmission data but still signal risk. Ultimately, lowering SNF recidivism shows that patients are staying stable in the least restrictive environment possible, a key driver of both cost savings and quality of life.

Percent of Social Determinants of Health (SDOH) Gaps Closed

Presidium measures the percentage of social determinants of health gaps closed within the first 30 days following discharge. From food security and transportation to housing stability and access to medication, closing these gaps is essential to preventing poor outcomes. Tracking closure rates ensures that our transitional care interventions address upstream barriers that drive avoidable utilization and hinder recovery. Measuring progress in closing upstream barriers like food insecurity or transportation is essential, aligning with our broader work on closing social determinants of health gaps in transitional care.

This metric is powerful because it demonstrates how transitional care reaches beyond the hospital walls. A patient may leave the hospital clinically stable, but if they lack transportation to follow-up visits or can’t afford medications, risks escalate quickly. Measuring SDOH gap closure confirms whether interventions are resolving these root causes — making the difference between temporary stability and long-term recovery.

Medication Access Rates

Unlike traditional medication reconciliation, which looks backward, we measure whether patients can actually obtain prescribed medications within 24–72 hours. This upstream metric highlights cost, transportation, or pharmacy access barriers before they lead to non-adherence.

The significance here is that access equals action. Patients who never pick up their prescriptions are invisible to most traditional measures until a complication arises. By measuring medication access directly, Presidium ensures that a lack of resources doesn’t derail recovery. This indicator gives our care team an immediate trigger to step in — arranging delivery, financial assistance, or education — before small issues spiral into costly readmissions.

Caregiver Confidence Rates

We assess whether caregivers feel prepared to manage care at home — including medication schedules, red-flag monitoring, and daily routines. Confidence surveys identify gaps in training and education early, ensuring families are equipped to prevent complications.

This metric matters because caregiver readiness is one of the strongest predictors of successful transitions. A confident caregiver is more likely to spot early warning signs, encourage adherence, and provide the right balance of support without unnecessary escalation. By contrast, caregivers who feel unprepared often experience stress that leads to mistakes or overuse of emergency services. Tracking and improving caregiver confidence strengthens the entire safety net around the patient.

Quality of Life Surveys

Beyond satisfaction, we conduct surveys that assess physical mobility, independence, emotional well-being, and social support. These proactive assessments provide real-time visibility into patient stability and allow the care team to intervene before deterioration occurs. To strengthen this measure, Presidium aligns its quality of life assessments with validated tools such as the NIH PROMIS quality of life survey. PROMIS is a nationally recognized framework designed to capture patient-reported outcomes across physical, mental, and social health domains, ensuring that metrics reflect what matters most to patients beyond clinical stability

This metric is significant because it reframes success from simply “avoiding readmissions” to actually improving the lived experience of patients. Quality of life surveys capture what matters most to patients themselves — whether they feel strong enough to return to activities, maintain independence, or manage chronic conditions confidently. By measuring this upstream, Presidium ensures that our transitional care program is not just keeping patients alive, but also helping them thrive.

Presidium Prime: Sharing Our Expertise

Through Presidium Prime, our learning and collaboration platform, healthcare organizations and leaders can access the same expertise that powers our own transitional care models. Prime offers direct guidance from Presidium Health experts, practical playbooks, and case-based learning so others can adopt, adapt, and scale proven strategies. By combining customized dashboards with a pathway to learn directly from our team, Presidium is advancing not just our own programs, but the broader field of transitional care.

By combining these upstream indicators with traditional metrics like readmission rates and follow-up adherence — and packaging them into custom dashboards for real-time insight — Presidium’s transitional care program creates a dashboard of success that is predictive, actionable, and patient-centered.

Build a Smarter Transitional Care Dashboard

To make these measures actionable, Presidium consolidates both lagging and leading indicators into a transitional care dashboard that is customized and agile to meet the program’s ongoing needs. Here is an example of a dashboard with lead, lag, financial, and operational success indicators.

This balanced approach creates transparency across the care team, enabling physicians, nurses, social workers, and primary care clinicians to see progress in real time, identify patients at high risk of poor outcomes, and intervene quickly. By highlighting both strengths and gaps, the dashboard empowers health systems to continuously refine their model of care.

Conclusion

Metrics are not just numbers—they are the story of how transitional care management succeeds or fails. The problem is that for too long, that story has been told after the fact. By relying solely on downstream metrics like readmissions and post-event visits, health systems limit their ability to act before patients decline.

Equally important, no single measure tells the full story. Reducing hospitalizations, for example, is not true success if patients simply cycle back into skilled nursing facilities. Metrics must be viewed together, in context, to ensure patients are genuinely stabilizing in the most appropriate and least restrictive setting.

Presidium’s approach blends these traditional measures with upstream indicators like medication access, caregiver confidence, peer support engagement, quality of life surveys, SNF recidivism, and SDOH resolutions. By treating metrics as part of an interconnected system, not isolated benchmarks, Presidium ensures care remains accessible, monitored, and delivered in a way that prevents avoidable harm while improving patients’ lives.

This proactive, holistic model not only reduces avoidable utilization but also delivers stronger patient outcomes, better continuity of care, and lasting improvements in the quality of life for patients navigating vulnerable transitions. For more insights, visit our full library of transitional care resources where you’ll find additional knowledge, policy perspectives, and models of care.