As parts of the Affordable Care Act are being implemented, patients will begin to see more attention paid to the quality of care after they leave the hospital. This focus on the transition from hospital to home is in response to an alarming rate of hospital readmissions in the United States.

Most readmissions are connected to the poor quality or lack of transitional care and posthospital care coordination. A recently released report by the Robert Wood Johnson Foundation brings the issue to the forefront.

While the report focuses mainly on patients receiving Medicare, the problem doesn't end there. One in five elderly patients is readmitted to the hospital within 30 days of discharge. Some are readmitted for an anticipated follow-up procedure, while others return for an unrelated cause. Yet data suggest that 76 percent of these readmissions are preventable and poor care transitions are most certainly to blame. "They are the result of a fragmented system of care that too often leaves discharged patients to their own devices, unable to follow instructions they didn't understand, and not taking medications or getting the necessary follow-up care," the study says.

I learned the hard way when my husband, Eric, a Philadelphia trial attorney, was felled by a brain-stem stroke just before he was to board a flight in Chicago two years ago. He was 53, with no prior health conditions or problems. From the outset, we knew his recovery and rehabilitation would be long and difficult. We didn't know that his transition to posthospital care would be just as challenging.

It was not possible to schedule follow-up appointments with specialists in the prescribed time frames. There was an issue with lost medical records, and a billing error that landed us in collection for $23,312. There were 10 pages of discharge guidelines, seven prescription medications, and 29 pages of accompanying instructions. What we did not have, however, was a comprehensive care plan - much less a contact within the system that would help us coordinate his extremely complicated care once he was home.

While my background and professional contacts made things easier, the vast majority of patients are not so lucky. The result is often readmission, a consequence that negatively impacts patients' health and costs Medicare $17 billion a year.

Why is this happening? The report offers countless reasons, though not all are easy to solve.

Particularly in situations like my husband's, patients can become overwhelmed - both with their health condition and with the logistics of care. Though care needs to be continuous once a patient leaves the hospital, many patients are not provided with a detailed discharge plan that tells them exactly what they need to do to preserve their health.

Some of the patients polled for the foundation report were not ready to change their behaviors, like smoking cigarettes or clocking in long days at the office. But others were simply unable to help themselves. Data show that more than half of patients could not accurately recall their diagnoses upon discharge, and nearly as many did not understand the medications prescribed for them. As a result, they don't recognize warning signs when a condition worsens, nor do they realize when a dosage is incorrectly prescribed. The lucky patients have a family member or friend who can serve as a caregiver, but too many have no support once they arrive at home.

While the patient himself struggles to manage his own care, it is also difficult to coordinate communication between hospitals and doctors that are serving the same patient. After a patient leaves the hospital, fewer than one in five see any direct communication between the hospital and the individual's primary care physician. The lack of communication, according to medical providers who participated in the foundation's study, results from confusion concerning who is "in charge." Patients with chronic conditions often see multiple doctors and there is no protocol on who should take the lead. Likewise, there is no one professional identified for the patient to contact with any post-discharge questions.

There is no end to the factors that cause preventable hospital readmissions, but it's a subject that is finally getting the attention it deserves. We need to change "patient-centered care" from a trendy phrase to true coordination that prepares a patient and his family for the outpatient care required once home - and whatever it takes to keep that patient at home instead of back in a hospital bed.

The Affordable Care Act (ACA) includes a number of provisions that are designed to do just that.

It creates the Center for Medicare and Medicaid Innovation to test delivery and payment models such as accountable care organizations, which are designed to focus on what it takes to keep patients healthy, treat those who are sick, and help those with chronic illnesses manage their disease.

The ACA also requires the development of a National Quality Improvement Strategy that focuses on, among other things, improving the overall quality of care by making it more patient-centered, reliable, accessible, and safe.

In addition, the ACA focuses new attention on the need for "patient navigators." It will be important to ensure that these navigators help us navigate the insurance world and the health-care system itself, especially when we need a high level of care coordination.

Finally, over the past few years, the federal Department of Health and Human Services has been providing financial incentives to encourage health-care providers to move forward on developing electronic health records. If used properly, these records could go a long way toward enhancing the exchange of information and coordination among providers.

Beth Ann Swan is dean and professor at the Jefferson School of Nursing, Thomas Jefferson University. E-mail her at