Statewide Transitional Care Program Cuts Hospital Readmissions for Medicaid Patients

A new Health Affairs study reveals patients who received transitional care were 20 percent less likely to experience a readmission in the first year following hospital discharge than clinically similar patients who received standard care.

To evaluate North Carolina's statewide population-based transitional care initiative, researchers looked at 1,375 Medicaid recipients with complex chronic conditions hospitalized between July 2010 and June 2011. They found that for every six patients who received transitional care services, one readmission was averted in the following year, while one readmission was averted for every three of the highest-risk patients who received transitional care.

Moreover, the study revealed the benefits of transitional care extended beyond 30 days after discharge. For every 100 patients receiving transitional care, 8.7 readmissions were avoided within the first 30 days and 17.4 readmissions were avoided within the first year.

With such longer-term benefits, the researchers question the industry's increased focus on 30-day readmissions. "Indeed, efforts by the Centers for Medicare and Medicaid Services to incentivize hospital-based efforts to reduce thirty-day readmission rates through the public reporting of readmission statistics and the phasing in of financial penalties for hospitals could divert attention from the potential of improved care transitions to yield longer-term benefits," they wrote.

To achieve the drop in 30-day and first-year readmissions, patients received transitional care services of varying intensity. For example, moderate-intensity interventions included a hospital bedside visit before discharge and high-intensity transitional care services involved a home visit by a care manager or a comprehensive medication review by a clinical pharmacist. Low-intensity transitional care activities included phone calls or communication without further intervention.

For further proof that transitional care is the answer to lowering readmissions, look at three nonprofit hospitals in the Bronx, N.Y., that significantly dropped readmission rates thanks to personal contact with patients before and after discharge. Of the 500 patients who received two or more personal contact interventions from nurse care transition managers, only 17.6 percent bounced back to the hospital within 60 days of discharge, compared to 26.3 percent of 190 patients who received standard care, FierceHealthcare previously reported.