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J Gen Intern Med. 2019 Sep;34(9):1815-1824. doi: 10.1007/s11606-019-05082-8. Epub 2019 Jul 3.

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

Author information

1
Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA. jeb@uthsc.edu.
2
Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA. jeb@uthsc.edu.
3
Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA. jeb@uthsc.edu.
4
Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA.
5
Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
6
Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
7
Express Scripts Holding Company, Memphis, TN, USA.
8
Department of Health Management and Policy, University of Kentucky College of Public Health, Lexington, KY, USA.
9
Methodist Le Bonheur Healthcare, Memphis, TN, USA.
10
Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, GA, USA.

Abstract

BACKGROUND:

Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.

OBJECTIVE:

To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs.

DESIGN:

Quasi-experimental study.

PATIENTS:

Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls.

INTERVENTIONS:

The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days.

MAIN MEASURES:

Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures.

KEY RESULTS:

Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (- 0.40; 95% confidence interval (CI), - 0.73 to - 0.06), 31% fewer 30-day readmissions (- 0.34; 95% CI, - 0.61 to - 0.07), and reduced medical expenditures ($- 8690; 95% CI, $- 14,441 to $- 2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+ 2.6%; 95% CI, - 39.1% to 72.9%).

CONCLUSIONS:

Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

KEYWORDS:

Medicaid; Medicare; care transitions; chronic disease; health care delivery; multiple chronic conditions; quality improvement; super-utilizer; underserved populations

PMID:
31270786
PMCID:
PMC6712187
[Available on 2020-09-01]
DOI:
10.1007/s11606-019-05082-8

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