Evaluation of a Family Medicine Transitional Care Service Line

Abstract

As of 2013, the all-cause readmission rate among Medicare fee-for-service beneficiaries was 17.5%. In addition to poor outcomes, 30-day hospital readmissions account for over $17 billion in Medicare expenditures. The presence and involvement of a primary care provider can be essential during the transition period from hospital discharge to the outpatient setting. Objective: In an effort to reduce 30-day hospital readmissions a transitional care management (TCM) service was implemented in a multi-site family medicine practice. Methods: The transitional care service line was structured after the 2013 Centers for Medicare & Medicaid Services recommended process for transitioning patients from an inpatient to an outpatient setting. The service included a care team RN, electronic documentation in an electronic medical record and the primary care physician. Results: The 30-day readmission rate was 12.0% in the 10 months before implementation of the new service line and 12.4% in the first 10 months after implementation of the new service line. There was no evidence of an impact of the new service line on a decline in 30-day readmission rates (P ‫؍‬ .18). Discussion: Hospital readmissions generate unnecessary costs and often present a major burden on patients and their families. Early engagement with patients after hospital discharge will help to address any acute needs, verify medication adherence and ensure that necessary equipment and services are available. Conclusion: Although there was no evidence of an impact of the new service line on a decline in 30day readmission rates it was decided that this service was a benefit to the patients and the physicians involved. (

Implementing Practice Changes in Family Medicine to Enhance Care and Prevent Disease Progression

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Can Transitional Care Decrease Readmission in Stroke Patients?

“…A lack of prompt PCP follow-up (within 4 weeks after discharge) has been shown to be linked to an increased risk of hospital readmission for the same condition and is likely to lead to a longer hospital stay. Patients are more likely to experience unfavorable outcomes following discharge if prescription mistakes, inadequate follow-up on unfinished tests, or lost opportunities for advised testing or outpatient procedures are present (Farford et al, 2019;Misky et al, 2010).…”

Improved transitional care as a strategy to decrease readmission in stroke patients: A systematic review

“…A lack of prompt PCP follow-up (within 4 weeks after discharge) has been shown to be linked to an increased risk of hospital readmission for the same condition and is likely to lead to a longer hospital stay. Patients are more likely to experience unfavorable outcomes following discharge if prescription mistakes, inadequate follow-up on unfinished tests, or lost opportunities for advised testing or outpatient procedures are present (11,12).…”