Impact of a scalable care transitions program for readmission avoidance

To evaluate the Care Transition Solution (CTS) as a means to improve quality through reduction of preventable hospital readmissions among patients with readmission-sensitive conditions subject to penalties imposed by the Affordable Care Act.

A retrospective quasi-experimental evaluation of the impact of the CTS among admitted patients diagnosed with heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, and/or pneumonia (CMS readmission-penalty diagnoses) in 14 acute care hospitals in Texas. The program, designed for scalable delivery, incorporated identification of high readmission-risk patients, assessment of individual needs, medication reconciliation, discharge planning, care coordination, and telephonic postdischarge follow-up.

The treatment group of program enrollees (N = 560) and the comparison group with no program contact (N = 3340) were matched on 8 coarsened demographic, diagnosis, and severity variables associated with readmission risk. Assessed outcomes included relative risk and odds of readmission within 30 days postdischarge and overall within the 6-month evaluation period. Zero-inflated Poisson multivariate models were used to estimate intervention effects controlling for matching-generated weights, age, disease status, and period of evaluation.

Treatment group risk of readmission was 22% lower overall (incidence rate ratio [IRR], 0.78; P < .01) and 30-day readmission risk was 25% lower (IRR, 0.75; P = .01) relative to the comparison group. Odds of any or 30-day readmission were 0.47 (95% CI, 0.35-0.65) and 0.56 (95% CI, 0.41-0.77), respectively, for treatment relative to comparison.

Participation in the CTS resulted in significantly lower rates of readmissions among patients with readmission-sensitive conditions, offering a scalable and sustainable approach to reduce the number of preventable hospital readmissions.