Evaluation of a nurse practitioner-led transitional care program

Transitional care management (TCM) is a growing field in the delivery of post hospital discharge care. Current data suggest that implemented nurse practitioner (NP)-led transitional care models can be useful in reducing 30-day readmission rates. However, there is lack of data regarding the costs involved to implement and sustain a transitional care model.

The Transitional Care Encounter Program (TCEP) implemented by an NP at a private practice affiliated with a 250-bed acute care facility required program evaluation. This article addresses the TCEP's cost and sustainability, reimbursement, and nonmonetary value added to the practice.

The Centers for Disease Control and Prevention (1999) "Framework for Program Evaluation in Public Health" was used for formal program evaluation. The TCEP's billing and revenue data compared with the TCEP's cost determined the financial impact. Qualitative data were also collected.

Patients discharged from the hospital to home had a TCEP visit within 7 days of discharge. The patient's hospital records were extensively reviewed. Medication reconciliation, education about current medications, diagnosis, and treatment plan were incorporated.

Total reimbursement was $53,330.32. Providers expressed they could allocate more time to primary care patients and averaged 2-3 more patients by having a dedicated transitional care provider. Providers expressed patients were "empowered" after the TCEP visit.

The TCEP was a source of revenue and improved provider satisfaction. Exploration of the TCM's impact on 30-day readmission rates and patient satisfaction are recommended to further support the model.