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Evaluation of a nurse practitioner-led transitional care program.

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The Transitional Care Encounter Program (TCEP) generated revenue and improved provider satisfaction. Further research into its impact on readmission rates and patient outcomes is recommended for this nurse practitioner-led model.

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Area of Science:

  • Healthcare Management
  • Patient Care Coordination
  • Nurse Practitioner Practice

Background:

  • Transitional care management (TCM) is crucial for post-hospital care.
  • Nurse practitioner (NP)-led TCM models show potential in reducing readmissions.
  • Data on the cost and sustainability of TCM models are limited.

Purpose of the Study:

  • Evaluate the Transitional Care Encounter Program (TCEP) for cost, sustainability, reimbursement, and nonmonetary value.
  • Assess the financial impact and added value of an NP-led TCM program in a private practice setting.

Main Methods:

  • Utilized the CDC's "Framework for Program Evaluation in Public Health".
  • Analyzed TCEP billing and revenue data against program costs for financial impact.
  • Collected qualitative data and conducted patient visits within 7 days of hospital discharge, including medication reconciliation and treatment plan review.

Main Results:

  • The TCEP generated $53,330.32 in total reimbursement.
  • Providers reported increased capacity for primary care patients due to the dedicated transitional care provider.
  • Patients reported feeling "empowered" following TCEP visits.

Conclusions:

  • The TCEP demonstrated financial viability and enhanced provider satisfaction.
  • Further investigation into TCEP's effect on 30-day readmission rates and patient satisfaction is warranted.
  • The study supports the value of NP-led transitional care models.