Implementation and Evaluation of a Team-Based Approach to Hospital Discharge Transition of Care

Transitional care management (TCM) programs guide patients from hospital discharge to outpatient follow-up with the goal to decrease hospital readmissions and the cost of care. In 2017, the department of primary care internal medicine (PCIM) at Eastern Virginia Medical Group implemented TCM. We aimed to evaluate the efficacy and self-sustainability of this TCM program.

The TCM team contacted patients upon discharge to schedule the follow-up appointment. We coded patient contact as (1) no successful phone-call contact, patient did not attend appointment; (2) successful phone-call contact, patient did not attend appointment; and (3) patient attended appointment. We collected patient demographics, readmissions, and visit costs using manual chart review and electronic health record (EHR) data extraction. We conducted χ ² analysis, one-way analysis of variance, and unpaired t tests to assess associations between readmission rates or costs and TCM care.

Initial analysis did not indicate significant associations between readmission rates and level of TCM care at 30 (χ ²=1.40, P=.50), 60 (χ ²=5.48, P=.06), or 90 (χ ²=4.23, P=.12) days or significant differences in patient charges at 30 (F[2,59]=2.85, P=.06), 60 (F[2,91]=2.00, P=.14), or 90 (F[2,126]=1.39, P=.25) days. Follow-up analysis indicated significant associations between readmission rates and any level of TCM care at 60 (χ ²=5.40, P=.02) and 90 (χ ²=4.21, P=.04) days, but not at 30 days (χ ²=1.39, P=.28).

Our TCM program review suggests that the benefits of transitional care extend beyond 30 days by decreasing readmission rates at 60 and 90 days after hospital discharge.