Care transition management and patient outcomes in hospitalized Medicare beneficiaries

To assess whether discharging hospitals' self-reported care transition activities (CTAs) were associated with transitional care management (TCM) claims following discharge to the community and whether CTAs and TCM were associated with better patient outcomes.

Cross-sectional study of 424,115 hospitalized Medicare fee-for-service beneficiaries 66 years and older who were discharged to the community in 2017 and attributed to 659 hospitals in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate, 46.5%). Of these beneficiaries, 76,156 were categorized into a Hospital Readmissions Reduction Program (HRRP) cohort based on admission principal diagnoses.

Using logistic regression, we examined the association between survey-based hospital-reported CTAs and an attributed beneficiary's TCM claim. We assessed the associations between hospital CTAs and TCM and beneficiary spending, utilization, and mortality in linear (continuous outcomes) and logistic (binary outcomes) regressions.

Beneficiaries attributed to hospitals reporting high (top tertile vs bottom tertile) CTA had a higher probability of TCM after discharge by 3 percentage points. TCM was associated with lower 90-day episode spending (-$2803; P < .001) and improved quality (-28.7 30-day readmissions/1000 beneficiaries; P < .001; -29.7 deaths/1000 beneficiaries; P < .001), and greater use of evaluation and management visits (491/1000 beneficiaries; P = .001). Billing for TCM was associated with significantly lower spending, emergency department visits, hospitalizations, readmissions, and 90-day mortality in the HRRP cohort. Significant utilization reductions were estimated for beneficiaries attributed to high-CTA hospitals.

Beyond recent increases in provider TCM compensation and relaxed billing restrictions, hospitals should be encouraged to increase CTA and to enhance care transitions to improve patient outcomes and lower spending.