Utilization of transitional care management services and 30-day readmission

Area of Science:

• Healthcare Management
• Patient Readmission Reduction
• Clinical Workflow Optimization

Background:

• Transitional care management (TCM) visits are known to decrease 30-day hospital readmissions.
• The specific drivers of this reduction, whether the visit itself or broader clinic changes, remain unclear.

Purpose of the Study:

• To analyze the association between post-discharge follow-up visit type and 30-day readmissions.
• To determine if provider utilization of TCM or the TCM visit itself impacts readmission rates.

Main Methods:

• Cross-sectional analysis of adult Medicine service patients from Northwell Health (Feb 2018-Feb 2020).
• Compared 30-day unplanned readmissions for TCM versus non-TCM follow-up visits post-discharge.
• Assessed impact of provider TCM utilization frequency on readmission odds.

Main Results:

• TCM follow-up visits were associated with significantly decreased 30-day readmissions (HR=0.74).
• Patients with non-TCM visits seen by frequent TCM users had lower readmission odds (OR=0.84).
• Among frequent TCM users, TCM visits further reduced readmissions compared to non-TCM visits (OR=0.78).

Conclusions:

• Reduced 30-day readmissions are linked to both TCM visits and care from providers with high TCM utilization.
• Both the specific transitional care management visit and the provider's engagement with the TCM model contribute to improved patient outcomes.
• Findings suggest a dual mechanism for readmission reduction in transitional care management.