Design Thinking Improved Transitional Care Management and Primary Care Continuity in Rural America

Transitional care management (TCM) supports timely postdischarge follow-up and is associated with decreased emergency department visits and 30-day readmissions. However, delivering TCM in rural settings remains challenging, and staff frequently report frustration with existing processes.

This quality improvement study aimed to maximize the interdisciplinary team's expertise by applying a design thinking process. The study assessed current TCM practices, co-developed solutions, and iteratively implemented and evaluated interventions. This process enabled the identification of interventions beyond previously ineffective actions.

Using design thinking as a framework, the authors developed an enhanced TCM model. The authors conducted descriptive and inferential analyses to assess the impact of the enhanced TCM model on post-discharge TCM visits among the 35 participating patients.

Continuity with the patient's primary care clinician (PCC) at the TCM visit increased from 66% to 97% (P < .001). Transitional care management visits occurring within 7 days of discharge increased from 50% to 74% (P < .05), and those that occurred both with the continuity PCC and within 7 days increased from 28% to 69% (P < .01).

Patients receiving in-reach care coordination had higher rates of timely TCM visits with their PCCs compared to those who did not receive the intervention. These exploratory findings suggest that incorporating design thinking into transitional care in a rural health setting was feasible and may support continuity of care following hospital discharge. Future research is needed to better understand the impact on patient-reported outcomes and other quality measures.