Evaluating Transitional Care Investments Across Diverse Hospitals

Leaders investing in transitional care must consider whether potential economic benefits outweigh costs. We sought to identify drivers of costs/benefits of the nurse-delivered, telephone-based Coordinated Transitional Care (CTraC) program and examine how economic returns varied across facilities.

A cohort of patients ≥ 65-years-old, discharged from hospitals to home after a medical or neurological admission (October 2022-September 2023) was used to identify VA facility: patient volume, 30-day unplanned readmission rates, and readmission lengths of stay. We obtained VA bed-day-of-care costs, non-VA charges, and nursing salaries. We estimated facilities' annual net costs/savings from changes in readmissions (2023-dollars), net per patient costs/savings, and number of VA bed-days freed from investing in one nurse, given varying program effectiveness (10%-30% relative readmission reduction). Estimates were also calculated for a hypothetical base-case derived from median facility characteristics.

Among 99,778 patients discharged from 120 VA hospitals: median facility patient volume was 786; 30-day unplanned readmission rate was 14.1%. Given one nurse serving 307 patients/year and a 20% readmission reduction among CTraC patients, CTraC was estimated (base-case) to reduce non-VA hospital readmission charges by $22,369 and free 55.5 VA bed-days-of-care annually. Savings varied across facilities and were associated with readmission rates and volume. Estimates based on median facility characteristics overstated potential benefits for some hospitals and understated it for others.

Investments in transitional care may reduce readmissions and generate economic benefit, but the magnitude of returns varied across VA hospitals. Facility-specific data were essential for accurate assessment of value and informed policy-making.