Care Transition Program Significantly Lowers Readmission Rates

A study conducted by the Bronx Collaborative group of hospitals and health insurers found that personal contact with patients before and after hospital discharge resulted in significantly lower readmission rates.

Among 500 patients who received two or more interventions in a special program that managed the transition between hospital and home, 17.6 percent of the patients were readmitted to the hospital within 60 days of discharge. Among a control group of 190 patients who received the current standard of care, the readmission rate was 26.3 percent. Among the 85 patients who received only one intervention, there was a 22.8 percent rate of readmission.

Interventions included pre-discharge education, scheduling a post-discharge follow-up appointment with the patient’s personal physician, and post-discharge telephone calls to review medications, address questions, and verify completion of the follow-up physician visit.

The study concluded that in addition to receiving at least two interventions, the follow-up visit with the physician within 14 days of discharge appeared to be a key factor in preventing readmission. Ann Meara, RN, MBA, associate vice president of Network Care Management, CMO of Montefiore Care Management, and leader of the Bronx Collaborative’s project design team, said the Care Transitions Program (CTP) was designed to reflect the key concepts of accountable care — improving outcomes and patient satisfaction while lowering costs.

“We met those goals and identified opportunities that could possibly be applied successfully at other hospitals,” Meara said.

The Bronx Collaborative includes three nonprofit hospital systems — Bronx Lebanon Hospital Center, St. Barnabas Hospital, and Montefiore Medical Center — and two payer organizations — EmblemHealth and Healthfirst — that work together to address health care issues in the Bronx, which is one of the most economically deprived counties in the country.

The CTP was supported by a grant from the New York State Health Foundation and the New York Community Trust. The results of the study were presented at the annual meeting of the Case Management Society of America in New Orleans in June 2013.